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The effects of high voltage defibrillation shocks given to six swine were studied to determine if there is a limit to the advantage gained from increasing the shock strength. An endocardial electrode was placed in the right ventricle, and a 114-cm² cutaneous patch was placed on the left lateral thorax. Monophasic (10 msec) and single capacitor biphosic (5/5 msec) shocks with leading edge voltages of 200, 400, 600, 800, and 990 volts (approximately 2.3-59 J) were tested. For monophasic shocks, the probability of successful defibrillation ranged from 0% at 200 V to 90% at 990 V. The incidence of postshock arrhythmia increased from 0% for successful shocks at 600 V to 67% for successful shocks at 990 V. For biphasic shocks, the probability of success peaked at 97% for the 600-, 800-, and 990-V shocks. The incidence of postshock arrhythmia increased from 8% at 400 V to 55% at 990 V. Although more postshock arrhythmias occurred at lower strengths for biphasic than for monophasic shocks, an efficacy criterion, quantifying the probability of defibrillation success acid the probability that a postshock arrhythmia will not occur, was always higher for biphasic shocks. The probability of success never reached 100% for either waveform while the incidence of postshock arrhythmia increased as the shock strength increased. In conclusion, for the catheter-patch electrode configuration, increasing the shock strength does not always improve the probability of success and may increase the incidence of postshock arrhythmia. [ABSTRACT FROM AUTHOR]

Competing Interests: Dr Souza is a consultant for Cardiac Ablation Solutions, Medtronic, Inc, Minneapolis, MN. Dr Lim is an employee of Medtronic, Inc, Minneapolis, MN. Drs Nelson, Reynolds, Dhawan, and Antimisiaris do not have any conflicts regarding this manuscript.

Evidence of microplastic (MP) pollution in Antarctic terrestrial environments reinforces concerns about its potential impacts on soil, which plays a major role in ecological processes at ice-free areas. We investigated the effects of two common MP types on soil physicochemical properties and microbial responses of a marine terrace from Fildes Peninsula (King George Island, Antarctica). Soils were treated with polyethylene (PE) fragments and polyacrylonitrile (PAN) fibers at environmentally relevant doses (from 0.001% to 1% w w -1 ), in addition to a control treatment (0% w w -1 ), for 22 days in a pot incubation experiment under natural field conditions. The short-term impacts of MPs on soil physical, chemical and microbial attributes seem interrelated and were affected by both MP dose and type. The highest PAN fiber dose (0.1%) increased macro and total porosity, but decreased soil bulk density compared to control, whereas PE fragments treatments did not affect soil porosity. Soil respiration increased with increasing doses of PAN fibers reflecting impacts on physical properties. Both types of MPs increased microbial activity (fluorescein diacetate hydrolysis), decreased the cation exchange capacity but, especially PE fragments, increased Na + saturation. The highest dose of PAN fibers and PE fragments increased total nitrogen and total organic carbon, respectively, and both decreased the soil pH. We discussed potential causes for our findings in this initial assessment and addressed the need for further research considering the complexity of environmental factors to better understand the cumulative impacts of MP pollution in Antarctic soil environments., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Brazil is one of the largest melon ( Cucumis melo ) producers in the world and most of the production is exported to international markets. Currently, over 15% of Brazilian melon shipments are lost during export transportation due to Fusarium fruit rot, which is jeopardizing the livelihood of Brazilian melon producers. We focused on understanding the aggressivity of five species of Fusarium causing fruit rot on the main types of melon produced in Brazil. We also investigated the correlation between pathogenicity and fruit quality. Experiments were performed under a completely randomized experimental design, in a 5 × 8 factorial scheme, using two methods for inoculation: deposition of discs of culture media containing fungal structures and deposition of spore suspensions in needle-punctured lesions. The fungal species used were Fusarium falciforme , F. sulawesiense , F. pernambucanum , F. kalimantanense , and Fusarium sp. Fruits of two hybrids from four types of melons, canary (Goldex and Gold Mine), piel de sapo (Grand Prix and Flecha Verde), galia (McLaren and DRG3228), and cantaloupe (SV1044MF and Bonsai), were used. Disease severity was assessed by measuring the lesions, disease severity index, fruit firmness, and degrees Brix of fruits. The five Fusarium species caused rot in the fruits of all melon hybrids studied and the aggressivity of those fungal species varied with the type and hybrid. Fruits of the hybrids McLaren and Bonsai presented the largest lesions among all melon hybrids, and hybrids of canary type (Gold Mine and Goldex) were the most tolerant to rot caused by the Fusarium species investigated. Furthermore, the greater the severity of Fusarium fruit rot, the lower the pulp firmness of the fruits, but degrees Brix did not correlate with the onset of the disease.

Objectives: To evaluate the clinical performance of a new dual-cure universal adhesive system (Futurabond U, Voco) when applied using different application strategies in non-carious cervical lesions (NCCLs) after 36 months., Material and Methods: Futurabond U was applied in NCCLs of 50 subjects using four adhesion strategies (n = 50 restorations per group): only self-etch (SEE); selective enamel etching + self-etch (SET); etch-and-rinse with dry dentin (ERDry); and etch-and-rinse with wet dentin (ERWet). All cavities were restored using Admira Fusion composite resin (Voco). Restorations were evaluated after 36 months using the World Federation criteria (FDI) and the modified United States Public Health Service (USPHS) criteria., Results: The after 36-month retention rates were 87% (75-92%) for SEE, 94% (83-98%) for SET, 91% (80-97%) for ERDry, and 94% (83-98%) for ERWet. Forty-three restorations were considered to have minor discrepancies in marginal adaptation at the 36-month recall (18 for SEE, 12 for SET, 7 for ERDry, and 6 for ERWet; p > 0.05). One restoration was detected as a minor marginal discoloration at the 36-month recall (1 for SET; p > 0.05). No restorations showed postoperative sensitivity and caries recurrence at 36 months., Conclusion: The clinical performance of the Futurabond U did not depend on the employed bonding strategy, and it was considered reliable after 36 months of clinical evaluation. However, greater marginal discrepancy was observed in the self-etch groups., Clinical Relevance: NCCLs restorations using a dual-cure universal adhesive in self-etch and etch-and-rinse modes showed satisfactory clinical performance after 36 months., (Copyright © 2022. Published by Elsevier Ltd.)

