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Background: The addition of droperidol to morphine for patient-controlled analgesia reduces the incidence of nausea and vomiting, but may result in unwanted side effects. Method: We studied 40 women randomised to receive morphine sulphate with or without added droperidol (10mg droperidol/60mg morphine) by patient-controlled analgesia following elective caesarean section under spinal anaesthesia. Results: Median morphine demand in the 20h after surgery was 74mg with morphine alone, and 53mg with added droperidol, the median consumption of which was 8.8mg. The incidence of nausea was reduced from 80% to 38.8% (P

Cerebral oximetry was evaluated as a monitor of oxygenation during carotid endarterectomy in 22 patients. The oximeter was a reliable continuous monitor, identifying changes in cerebral oxygenation during episodes of hypotension and after arterial occlusion. Changes in oxygenation correlated well with the surgical assessment of backbleeding after arterial clamping, but less well with other methods which are used to make a decision on insertion of an arterial shunt. There was no correlation between internal carotid artery stump pressure and change in cerebral oxygenation after application of the arterial cross clamp. However, cerebral oxygenation correlated weakly with the change in middle cerebral artery velocity as measured by transcranial Doppler ultrasonography (r = 0.49, p < 0.02).

Estradiol 17 beta-hydroxysteroid dehydrogenase (17 beta HSD) mediates the interconversion of estrone and estradiol in endocrine-responsive tissues such as the breast. The control of 17 beta HSD expression by all-trans-retinoic acid (RA) in T47D breast cancer cells was examined using a specific 17 beta HSD complementary DNA probe. Two main 17 beta HSD messenger RNA (mRNA) transcripts of 2.2 and 1.3 kilobases (kb) were detected, of which only the 1.3-kb mRNA was regulated. RA increased expression of the 17 beta HSD 1.3-kb mRNA in a dose- and time-dependent manner, and the increased expression of this mRNA by RA was inhibited by a 10-fold excess of a RA antagonist Ro 41-5253. Insulin-like-growth factor-I, interleukin-1, and estradiol, previously shown to increase 17 beta HSD activity in breast cancer cells, had little effect on 17 beta HSD gene expression. To relate the effect of increased 17 beta HSD 1.3-kb mRNA expression to 17 beta HSD activity, the conversion of estrone to estradiol (reductive) and that of estradiol to estrone (oxidative) were measured in intact T47D cell monolayers. Whereas RA increased 17 beta HSD reductive activity, it had no effect on oxidative activity. The addition of excess NAD increased 17 beta HSD oxidative activity in control and RA-treated cells, but the addition of NADH had no effect on 17 beta HSD reductive activity. These results suggest that the increased expression of the 17 beta HSD 1.3-kb mRNA induced by RA is associated with an increase in 17 beta HSD reductive activity, but that endogenous cofactor levels may determine the direction in which this enzyme acts in T47D cells.

Prenatal diagnosis for glutathione synthase (EC 6.3.2.3) deficiency in two pregnancies of an at-risk couple was performed on amniotic fluid taken at 16 weeks' gestation. 5-Oxoproline (pyroglutamic acid) levels were 970 and 790 mumol/l compared with the normal mean value of 29 mumol/l (range 13-51 mumol/l). The pregnancies were terminated and the diagnosis in one case was subsequently confirmed by assay of glutathione synthase in cultured fetal fibroblasts. In the other, post-mortem tissue samples failed to grow.

In a question-and-discussion format, the authors summarize the major studies on melanoma and pregnancy. The laboratory studies reviewed give conflicting results; however, excellent epidemiologic studies suggest that pregnancy and melanoma are not closely linked. Specifically, the prognosis of pregnant women with melanoma is similar to the prognosis of nonpregnant women with melanoma of equal tumor thickness, and melanoma is neither more nor less likely to occur in previously pregnant women. Some studies have shown that pregnant women have melanomas that are thicker than nonpregnant women's melanomas. The reason is unclear, but it may be because malignant changes in pigmented lesions during pregnancy have been ignored. Treatment options for pregnant women with melanoma are limited, but early detection and surgical excision of thin melanomas is the goal. Changes in mole size or color during pregnancy can be normal, but all changing moles warrant careful examination, and irregular or asymmetric change is suspicious for melanoma.

