Molecular diagnostics of Salmonella and Campylobacter in human/animal fecal samples remain feasible after long-term sample storage without specific requirements.

Rapid advances in the development of sequencing technologies, numbers of commercial providers and diminishing costs have made DNA-based identification and diagnostics increasingly accessible to doctors and laboratories, eliminating the need for local investments in expensive technology and training or hiring of skilled technicians. However, reliable and comparable molecular analyses of bacteria in stool samples are dependent on storage and workflow conditions that do not introduce post-sampling bias, the most important factor being the need to keep the DNA at a stable detectable level. For that reason, there may remain other prohibitively costly requirements for cooling or freezing equipment or special chemical additives. This study investigates the diagnostic detectability of Salmonella and Campylobacter DNA in human, pig and chicken stool samples, stored at different temperatures and with different preservation methods. Stool samples were spiked with 106 CFU/mL of both Salmonella and Campylobacter strains stored at -20 °C, 5 °C and 20 °C (Room temperature, RT) and treated with either RNAlater, EDTA or Silica/ethanol. DNA was extracted at 9 different time points within 30 days and quantified by Qubit (total DNA) and qPCR (Salmonella and Campylobacter DNA). We found no statistically significant differences among the different preservation methods, and DNA from both species was easily detected at all time points and at all temperatures, both with and without preservation. This suggests that infections by these bacteria can be diagnosed and possibly also analysed in further detail simply by taking a stool sample in any suitable sealed container that can be transported to laboratory analysis without special storage or preservation requirements. We briefly discuss how this finding can benefit infection control in both developed and developing countries.

Comparison of family nursing in Slovenia and Scotland: integrative review.

AIM: The aim of this study was to examine and compare the advantages and disadvantages of two systems of community nursing through the history of their development, and to compare these systems with the World Health Organization model of the Family Health Nurse. BACKGROUND: In Slovenia, the family/community nursing service is designed according to the World Health Organization policies and is performed by the generalist family/community nurse. In contrast, across Scotland there is no universal model and the current system comprises several different specialist-nursing pathways. The study aimed to describe each model and to understand why the family health nurse model was preferred in Slovenia but rejected in Scotland. METHODS: This study was based on integrative review method conducted from August 2013 to September 2015 using national and international specialized databases. While the published literature on this topic is very limited, this review also includes unpublished material. For data analysis, the Walker and Avant's concept analysis model was used. RESULTS: Three main themes were identified through the process of the literature search; the Family Health Nurse concept, family/community nursing development in Slovenia, and community nursing development in Scotland. Findings related specifically to the different roles of nurses in the community in Slovenia and Scotland are reported. CONCLUSIONS: It is clear that the WHO guidelines and recommendations are not suitable for implementation in all member countries. Both models have advantages and disadvantages. In developing community nursing services, it would be wise to look for systems that represent the best solutions for treatment of the individual, the family and the community. IMPLICATIONS FOR NURSING AND HEALTH POLICY: The findings should be used when designing new models applied in different healthcare systems within each country, with a focus on strategy aimed at the welfare of the patient and his family. Findings give a possible solution for financially restricted healthcare systems, regarding the patient's care in the home environment.

Multiorgan thrombotic disorder in a young patient with primary antiphospholipid syndrome (APS) and ovarian tumor.

Catastrophic antiphospholipid syndrome (CAPS) is a life-threatening condition with high mortality rate besides aggressive multimodal treatment. Underlying triggers of "thrombotic and cytokine storm" include pregnancy, inflammation, trauma, surgery, and infection. The authors present a case of a young female patient with primary antiphospholipid syndrome (APS) who was admitted to the hospital due to abdominal pain caused by ovarian tumor with elevated tumor markers. After the prophylactic anticoagulants and antibiotic treatment, surgery was performed. Suddenly after treatment, her clinical status deteriorated and she died regardless of intensive immunosupresive and anticoagulant therapy attempts. This condition requires all clinical awareness, timely diagnosis, and therapeutical approach, including a better understanding of the pathophysiology that leads to CAPS.