Objectives: To evaluate the influence of the sonic device on the clinical performance of one-step self-etch adhesive systems in non-carious cervical lesions (NCCLs) after 18 months., Materials and Methods: Forty patients participated in this study. Eighty restorations were assigned to two groups (n = 40): Sonic application and Manual application. After the adhesive application (iBond Self-Etch, Kulzer, Hanau, Germany), NCCLs were restored using composite resin (Charisma, Kulzer, Hanau, Germany). The restorations were evaluated at baseline and after 18 months both according to the Word Dental Federation (FDI) and the United States Public Health Service (USPHS) criteria. Friedman repeated measures analysis of variance by rank and Wilcoxon test for significance in each pair were applied (α = 0.05)., Results: After 18 months, 38 patients were evaluated. Twenty-three restorations were lost (19 for manual vs. 4 for sonic application). The retention rates (95% confidence interval) were 50% (CI 34.8%-65.1%) for manual application and 84.2% (CI 69.6%-92.6%) for sonic application (p < 0.05). Twelve restorations showed marginal staining (nine for manual vs. three for sonic application; FDI, p < 0.05) and nine some marginal discrepancy (seven for manual vs. two for sonic application; FDI, p < 0.05). No restorations showed postoperative sensitivity and caries recurrence at the time., Conclusion: The sonic application increases the retention rate of iBond Self-Etch after 18 months of clinical evaluation in NCCLs., Clinical Relevance: The application of a simplified self-etch adhesive (iBond Self-Etch) associated to a sonic device seems to be an alternative to improve the clinical behavior in NCCLs., (© 2022 Wiley Periodicals LLC.)

Objective: This study aimed to evaluate the effect of prolonging polymerization time on the 18 months clinical performance of a universal adhesive system used as etch-and-rinse (ER) and self-etch (SE)., Methods: 140 restorations were randomly placed in 35 subjects according to the following groups: ER10 (light-curing for 10 s); ER40 (light-curing for 40 s); SE10 (light-curing for 10 s) and; SE40 (light-curing for 40 s/1200 mW/cm 2 ). A resin composite was placed incrementally. The restorations were evaluated at baseline and after 18 months by using the FDI criteria. The following outcomes were evaluated: marginal staining, marginal adaptation, spontaneous post-operative sensitivity and recurrence of caries. The differences among the groups were calculated using Friedman repeated measures analysis of variance rank (α = 0.05)., Results: After 18 months the retention/fracture rates were 88.9% (95%CI 74.1-95.6%) for ER10, 94.3% (95%CI 91.4-98.5%) for ER40, 77.2% (95%CI 60.1-87.9) for SE10 and 97.2% (95%CI 85.5-99.9%) for SE40. A significant difference was detected in the retention rate when SE10 was compared to the SE40 (p = 0.01). Also, ER40 showed a significant improvement of the marginal adaptation when compared to ER10 (p = 0.01)., Significance: This is the first study that demonstrates an improvement in the clinical performance of universal adhesive systems in non-carious cervical lesions when prolonged light-cured was applied., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 The Academy of Dental Materials. Published by Elsevier Inc. All rights reserved.)

Objectives: This study investigated the ability of modified phosphoric acids containing chlorhexidine (CHX) or grape seed extract (GSE) for promoting simultaneous biomodification during acid etching on bonding properties in caries-affected dentin (CAD)., Materials and Methods: Thirty-two human molars (8 with sound dentin [SD] and 24 naturally CAD) were selected for the study. The SD and CAD were initially exposed, then randomized and etched according to the following groups: (1) SD (SD-CT) and CAD (CAD-CT) both with 37% phosphoric acid, (2) CAD with 2% CHX containing 37% phosphoric acid (CAD-CHX), and (3) CAD with 2% GSE containing 10% phosphoric acid (CAD-GSE). The bonding procedure and composite build-ups were performed after acid etching. Subsequently, they were sectioned in resin-dentin specimens. The specimens were submitted for chemical profiling by micro-Raman, microtensile bond strength (μTBS), failure mode with chemical characterization by FEG/SEM-EDX, and in situ zymography by CLSM. The data from μTBS and CLSM were statistically analyzed (1-way ANOVA and Tukey's test; α = 0.05)., Results: The highest μTBS results were shown for SD-CT in comparison with all CAD groups (p < 0.001), and the lowest for CAD-CT and CAD-CHX (p < 0.001). The etching with CHX did not increase the μTBS for CAD when compared with CT (p = 0.52). However, the etching with GSE improved significantly the μTBS for CAD when compared with CT and CHX (p < 0.001). The chemical profile detected chemical and structural changes in collagen peaks for CAD-CT, which were not detected when the CAD was etched by modified acids. Also, the poorest hybridization ability was detected in CAD for CT, which was significantly improved with modified acids, especially the GSE, as evaluated by chemical profile and failure mode. A significant reduction of MMP activity on CAD was promoted by modified acids in comparison with CT (both p < 0.001)., Conclusions: The GSE-containing acid was able to promote biomodification during the acid etching, increasing the bonding properties and reducing the activity of the MMPs within the hybrid layer., Clinical Relevance: The use of GSE-containing phosphoric acid can be a promising alternative to improve the bonding performance on caries-affected dentin, since it is capable of biomodifying the dentin during the acid etching, without adding any extra step in bonding procedures.