Sentinel lymph node biopsy following radioisotope labeling is a recently developed, minimally invasive surgical staging procedure used in the management of primary cutaneous malignant melanoma. If histologic analysis reveals melanoma metastasis in the sentinel lymph node, completion lymphadenectomy is performed and adjuvant therapy considered. The routine pathologic assessment of the sentinel lymph node consists of bisecting the lymph node along its long axis and histologic examination of one hematoxylin and eosin-stained section of each cut surface.In this study, the authors reexamined 235 sentinel lymph nodes reported as negative for melanoma metastasis following routine histologic examination, from 94 patients with American Joint Committee on Cancer (AJCC) Stage I and II cutaneous melanoma.Deeper sections into the lymph node and immunohistochemical stains with antibodies to S-100, HMB-45, NK1C3, and MART-1 led to the identification of microscopic metastases in 11 sentinel lymph nodes from 11 patients and capsular nevi in 9 sentinel lymph nodes from 8 patients.Deeper serial sections and immunohistochemical stains detected microscopic metastases in approximately 12% of cases that would be reported as negative for metastasis by routine pathologic analysis. These techniques also allowed for the identification of capsular melanocytic nevi in the sentinel lymph nodes of 9% of patients. [See editorial on pages 551-2, this issue.]

Both the REAL and EORTC classification schemes classify lymphomas according to their cell of origin. These schemata also incorporate clinical features that allow for the distinction of some of these disorders. The EORTC classification scheme for primary cutaneous tumors uses terminology similar to that of the REAL classification and should allow for the recognition of teleologically similar tumors in cutaneous and extracutaneous sites. Future investigations will no doubt yield information regarding the true nature of the low-grade B-cell lymphomas of the skin and sort out the ever-increasing number of tumors found to express CD30. Most important, the continued expansion of knowledge regarding cutaneous lymphomas should enhance the ability of physicians to predict prognosis and to arrive at the most effective therapy for patients with these diseases.

To allow meaningful approaches to vaccine development, it is important to know the extent of exposure to human papillomavirus (HPV) within the general population, and particularly the age at which the at risk population is infected. The humoral response to human papillomavirus is directed largely to conformationally-dependent epitopes on the whole virion. Virus-like particles (VLPs) of HPV types 1, 2, and 16 were produced using a baculovirus expression system, and were used in the intact state as antigen in an indirect ELISA. Anonymised serum samples from a cohort of Edinburgh schoolgirls were tested for the presence of IgG antibodies directed against the VLPs. The reproducibility of the ELISA was assured by repeated testing of control samples, and by testing all samples in duplicate and, where possible, on several occasions. Of 1,192 tested with the HPV16 VLPs, 90 (7.6%) were classified as clearly positive, and a further 87 (7.3%) were positive but close to the cutoff calculated by comparison with a group of consistently negative sera. Antibodies to HPV2 were detected in 37.5% (407/1,139) and antibodies to HPV 1 in 51.9% (558/1,076) of the schoolgirls. Antibodies to both HPV1 and HPV2 were found frequently, being present in 29.7% (295/ 993) of samples tested; 40 samples had antibodies to all three types. The significance of these results is discussed.

This article identifies antecedent characteristics of individuals who found the women's movement important and then shows how finding it important was associated with personality change. Eighty-six women provided personality and life data as college seniors in 1958 or 1960, prior to the onset of the women's movement, and in 1981, after the movement gained momentum. A combination of openness, ambition, and dissatisfaction, as assessed by California Psychological Inventory (CPI; H. Gough, 1957/1966) in college, and subsequent life path from ages 28 to 43 significantly predicted importance attributed to the women's movement (IWM). On CPI scales, IWM was associated with significant increases on scales including Dominance, Self-Acceptance, Empathy, Psychological Mindedness, and Achievement via Independence. Correlates of IWM with self-reported feelings at ages 33 and 43 and observer-based personality ratings at age 43 supplemented analyses of personality change. Findings support the utility of examining the impact of social change on personality.

