Fetal alcohol syndrome: an international perspective.

This article represents the proceedings of a workshop at the 2000 ISBRA Meeting in Yokohama, Japan. The chairs were Kenneth R. Warren and Faye J. Calhoun. The presentations were (1) Epidemiological research on fetal alcohol syndrome (FAS) in the United States, by Philip A. May; (2) An overview of fetal alcohol syndrome in the Western Cape Province of South Africa, by Denis L. Viljoen and Ting-Kai Li; (3) Diagnostic perspectives of fetal alcohol and tobacco syndromes, by Harumi Tanaka; (4) FAS among pupils of special boarding schools and orphanages in Moscow, Russia, by Galina S. Marinicheva and Luther K. Robinson; and (5) Research on FAS and FAE in Germany: Update and perspectives, by Goetz Mundle.

Serial creatinine kinase (CK) MB testing during the emergency department evaluation of chest pain: utility of a 2-hour deltaCK-MB of +1.6ng/ml.

BACKGROUND: Traditional methods of using creatinine kinase (CK)-MB to diagnose acute myocardial necrosis rely on the total CK-MB exceeding a threshold of normalcy before being considered diagnostic. Because the CK-MB rapid immunoassay is both sensitive and precise, a small difference between two serial samples over an appropriate time interval may result in an increased sensitivity for acute myocardial infarction (AMI) compared with traditional methods if an appropriate cutoff value is chosen. METHODS AND RESULTS: Baseline and 2-hour CK-MB immunoassay measurements were performed in 710 patients with chest pain whose baseline CK-MB was less than two times upper limits of normal (<12 ng/ml) to determine whether a rise in CK-MB > or =+1.6 ng/ml is more sensitive and specific than an abnormal 2-hour CK-MB in the detection of patients with AMI during the initial emergency department evaluation of chest pain. The baseline (MBO) or 2-hour (MB2) CK-MB was considered positive if the CK-MB level was > or =6 ng/ml. MBdelta was defined as the difference of MB2 and MBO and was considered positive if the value was > or =+1.6 ng/ml. A positive MB2 was more sensitive for the detection of AMI (75.2% vs 17.7%; p < 0.0001) than a positive MBO. A positive MBdelta was more sensitive for the detection of AMI (93.8% vs 75.2%; p < 0.0001 ) than a positive MB2. There were no statistically significant differences in specificities for AMI for any test modality. CONCLUSIONS: A rise in CK-MB of > or =+ 1.6 ng/ml in 2 hours is a useful marker of AMI during the initial emergency department evaluation of patients with chest pain.

Usefulness of automated serial 12-lead ECG monitoring during the initial emergency department evaluation of patients with chest pain.

STUDY OBJECTIVE: To determine whether the use of automated serial 12-lead ECG monitoring (SECG) is more sensitive and specific than the initial 12-lead ECG in the detection of injury and ischemia in patients with acute coronary syndromes (ACS) during the initial ED evaluation of patients with chest pain. METHODS: A prospective observational study was performed in 1,000 patients with chest pain who were admitted to a university teaching hospital and who underwent continuous ST-segment monitoring with SECG during the initial ED evaluation. The initial ECG was obtained on presentation, and SECG readings were obtained at least every 20 minutes during the ED evaluation. Diagnostic abnormalities on the initial ECG were defined as injury or ischemia. Diagnostic changes on SECG were defined as evolving injury, evolving ischemia, new injury, or new ischemia. ACS was defined as acute myocardial infarction (AMI), recent myocardial infarction or unstable angina. RESULTS: A diagnostic SECG was more sensitive than a diagnostic initial ECG for detection of AMI (68.1% versus 55.4%; P < .0001) and ACS (34.2% versus 27.5%; P < .0001). A diagnostic SECG was more specific than a diagnostic initial ECG for detection of ACS (99.4% versus 97.1%; P < .01). SECG detected injury in an additional 16.2% of AMI patients compared with the initial ECG (61.8% versus 45.6%; P < .0001; 95% confidence interval for difference of proportions, 10.9% to 21.4%). CONCLUSION: SECG during the initial ED evaluation is more sensitive and more specific than the initial ECG in the identification of ACS. Patients with a diagnostic SECG need intensive antiischemic therapy, evaluation for reperfusion therapy, and admission to an ICU.

