Have the boundaries of the 'grey zone' of perinatal resuscitation changed for extremely preterm infants over 20 years?

AIM: To determine the boundaries of the grey zone of discretionary resuscitation over the past 20 years. BACKGROUND: As the likelihood of survival improves over time, the BW- and GA-specific boundaries of discretionary nonresuscitation should fall. HYPOTHESIS: Between 1988 and 2008 reductions in BW- and GA-specific mortality would drive a parallel reduction in BW and GA boundaries of discretionary resuscitation. METHODS: We determined the likelihood of resuscitation and survival to NICU discharge for all infants born <700 g or <26 gestational weeks from 1988 to 2008. In addition, for 1988, 1993, 1998, 2003 and 2008, we determined the BW and GA for the 10 smallest infants who were resuscitated, and the 10 largest infants who were not resuscitated. We excluded any infant born with congenital anomaly. RESULTS: Mortality fell from 80% in 1988 to 28% in 2008, and as expected, the percentage who were resuscitated rose from 63% in 1988-93 to 95% in 2004-2008. However, unexpectedly, over the 20-year study period, the smallest infants who were resuscitated despite extreme immaturity did not change (450-550 g and 23-24 weeks) and the largest infants not resuscitated did not change (600-700 g and 23-24 weeks. CONCLUSION: Neither the BW nor GA boundaries of the grey zone of discretionary resuscitation have fallen over the past 20 years. Factors guiding resuscitation at the border of viability are complex and incompletely understood.

Suprapubic prostatectomy for benign prostatic hyperplasia in rural Asia: 200 consecutive cases.

OBJECTIVES: To assess the safety and efficacy of a suprapubic prostatectomy technique performed in a rural hospital in Asia. METHODS: A retrospective study of 200 consecutive suprapubic transvesical prostatectomies with a removable bladder neck partition suture for benign prostatic hyperplasia from 1995 to 1998 in a rural mission hospital in northern Pakistan was performed. RESULTS: Despite preoperative comorbidities in 28% of patients, the postoperative morbidity (14%) and mortality (1%) was low. The partition suture is credited with a very low transfusion rate (1%) and a lower intensity of nursing care in the postoperative period. Patient satisfaction was high with regard to both relief of symptoms and cost. CONCLUSIONS: This study demonstrated that suprapubic prostatectomy with a routine bladder neck partition suture for benign prostatic hyperplasia can be carried out with a high degree of safety and efficacy in a rural setting with limited facilities in a developing country.

Isolation, expression and phylogenetic inheritance of an acetolactate synthase gene from Brassica napus.

An acetolactate synthase gene was isolated and characterized from Brassica napus. This B. napus acetolactate synthase gene encodes a deduced polypeptide sequence of 637 amino acids which is 85% homologous to the corresponding proposed gene product from Arabidopsis thaliana. Peptide domains recently associated with herbicide resistance/sensitivity are conserved between the two sequences. From Southern analysis we conclude that the gene isolated is one member of a multigene acetolactate synthase gene family comprising four or five members. A probe spanning the presumptive transit peptide sequence of this gene was shown by Southern analysis to hybridize to a unique sequence in the B. napus genome. This unique probe was used to analyse DNA from B. campestris and B. oleracea, the presumed progenitors of B. napus. On the basis of restriction fragment length polymorphism, we conclude that the B. napus gene isolated here originated in B. campestris. Total acetolactate synthase-homologous transcripts were analysed in a variety of B. napus tissues, and showed preferential accumulation in rapidly growing material. The genomic clone was mutated in vitro at codon 173 to replace a proline residue with serine. This was re-introduced into plants, using Agrobacterium vectors, producing a herbicide-resistant phenotype which is characteristic of the predicted gene product.

Allelic interactions at the engrailed locus of Drosophila: engrailed protein expression in imaginal discs.

Many embryonic lethal engrailed (enlethal) mutations are known to partially complement the cuticular defects of the original engrailed mutation, en1. To explore the nature of this complementation, the adult phenotypes of several different en1/enlethal transheterozygotes were compared with the corresponding patterns of engrailed protein expression in third larval instar imaginal discs (determined by immunofluorescence). Transheterozygotes of en1 and deletions of the locus (enDf) typically show slight complementation in the adult cuticle. The pattern of engrailed protein expression in some en1/enDf wing discs is indistinguishable from en1 homozygotes, but in others the pattern is nearly normal. en1/enDf leg discs appear to express engrailed protein normally. Transheterozygotes of en1 and EMS-induced, cytologically normal enlethal alleles have almost normal adult cuticle phenotypes and also exhibit normal patterns of engrailed protein expression in all of the thoracic imaginal discs. Surprisingly, the intensity of anti-engrailed staining in these discs is elevated relative to that in wild type. en2 is an unusual lethal allele in that it does not complement either the en1 adult cuticle phenotype or the protein expression pattern in imaginal discs. Moreover, the cytologically normal enlethal alleles also complement en2, at least partially. Both wing and leg imaginal discs from en2/enlethal transheterozygotes show abnormal patterns of engrailed protein expression. These results are discussed in the context of an autoregulatory model for engrailed regulation.