Background. Previous studies of oculomotor dysfunction in schizophrenia have tended to concentrate on abnormalities of smooth pursuit eye tracking in chronic medicated patients. We report the results of a study of smooth pursuit, reflexive and antisaccade performance in drug naive and antipsychotic treated first-episode schizophrenic patients.Methods. Smooth pursuit and saccadic eye movements were recorded in 36 first-episode schizophrenic patients and 36 controls matched for age and estimated IQ. The schizophrenic patients were divided into drug-naive (N=17) and antipsychotic treated groups (N=19).Results. Smooth pursuit velocity gain was significantly lower than controls only in the drug-naive patients. The treated patients did not differ significantly from either the controls or the untreated group. In an antisaccade paradigm both treated and drug-naive schizophrenic patients demonstrated an increased number of errors, but only drug-naive patients also demonstrated an increased latency in initiating correct antisaccades.Conclusions. These impairments are unlikely to be due to a generalized deficit in oculomotor function in the schizophrenic groups, as there were no differences between the groups in saccadic metrics on a reflexive saccade task. The results show that both smooth pursuit and saccadic abnormalities are present at the onset of schizophrenia and are integral to the disorder.

We have compared intermittent bolus and continuous infusion of extradural local anaesthetic for pain relief in a randomized, double-blind study of 48 patients who underwent major abdominal gynaecological surgery. Each patient received 5 ml of 0.375% bupivacaine hourly, either as a bolus over 5 min or as a constant infusion. Patients who received the intermittent administration technique maintained a more extensive sensory block, reported marginally better analgesia and had a lower requirement for rescue medication. The intermittent bolus technique was not associated with an increase in side effects.

BACKGROUND: We tested the hypothesis that schizophrenia is primarily a frontostriatal disorder by examining executive function in first-episode patients. Previous studies have shown either equal decrements in many cognitive domains or specific deficits in memory. Such studies have grouped test results or have used few executive measures, thus, possibly losing information. We, therefore, measured a range of executive ability with tests known to be sensitive to frontal lobe function. \ud METHODS: Thirty first-episode schizophrenic patients and 30 normal volunteers, matched for age and NART IQ, were tested on computerized test of planning, spatial working memory and attentional set shifting from the Cambridge Automated Neuropsychological Test Battery. Computerized and traditional tests of memory were also administered for comparison. RESULTS: Patients were worse on all tests but the profile was non-uniform. A componential analysis indicated that the patients were characterized by a poor ability to think ahead and organize responses but an intact ability to switch attention and inhibit prepotent responses. Patients also demonstrated poor memory, especially for free recall of a story and associate learning of unrelated word pairs. \ud CONCLUSIONS: In contradistinction to previous studies, schizophrenic patients do have profound executive impairments at the beginning of the illness. However, these concern planning and strategy use rather than attentional set shifting, which is generally unimpaired. Previous findings in more chronic patients, of severe attentional set shifting impairment, suggest that executive cognitive deficits are progressive during the course of schizophrenia. The finding of severe mnemonic impairment at first episode suggests that cognitive deficits are not restricted to one cognitive domain.

The testosterone biosynthesis defect, 17 beta-hydroxysteroid dehydrogenase deficiency, is generally characterized by marked virilization at puberty of children raised as females. We describe an unusual case with a persistent female body habitus presenting with primary amenorrhoea and mild facial hirsutism. Whilst awaiting gonadectomy, serum androgen concentrations were observed to fall spontaneously to within the adult female reference ranges. Location of the gonads was a problem and was finally achieved by magnetic resonance imaging.