Instability of ST segments in the early stages of acute myocardial infarction in patients undergoing continuous 12-lead ECG monitoring.

Many patients presenting to the emergency department with suspected acute myocardial infarction (AMI) have an initial 12-lead electrocardiogram (ECG) nondiagnostic for acute injury and thus do not meet any accepted ECG criteria for thrombolytic therapy. Early studies in the use of intracoronary thrombolytic therapy documented that cyclic variations in ST segment magnitudes between normalcy and injury are common during the early phase of AMI and correspond to spontaneous intermittent coronary opening and reocclusion. The reliance on a single ECG to diagnose AMI may mean that many patients with AMI are missed if the initial ECG is obtained during a window of ST segment normalcy. We present 3 patients with AMI who underwent continuous 12-lead ST segment monitoring with frequent serial ECGs whose ST segments periodically normalized during the acute injury phase. We believe continuous 12-lead ST segment monitoring with frequent serial ECGs can aid the physician in identifying patients with AMI who may benefit from thrombolytic therapy and other urgent revascularization techniques.

Histopathology, morphometry, and nuclear DNA content of iris melanocytic lesions.

PURPOSE: To compare the histologic, morphometric and nuclear DNA content of a group of benign and malignant melanocytic lesions of the iris. METHODS: Forty-four surgically excised melanocytic lesions of the iris were histologically classified as nevus or melanoma. Morphometric analysis using a digital filar micrometer (LaSICO 1602N-10 and 5-4A) measured the mean size of the 10 largest nucleoli, and Feulgen staining and image cytometry (CAS 200 Cell Analysis Systems) analyzed the nuclear DNA ploidy in the lesions. Patient follow-up information was obtained whenever possible. RESULTS: Sixteen cases were histologically classified as nevi and twenty-eight cases as melanoma. The mean of the 10 largest nucleoli of the nevi was smaller than the mean among the melanomas (1.772 microns [SD = 0.366] and 2.773 microns [SD = 0.565], respectively). Feulgen staining revealed that all lesions were diploid, with the exception of two hyperdiploid and two hypodiploid melanomas. Of the patients with follow-up information available, none with nevi developed a metastasis and two with melanoma died of metastatic disease. CONCLUSIONS: The histologic classification of iris melanocytic lesions (i.e., nevus versus melanoma) correlates to nucleolar size (P < 0.001) but not to nuclear DNA ploidy.

Rating intervals: an experiment in peer review.

The National Institute of Health (NIH) peer review process for research grant applications is one of the largest and most respected systems of its kind in the world. Recently, however, the distribution of raw priority scores voted by NIH study sections has been skewed, and the rating behavior of individual review groups has been quite variable. These phenomena have made funding decisions more difficult. To achieve greater uniformity of rating behavior and a broader description of scores, an experiment was conducted involving 24 study sections. Standard adjectival descriptors and standard rating scales were used. On a random basis, half of the study sections were instructed to vote in units of 0.1 while the other half used an interval of 0.5. The results of this study have now been translated into standard practice at NIH.

The cervical cap: effectiveness, safety, and acceptability as a barrier contraceptive.

PIP: The experiences of 217 volunteers fitted with the cervical cap were analyzed to asses the cap's effectiveness. The cervical cap's a contraceptive barrier device used widely in Europe and currently under consideration by the Food and Drug Administration for release in the US. In 24 months of use, 43 pregnancies were reported among 39 women (4 became pregnant twice with the cap). The Pearl Index was 22.7 pregnancies/100 woman-years of use. Neither the characteristics of participants nor the characteristics of cap use affected the pregnancy rate significantly. However, the pregnancy rate was higher in participants reporting an average frequency of intercourse of 20 or more times/month and in those who observed cap displacement sometime during intercourse. Medical problems associated with cap use were minimal. Increased vaginal odor was the side effect reported most frequently. The majority of participants deemed the cap a positive contraceptive; 83% stated they would recommend it to friends.^ieng

The distribution of skeletal metastases in breast and pulmonary cancer: concise communication.

