Porotic hyperostosis, anemias, malarias, and marshes in the prehistoric Eastern Mediterranean.

Porotic hyperostosis, formerly called osteoporosis symmetrica, is an overgrowth of the spongy marrow space of the skull. In children, other bones may also be affected. The disease is a consequence of one of the thalassemias or sicklemia. These anemias are balanced polymorphisms which are apparently maintained by falciparum malaria. Falciparum malaria spread over the anopheline belts of the Old World in coincidence with porotic hyperostosis, but did not penetrate the New World. Here some other parasitism or deficiency anemia must have been the cause of porotic hyperostosis in ancient times. In Anatolia, Greece, and Cyprus from the seventh to second millennia B.C., porotic hyperostosis occurred frequently in early farmers who lived in marshy areas, but rarely in inhabitants of dry or rocky areas or in latest Paleolithic hunters. As shown by skeletal samples from Greece, the frequency of the disease decreased as farming methods improved. However, from Hellenistic to Romantic times it again increased together with increases in the incidence of malaria and in poorer farming. There are correlations between porotic hyperostosis and adult stature and fertility. The mutations producing falciparum malaria therefore must antedate seventh millenium B.C. and I think may have an Eastern Mediterranean origin.

Portraiture and excavations.

In a footnote to the review of M. M. Gerasimov's The Face Finder [173, 712 (1971)], the misspelling of Julius Koliman's name is erroneously attributed to a bibliography (1962) by W. M. Krogman. The error occurs in a different authority's work. Kollmann established methods (1898) for building on a skull a face recognizably correct.

Problems in determination of skeletal lead burden in archaeological samples: an example from the First African Baptist Church population.

Human bone lead content has been demonstrated to be related to socioeconomic status, occupation and other social and environmental correlates. Skeletal tissue samples from 135 individuals from an early nineteenth century Philadelphia cemetery (First African Baptist Church) were studied by electrothermal atomic absorption spectrometry and X-ray fluorescence for lead content. High bone lead levels led to investigation of possible diagenetic effects. These were investigated by several different approaches including distribution of lead within bone by X-ray fluorescence, histological preservation, soil lead concentration and acidity as well as location and depth of burial. Bone lead levels were very high in children, exceeding those of the adult population that were buried in the cemetery, and also those of present day adults. The antemortem age-related increase in bone lead, reported in other studies, was not evidenced in this population. Lead was evenly deposited in areas of taphonomic bone destruction. Synchrotron X-ray fluorescence studies revealed no consistent pattern of lead microdistribution within the bone. Our conclusions are that postmortem diagenesis of lead ion has penetrated these archaeological bones to a degree that makes their original bone lead content irretrievable by any known method. Increased bone porosity is most likely responsible for the very high levels of lead found in bones of newborns and children.

Computed tomography in diagnosis of puerperal ovarian vein thrombosis.

The syndrome of puerperal ovarian vein thrombosis is often a diagnostic enigma. In the past, laparotomy has been the most frequent modality used to establish the diagnosis. The clinical picture and characteristic mass have not accurately predicted the presence of this syndrome, resulting in potentially dangerous and unnecessary surgery. The use of computed tomography is suggested as a noninvasive ancillary method.

Late diagnosis of nonconjoined monoamniotic twins using computed tomographic imaging: a case report.

Monoamniotic twin gestations, although rare, are associated with a high perinatal mortality rate. Early antenatal diagnosis is important to ensure optimal perinatal care. However, the diagnosis can be difficult to confirm, especially in late gestation when a dividing membrane may be difficult to visualize. Intra-amniotic injection of Renografin followed by a single-slice computed tomographic scan at the level of the umbilicus is described. This imaging method assisted in the confirmation of monoamniotic twinning.

Cephalocele involving the oral cavity.

A cephalocele is an uncommon neural tube defect that rarely involves the oral cavity. We present a case of an oral cephalocele associated with polyhydramnios discovered on antenatal ultrasound. The differential diagnosis includes epignathus and epulis. The prognosis is dependent not only on the extent of brain involvement and associated anomalies, but also on the exact location of the herniated mass. If the oral cavity is extensively involved, airway management at birth may be difficult. Therefore, preparations for delivery may include maternal tertiary site referral, antenatal neurosurgical and pediatric consultation, and anticipation of complications such as rupture of the sac, dystocia, or the need for immediate tracheostomy if intubation is not possible.