Objective: This study aimed to evaluate the addition of copper nanoparticles (CuNp) on the clinical performance of a universal adhesive system used as etch-and-rinse (ER) and self-etch (SE)., Methods: 216 restorations were randomly placed in 36 subjects according to the following groups: ERcu = etch-and-rinse with 0.1% CuNp; ERct = etch-and-rinse without CuNp; SEcu = self-etch with 0.1% CuNp; SEct = self-etch without CuNp. Resin composite was placed incrementally and light-cured. The restorations were evaluated at baseline and 6, 12 and 18 months using the FDI and USPHS criteria. Statistical analyses were performed using appropriate tests (α = 0.05)., Results: The addition of CuNp did not increase the clinical performance (FDI / USPHS) of the universal adhesive tested after 18-month when applied in the ER mode (p > 0.05). The addition of CuNp in SE restorations increased the retention rate significantly and decreased the marginal discrepancies after 18 months (p < 0.05)., Conclusion: The clinical performance of universal adhesive was significantly increased when applied in the SE mode with the addition of copper nanoparticles., Clinical Relevance: This is the first study that demonstrates a slight improvement in the clinical performance of universal adhesive systems in non-carious cervical lesions when added CuNp in lower concentration., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: Pulmonary arterial hypertension (PAH) occurs in 35% to 65% of hyperthyroid patients. Despite this high frequency, only a few authors have examined the effects of hyperthyroidism treatment on PAH and the right ventricle. We evaluated the effects of hyperthyroidism and its reversal on cardiovascular structure and function using Doppler echocardiography., Methods: We prospectively evaluated 32 patients (42.5±11.9years old) with thyrotoxicosis. Exclusion criteria included previous cardiovascular disease. An echocardiogram was performed at the time of hyperthyroidism diagnosis and after normalisation of free thyroxine (T4) levels. Patients were divided into two groups according to the presence or absence of PAH at the diagnosis, or at two moments, before and after T4 normalisation., Results: Graves' disease was the most frequent aetiology (75%) of hyperthyroidism. Pulmonary arterial hypertension was observed in 43.8% of patients. Free T4 concentration was higher in PAH than non-PAH patients. Free T4 normalised after 5 (2.0-10.5; median and percentiles) months of treatment. Cardiac chamber sizes and cardiac output were higher in PAH. Right ventricular (RV) systolic function was impaired in PAH. Cardiac output and free T4 (r=0.42; p<0.05) correlated with pulmonary artery systolic pressure (PASP). Cardiac chamber size, cardiac output, left ventricular ejection fraction, and PASP (34.0±8.6 to 21.7±4.5mmHg) reduced after treatment. Right ventricular myocardial performance index and fractional area change improved after T4 normalisation., Conclusions: Pulmonary arterial hypertension is highly prevalent in hyperthyroid patients and is combined with increased cardiac chambers size and cardiac output, and impaired RV function. Cardiovascular changes are reversible after T4 normalisation in patients without cardiovascular disease., (Copyright © 2018 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Since 2009 a policy has been implemented in Brazil to establish the natural concentrations of potentially toxic substances in soil for each state. Historically a 'mining state', Minas Gerais established a Quality Reference Value for metal(loid)s for all of the soils in the state. To successfully establish these values it is important to study the spatial geochemical diversity for the state. In this context, the objectives of this work are: (1) to evaluate the natural concentrations of metal(loid)s in pristine Minas Gerais soils and (2) to interpret the spatial variability in concentration of these elements. The 0-20 cm layer of soils was sampled for 697 georeferenced sites including the main geological materials and soil groups. Soil properties were analyzed according to methodologies suitable for Brazilian soils. The concentration of metal(loid)s was determined by acid extraction according to EPA 3051A. Descriptive statistics, Pearson correlation and spatial variability analyses were performed. The dominance of acidic pH and low CEC values reflects the pervasive deep acid weathering. The variability of metal(loid) concentrations for soils of the state may be attributed to geological diversity and different pedogenesis. Correlation and spatial analysis indicated that the Fe concentration is strongly associated with metal(loid) concentrations in topsoil. According to the spatial geochemical diversity of the state, a k-means cluster analysis was performed which identified four clusters. A significant difference in the mean values of metal(loid) concentrations between the clusters confirmed that the single Quality Reference Value established does not represent the geochemical diversity of soils in Minas Gerais., (Copyright © 2014 Elsevier B.V. All rights reserved.)

Aims: Cryoballoon (CB) ablation with the second-generation cryoballoon (CBG2) seems to be more effective than its predecessor [first-generation cryoballoon (CBG1)], but phrenic nerve palsies were observed more frequently. The aim of this study was to compare the safety and efficacy of CBG1 and CBG2 in a substudy of the prospective multicentre, multinational FREEZE Cohort Study., Methods and Results: Periprocedural data were analysed, and a total of 532 patients with paroxysmal atrial fibrillation (AF) were examined (n = 224 for CBG1 and n = 308 for CBG2). Procedure time decreased significantly from 149 to 130 min when comparing CBG1 with CBG2 (P < 0.0001), and pulmonary vein isolation (PVI) was achieved in 97.8 and 97.6% of PVs with CBG1 and CBG2 (P = 0.77), respectively. The need for dual-balloon usage within a procedure dropped (20.1 vs. 9.0%, P < 0.001), and the fluoroscopy time was reduced when operating the CBG2. Atrial fibrillation recurrence rates until discharge were similar (5.0 vs. 5.8%, P = 0.69). Comparable low rates of major complications were observed with both CBs, and there was a non-significant trend for more phrenic nerve palsies., Conclusion: Second-generation cryoballoon demonstrated a high rate of acute PVI in a significant faster procedure, which also utilized less radiation exposure and less dual-balloon usage during an average procedure. The safety profile remains favourable with a non-significant trend for more phrenic nerve palsies. If the enhancements lead to a higher clinical benefit has to be determined. The 1-year outcome data from the ongoing FREEZE Cohort Study comparing radiofrequency and CB ablation will shed some light on that issue., Clinical Trials Gov Identifier: NCT01360008., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2014. For permissions please email: journals.permissions@oup.com.)

A new natural product, a 3,9-(1,2,3-trioxocine)-type steroid, named rauianodoxy (6), was isolated from Rauia nodosa, together with five steroids: sistostenone (1), stigmastenone (2), sitosterol (3), stigmasterol (4) and ergosterol peroxide (5), one coumarin, O-geranylosthenol (7), and three alkaloids, N-methylflindersine (8), zantobungeanine (9) and veprissine (10). Compounds 5-8 were isolated for the first time in the genus Rauia. These compounds were characterized on the basis of their spectral data, mainly one and two-dimensional NMR, and mass spectra, also involving comparison with the literature data. Theoretical studies at the DFT level reveal structural parameters for the 1,2,3-trioxole bridge compatible with known structures containing a similar group.

One novel triterpene cycloartane-type, named hirtinone (1), six protolimonoids - nilocitin (2), dihydronilocitin B (3), melianone epimers (4) and (5), piscidinol A (6) and melianone lactone (7), one tertranortriterpenoid, hirtin (8), and one sesquiterpene, spathulenol (9), were identified in the fruits of Trichilia hirta. The structures were established by 1D and 2D NMR (1H and 13C-NMR, DEPTQ, 1H-1H-COSY, 1H-1H-NOESY, HSQC and HMBC), high resolution mass spectroscopy (HR-ESI-MS) and infrared (IR) spectral data.

This work reviews the production of terpenoids by endophytic fungi and their biological activities, in period of 2006 to 2010. Sixty five sesquiterpenes, 45 diterpenes, five meroterpenes and 12 other terpenes, amounting to 127 terpenoids were isolated from endophytic fungi.