Duplication of the phycocyanin operon in the unicellular cyanobacterium Anacystis nidulans R2.

Two phycocyanin (PC) operons, each containing alpha- and beta-subunit genes, have been isolated from the unicellular cyanobacterium Anacystis nidulans R2. Using oligodeoxyribonucleotide probes for the PC-coding regions, three PstI fragments were obtained and shown to contain the two operons, which are 2.7 kb apart, with a proposed gene order of 5'-(beta I-alpha I)-(beta II-alpha II)-3'. The nucleotide sequences of both alpha-subunit genes are identical, as are the beta-sequences and the 51-bp intergenic regions. However, significant nucleotide sequence differences are found in both the 5' and 3' untranslated regions of the two operons. Two mRNA species of 1.65 and 1.5 kb were detected in A. nidulans R2 RNA when probed with either the alpha-specific or the beta-specific probe. The results demonstrate the existence of two PC operons which are both transcriptionally active.

Nucleotide sequences from the colicin E5, E6 and E9 operons: presence of a degenerate transposon-like structure in the ColE9-J plasmid.

The nucleotide sequences of 1288 bp of plasmid ColE5-099, 1609 bp of ColE6-CT14 and 2099 bp of ColE9-J were determined. These sequences encompass the structural genes for the C-terminal receptor-binding and nuclease domains of colicins E5, E6 and E9, their cis- or trans-acting immunity proteins and four lysis proteins including an atypical one of non-lipoprotein nature (Lys) present in the ColE9-J plasmid. The ColE6 gene organisation, in the order col-imm-E8imm-lys, is identical to that found in the previously described double-immunity gene system of ColE3-CA38 (an RNase producer). The corresponding genes in the two plasmids are 87%-94% homologous. In ColE9-J, the genes are organised as col-imm-lys-E5imm-lys. The E9 col-imm gene pair is homologous to the colicin E2-P9 type (a DNase producer). Downstream from E9imm is an E5imm (designated E5imm[E9]) which is trans-acting. Neither the predicted structures of E5Imm[E9] nor the cis-acting Imm resident in the ColE5-099 plasmid which differs by a single amino acid shows any resemblance to other immunity structures which have been sequenced. Furthermore, the E5col sequences differ from those predicted previously for other colicins except for the conserved btuB-specified receptor-binding domain. A novel 205 nucleotide long insertion sequence is found in the ColE9-J plasmid. This insertion sequence, which we named ISE9, has features reminiscent of the degenerate transposon IS101 previously found in plasmid pSC101. One effect of ISE9 is the presence of the atypical lysis gene, lys.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgical treatment for ductal adenocarcinoma of the pancreas.

A ten year community hospital experience of 124 patients with ductal adenocarcinoma of the pancreas proved at biopsy is reported. All patients underwent a celiotomy, and 94 per cent were observed until death. All of the patients were stratified by stage (I, 9 per cent; II, 30 per cent; III, 18 per cent, and IV, 43 per cent). Nine of the patients with Stage I disease underwent resection with a high postoperative mortality rate of 44 per cent and only one five year survivor. Fifty-nine patients with Stages II and III disease underwent biliary bypass with a low postoperative mortality rate of 2 per cent. Bypass of the common bile duct (N = 24) provided more permanent palliation against recurrent jaundice or cholangitis (p less than 0.05), but did not improve the survival time when compared with bypass of the gallbladder (N = 20). This was not true for those with Stage IV disease in whom recurrent jaundice did not develop in those with either bypass of the gallbladder or common duct. Adding prophylactic gastroenterostomy (GE) to biliary bypass (N = 25) conferred no survival benefit, but did protect against subsequent duodenal obstruction (p less than 0.05). Thirty-seven per cent of the 38 patients in whom a GE was not performed had duodenal obstruction develop. Adjuvant radiation and chemotherapy in 22 patients with unresectable Stages II and III disease resulted in a significant prolongation of survival time compared with 15 untreated patients in the control group (p less than 0.05). Fifty-one patients with Stage IV disease underwent biliary bypass or biopsy of the tumor resulting in a 14 per cent postoperative mortality rate and a median survival time of four months. Nine per cent of the 44 survivors with Stage IV disease lived at least one year. The implications of these findings to clinical practice are discussed.

Charcoal bezoar. Small-bowel obstruction secondary to amitriptyline overdose therapy.