A randomized study of antibiotic therapy in idiopathic preterm labor.

A randomized study was undertaken to test the effects of antibiotics as an adjunct to established methods of tocolysis. One hundred fifty patients with cervical dilation of 1 cm or more and no clinically identifiable cause for preterm labor qualified for the study. Fifty-three (35%) received 500 mg ampicillin orally every 6 hours, 50 (33%) received 500 mg erythromycin orally every 6 hours, and 47 served as controls. Antibiotics were prescribed for 10 days, and the treatment was not altered by the results of cervical cultures. Of these 150 patients, 16 (11%) had positive amniotic fluid cultures. The pregnancies with positive amniotic fluid culture were characterized by significantly less time gained after admission (2.6 versus 28.7 days) and lower birth weight (1262 versus 2470 g) than in those with negative cultures. Histologic studies of the placenta revealed chorioamnionitis in 22 (16%) of 134 patients with negative amniotic fluid cultures; these pregnancies were associated with less time gained after admission (12.5 versus 31.9 days) and lower birth weight (1680 versus 2618 g) compared with pregnancies without histologic chorioamnionitis. In patients with similar gestational age and cervical dilation, the adjunctive use of antibiotic therapy resulted in a statistically significant delay from admission to delivery (30 versus 17 days). In cases of negative amniotic fluid cultures, cervical colonization with group B streptococcus and/or Gardnerella vaginalis increased the risk of prematurity, which improved significantly when ampicillin was given.

Infusion of packed erythrocytes: an in vitro study of hemolysis.

Blood infusion through standard 20- and 22-gauge spinal needles, with varying hematocrit and rates of 1-6 mL/minute, did not result in significant amounts of erythrocyte hemolysis.

Fetal lung maturation: the combined use of corticosteroids and thyrotropin-releasing hormone.

The purpose of this randomized study was to evaluate whether the combined use of corticosteroids and thyrotropin-releasing hormone would enhance fetal lung maturation to a greater degree than would corticosteroids alone. The study was restricted to patients under 34 weeks' gestation with a lecithin/sphingomyelin (L/S) ratio less than 2.0. The patients were randomized into a study group receiving intravenous thyrotropin-releasing hormone along with intramuscular corticosteroids over 48 hours and a control group receiving only corticosteroids. Patients undelivered 1 week after the onset of therapy underwent a repeat amniocentesis to document changes in the L/S ratio. In those patients delivering within 1 week of therapy, the neonatal clinical course was established by two investigators blinded to the antenatal therapy. Compared with the control group, the group receiving antenatal corticosteroids plus thyrotropin-releasing hormone showed a greater post-therapy increase in L/S ratio, fewer respirator days, and a lower incidence of bronchopulmonary dysplasia. The results of this study suggest that the combined use of corticosteroids and thyrotropin-releasing hormone results in enhanced fetal pulmonic maturation superior to that achieved with corticosteroids alone.

Postcoital pneumoperitoneum.

Acute abdominal and shoulder pain in association with a pneumoperitoneum are common signs and symptoms of perforation of a hollow viscus. We report a case that describes the development of a postcoital pneumoperitoneum in an otherwise healthy postpartum patient. The literature is discussed, and supports this case as pneumoperitoneum in association with vigorous coital activity.

Instructional model for percutaneous fetal umbilical blood sampling.

Percutaneous umbilical cord sampling is gaining widespread acceptance for diagnostic and therapeutic procedures on the fetus. The sampling technique has been reported to be relatively safe in experienced hands. Attainment of the skills for this procedure follows a learning curve, with improvement in successful sampling occurring over time. This paper presents a practical instructional model for percutaneous umbilical cord sampling.

Percutaneous balloon aortic valvuloplasty in pregnancy.

Severe symptomatic aortic stenosis in pregnancy carries a poor prognosis. Although cardiopulmonary bypass and surgical repair has been reported to have a low maternal mortality, the fetal risk remains substantial. We report a case in which percutaneous balloon valvuloplasty was performed successfully at 19 weeks' gestation. The procedure restored physiologic left ventricular outflow and improved the aortic valve peak systolic pressure gradient. This allowed progression of the pregnancy to term and an uneventful delivery of a healthy infant, with no maternal complications. Although the long-term efficacy of percutaneous balloon aortic valvuloplasty has not been established, this case report has shown it to be useful as a palliative procedure.