Distinguishing congenital long QT syndrome from QT prolongation caused by drugs or a different underlying disease process is essential for selecting the proper treatment. Herein, we present a case of a patient referred for left cardiac sympathetic denervation as a last resort treatment option for her 19-year standing diagnosis of long QT syndrome with malignant ventricular fibrillation. However, based on her atypical clinical course and additional imaging studies, a diagnosis of left ventricular noncompaction, rather than long QT syndrome, was made. She left the clinic with a drastically different treatment plan and an improved quality of life. Because many cardiac and noncardiac diseases can demonstrate QT prolongation on electrocardiogram, all possible diagnoses should be considered before diagnosing a patient with congenital long QT syndrome especially with regard to the profound treatment implications and genetic follow-up in family members., (© 2011 Copyright the Authors. Congenital Heart Disease © 2011 Wiley Periodicals, Inc.)

Unlabelled: In neuroschistosomiasis, the spinal cord is the most common place of the disease. In high prevalent areas for schistosomiasis mansoni, the clinical alertness is important for an early diagnostic, in order to decrease the final neurological damage. This study provides some useful neurologic information about a series of patients with schistosomal myelitis., Method: The sample consisted of 13 schistosomiasis mansoni carriers examined at the moment of the diagnosis of myelitis., Results: The classical triad (lumbago, weakness at the lower limbs and urinary dysfunctions) was documented in 11 (86.61%) patients. The distribution of the clinical forms was: myeloradicular in six patients (46.15%), radicular in four (30.76%) and myelitic in three (23.07%)., Conclusion: The radicular dysfunction and their clinical associated forms were the most prominent pattern during the early phase of this disease.

The pharmacotherapy for Alzheimer's disease (AD) includes the use of acetylcholinesterase inhibitors (AChEI). Recent investigations for novel AD therapeutic agents from plants suggested that Tabernaemontana genus is a promising source of novel anticholinesterasic indole alkaloids. In this work two fast screening techniques were combined in order to easily identify novel cholinesterase inhibitors (ChEI). Gas chromatography-mass spectrometry (GC-MS) of the less polar alkaloidic fractions obtained from the acid-base extraction of the stalk of T. laeta revealed thirteen monoindole alkaloids, four of them confirmed by co-injection with previously isolated alkaloids. The others were tentatively identified by mass fragmentation analysis. By gas chromatography with flame ionization detection (GC-FID) and using isatin as internal standard, affinisine and voachalotine were determined as major compounds. These fractions and fourteen previously isolated alkaloids, obtained from root bark of T. laeta and T. hystrix were investigated for acetyl (AChE) and butyrylcholinesterase (BuChE) inhibitory activities by the modified Ellman's method in thin layer chromatography(TLC-ChEI). Results showed selective inhibition of the alkaloids heyneanine and Nb-methylvoachalotine for BuChE, and 19-epi-isovoacristine for AChE, whereas olivacine, affinisine, ibogamine, affinine, conodurine and hystrixnine inhibited both enzymes. In addition to confirming that monoterpenoid indole alkaloids can be novel therapeutic agents for AD, this is the first report of the ChEI activity of olivacine, a pyridocarbazole alkaloid.

Background/aims: Obesity and diabetes mellitus (DM) are associated with pancreatic cancer. The present study evaluated tumor staging and resection of pancreatic adenocarcinoma (PaC) according to previous Body Mass Index (BMI), BMI on admission and DM duration., Methods: A retrospective analysis of 151 consecutive patients with PaC was performed: 73 were evaluated according to BMI preceding tumor-related weight loss and BMI on admission; 118 according to DM diagnosis; and 38 were assessed according to DM duration (less than 1 year [recent-onset] versus more than 2 years [long-standing])., Results: There was no difference in the prevalence of tumor stage III or IV between previously normal weight and overweight/obese patients (56 vs. 42%, NS). Tumor resection rate was higher in previously obese than in previously lean patients (58 vs. 24%, p < 0.05). Tumor staging and resection were similar between normal weight and overweight/obese patients considering BMI on admission and diagnosis of DM. Weight loss was more pronounced in diabetic than in non-diabetic patients (21.7 vs. 13.3%, p < 0.01). Tumor staging and resection were similar between recent-onset and long-standing diabetic patients., Conclusion: Tumor resection rate was lower in previously normal weight patients. Diabetics lost more weight than non-diabetic patients. Neither BMI on admission nor the presence of DM nor DM duration influenced tumor staging or resection in PaC patients., ((c) 2007 S. Karger AG, Basel and IAP.)

Background: Azapirones are a group of drugs that work at the 5-HT1A receptor and are used to treat patients suffering from generalized anxiety disorder (GAD). However, several studies have shown conflicting results. Whether azapirones are useful as first line treatment in general anxiety disorders still needs to be answered., Objectives: To assess the efficacy and the acceptability of azapirones for the treatment of GAD., Search Strategy: Initially the Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Register (CCDANCTR) and The Cochrane Central Register of Controlled Trials (CENTRAL) were searched, incorporating results of group searches of MEDLINE (1966 to June 2005), EMBASE (1980 to June 2005), CINAHL (1982 to June 2005), PsycLIT (1974 to June 2005), PSYNDEX (1977 to June 2005), and LILACS (1982 to June 2005). Subsequently the revised Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Registers (CCDANCTR-Studies and CCDANCTR-References) were searched on 21-10-2005. Reference lists of relevant papers and major text books of anxiety disorder were examined. Authors, other experts in the field and pharmaceutical companies were contacted for knowledge of suitable trials, published or unpublished. Specialist journals concerning azapirones were handsearched., Selection Criteria: Randomized controlled trials of azapirones, including buspirone versus placebo and/or other medication and/or psychological treatment, were included. Participants were males and females of all ages with a diagnosis of generalized anxiety disorder., Data Collection and Analysis: Data were extracted from the original reports independently by CC, MA and MT. The main outcomes studied were related to the objectives stated above. Data were analysed for generalized anxiety disorder versus placebo, versus other medication and versus psychological treatment separately. Data were analysed using Review Manager Version 4.2.7., Main Results: Thirty six trials were included in the review, reporting on 5908 participants randomly allocated to azapirones and/or placebo, benzodiazepines, antidepressants, psychotherapy or kava kava. Azapirones, including buspirone, were superior to placebo in treating GAD. The calculated number needed to treat for azapirones using the Clinical Global Impression scale was 4.4 (95% confidence interval (CI) 2.16 to 15.4). Azapirones may be less effective than benzodiazepines and we were unable to conclude if azapirones were superior to antidepressants, kava kava or psychotherapy. Azapirones appeared to be well tolerated. Fewer participants stopped taking benzodiazepines compared to azapirones. The length of studies ranged from four to nine weeks, with one study lasting 14 weeks., Authors' Conclusions: Azapirones appeared to be useful in the treatment of GAD, particularly for those participants who had not been on a benzodiazepine. Azapirones may not be superior to benzodiazepines and do not appear as acceptable as benzodiazepines. Side effects appeared mild and non serious in the azapirone treated group. Longer term studies are needed to show that azapirones are effective in treating GAD, which is a chronic long-term illness.