Nasogastric administration of activated charcoal is effective in decreasing the half-life of amitriptyline. A case is reported in which this therapy for amitriptyline overdose led to charcoal bezoar formation and small-bowel obstruction. Amitriptyline's atropinic side effects on the gut make this a possible complication in such patients.

Surgical treatment for inflammatory bowel disease in the older patient.

Twenty-six patients who were 60 years of age or older underwent a surgical procedure for inflammatory bowel disease (IBD). Twenty patients had involvement of the colon (14 had ulcerative colitis and six, Crohn's disease). The indications for operation were intractable colitis (eight patients), perforation (three patients), stricture (three patients), toxic megacolon (three patients), anorectal disease (two patients) and carcinoma (one patient). Operations performed were abdominal colectomy (ten patients), segmental colectomy (seven patients), local anorectal procedures (two patients) and total coloprotectomy (one patient). Five patients had a preoperative diagnosis of diverticulitis and two of carcinoma. Among 17 patients who were observed, nine had symptomatic recurrences. In six patients with Crohn's disease of the small intestine, operation was performed for intractability in two patients, perforation in two patients and obstruction, two patients. All underwent resection and primary anastomosis. Four of five patients had recurrences. IBD in the older patient may be confused with other diseases. Recurrence is frequent with limited colonic resection.

Segmentally repeated pattern of expression of a cell surface glycoprotein in Drosophila embryos.

We report here that a previously described cell surface antigen (Brower, Smith & Wilcox, 1980) is expressed in a segmentally repeating pattern of stripes in the epidermis and nervous system of segmented Drosophila embryos. We also report that the antigenic activity is found on two closely related cell surface glycoproteins. The pattern of expression of this antigen is reminiscent of the expression of some segmentation genes and is affected by mutation of at least two of these genes, fushi tarazu and paired. Thus these glycoproteins are candidates for cell surface molecules involved in carrying out the patterning processes controlled by segmentation genes.

Drosophila histone H2A.2 is associated with the interbands of polytene chromosomes.

Drosophila chromatin contains two antigenically distinct H2A histones, H2A.1 and H2A.2. Indirect immunofluorescence analyses revealed that anti-H2A.1 binding was distributed throughout polytene chromosomes, whereas anti-H2A.2 binding was interband-specific. Thus, H2A.2 probably contributes to the less compacted structure of interbands. Since each band-interband region is thought to contain a single gene, our results suggest that the distribution of H2A.2 echoes the functional organization of the Drosophila genome. Similar H2A histones occur in eukaryotes ranging from protozoa to mammals. Their placement might be an important determinant of chromatin structure.

Induction of prostaglandin synthesis-dependent suppressor cells with endotoxin: occurrence in patients with thermal injuries.

The induction of lymphocyte suppressor activity with bacterial endotoxin is well documented. While most of the evidence has been obtained using animal models and has required large doses of endotoxin, we have demonstrated that additions of as little as 1.0 ng of chromatographically purified endotoxin [from Escherichia coli 055:B5, E. coli 0111:B4, Pseudomonas aeruginosa (Fisher-Devlin immunotype 1), Serratia marcescens, or Salmonella minnesota] to human mixed lymphocyte or to mitogen-stimulated cultures produced statistically significant suppression. In each case, endotoxin was most suppressive when present in the culture system prior to the introduction of the alloantigen or mitogen. Suppressive effects were dependent upon the participation of peripheral blood monocytes and could be blocked by the addition of the prostaglandin synthetase inhibitor indomethacin or meclofenamate sodium. Prostaglandin production by monocytes appeared to induce a population of "short-lived" suppressor cells, identified by the immediate and delayed addition of lymphocyte cocultures to endotoxin-preincubated cells. The suppressive behavior of endotoxin-primed lymphocytes was identical to the behavior of burn patient serum-primed lymphocytes or to lymphocyte populations derived from a subpopulation of burn patients whose serum was Limulus positive. We, therefore, feel that endotoxin plays a significant immunologic role in these patients.

Isolation immunosuppressive serum components following thermal injury.

There has been increasing recognition in recent literature that immunoregulatory factors can often be detected in the serum of patients with thermal and traumatic injuries. We, too, have shown that a significant number of patients with severe thermal injuries are profoundly immunosuppressed. This immunosuppression was mediated by substances which circulate in the serum which could be easily detected using in vitro lymphocyte assays. The suppressive material was not present in normal serum, and exerted its effects through the activity of a specific (suppressor) subpopulation of lymphocytes. In this study, we have analyzed serum samples obtained from burn patients by plasmapheresis for suppressive activity, then fractionated each using Sephadex G-200. Individual fractions were tested for suppressive activity in mixed lymphocyte cultures, and approximate molecular weights established for suppressive peaks by means of chromatography calibration standards. Evidence linking suppressive activity of the sera to the presence of endotoxin, prostaglandin E, interferon, and "cutaneous burn toxin' is discussed.