Direct and indirect causes of sex differences in mercury concentrations and parasitic infections in a marine bird.

In many animal species, males and females differ in their levels of contaminants and/or parasitic infections. Most contaminants and gastro-intestinal parasites are obtained through prey ingestion, and thus the causes of sex differences in the distribution of these factors might follow similar pathways. We studied the northern common eider duck (Somateria molissima borealis) as an avian model, and used directed separation path analysis to explore the causes of sex differences in mercury (Hg) and gastro-intestinal helminths. Two trophically transmitted helminths were examined: a cestode (Lateriporus sp.) and an acanthocephalan (Polymorphus sp). We found that the number of Lateriporus sp. varied positively with stable isotope signature (as indicated by δ(15)N in eider breast muscle tissue), and negatively with crustaceans being present in the short term diet. We also found that Polymorphus sp. varied positively with eider tissue stable isotope signature. However, Polymorphus sp. varied negatively with sex indirectly through condition and liver mass. Similarly, Hg concentrations also varied negatively with sex indirectly through condition and liver mass, with both Polymorphus sp. intensity and Hg concentrations significantly higher in males. We found that model fit increased when a negative relationship between the two helminth species was included, suggesting a yet unknown causal mechanism linking these parasites. Our findings suggest that although Hg and gastro-intestinal parasites are both trophically transmitted through the eider's prey items, the factors that contribute towards bioaccumulation of these two burdens differ in source, likely caused by several different factors and may potentially influence each other.

Measurement of Whole-Body CO2 Production in Birds Using Real-Time Laser-Derived Measurements of Hydrogen (δ(2)H) and Oxygen (δ(18)O) Isotope Concentrations in Water Vapor from Breath.

The doubly labeled water (DLW) method is commonly used to measure energy expenditure in free-living wildlife and humans. However, DLW studies involving animals typically require three blood samples, which can affect behavior and well-being. Moreover, measurement of H (δ(2)H) and O (δ(18)O) isotope concentrations in H2O derived from blood using conventional isotope ratio mass spectrometry is technically demanding, time-consuming, and often expensive. A novel technique that would avoid these constraints is the real-time measurement of δ(2)H and δ(18)O in the H2O vapor of exhaled breath using cavity ring-down (CRD) spectrometry, provided that δ(2)H and δ(18)O from body H2O and breath were well correlated. Here, we conducted a validation study with CRD spectrometry involving five zebra finches (Taeniopygia guttata), five brown-headed cowbirds (Molothrus ater), and five European starlings (Sturnus vulgaris), where we compared δ(2)H, δ(18)O, and rCO2 (rate of CO2 production) estimates from breath with those from blood. Isotope concentrations from blood were validated by comparing dilution-space estimates with measurements of total body water (TBW) obtained from quantitative magnetic resonance. Isotope dilution-space estimates from δ(2)H and δ(18)O values in the blood were similar to and strongly correlated with TBW measurements (R(2) = 0.99). The (2)H and (18)O (ppm) in breath and blood were also highly correlated (R(2) = 0.99 and 0.98, respectively); however, isotope concentrations in breath were always less enriched than those in blood and slightly higher than expected, given assumed fractionation values between blood and breath. Overall, rCO2 measurements from breath were strongly correlated with those from the blood (R(2) = 0.90). We suggest that this technique will find wide application in studies of animal and human energetics in the field and laboratory. We also provide suggestions for ways this technique could be further improved.

Vesicouterine fistula in pregnancy: a case report.

BACKGROUND: Vesicouterine fistula is a rare complication of Caesarean delivery. This is the third known report of vesicouterine fistula diagnosed during pregnancy. CASE: Linda (pseudonym), a 28-year-old woman in her second pregnancy, having had a Caesarean delivery in her first pregnancy, was admitted to the delivery unit with possible preterm ruptured membranes at 23 weeks' gestation. She also complained of a fluid-filled sac bulging from her introitus during her admission assessment. Diagnosis of premature rupture of membranes was confirmed by a positive nitrazine paper test and appearance of ferning during microscopic evaluation of vaginal fluid. Cystoscopy, performed 3 days after admission, demonstrated ballooning of amnion into the bladder. At 24 weeks' gestation, the woman had a precipitous vaginal breech delivery. Two months later, the fistula was successfully repaired through a transabdominal route. CONCLUSION: Although uncommon in pregnancy, vesicouterine fistula should be considered in women who present with urinary incontinence or recurrent urinary tract infections after a lower transverse Caesarean section. Evaluation in pregnancy is usually limited to cystoscopy. Treatment is usually surgical and is often delayed until 2 to 3 months following delivery.