PURPOSE To determine the effects of sargramostim (recombinant human granulocyte-macrophage colony-stimulating factor [rhu GM-CSF]) on the incidence, duration, and complications of myelosuppression after moderate-dose fluorouracil, doxorubicin, cyclophosphamide (FAC) adjuvant chemotherapy in patients with node-positive breast cancer. PATIENTS AND METHODS In this randomized, double-blind, placebo-controlled study, 142 women with stage II and III breast cancer were to receive four 21-day cycles of chemotherapy that consisted of fluorouracil 600 mg/ m2 intravenously (IV), doxorubicin 60 mg/m2 IV, and cyclophosphamide 750 mg/m2 IV on day 1, followed by placebo or GM-CSF 250 micrograms/m2/d daily subcutaneously (SC) on days 3 through 15. All patients received prophylactic ciprofloxacin by mouth when the absolute neutrophil count (ANC) was less than 1,000/microL. RESULTS Eighty-six percent of GM-CSF patients (n = 62) and 96% of placebo patients (n = 69) completed four assessable cycles of treatment on study. Overall, the median duration of severe neutropenia (ANC < 500/microL) was 2.8 days with GM-CSF and 6.8 days with placebo (P < .001); the duration of ANC less than 1,000/microL was 6.0 versus 9.1 days, respectively (P < .001). Hospitalizations for febrile neutropenia were uncommon in either group: GM-CSF, six; placebo, eight. The only other difference in hematologic toxicity was grade 3/4 thrombocytopenia observed with greater frequency in GM-CSF patients than placebo patients in cycles 3 and 4. GM-CSF increased mean the FAC dose-intensity among patients who completed two or more cycles (P < .001). GM-CSF was generally well tolerated and associated with more injection-site reactions, but less mucositis than placebo. There were no deaths on study. CONCLUSION GM-CSF significantly enhanced ANC recovery after FAC chemotherapy; it decreased the incidence and duration of associated neutropenia and moderately increased the dose-intensity of adjuvant chemotherapy. Whether these effects will ultimately translate into improved long-term outcome remains to be determined.

Caesarean section is associated with significant cardiovascular disturbances. We present a patient known to have a large pelvic arteriovenous malformation who underwent elective Caesarean section. To assist in the monitoring and management of the anticipated haemodynamic changes a flow directed pulmonary artery catheter with the capacity to allow continuous cardiac output measurement was used.

Forced antipsychotic medication procedures are generally perceived to be clinically necessary options, albelt violations of individuals' bodies and autonomy. Previous studies have explored forcibly medicated patients' attitudes concerning these procedures, but as patients were interviewed while still in the hospital, this may have affected their responses. We interviewed consecutively forcibly medicated English-speaking acute-care inpatients after their discharge to the community. The interviews were conducted by telephone by a clinician not involved with their treatment. Of 65 such patients, 7 had already been rehospitalized, 3 could not recall the procedure, and 25 others refused the interview or were not locatable. Of the 30 who were successfully interviewed, only 47 percent had received any forced injections; the remainder had accepted oral medication under duress. Recollecting their experiences, 57 percent professed fear of side effects, 17 percent feared "addiction," and 17 percent objected to others' controlling them. Forty percent recalled feeling angry, 33 percent helpless, 23 percent fearful, 13 percent embarrassed, but 23 percent were relieved. Surprisingly, 60 percent retrospectively agreed with having been coerced, 53 percent stating they were more likely to take medication voluntarily in the future. Other forcibly medicated patients had poorer outcomes, such as rapid readmission or discharge to a state hospital: those patients may have harbored more negative feelings. However, a substantial fraction of the patients who were reached in the community appeared to support having received medication forcibly as inpatients.

The frequency of small (or = 1 cm) axillary lymph node negative invasive breast cancers (T1a,b N0 M0) is increasing because of wider implementation of breast cancer screening. Identification of prognostic factors for these patients has been based largely on retrospective pathology review. The authors analyzed histologic factors recorded in the original pathology reports to determine predictors of recurrence for patients with T1a,b N0 M0 breast cancer.Two hundred eighteen patients were studied. Potential prognostic factors including measured millimeter tumor size in three dimensions, histologic grade, nuclear grade, and presence or absence of lymphatic vessel invasion were documented prospectively in routine surgical pathology reports of a large community (nonuniversity based) hospital. Follow-up was performed annually by the tumor registry.With a median follow-up of 6.9 years (range, 3-15.8 years), overall recurrence free survival was 93%. Poor nuclear grade (hazard ratio, 5.8; 95% confidence interval, 1.70-19.82; P = 0.004) and lymphatic vessel invasion (hazard ratio, 4.6; 95% confidence interval, 1.34-15.61; P = 0.01) were independent predictors of recurrence. Only 10% of patients had cancers with both poor nuclear grade and lymphatic vessel invasion and their 67% 7-year recurrence free survival (RFS) rate was significantly lower than the 92% RFS rate observed for patients with one of these two factors (P = 0.007) and the 99% RFS for patients with neither poor risk factor (P = 0.0001).The combination of poor nuclear grade and lymphatic vessel invasion identifies a very small subset (10%) of patients with T1a,b N0 M0 breast cancer with a significant relapse risk that warrants consideration of adjuvant systemic therapy. However, the majority of patients with T1a,b N0 M0 breast cancer have an exceptionally good prognosis.