Endometrial stromal sarcoma with intracaval extension at initial presentation.

Endometrial stromal sarcoma (ESS) is a rare uterine neoplasm. Tumor involvement of the large vessels is extremely rare. This is a case report of ESS with tumor invasion of the inferior vena cava at initial presentation.

Prediction of fetal macrosomia with ultrasound parameters and maternal glycemic controls in gestational diabetes mellitus.

PURPOSE OF INVESTIGATION: Evaluation of ultrasound measurements of fetal adipose subcutaneous tissue (ASCT), abdominal circumference (AC), liver length (LL), and amniotic fluid index (AFI) in prediction of fetal macrosomia (FM) and gestational diabetes mellitus (GDM). MATERIALS AND METHODS: In a prospective clinical trial, 280 pregnant women underwent 100 g oral glucose tolerance test (oGTT) at 28th week of gestation (wg) and measurements ofAC, LL, AFI, and ASCT at 32nd, 34th, 36th, and 38th wg. RESULTS: For GDM, the best sensitivity was achieved by ACST at 32nd and 34th wg, the best specificity by LL at 32nd wg (90.6%), the best area under the curve (AUC) by LL at 34th wg (0.944). For FM the best sensitivity was achieved by AC at 32th, 34th, 36th, and 38th wg and by ASCT at 34th wg (94.2%), and the best AUC at 38th wg for AC (0.974). CONCLUSION: Ultrasound parameters of glycemic control were good predictors of FM and GDM.

Surgical treatment of ovarian cancer and early detection of venous thromboembolism.

INTRODUCTION: Deep vein thrombosis (DVT) is present in 10.6% patients after operative treatment for ovarian malignancy. We undertook the present study to find the risk factors for venous thromboembolism (VTE) after surgical treatment for ovarian cancer and to clarify the prognostic value of D-dimer and a positive PTP test (Wells score) in these patients. MATERIAL AND METHODS: A total of 31 consecutive patients with histologically confirmed ovarian cancer after surgery, clinically suspicious for DVT were followed from January 2006 to December 2008. All patients were operatively treated at the Clinical Center of Serbia. Study variables included age, cardiovascular disease, FIGO stage, histology, BMI, presence of massive ascites and tumor size, D-dimer level and Wells score. All patients were postoperatively administered anticoagulant therapy. RESULTS: DVT was found in nine of 31 patients (29.0%). High BMI and presence of massive ascites were significantly associated with DVT. D-dimer (DD) levels were high in 27 of out 31 patients (87.1%). Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were 100, 18.2, 33.3 and 100%. Results of the PTP test (according to Wells score) was positive in 20 out of 31 patients (64.5%). PTP score was not significantly different in patients with or without VTE (p = 0.606). Sensitivity, specificity, PPV and NPV were 66.7, 36.4, 30.0 and 72.7%, respectively. CONCLUSION: Incidence of VTE after gynecological operations for ovarian cancer in our study was similar to other investigators. Obesity and the massive ascites are statistically significant risk factors. Measurement of DD level and ultrasonography could become the standard in predicting VTE in ovarian cancer surgery. The use of Wells score is not satisfying in these patients. Prediction of VTE after gynecological surgery needs further confirmation in randomized controlled trials.

Synchronous primary tumors: appendiceal and ovarian cancer--case report.

A 64-year-old women was operated on for acute abdomen and both appendiceal and ovarian tumors were found. Histology revealed synchronous adenocarcinoma of the appendix and serous pappillary carcinoma of the right ovary. The patient was given adjuvant chemotherapy and received six cycles of cisplatinum. Regular follow-up showed no recurrence of the two synchronous primary tumors. A rare case of synchronous primary tumors of appendiceal and ovarian origin is reported. The tumors proved to be difficult to treat requiring several combined medical therapies, including surgery, chemo- and radiotherapy.

Intramuscular fetal corticosteroid therapy: short-term effects on the fetus.