Early events in ovarian epithelial carcinogenesis: progress and problems in experimental approaches.

The etiology and early events in the progression of epithelial ovarian carcinomas are among the least understood of all major human malignancies. There are no adequate means for early detection of these neoplasms and, as a result, they are usually diagnosed in late stages. The purpose of this review is to point out some of the peculiar problems and limitations that have hampered progress in ovarian carcinogenesis research and to summarize new approaches and recent advances in our understanding of this process. The review first presents an overview of the properties of the ovarian surface epithelium (OSE) which is thought to be the source of epithelial ovarian carcinomas, followed by a discussion of recent research based on human OSE. This includes sections on methodology for the attainment and study of OSE, investigations of OSE from women with predisposing mutations, and attempts to convert normal OSE to malignancy. This overview is followed by a discussion of the contributions, potential, and limitations of animal models. The knowledge gained by these approaches will likely lead to improvements in our ability to prevent, diagnose, and treat ovarian cancer.

Small-dose selective spinal anesthesia for short-duration outpatient laparoscopy: recovery characteristics compared with desflurane anesthesia.

UNLABELLED: We conducted a randomized controlled trial to compare the recovery characteristics of selective spinal anesthesia (SSA) and desflurane anesthesia (DES) in outpatient gynecological laparoscopy. Twenty ASA physical status I patients undergoing gynecological laparoscopy were randomized to receive either SSA with lidocaine 10 mg + sufentanil 10 microg or general anesthesia with DES and N(2)O. Intraoperative conditions, recovery times, postanesthesia recovery scores, and postoperative outcomes were recorded. Intraoperative conditions were comparable in both groups. All patients in the SSA group were awake and oriented at the end of surgery, whereas patients in the DES group required 7 +/- 2 min for extubation and orientation. SSA patients had a significantly shorter time to straight leg raising (3 +/- 1 min versus 9 +/- 4 min; P < 0.0001) and to ambulation (3 +/- 0.9 min versus 59 +/- 16 min; P < 0.0001) compared with the DES group. SSA patients had significantly less postoperative pain than DES patients (P < 0.05). We concluded that SSA was an effective alternative to DES for outpatient gynecological laparoscopy. IMPLICATIONS: This study compared the use of a desflurane general anesthetic to a small-dose spinal anesthetic in ambulatory gynecological laparoscopy. Using the spinal technique, patients can walk from the operating room table to a stretcher on completion of surgery. Their recovery time was similar to that of the desflurane group.

Small-dose selective spinal anaesthesia for short-duration outpatient gynaecological laparoscopy: recovery characteristics compared with propofol anaesthesia.

A randomized controlled trial compared recovery characteristics after selective spinal anaesthesia (SSA) or propofol general anaesthesia (GA) for short-duration outpatient laparoscopic surgery. Forty women were randomized to receive either SSA (1% lidocaine 10 mg, sufentanil 10 microg and sterile water 1.8 ml) or GA (propofol and nitrous oxide 50% in oxygen). Compared with the GA group, times to leaving the operating room, performing a straight leg raise, performing deep knee-bends and achieving an Aldrete score >9 and the time in Phase II recovery were significantly shorter (P < 0.05) in the SSA group.

Selective spinal anesthesia for outpatient laparoscopy. I: characteristics of three hypobaric solutions.

PURPOSE: To determine the characteristics and recovery profiles of three hypobaric spinal anesthetic solutions. METHODS: Thirty outpatients undergoing outpatient laparoscopy were randomly assigned to receive spinal anesthesia with one of three small-dose solutions. Group I--20 mg lidocaine plus 25 microg fentanyl; Group II--20 mg lidocaine plus 10 microg sufentanil; Group III--10 mg lidocaine plus 10 microg sufentanil. Solutions were diluted to three ml with sterile water for injection. A 27-gauge Whitacre needle was inserted at L2-3 or L3-4 in the sitting position. Sensory and motor recovery were assessed with pinprick, proprioception, light touch and a modified Bromage scale. RESULTS: Operating conditions were good to excellent in all three groups. The incidence of shoulder tip discomfort, pruritus and nausea was not significantly different between groups. Light touch was present in all three groups and proprioception was present in most patients during and after surgery. Group III patients had a more rapid recovery of pinprick analgesia and Group II patients had the slowest recovery of pinprick analgesia. Motor block recovery was comparable in the three groups. Eighty percent of patients in Groups III and I were able to perform 'deep knee bends' and 'straight leg raises' at the end of surgery. CONCLUSION: For short duration laparoscopy, spinal 10 mg lidocaine with 1O microg sufentanil provided selective pin prick analgesia, with preserved touch, proprioception and limited motor block. Operating conditions were satisfactory and most patients were able to fulfill 'walk out' criteria at the end of surgery.