Insulinomas are rare endocrine neoplasias that constitute the most frequent islet cell tumours. Somatostatin (SST) analogs are tentatively used to inhibit insulin secretion and control tumour growth in patients with local invasion or inoperative metastasis, but variable responses have been reported. Data regarding somatostatin receptor (SSTR) subtypes expression in insulinomas are conflicting. In this study, we evaluated 16 cases of primary insulinomas (including four primary plurihormonal tumours) and two hepatic metastases. Histopathological and immunohistochemical analysis for some features associated with tumour aggressiveness and semi-quantitative RT-PCR for SSTR1-5 and real-time qPCR for SSTR5 were performed. SSTR subtypes 1, 3, and 5 were expressed in 100%, SSTR2 in 89%, and SSTR4 only in 22% of the insulinomas. SSTR5 mRNA was positively correlated with histopathological features related to tumour aggressiveness (large tumour diameter, well-differentiated endocrine tumour with uncertain behaviour and higher number of cells with nuclear atypia). SSTR5 mRNA expression in primary insulinomas was lower than in primary plurihormonal tumours (P < 0.05). The observed positive correlation between SSTR5 expression and tumour size suggests that the use of SST analogues more specific to SSTR5 in the treatment of insulinomas deserves attention.

Bromocriptine (BRC) and other dopamine agonist drugs are the first-choice treatment for prolactinomas. However, the major disadvantage is the need for prolonged therapy. We retrospectively studied 131 patients [62 microprolactinoma (MIC), 69 macroprolactinoma (MAC)], who achieved serum prolactin (PRL) normalization during BRC use. Twenty-seven percent of them (31% MIC and 69% MAC) underwent previous surgery. Twenty-seven patients (20.6%: 25.8% MIC and 15.9% MAC) persisted with normoprolactinemia after a median time of 44 months of BRC withdrawal. The median time of BRC use was 47 months. There were no statistically significant differences regarding age, gender, BRC initial dose, length of BRC use, tumor size, pregnancy during treatment, previous surgery, or radiotherapy among patients who persisted with normoprolactinemia and those who did not, using both univariate and multivariate analysis. BRC-induced prolactinoma cell alterations are highly controversial; and so, whether the mechanism of PRL normalization after BRC withdrawal is related to BRC use or whether it is attributable to natural history is a matter for debate. A periodic assessment of PRL levels during BRC (and other dopamine-agonist drugs) withdrawal is recommended to avoid the unnecessary maintenance of therapy in a subset of patients with prolactinomas.

Introduction: The main causes of illness and death in Brazil have been migrating backwards into the younger population during the last few years, increasing especially in the more productive age groups. Given the relationship between work and health/disease process, the hypothesis to be considered is that this phenomenon is partially due to the deterioration of workplace conditions. To contribute to investigating this hypothesis, this study estimates mortality risk indicators for the population of Botucatu, in the Southeast region of Brazil, classified according to their occupation., Methods: Standardized mortality coefficient, standardized risk ratio, and years of potential life lost were calculated for the inhabitants of Botucatu who died after their 10th birthday, between January 1997 and March 1998, and classified according to their occupation and main cause of death. Occupational and medical information was obtained by interviewing families of the deceased and their doctors, and checking medical files., Results: The standardized mortality coefficient ranged from 0.6 to 39.9 deaths/1000 workers in different occupations. The years of potential life lost ranged form 33 to 334 years/1000 workers. The ranking of causes of death varied according to occupation and the mortality risk considered., Conclusion: The risk measures analyzed showed a high heterogeneity when associated to occupation and causes of death, which reflects the great social inequality existing in the studied population.

The aim of this paper was to evaluate the accuracy of data on death certificates for occupation and main cause of death. Measure of agreement was assessed comparing data from death certificates with those from both medical records and next-of-kin interviews, analyzing information for 552 residents of Botucatu, Southeast Brazil, who died in 1997. Kappa coefficients of 0.31 (95% C.I. 0. 29-0.34) and 0.76 (95% C.I. 0.75-0.76) were obtained for data on occupation and main cause of death, coded by a Brazilian two-digit classification and the three-digit ICD-10 classification, respectively. One can conclude that, although quality of the main cause of death is acceptable for pilot studies, data on occupation taken only from death certificates is not accurate enough to be used in epidemiological research.

With use of transesophageal echocardiography, the short-term effects of transthoracic electrical cardioversion of atrial flutter (AFI) on atrial mechanical function and spontaneous echo contrast were determined. Thirty patients who had AFI for a mean of 6.4 +/- 12.2 months underwent transthoracic cardioversion. A transesophageal echocardiogram was recorded immediately before cardioversion, and left atrial appendage emptying velocity and spontaneous contrast were assessed serially at 1, 3, and 5 minutes after cardioversion in 28 patients, and also at 8, 10, and 15 minutes after cardioversion in a subgroup of 13 patients. Cardioversion was deferred in 2 patients (7%) because a thrombus was found in the left atrial appendage. Before cardioversion, spontaneous contrast was present in the left atrium in 7 of 28 patients (25%) who underwent cardioversion. The mean left atrial appendage emptying velocity of 54 +/- 22 cm/s before cardioversion fell by 26% to 40 +/- 25 cm/s at 1 minute after restoration of sinus rhythm (p <0.01). There were no significant changes in the mean left atrial appendage-emptying velocity between 1 and 15 minutes after cardioversion. Within 5 minutes after conversion to sinus rhythm, left atrial spontaneous echo contrast developed de novo or worsened in 12 of the 28 patients (43%). In conclusion, the results of this study demonstrate that persistent AFI may be associated with left atrial thrombi before cardioversion and that cardioversion of AFI is associated with a significant degree of atrial stunning and formation of spontaneous echo contrast.