In a review of all radionuclide bone scans performed in a 3-mo period, 318 patients with established tumor diagnosis were studied. In this tumor population the incidence of skeletal metastases was statistically similar (p = 0.7), and regional distribution of lesion involvement was, in decreasing order, thorax, spine, pelvis, limbs, and skull. In the two largest tumor groups (breast and lung) the regional distribution of metastases was not different when examined for both the presence and the number of lesions (p greater than 0.1). In particular, the incidence of rib metastases was similar( p greater than 0.99) as was their frequency distribution (0.78). Indeed, the frequency distribution of rib metastases was similar for all major tumor categories (p = 0.83).

Right renal pelvis visualization in females: incidental detection in routine bone scanning.

A 22% incidence of renal pelvis or calyceal "hot spot" anomalies was found incidental to routine bone scanning. The majority of these anomalies were due to bilateral or right renal pelvis visualization, and statistical analysis determined there to be a significant female incidence, and persistence in repeat studies. This suggests an anatomical or functional basis for this finding.

The management of glaucoma in nanophthalmos.

Patients with nanophthalmos are prone to develop a chronic painless type of glaucoma in middle age, probably due to the natural increase in the size of the lens which is already relatively too large for the small eye. Although the underlying mechanism is obscure, a slowly progressive "creeping" chronic angle-closure is postulated, but gonioscopic evaluation is difficult due to the shallow anterior chamber, with grade I and slit angles. Response to medical treatment is poor and miotics may even make the condition worse by producing relative pupillary block and by relaxing the lens zonule. Ordinary glaucoma surgery is to be avoided in nanophthalmos because of the fear of postoperative ciliary-block malignant glaucoma. Periopheral iridectomy performed in five eyes at an advanced stage of the chronic angle-closure did not facilitate glaucoma control in three eyes, and in two eyes in which the operation was combined with posterior sclerotomy, the eyes became blind from vitreous hemorrhage. Lenx extraction in five eyes controlled the glaucoma but was followed by choroidal effusion and nonrhegmatogenous retinal detachements in two eyes and blindness in another eye when combined with a posterior sclerotomy. No firm therapeutic recommendations can be made on the basis of the author's experience in the six reported cases. Conventional medical therapy seems ineffectual even when begun early in the glaucoma. Conventional glaucoma surgery must be performed early, before permanent damage to the outflow mechanism occurs but removal of the lens must be anticipated. The surgeon must also remain aware of the high incidence of serious posterior-segment complications which inexplicably follow glaucoma or lens surgery in nanophthalmos, as described by Brockhurst.

Nutrient-dependent inhibition of perithecial development due to sequential crosses on the same mycelium of Neurospora tetrasperma.

An explanation of perithecial inhibition in the second of two sequential crosses at different locations on the same mycelium of Neurospora tetrasperma was sought by (1) assaying media that had supported inhibited and uninhibited portions of the mycelium which contained no developing perithecia, (2) determining the effect of these media on perithecial development, (3) adding nutrients to inhibited portions of the mycelium, and (4) assaying carbon sources in media that had supported portions of the mycelium which contained developing perithecia, and portions, both inhibited and uninhibited, which contained no developing perithecia. Different kinds and volumes of media and various intervals of time between sequential crosses were used to aid in determining limits of perithecial inhibition. Perithecial inhibition was observed to be independent of volatile metabolites and pH, independent of non-volatile metabolites, reversible by addition of nutrients, dependent upon nutrient volume, and correlated with the concentration of the carbon source in the medium. It is proposed that second crosses are inhibited because of a previous lowering of the concentration of nutrients in the medium in second-cross locations, owing to prior demand upon those nutrients by the developing perithecia in first-cross locations. The possibility of an activation signal between first- and second-cross locations is discussed. No inhibitory substance in inhibited locations was detected.