Selective spinal anesthesia for outpatient laparoscopy. II: epinephrine and spinal cord function.

PURPOSE: To compare two small-dose solutions (with and without epinephrine) for spinal anesthesia during outpatient laparoscopy and to determine spinal cord function with these low-dose solutions. METHOD: Twenty outpatients undergoing gynecological laparoscopy were randomly assigned to receive spinal anesthesia with one of two low dose solutions. Group LS-10 mg lidocaine plus 10 microg sufentanil; Group LSE-10 mg lidocaine plus 10 microg sufentanil plus epinephrine 50 microg. Solutions were diluted to three millilitres with sterile water for injection. A 27-gauge Whitacre needle was inserted at L2-3 or L3-4 in the sitting position. Operating conditions and spinal cord function (spinothalamic, dorsal column and motor) were assessed. RESULTS: Operating conditions were good-excellent in both groups. The incidence of shoulder tip discomfort, pruritus and nausea, and the amount of supplementation with alfentanil and midazolam was not different between groups. Most patients in both groups had preserved dorsal column function and normal motor power on arrival in PACU and were able to satisfy 'walk out' criteria. Recovery of pinprick sensation and discharge times were not different. Mild pruritus (VAS score < or = 5) was present in both groups. CONCLUSION: For short duration laparoscopy, addition of 50 microg epinephrine to a small dose of spinal 10 mg lidocaine with 10 microg sufentanil did not provide additional benefit in terms of intraoperative analgesia or operating conditions. Spinal cord function was preserved with small-dose techniques.

Selective spinal anesthesia for outpatient laparoscopy. IV: population pharmacodynamic modelling.

PURPOSE: To apply a population pharmacodynamic model to small-dose hypobaric spinal anesthesia for outpatient laparoscopy. METHODS: The level of spinal analgesia after spinal blockade with small-dose (20-25 mg) hypobaric lidocaine was assessed by means of pinprick in patients undergoing outpatient laparoscopy. In 57 patients, 385 measurements were available for analysis. We first modelled the data for each patient with a mixed-effects model described by Schnider (Model 1). The population mean parameters, inter-individual variance, and residual variance were estimated. Clinically important endpoints (time to reach T10 (onset), time to maximal level, duration and maximally attained level) of each patient were calculated based on the estimated time course of analgesia level for each patient. The model was used to predict the later data with respect to level of spinal analgesia of each patient from fits based on the observed data in the first 75 min. RESULTS: The mean +/- SD onset time was 8.3 +/- 1.9 min, time to maximal level was 20.8 +/- 5.3 min, duration of effect was 37.9 +/- 13.1 min, and mean maximal level was T5. There was a good correlation (R2 = 0.90) between the observed levels of analgesia and those predicted from the model. Data from the first 75 min predicted the later observed data for each patient moderately well (R2 = 0.38). CONCLUSION: A population pharmacodynamic model was applied to low-dose hypobaric lidocaine spinal anesthesia. Clinically important endpoints were determined and forecasting of later data with respect to level of spinal analgesia was attempted. Such an approach may be useful in the management of low-dose spinal anesthetic techniques in outpatients.

Selective spinal anesthesia for outpatient laparoscopy. III: sufentanil vs lidocaine-sufentanil.

PURPOSE: The efficacy of low dose intrathecal lidocaine-sufentanil was compared with intrathecal sufentanil for short duration outpatient gynecological laparoscopy. METHODS: Thirteen ASA I and II patients undergoing gynecological laparoscopy were studied in a randomized double-blind trial. Patients received either intrathecal 10 mg lidocaine plus 10 microg sufentanil (Group LS) or intrathecal 20 microg sufentanil (Group S), each diluted to 3 mL with sterile water through a 27g Whitacre needle in the sitting position. Sensory and motor recovery were assessed with pinprick and a modified Bromage scale. RESULTS: One of seven Group LS patients and two of five Group S patients required conversion to general anesthesia for failed skin test with forceps. Two of the remaining three Group S patients felt sharpness with skin incision. The study was terminated early because of inadequate anesthesia in Group S. The small sample size (n = 9) made statistical analysis uninformative. CONCLUSION: Intrathecal 20 microg sufentanil is unsuitable as a sole agent for gynecological laparoscopy.