Introduction: Defibrillation energy requirements in patients with nonthoracotomy defibrillators may increase within several months after implantation. However, the stability of the defibrillation energy requirement beyond 1 year has not been reported. The purpose of this study was to characterize the defibrillation energy requirement during 2 years of clinical follow-up., Methods and Results: Thirty-one consecutive patients with a biphasic nonthoracotomy defibrillation system underwent defibrillation energy requirement testing using a step-down technique (20, 15, 12, 10, 8, 6, 5, 4, 3, 2, and 1 J) during defibrillator implantation, and then 24 hours, 2 months, 1 year, and 2 years after implantation. The mean defibrillation energy requirement during these evaluations was 10.9+/-5.5 J, 12.3+/-7.3 J, 11.7+/-5.6 J, 10.2+/-4.0 J, and 11.7+/-7.4 J, respectively (P = 0.4). The defibrillation energy requirement was noted to have increased by 10 J or more after 2 years of follow-up in five patients. In one of these patients, the defibrillation energy requirement was no longer associated with an adequate safety margin, necessitating revision of the defibrillation system. There were no identifiable clinical characteristics that distinguished patients who did and did not develop a 10-J or more increase in the defibrillation energy requirement., Conclusion: The mean defibrillation energy requirement does not change significantly after 2 years of biphasic nonthoracotomy defibrillator system implantation. However, approximately 15% of patients develop a 10-J or greater elevation in the defibrillation energy requirement, and 3% may require a defibrillation system revision. Therefore, a yearly evaluation of the defibrillation energy requirement may be appropriate.

Introduction: The effect of implantable defibrillator shocks on cardiac hemodynamics is poorly understood. The purpose of this study was to test the hypothesis that ventricular defibrillator shocks adversely effect cardiac hemodynamics., Methods and Results: The cardiac index was determined by calculating the mitral valve inflow with transesophogeal Doppler during nonthoracotomy defibrillator implantation in 17 patients. The cardiac index was determined before, and immediately, 1 minute, 2 minutes, and 4 minutes after shocks were delivered during defibrillation energy requirement testing with 27- to 34-, 15-, 10-, 5-, 3-, or 1-J shocks. The cardiac index was also measured at the same time points after 27- to 34-, and 1-J shocks delivered during the baseline rhythm. The cardiac index decreased from 2.30 +/- 0.40 L/min per m2 before a 27- to 34-J shock during defibrillation energy requirement testing to 2.14 +/- 0.45 L/min per m2 immediately afterwards (P = 0.001). This effect persisted for > 4 minutes. An adverse hemodynamic effect of similar magnitude occurred after 15 J (P = 0.003) and 10-J shocks (P = 0.01), but dissipated after 4 minutes and within 2 minutes, respectively. There was a significant correlation between shock strength and the percent change in cardiac index (r = 0.3, P = 0.03). The cardiac index decreased 14% after a 27- to 34-J shock during the baseline rhythm (P < 0.0001). This effect persisted for < 4 minutes. A 1-J shock during the baseline rhythm did not effect the cardiac index., Conclusion: Defibrillator shocks > 9 J delivered during the baseline rhythm or during defibrillation energy requirement testing result in a 10% to 15% reduction in cardiac index, whereas smaller energy shocks do not affect cardiac hemodynamics. The duration and extent of the adverse effect are proportional to the shock strength. Shock strength, and not ventricular fibrillation, appears to be most responsible for this effect. Therefore, the detrimental hemodynamic effects of high-energy shocks may be avoided when low-energy defibrillation is used.

Introduction: Several studies have shown that the fast pathway is more responsive to adenosine than the slow pathway in patients with AV nodal reentrant tachycardia. Little information is available regarding the effect of adenosine on anterograde and retrograde fast pathway conduction., Methods and Results: The effects of adenosine on anterograde and retrograde fast pathway conduction were evaluated in 116 patients (mean age 47 +/- 16 years) with typical AV nodal reentrant tachycardia. Each patient received 12 mg of adenosine during ventricular pacing at a cycle length 20 msec longer than the fast pathway VA block cycle length and during sinus rhythm or atrial pacing at 20 msec longer than the fast pathway AV block cycle length. Anterograde block occurred in 98% of patients compared with retrograde fast pathway block in 62% of patients (P < 0.001). Unresponsiveness of the retrograde fast pathway to adenosine was associated with a shorter AV block cycle length (374 +/- 78 vs 333 +/- 74 msec, P < 0.01), a shorter VA block cycle length (383 +/- 121 vs 307 +/- 49 msec, P < 0.001), and a shorter VA interval during tachycardia (53 +/- 23 vs 41 +/- 17 msec, P < 0.01)., Conclusion: Although anterograde fast pathway conduction is almost always blocked by 12 mg of adenosine, retrograde fast pathway conduction is not blocked by adenosine in 38% of patients with typical AV nodal reentrant tachycardia. This indicates that the anterograde and retrograde fast pathways may be anatomically and/or functionally distinct. Unresponsiveness of VA conduction to adenosine is not a reliable indicator of an accessory pathway.

Introduction: A stimulus delivered in the T wave of a paced cardiac cycle can induce ventricular fibrillation (VF). If the stimulus strength is increased, the probability of inducing VF decreases. This study determines an ideal mathematical model (a dose-response curve) for the relationship between the shock strength and the probability of inducing VF or defibrillating., Methods and Results: Defibrillating electrodes were implanted in the right ventricle and superior vena cava in 16 pigs. The electrode in the vena cava was electrically connected to a cutaneous patch. The same electrodes were used for both VF induction and defibrillation. T wave stimuli were given at the peak of the T wave according to a modified up-down protocol (40 V up, 20 V down). When a T wave stimulus induced VF, a defibrillation stimulus was delivered 10 seconds later, also according to the modified up-down protocol. Exponential, logistic, log-dose logistic, piecewise linear and Box-Tiao dose-response curves were fit to the resulting data using the maximum likelihood method. For the defibrillation data, it was found that only the logistic and Box-Tiao curves fit all of the animals (P < 0.05). For VF induction, only the Box-Tiao curve fit all of the animals (P < 0.05). Extrapolating along a dose-response curve that did not fit to a shock strength with a very low probability of inducing VF or a very high probability of defibrillating yielded errors as great as 610 V., Conclusion: The Box-Tiao dose-response curve is the best single choice for fitting VF induction or defibrillation datasets.