Two studies examined the intersection of life stage with the experience of social events. Study 1 tested whether social events coinciding with early adulthood are more meaningful to individuals than events during other life stages (K. Mannheim, 1972; A. J. StewartJ. M. Healy, 1989). In 4 of 5 samples of college-educated women (3 age cohorts), the hypothesis was supported. Study 2 examined the impact of the women's movement on the personalities and careers of women who experienced the movement during early adulthood versus early middle adulthood. Women in both cohorts who found the movement meaningful attained higher education, work status, and income levels; were employed in upwardly mobile careers; and were more assertive and self-confident at midlife than women who found the movement less important. Consistent with hypotheses, finding the women's movement meaningful was associated with personality change in the older cohort.

Protein A immunoadsorption is a novel therapy for the treatment of diseases mediated by pathogenic autoantibodies. This procedure consists of circulating patients' plasma through a column containing staphylococcal protein A, which binds to the Fc portion of IgG, enabling removal of IgG. Presently, protein A immunoadsorption is used in the treatment of idiopathic thrombocytopenic purpura, but may be more widely used as an immunomodulator in human immunodeficiency virus infection and metastatic carcinoma.We present two histologically documented cases of leukocytoclastic vasculitis in the setting of protein A immunoadsorption. This potentially severe adverse effect is probably more common than the literature reflects and should be recognized by physicians who are treating patients with protein A column pheresis.The pathogenesis of protein A therapy-associated leukocytoclastic vasculitis remains unclear. Further study of vasculitis in the setting of protein A column pheresis may lead to modifications of this therapy, resulting in fewer adverse effects. Protein A-associated leukocytoclastic vasculitis may serve as a useful model of the relation of immune complexes and vasculitis.

From November 1985 to February 1986 two unplanned settlements near Port Moresby experienced a small person-to-person outbreak of typhoid fever, which included one death. Investigation showed that of the 20 individuals who were diagnosed as either ill, culture positive or a carrier, 15 were related by blood, marriage or through shared living quarters. The remaining 5 lived in the same house, but were not related to the larger group. Drinking water was contaminated with coliforms, but was not implicated. The outbreak resolved with no additional cases after February 1986. Outbreaks of this nature highlight the need for continuing public health education for local health officers in contact tracing, field testing and transportation of specimens, and epidemiological skills in ivestigating person-to-person outbreaks. They also make a strong case for public health laboratories equipped to perform rapid, comprehensive pathological examination of specimens collected during any outbreak of infectious illness.

Sweat gland carcinomas with clear cell features are extremely rare neoplasms, with few well documented cases reported in the literature.Data on nine patients with malignant eccrine adnexal neoplasms characterized by a prominent clear cell neoplastic component were studied. Immunohistochemical stains with a panel of antibodies against epithelial, stromal, and neural antigens were performed on five tumors and electron microscopic examination of one.The tumors showed a spectrum of histologic features and growth patterns that ranged from well differentiated, low grade malignant neoplasms to poorly differentiated, highly aggressive, recurrent, and metastasizing tumors. All tumors contained a varied proportion of cells with abundant clear cytoplasm, similar to those seen in a group of benign eccrine adnexal neoplasms that have been variously designated as clear cell hidradenoma, nodular hidradenoma, clear cell myoepithelioma, and eccrine acrospiroma. Immunohistochemical stains on five tumors and ultrastructural examination in one were consistent with eccrine differentiation. Clinical follow-up of eight patients showed local recurrence in six, followed by metastases in three, despite local excision, radiation, and chemotherapy. Criteria for differentiating these tumors from their benign counterparts and from other types of malignant adnexal neoplasms and metastatic lesions are presented.The findings indicate that clear cell eccrine carcinomas comprise a heterogeneous group of lesions that may range from locally recurring, low grade well differentiated tumors to highly aggressive, high grade tumors with a definite potential for uncontrollable local recurrence and metastasis. Wide surgical excision is recommended as the primary treatment for such neoplasms.