Selective spinal anesthesia for outpatient laparoscopy. V: pharmacoeconomic comparison vs general anesthesia.

PURPOSE: To compare the cost and effectiveness of small-dose spinal anesthesia (SP) with general anesthesia (GA) for outpatient laparoscopy. METHODS: A retrospective record analysis of 24 patients who received SP were compared with 28 patients who received GA in our Daycare centre. The costs of anesthesia and recovery were calculated, from an institutional perspective, using 1997 Canadian Dollar values. Effectiveness was measured in terms of time for anesthesia and recovery, and postoperative antiemetic and analgesic requirements. RESULTS: Both groups were well matched for age, weight, duration and type of surgery. The mean total cost for the SP group of $53.45 +/- 10.40 was no different from that for the GA group of $48.92 +/- 10.25 (95% CI -10.3, 1.2). Time to administer anesthesia was longer in the SP group with a mean time of 18 +/- 8 min compared with 10 +/- 3 min in the GA group (CI -11.3, -4.7). Recovery time in the PACU was longer in the SP group 123 +/- 51 min compared with 94 +/- 48 min (CI -56.6,-1.4). Postoperative antiemetic requirements were similar: 8% in SP group vs 14% in GA group, whereas analgesic requirements were less in the SP group with 25% receiving analgesia compared with 75% in the GA group (P < 0.05). CONCLUSION: The total cost of anesthesia and recovery using SP is similar to that for GA when used for outpatient laparoscopy. Spinal anesthesia was less effective than GA in time to administer anesthesia and in duration of recovery. Postoperative analgesic requirements were reduced using SP.

Induction of labour: a continuous quality improvement and peer review program to improve the quality of care.

This article describes a program developed to improve the process of planned induction of labour and to reduce the rates of inappropriate induction. The setting is a tertiary-care maternity hospital in urban Vancouver, BC, in which 7000 deliveries take place annually. Approximately 65% of these can be considered primary care; the remainder are secondary- or tertiary-level cases. Continuous quality improvement (CQI) methods were used by a multidisciplinary team, which included nursing staff, physicians, health records personnel and a CQI facilitator. Interventions included the development of a new induction-booking process, clear criteria for induction, feedback to caregivers about changes and a peer review system to oversee and maintain improvement. The overall induction rate for the institution decreased, and this change has been maintained.

alphavbeta3 and vitronectin expression by normal ovarian surface epithelial cells: role in cell adhesion and cell proliferation.

The alphavbeta3 integrin and its ligand vitronectin are expressed by differentiated epithelial ovarian carcinomas and carcinoma cell lines in culture. Moreover, alphavbeta3/vitronectin interaction influences adhesion and migration of ovarian carcinoma cells in culture. For a better understanding of the behavior of these carcinomas, it appeared necessary to study the characteristics of their normal counterpart, the ovarian surface epithelium (OSE). The present study showed that normal cultured human OSE cells, like the carcinoma cells, have the ability to synthesize vitronectin. The vitronectin receptor, alphavbeta3 integrin, is also expressed by OSE cells and is localized in focal contacts close to paxillin, a focal contact-specific protein, and p125(FAK), a cytoskeletal and signaling molecule. This localization suggested an active participation of the integrin in the adhesion and/or proliferation of OSE cells. Indeed, the use of a blocking antibody demonstrated that alphav integrins promote OSE cell adhesion on vitronectin but not on fibronectin and that these integrins are required for maximal proliferative activity. The results suggest a role of the alphavbeta3/vitronectin system in normal OSE physiology and demonstrate that the expression of this system by well-differentiated ovarian carcinomas reflects the retention of normal cell properties.

Urinary myelin basic protein-like material in patients with multiple sclerosis during interferon beta-1b treatment.