Background: Defibrillation waveform and its spatial and temporal distribution are important determinants of its efficacy. Previous comparisons of monophasic, biphasic and sequential waveforms have used one current pathway for monophasic and biphasic defibrillation and two pathways for sequential defibrillation thus confounding a direct comparison of the waveforms., Design: This study compared monophasic, biphasic and sequential pulse defibrillation over a single current pathway using a nonthoracotomy and a thoracotomy lead system in a dog model., Main Results: Eight mongrel dogs (mean weight 21.6+/-2.9 kg) first underwent nonthoracotomy defibrillation testing followed by a median sternotomy and implantation of two 13.9 cm2 epicardial patch electrodes posterior = cathode). Nonthoracotomy electrode configuration consisted of a right ventricular catheter (cathode) and a chest wall subcutaneous patch (anode). After 10 s of alternating current induced ventricular fibrillation, defibrillation was attempted with a test shock. Monophasic, biphasic and sequential shocks of 10 ms total duration were compared. Biphasic and sequential shocks consisted of two 5 ms components separated by 0.25 ms switch time constant. Four trials of five leading edge voltages were performed for each waveform and stepwise logistic regression analysis was used to determine 80% probability of successful defibrillation (E80). For epicardial defibrillation, E80s were monophasic 11.3+/-1.5 J; biphasic 7.9+/-1.2 J; and sequential 12.1+/-1.4 J. For nonthoracotomy defibrillation, E80s were monophasic 17.7+/-3.4 J; biphasic 13.8+/-3.3 J; and sequential 18.2+/-3.5 J. The mean E80 for biphasic pulses was significantly lower than monophasic or sequential pulses for either lead system., Conclusions: Biphasic pulses are superior to monophasic or sequential pulses delivered over a single current pathway.

Background: An upper limit to the strength of shocks that induce fibrillation during the vulnerable period, the upper limit of vulnerability (ULV), has been shown to exist in both humans and animals. The purpose of this study was to compare ULV and defibrillation (DF) probability of success curves for a clinically useful nonthoracotomy lead system., Methods and Results: Sixteen pentobarbital-anesthetized pigs were studied. Single-capacitor biphasic waveforms with both phases 5.5 ms in duration were used for ULV and DF testing. A right ventricular catheter electrode served as first-phase cathode and a superior vena cava catheter electrode coupled with a cutaneous R2 patch electrode served as common first-phase anodes. A pacing catheter was placed in the right ventricle to deliver a train of 15 S1 stimuli at a pacing interval of 250 to 300 ms. A ULV shock was delivered on the peak of the T wave as measured from the surface ECG; if ventricular fibrillation was induced, a DF shock was delivered after 10 seconds of fibrillation. Shock voltages were determined by an up-down protocol. Ventricular fibrillation was induced an average of 53 times in each animal. The composite data indicate that below V97, that is, the voltage that leaves the animal in normal sinus rhythm 97% of the time when delivered on the peak of the T wave or the voltage that defibrillates 97% of the time, ULV is lower than DF. ULV and DF became significantly correlated at V80 and maximally correlated at V97. Even at V97, however, ULV and DF differed by more than 100 V in 2 of the 16 animals., Conclusions: ULV approximately equaled DF at V97. This is fortunate because it is clinically important to set the device voltage at the uppermost portion of the probability of success curve. Estimating DF V97 from ULV V97 would reduce the number of fibrillation inductions needed to establish defibrillation shock strength requirements. However, the large difference between ULV V97 and DF in a few animals indicates that further improvement and testing of algorithms for determining ULV V97 must be developed before the technique is used clinically.

Defibrillation using epicardial patches may be associated with lower energy requirements than nonthoracotomy defibrillation although a direct comparison using various waveforms has not been reported. To directly compare defibrillation efficacy using these two configurations, nine mongrel dogs (20.9 +/- 2.3 kg) first underwent nonthoracotomy defibrillation testing followed by a thoracotomy and implantation of epicardial patch electrodes and redetermination of defibrillation efficacy. Each dog served as its own control. Nonthoracotomy electrode configuration consisted of a right ventricular catheter (cathode) and a chest wall subcutaneous patch (anode). The epicardial configuration consisted of two 13.9 cm2 epicardial patches. Alternating current induced ventricular fibrillation was allowed to persist for 10 seconds, followed by either a monophasic or a single capacitor biphasic shock of 10-msec total duration. Four trials of five leading edge voltages were performed for monophasic and biphasic pulses and stepwise logistic regression analysis was used to determine 80% probability of successful defibrillation (E80). For epicardial defibrillation E80s were: monophasic 19.2 +/- 4.2 J and biphasic 12.6 +/- 4.0 J; nonthoracotomy defibrillation E80s were: monophasic 24.2 +/- 4.4 J and biphasic 17.8 +/- 4.1 J. Epicardial patch defibrillation required less energy than nonthoracotomy electrode configuration. However, using biphasic pulses nonthoracotomy defibrillation could achieve lower defibrillation energy requirements than epicardial defibrillation with monophasic pulses.

The effects of high voltage defibrillation shocks given to six swine were studied to determine if there is a limit to the advantage gained from increasing the shock strength. An endocardial electrode was placed in the right ventricle, and a 114-cm2 cutaneous patch was placed on the left lateral thorax. Monophasic (10 msec) and single capacitor biphasic (5/5 msec) shocks with leading edge voltages of 200, 400, 600, 800, and 990 volts (approximately 2.3-59 J) were tested. For monophasic shocks, the probability of successful defibrillation ranged from 0% at 200 V to 90% at 990 V. The incidence of postshock arrhythmia increased from 0% for successful shocks at 600 V to 67% for successful shocks at 990 V. For biphasic shocks, the probability of success peaked at 97% for the 600-, 800-, and 990-V shocks. The incidence of postshock arrhythmia increased from 8% at 400 V to 55% at 990 V. Although more postshock arrhythmias occurred at lower strengths for biphasic than for monophasic shocks, an efficacy criterion, quantifying the probability of defibrillation success and the probability that a postshock arrhythmia will not occur, was always higher for biphasic shocks. The probability of success never reached 100% for either waveform while the incidence of postshock arrhythmia increased as the shock strength increased. In conclusion, for the catheter-patch electrode configuration, increasing the shock strength does not always improve the probability of success and may increase the incidence of postshock arrhythmia.