Cocaine and indomethacin: fetal anuria, neonatal edema, and gastrointestinal bleeding.

A case is reported in which exposure to cocaine and indomethacin was associated with development of fetal anuria, anasarca, and neonatal gastrointestinal hemorrhage. Cocaine and indomethacin may act synergistically to adversely affect renal, cardiovascular, and platelet function. It may be prudent to obtain a drug history and urine screen for cocaine before instituting indomethacin therapy for preterm labor or polyhydramnios.

Human fetal response to vibroacoustic stimulation as a function of stimulus duration.

The effect of stimulus duration on the initial fetal heart rate (FHR) acceleration response was evaluated by assessing its amplitude and span following a single vibroacoustic stimulation with durations of 0 (sham), 1, 3, or 5 seconds. Statistically significant differences were observed in the mean amplitude and duration of acceleration in groups 3 and 5 when compared with groups 0 and 1 (P less than .05). In addition, groups 3 and 5 demonstrated significantly greater fetal reactivity than group 0 and a decrease in testing time over groups 0 and 1 (P less than .05). Our results suggest that the magnitude of the FHR acceleration response is dependent on the duration of the stimulus. Furthermore, a 3-second sound stimulus appears to be adequate for a shift to the fetal behavioral "awake" state.

Use of ampicillin and corticosteroids in premature rupture of membranes: a randomized study.

A randomized study was conducted to investigate the effects of antenatal corticosteroids and ampicillin in the management of preterm pregnancies under 34 weeks complicated by premature rupture of membranes. Patients with documented lecithin/sphingomyelin (L/S) ratios of less than 2.0 and a singleton gestation were eligible to participate in the study. One hundred sixty-five patients qualified and were randomized, using sealed envelopes, to four study groups. All patients were followed expectantly. Group I (41 patients) received neither ampicillin nor corticosteroids. Group II (43 patients) received 24 mg of antenatal betamethasone. Group III (37 patients) received 2 g of intravenous ampicillin every 6 hours, with discontinuation of antibiotic therapy if cultures were negative for pathogenic bacteria. Group IV (44 patients) received both corticosteroids and ampicillin as described for groups II and III, respectively. Compared with patients not receiving corticosteroids, those administered antenatal corticosteroids experienced a reduction in the incidences of respiratory distress syndrome (53 versus 26%), bronchopulmonary dysplasia (23 versus 9%), severe grades of intracranial hemorrhage (15 versus 3%), and patent ductus arteriosus (18 versus 6%), with no difference in the incidence of maternal or neonatal infection. Compared with patients not receiving antenatal antibiotics, the group of patients treated with ampicillin on admission had a lower incidence of clinical chorioamnionitis (4 versus 26%) and neonatal sepsis (5 versus 10%). This reduction in infectious morbidity by antenatal ampicillin was restricted to those patients (28.4% of the study population) colonized with group B streptococci.(ABSTRACT TRUNCATED AT 250 WORDS)

Efficacy and safety of indomethacin versus ritodrine in the management of preterm labor: a randomized study.

One hundred six patients in preterm labor with intact amniotic membranes and gestational age less than or equal to 32 weeks were randomized to receive either ritodrine hydrochloride or a 48-hour course of indomethacin for tocolysis. The relative efficacy, maternal and neonatal safety, and costs were evaluated to determine which may be the more appropriate first-line pharmacologic agent used to manage preterm labor. Fifty-four patients and 52 patients were randomized to receive ritodrine hydrochloride or indomethacin, respectively. Ritodrine hydrochloride and indomethacin were equally effective in inhibiting uterine contractions and delaying delivery. Delivery was delayed for at least 48 hours in 83 and 94%, and for at least 7 days in 70 and 75% of patients receiving ritodrine or indomethacin, respectively. Tocolysis with indomethacin was associated with no maternal side effects, whereas tocolysis with ritodrine hydrochloride was associated with a 24% incidence of serious cardiovascular and metabolic adverse effects prompting discontinuation of the drug. There were no differences in outcome between the infants exposed to indomethacin versus ritodrine hydrochloride when delivered either remote from therapy or during therapy, except for a statistically higher serum glucose in the infants exposed to ritodrine hydrochloride when delivered during tocolytic therapy. There were no cases of premature closure of the ductus arteriosus or pulmonary hypertension. Tocolysis with indomethacin was 17 times less costly than tocolysis with ritodrine hydrochloride. For gestations less than or equal to 32 weeks complicated by preterm labor, indomethacin may be an appropriate alternative as a first-line tocolytic agent.