We describe two examples of malignant melanoma that present with clinical and histopathologic characteristics resembling the benign acquired dermal nevus and the spindle and epithelioid cell nevus (Spitz's nevus), respectively. Both lesions were present on the trunk of adult patients. The clinical impression in both cases was dermal nevus. Histopathologically, these lesions were fairly well circumscribed and symmetrical; they exhibited an expansile dermal proliferation of atypical nevomelanocytes in nests and fascicles with only minimal intraepidermal involvement. These lesions which we will designate as "nevoid" melanoma can be misinterpreted as benign nevi because of the absence of prominent intraepidermal pagetoid spread and the pattern of apparent dermal maturation at the base of the tumor associated with a gradual diminution of cell size. These features mimic the maturation phenomena in banal dermal nevi and spindle and epithelioid cell nevi. The differential diagnosis includes other types of melanoma, and various benign entities characterized by a predominantly dermal proliferative process, such as deep penetrating nevus and cellular neurothekeoma. The recognition of nevoid melanoma is critical so that patients with these lesions receive appropriate therapy for malignant melanoma.

Objective— To compare the frequency of common antenatal problems, the amount of antenatal surveillance and the obstetric and neonatal outcome in women with and without a history of infertility. Design— A prospective cohort study with age and parity matched controls. Setting— A single consultant unit at the Jessop Hospital for Women, Sheffield, over a 22-month period. Subjects— 114 women with a history of infertility who reached 16 weeks gestation with a singleton live fetus and 114 control women matched for age and parity. Main outcome measures— Frequency of antepartum, complications, amount of antepartum surveillance, obstetric and neonatal outcome. Results— Common antenatal complications were not increased. In the infertility compared with the control group, the relative risk of requiring an emergency caesarean section was 2.43 (95% CI 1.05–5.63). There was no difference in birthweight. Conclusion— Many of the previously observed differences in outcome of pregnancy in women after infertility compared with those without are associated with age and parity but these characteristics do not explain the increased frequency of emergency caesarean section.

We examined the expression of IL-1 mRNA in vivo by in situ hybridization. RNA probes for murine IL-1 alpha and IL-1 beta were used to detect IL-1 mRNA in frozen sections of spleen, lymph node, and thymus of mice injected with Salmonella typhi LPS or SRBC. No IL-1 was detected in lymphoid tissues from un-injected mice. This lack of expression correlated with the absence of IL-1 biologic activity. However, after LPS injection, IL-1 alpha and beta mRNA expression was found in macrophages of the red pulp and marginal zone of the spleen. The periarteriolar lymphoid sheath contained cells that only expressed IL-1 beta mRNA. These cells were not lymphocytes and did not stain with the macrophage marker F4/80. A similar cellular response was found after SRBC injection. Scattered macrophages in lymph nodes and thymus were positive, but only after LPS or SRBC injection. The spleens of mice injected with LPS had megakaryocytes containing IL-1 mRNA.

Sixty six women with first or second trimester fetal loss were investigated for the presence of lupus anticoagulant by routine coagulation tests and the dilute Russell's viper venom time with a platelet neutralisation procedure, and for raised anticardiolipin antibodies by an enzyme linked immunosorbent assay. Of 35 women with recurrent fetal loss, seven were positive for lupus anticoagulant and six had increased IgG anticardiolipin antibodies, while of 31 women with only one or two episodes of fetal loss, one had lupus anticoagulant and none increased IgG anticardiolipin antibodies. These findings were significantly different. There was no difference in the incidence of increased IgM anticardiolipin antibodies between the two groups (three and two cases, respectively). A further 11 women with intrauterine death in the third trimester were studied and lupus anticoagulant and raised IgM anticardiolipin antibodies were found in one case. No woman was known to have systemic lupus erythematosus. It is concluded that lupus anticoagulant and increased IgG anticardiolipin antibodies are independently associated with recurrent first and second trimester fetal loss and that such cases should be investigated, even in the presence of otherwise good health, by a comprehensive methodological approach.