OBJECTIVES: To determine levels of urinary myelin basic protein-like material (MBPLM) in patients with multiple sclerosis (MS) openly treated with interferon beta-1b and to correlate these with clinical changes. BACKGROUND: Levels of urinary MBPLM correlate with the presence of the progressive phase of MS and with the disease burden detected on T2-weighted, cranial magnetic resonance imaging. Measurement of urinary MBPLM level may be a feasible test for monitoring or predicting response to therapeutic measures. DESIGN AND METHODS: In a prospective study at one site, 166 patients with MS (131 with relapsing-remitting [RR] and 35 with secondary progressive [SP] disease) were treated for a minimum of 1 year and up to 3 years with interferon beta-1b and underwent assessment for neurologic disability (Expanded Disability Status Scale and Scripps Neurological Rating Scale) and change in disease subtype. Urine samples were obtained at 1219 of 1378 clinic visits, and urinary MBPLM level was determined and related to creatinine level to adjust for renal function. RESULTS: Statistical analysis using the general linear models procedure confirmed previous findings that the level of urinary MBPLM related to urinary creatinine level (MBPLM/creatinine) was higher (P<.001) in patients with SP than RR MS. Of the 131 patients with RR MS, SP disease developed in 13 during the observation period. Compared with those in the RR group, the RR to SP group had a higher level (P<.001) of urinary MBPLM and did not differ from the SP group. CONCLUSIONS: The level of urinary MBPLM is higher in SP MS than RR MS but not in RR MS that converts to SP MS. Level of urinary MBPLM may permit the examination of treatment tested to prevent RR disease from becoming progressive.

A cross-reactive anti-myelin basic protein idiotope in cerebrospinal fluid cells in multiple sclerosis.

We wanted to find evidence of antibody to myelin basic protein (MBP) in patients with MS by detecting their shared usage of immunoglobulin genes. As demonstrated by the idiotopes (i.d.) of murine monoclonal antibody to peptides of MBP, there is limited use of the variable (V) region immunoglobulin genes for the immune response in mice to this encephalitogenic protein. Cross-reactive Ids have been detected across different murine strains and shared by T and B cells. One cross-reactive Id, designated as 845D3 Id, is located on the V region of kappa light chains of two murine monoclonal antibodies, one to MBP peptide 80-89 and the other to MBP peptide acetyl 1-9. To examine the occurrence of 845D3 Id in MS, we used the V region of a light chain (VL) of one of the monoclonal antibodies to probe the VL genes expressed in B cells in CSF of 50 patients (31 MS and 19 non-MS). The VL genes expressed in B cells found in CSF were amplified by polymerase chain reaction using universal human V-region primers. The 845D3 Id probe detected the Id+ V region in the CSF of 14 of 31 MS patients, 1 of 9 patients with other neurologic diseases, and 1 of 10 non-neurologic patients. The gene product was more common in but not restricted to CSF with oligoclonal bands. The presence in CSF of MS patients of a cross-reactive Id to different MBP peptides is indicative of an immune response to this encephalitogenic myelin protein in a segment of MS patients. These findings are also evidence for limited usage of V-region Ig genes in the immune response of humans to MBP and the possible importance of an Id network for MBP in demyelinating disease.

Thalamic thought disorder: on being "a bit addled".

Humans can generate and maintain relatively coherent trains of thought in natural discourse. The neural mediation of this ability and the phenomenology of its breakdown are not well understood. We report a case of a woman with paramedian thalamic strokes involving the mammillothalamic tract, intralaminar nuclei, parts of the dorsomedial and ventral lateral nuclei bilaterally. She presented with a dense amnesia and confusion typical of the syndrome of bilateral paramedian thalamic infarcts. Her Tc-99m HMPAO brain SPECT scan showed decreased thalamic and basal ganglia blood flow. General diminution of cerebral blood flow and areas of further diminution in the right frontal, left temporal and left temporoparietal regions were also observed. Although her amnesia was characteristic of diencephalic amnesia, her most striking clinical feature was a bizarre, disconnected and at times incoherent speech output. Analysis of her speech revealed relatively preserved lexical and morpho-syntactic linguistic production. By contrast, analysis of the macrostructure of her discourse revealed frequent unpredictable topic shifts that were completely unconstrained by contextual factors. Many of her shifts were intrusions from previous topics. We interpret her severely disordered speech output as representing the surface manifestations of a thought disorder (rather than as a language disorder per se) characterized by an inability to maintain and appropriately shift themes that normally guide discourse. Median and intralaminar thalamic nuclei appear to be critical for the neurophysiologic regulation of thalamocortical and striatocortical circuits, which in turn may be critical for the functional regulation of contextually appropriate transitions of thought.