Acute pyelonephritis in pregnancy: a prospective study of oral versus intravenous antibiotic therapy.

Ninety pregnant women admitted to the high-risk pregnancy unit with a diagnosis of acute pyelonephritis were randomized to receive either oral (cephalexin 500 mg every 6 hours) or intravenous (IV) (cephalothin 1 g every 6 hours) antibiotic therapy. All patients were initially hydrated with 1 L of normal saline IV over 4 hours. Neither parenteral analgesics nor antiemetics were used. Bacteremia was noted in 13 (14.4%) of the 90 patients and mandated IV therapy. There was no difference between the oral and IV groups concerning predefined criteria for successful therapy (91.4 versus 92.9% successful therapy, respectively). No characteristic available at presentation predicted bacteremia or ultimate failure of therapy. Two patients (2.2%) experienced significant complications. These data suggest that in nonbacteremic patients, oral antibiotics are both safe and effective for the treatment of acute pyelonephritis in pregnancy.

Platelet inhibitory activity in placentas from normal and abnormal pregnancies.

Retroplacental blood flow requires inhibition of coagulation in the absence of an endothelial lining. We confirmed that trophoblast releases an inhibitor of platelet aggregation which functions via degradation of adenosine diphosphate. This inhibitor appears to be deficient in some pregnancies with abruptio placentae and intrauterine growth retardation. Unimpeded retroplacental blood flow may depend upon the local inhibition of platelet aggregation. Placental tissue contains an inhibitor of platelet aggregation which appears to be an adenosine diphosphatase distinct from heat-stable alkaline phosphatase. Placental tissue from patients with abruptio placentae contains abnormally low amounts of this enzyme.

Sequential outpatient application of intravaginal prostaglandin E2 gel in the management of postdates pregnancies.

A randomized blinded investigation was undertaken to determine the efficacy and safety of sequentially applied intravaginal prostaglandin E2 (PGE2) gel for accelerating cervical ripening in an outpatient setting in low-risk prolonged pregnancies. Fifty women with uncomplicated pregnancies at or beyond 41 weeks' gestation and Bishop scores below 9 received twice-weekly outpatient administration of gel containing 2.0 mg of PGE2 or placebo. Thirty nulliparas and 20 multiparas were enrolled. The PGE2 gel failed to improve cervical ripening over placebo, as judged by Bishop scores. There was no difference between the groups in gestational age on admission to the labor and delivery suite, number of gel applications, requirement for oxytocin, incidence of cesarean delivery, or neonatal outcome. Only two patients (4%) experienced regular uterine contractions after gel insertion; these subsided spontaneously in both. None of the subjects experienced labor, tetanic contractions, evidence of fetal distress, or any other side effects related to gel insertion. We conclude that PGE2 gel in this dosage may be used safely in an outpatient setting, but more frequent application or earlier initiation may be required to produce a clinical effect.

Serum prostacyclin binding and half-life in normal and hypertensive pregnant women.

The effective half-life of prostacyclin in human serum is highly dependent on binding to serum proteins. Abnormalities in prostacyclin binding appear to be important in some patients with thrombotic thrombocytopenic purpura. We investigated prostacyclin binding and half-life in normotensive and hypertensive pregnant women and in nonpregnant controls. Pregnancy was associated with a decrease in serum prostacyclin binding and a shorter prostacyclin half-life. This decrease was even greater in women with hypertensive disorders. The decrease in prostacyclin half-life in hypertensive disorders may play an important role in the pathogenesis of these disorders. Measurement of both production and metabolism, however, will be required to adequately assess the role of prostacyclin in normal and abnormal gestation.