A panel of monoclonal antibodies against neural and epithelial associated antigens was used to examine bone marrow from patients in clinical remission from small cell lung cancer (SCLC). A standard peroxidase-antiperoxidase technique and Ficoll-Hypaque enrichment were used to detect SCLC-like cells at the 1-2% level of contamination in 8 of 12 patients who were disease free by conventional criteria, including routine marrow cytology and histology and endobronchoscopic biopsy or cytology. Six of these patients ultimately relapsed, with metastatic sites found between 2 and 6 months after restaging. Furthermore, 6 patients had undergone chemointensification including autologous marrow rescue with radical irradiation to the primary lung tumor. Four of these 6 subsequently relapsed, also with metastatic sites. Of the 4 patients without bone marrow metastases at restaging using this technique, 2 relapsed, with cells found at the primary site, and 2 remained in complete remission. Serum free cell culture was attempted in 9 of 12 cases and SCLC-like cell colonies grew, in suspension, in 4. The SCLC-like nature of these cells has been confirmed by electron microscopy in 1 case and by repeat immunocytochemistry for small cell associated antigens in 3 cases. Bone marrow positivity using these techniques appears to predict a high risk of metastatic relapse regardless of further therapy.

Uterine activity was measured quantitatively during subsequent labor after prostaglandin E2 gel (PGE2). Thirty primigravidae with a low Bishop score were included in this randomized double-blind study. Fewer women who received PGE2 required subsequent surgical induction. The pattern of uterine activity was different. Cervical dilatation was achieved with less uterine activity in the PGE2 group, especially during the shorter latent phase.

Summary Severe pre-eclampsia leading to fetal death in advanced abdominal pregnancy is reported. Attention is drawn to the low reported incidence of pre-eclampsia in this condition and possible explanations are put forward.

The value of routine regular antenatal cardiotocography (CTG) in the management of high-risk pregnancy was assessed in a prospective randomized controlled study of 353 patients. All patients had a weekly CTG trace during the last 6 weeks of pregnancy and according to the random allocation the tracings were concealed from, or available to, the clinicians. Other methods of assessing fetal welfare were available to both groups. There was no significant difference between the concealed and revealed groups in the timing and mode of delivery, birthweights, Apgar score and neonatal morbidity. No apparent effect from the routine use of antenatal CTG in high-risk pregnancy was shown.

A structurally abnormal X chromosome was found in a nine year old girl with mild mental retardation and dysmorphic features. Subsequent clinical examination at 18 years of age showed tall stature and gonadal dysgenesis. Re-examination of her karyotype using a variety of banding techniques on prometaphase chromosomes allowed the identification of the abnormal chromosome as a duplication/deficient X chromosome, 46,Xder X(pter----q28::p11.2----pter). The clinical features are discussed in terms of karyotype/phenotype correlation.

Function of the pituitary-adrenal axis was assessed in 16 adult female patients who had been taking cyproterone acetate for greater than 1 year. Some evidence of reduced basal cortisol output was seen in 25% of the patients, but plasma cortisol levels could be stimulated both by hypoglycaemia and by direct corticotrophin (ACTH) stimulation. The latter effect was confirmed by analysis of steroid excretion in urine although basal excreation rates indicated extensive adrenal suppression. These results suggest that cyproterone acetate does have some glucocorticoid activity which is able partially to suppress the pituitary--adrenal axis, but leaves it still responsive to stress.

A 25 year old woman with gonadal dysgenesis but no other somatic features of Turner's syndrome was found to have a 45,X/46,XidicX(p22.3) karyotype. It is postulated that because her stature is within the normal range there has been no loss of genetic material in the fusion of the two Xs. Her mother, who also had a history of menstrual problems, was found to be a 46,XX/47,XXX mosaic.

Summary. Oxygen consumption of human endometrial tissue was measured in vitro in air and high oxygen gas phases using an oxygen electrode. The oxygen consumption increased throughout the proliferative phase, peaking around ovulation and then decreasing during the secretory phase. This pattern persisted whether the oxygen consumption was expressed on a dry weight, DNA or protein basis. Storage of the tissue and mincing produced lower values of oxygen consumption.