Experimental and clinical data using epicardial patch electrodes and monophasic waveform suggest that electrode polarity may be an important determinant of defibrillation efficacy. Our objective was to examine the effect of electrode polarity in an animal model using a nonthoracotomy system and monophasic and biphasic waveforms for defibrillation. We examined the effect of lead polarity in 14 pentobarbital anesthetized dogs (21.1 +/- 2.4 kg) using monophasic and biphasic shocks and a nonthoracotomy system. Monophasic and single capacitor biphasic shocks of 10-msec total duration were used. The lead system consisted of a right ventricular catheter electrode with 4-cm2 surface area and a left chest wall subcutaneous patch electrode with 13.9-cm2 surface area. Electrode polarities RV(-)-Patch(+) and RV(+)Patch(-) were tested using both monophasic and biphasic waveforms. Alternating current was used to induce ventricular fibrillation and test shocks were delivered after 10 seconds of ventricular fibrillation. Each polarity configuration for monophasic and biphasic waveforms was tested four times at five different capacitor voltage levels (200-600 V, in 100-V increments). Defibrillation efficacy curves were constructed using logistic regression analysis for each animal and energies associated with 80% probability of successful defibrillation (E80) were determined. The mean E80 +/- SD values were as follows. Monophasic waveform: RV(-)Patch(+) 23.4 +/- 7.5 J; RV(+)Patch(-) 20.9 +/- 7.9 J (P < 0.03). Biphasic waveform: RV(-)Patch(+) 15.8 +/- 6.8 J; RV(+)Patch(-) 12.5 +/- 6.0 J (P < 0.03). The mean impedance values for both waveforms using either polarity ranged from 65.4 to 67 ohms and were not significantly different.(ABSTRACT TRUNCATED AT 250 WORDS)

Pericardial effusion may increase defibrillation energy requirements. We examined the effect of pericardial effusion in seven pentobarbital anesthetized dogs (25.3 +/- 3.4 kg) using monophasic and biphasic shock. A median sternotomy was performed and two 13.9 cm2 patch electrodes were sewn extrapericardially; 3 cc/kg of 0.9% NaCl was instilled through an intrapericardial catheter used to create a hemodynamically insignificant pericardial effusion. Four trials of five leading edge voltages (200-600 volts, in 100 volt increments) were performed for monophasic and biphasic shocks of 10 msec total duration and defibrillation efficacy curves were determined by logistic regression analysis. Baseline impedance was 68.1 and 66.2 Ohms for monophasic and biphasic waveforms, respectively, and decreased to 52.9 and 49.9 Ohms, respectively, with pericardial effusion (P < 0.01). Energy associated with 80% probability of successful defibrillation (E80) for monophasic shock was 16.0 joules at baseline and increased to 18.5 joules with pericardial effusion (P < 0.016). Similarly, E80 for biphasic shocks increased from 10.6 joules to 13.0 joules (P < 0.016). Removal of pericardial effusion was associated with impedance and E80 returning to baseline. In this model, pericardial effusion increased defibrillation energy requirements and may explain early postimplant defibrillator failure.

A 59-year-old woman who underwent laparoscopic cholecystectomy for symptomatic cholecystitis presented four months later with fever, malaise, anorexia, hemoptysis and lithoptysis. Chemical analysis of the expectorated lithes revealed them to be gallstones. Ultrasound studies of the right upper quadrant demonstrated both supradiaphragmatic and subdiaphragmatic fluid collections containing echogenic fragments. ERCP failed to demonstrate retained ductal stones or fistula formation. To our knowledge, this is the first reported case of cholelithoptysis and demonstrates an unusual complication of gallstone retention following laparoscopic cholecystectomy.

In conditions associated with stimulation of cellular immunity and enhanced macrophage activity, for example, in viral infections, neopterin is elevated. Acute exacerbations of bronchial asthma--in particular in the case of intrinsic asthma--are frequently precipitated by viral infections of the upper airways. In both extrinsic and intrinsic asthma, neopterin is normal in the stable phases. In the exacerbation phase with signs of infection of the upper airways, however, neopterin in significantly elevated both in the serum and in the urine. In contrast, during and following positive inhalative provocation testing with histamine, allergens and aspirin, no increase in neopterin is to be observed.

The association between pre-operative serum carcinoembryonic antigen (CEA) and liver scanning employing technetium (99mTc)-tin colloid was investigated in 30 women subsequently proven to have primary epithelial ovarian carcinoma to determine whether these two investigations improve the detection of hepatic metastases. The upper limit of normal for CEA (greater than or equal to 5 ng/ml) did not represent the optimal levels for use in predicting ovarian carcinoma nor the presence of liver metastases. But with CEA levels greater than 10 ng/ml sensitivity for liver metastases was 57%. Liver scanning alone demonstrated metastases in five out of seven patients (71%) with parenchymal liver metastases. The combination of CEA and liver scan was positive in six out of these seven patients (86%).

A true XX hermaphrodite presenting in adulthood with male sex gender identity was found to have separate vaginal and urethral openings in the perineum. A total vaginectomy was performed at the same time as total abdominal hysterectomy and gonadectomy because the vaginal opening would interfere with a urethroplasty to repair the hypospadias and chordee phallus. During this procedure prostatic tissue was excised in the area of the anterior vaginal wall adjacent to the urethra. Recommendations regarding this rare XX true hermaphroditism are put toward and observations on some bizarre features of the entity are made. The authors plead for the formation of a national register to study this interesting condition.

Two hundred unbooked mothers were questioned after delivery and their reasons for non-attendance at antenatal clinics were determined. The control group consisted of 310 mothers who had booked early and were good clinic attenders. The most significant difference between the two groups was that the unbooked mothers were of lower socioeconomic status and lived in poorer areas situated further from the hospital. The main reasons given for not attending hospital clinics included the expense involved and the fact that the mothers often stayed outside the area during the pregnancy.

A case of acute myelomonocytic leukaemia in pregnancy with successful outcome is reported. Aspects of management are reviewed, especially with regard to expected complications following cytostatic therapy and the effects on both mother and fetus. The need to determine the optimal time for elective delivery is emphasized. The seasons for formation of an international tumour registry are outlined. The disease can no longer be regarded as invariably fatal for mother and child.

The value of maternal C-reactive protein (CRP) levels as predictors of fetal and maternal infective morbidity and fetal mortality was assessed prospectively over a 6-month period in all cases of premature rupture of the fetal membranes or suspected premature labour. Statistical analysis of results showed that CRP at a level of 1.32 mg/dl is a sensitive marker of infective morbidity in mother and neonate. Furthermore, there was a significant association between raised CRP levels and low-birth-weight babies, suggesting that intra-uterine infection is a major cause of prematurity in the study population.