SummaryThere is currently both an absolute and relative reduction in births to older women. In a single hospital population the number of older women. In a single hospital population the number of older women having amniocentesis for pre-natal diagnosis is only a small, though increasing, proportion of those at risk. The main factors in failure of offering amniocentesis are late booking and communication difficulty.

1. In anaesthetized rabbits 27-29 days pregnant (term is 31 days) uterine blood flow was measured in an extracorporeal loop between a carotid and the central end of an external iliac artery, the descending aorta and its other branches being tied. Mean flow was 45 +/- 2 ml. min(-1), or 105 +/- 4 ml. min(-1) per kg uterus and contents in thirty-four litters.2. The partition of uterine blood flow to placentas ( approximately 60%), myometrium ( approximately 27%) and vagina ( approximately 13%) as estimated by injection of isotopelabelled microspheres of 35 or 50 mu diameter, was similar in intact rabbits and in those with an extracorporeal loop.3. Maternal blood flow was greater to the placentas of larger foetuses both absolutely and per unit placental weight. Flow to the placentas of dead foetuses was much less than to those of live foetuses, but flow to the adjacent myometrium was not decreased.4. Maternal hypoxaemia (P(a, O2) approximately 40 mm Hg) caused vasoconstriction in the uterine vascular bed after 3-4 min. The distribution of blood flow within the uterus was altered, the placental fraction falling to 32%. This was unaffected by carotid denervation.5. These observations suggest that there are large differences in the physiological control of maternal blood flow to the placenta, myometrium and vagina.

The blood flow through the hands, feet, calf of the leg, and forearm is essentially the same during pregnancy and the puerperium in normal women, and in women with mild or severe toxaemia of pregnancy or essential hypertension. The resistance to flow of blood through the limbs is, however, raised.

1. In foetal lambs, delivered by Caesarean section under light chloralose anaesthesia, injection of sodium cyanide into the left atrium or ascending aorta caused a rise of arterial pressure and femoral vasoconstriction. The response to 0·77 mg/kg was barely present at 0·6 of term; by 0·8 of term there was a large response to one third of this dose. 2. The cardiovascular response to cyanide injection into the left atrium or ascending aorta was diminished either by section of the vagi or by carotid denervation, and was abolished by cutting both sets of nerves. 3. Injection of sodium cyanide into both common carotids simultaneously caused a substantial cardiovascular response and often a respiratory effort, abolished by carotid denervation, whereas injection into a single carotid rarely caused an effect. 4. It is concluded that the carotid chemoreceptors in mature foetal lambs can be excited by a stimulus of sufficient intensity, even though they do not respond to moderate hypoxaemia.

One hundred and seventy eight insulin dependent diabetics (IDDM) have been studied regarding their understanding of and compliance with a controlled carbohydrate diet. Forty per cent could not remember their dietary prescription, 35 per cent did not estimate carbohydrate and many scored badly in a 'quiz' on the carbohydrate content of common foods. Quiz scores were significantly associated with HbA1 levels (P less than 0.001). One hundred and thirty six patients completed a seven-day food record from which the pattern of eating was established. Of these 75 were injecting twice daily short and intermediate acting insulin; in this group there were significant relationships between HbA1 and both care with carbohydrate estimation and eating pattern (P less than 0.05). Thus, in IDDM, the understanding of a controlled carbohydrate diet and adherence to it are associated with better glycaemic control but adequate compliance is rare. Future dietary recommendations for insulin taking diabetics should be simple, easy to understand, acceptable in practice and of proven effectiveness if they are to appreciably influence the quality of diabetic control.

Summary. Women's ratings of their experience of childbirth were compared with midwives' ratings of the women's experience. The midwives' ratings were significantly different from those of their patients. Mid-wives presented a more positive picture of the woman's experience than did the woman herself. Furthermore, the women reported using psycho-prophylactic techniques for controlling discomfort for significantly more of the time than the midwives reported that the women used such techniques. The results are discussed in the context of similar findings reported in the literature.