OBJECTIVE: The aim of the study was to assess the short-term effects of direct intramuscular (i.m.) corticosteroid therapy on fetal biophysical profile, baseline fetal heart rate and the nonstress test, which indicate the degree of fetal hypoxia. METHOD: We evaluated the effect of direct i.m. fetal single-dose dexamethasone (4 mg/kg) on the fetal biophysical profile 2 h before and 2-4 h after corticosteroid therapy in 41 fetuses in the 32nd week of gestation at risk of preterm delivery. Risk factors for preterm delivery included pregnancy-induced hypertension and preeclampsia. RESULT: There was a statistically significant difference between fetal breathing movements before and after corticosteroid therapy (p = 0.019; 95% confidence interval for difference -11.75, -1.12). No significant changes were observed between baseline fetal heart rate before and after corticosteroid therapy (p = 0.99; 95% confidence interval for difference -4.81, +4.81), biophysical profile before and after fetal corticosteroid therapy, p = 0.235 as well as the nonstress test before and after therapy (p = 0.564). CONCLUSION: Direct corticosteroid i.m. fetal therapy results in increasing profound short-term fetal breathing movements. There are no changes in baseline fetal heart rate, biophysical profile score, and nonstress test.

Increased activity of interleukin-23/interleukin-17 proinflammatory axis in obese women.

OBJECTIVE: To compare the concentrations of cytokines belonging to Th17 axis (interleukin (IL)-17 and IL-23) and Th1 axis (IL-12 and interferon (IFN)-gamma) in obese and lean women, and to investigate their relationships with the proinflammatory adipokine leptin, proinflammatory cytokine macrophage migration inhibitory factor (MIF) and anthropometric and metabolic parameters of obesity. DESIGN: Cross-sectional study. SUBJECTS: Twenty-six obese women (age 20-52 years, body mass index (BMI): 30-48 kg/m(2)) and 20 healthy lean women (age 23-46 years, BMI: 18-25 kg/m(2)). MEASUREMENTS: Plasma levels of cytokines and leptin, BMI, waist circumference (WC) and insulin resistance index HOMA (homeostatic model assessment). RESULTS: Blood concentrations of IL-17, IL-23, MIF and leptin, but not IL-12 or IFN-gamma, were higher in obese compared with lean women (P=0.002, 0.046, 0.006 and 0.002, respectively). There was a positive correlation between IL-17 and IL-23 (r(s)=0.530), which was at the border of statistical significance (P=0.065). Neither IL-17 nor IL-23 correlated with leptin or MIF, and there was no association between IL-17 and IL-23 levels with BMI, WC or HOMA index. CONCLUSION: Interleukin-23/IL-17 axis is stimulated in obese women independently of the increase in abdominal fat, insulin resistance, leptin and MIF levels.

Intramuscular fetal corticosteroid therapy short-term effect on maternal-fetal Doppler velocimetry.

AIM: The aim of the study was to assess the short-term effects of intramuscular (IM) corticosteroid therapy (CST) on fetoplacental and fetal circulation in high-risk pregnancies of preterm labor. METHOD: We evaluated the effect of IM fetal single-dose dexamethasone (4 mg/kg) on fetoplacental and fetal circulation two hours before and 0-4 hours after CST in 38 fetuses after the 32nd week of gestation. RESULT: Changes in the umbilical artery (UA) resistance index (RI) after fetal CST (AU RI1) were significantly correlated with gestational age after the 32nd week at recording r = 0.354; p < 0.05. There was a statistically significant difference of RI in the descending aorta (DAo) before and after therapy; p < 0.001 (-0.04-0.01), 95% confidence interval (CI) for differences. CONCLUSION: Short-time effects after fetal IM CST include an increased index resistance in DAO as well as decreased RI in UA after the 32nd week.

Cold-knife conization versus the loop electrosurgical excision procedure for treatment of cervical dysplasia.

INTRODUCTION: Classical conization is a standard procedure for treatment of cervical lesions. Conization with loop diathermy is well established and lesions can be excised in more than 90% of cases. OBJECTIVE: To compare two methods of conization for the treatment of cervical dysplasia. METHOD: The study included 172 patients who had conization for diagnosed cervical dysplasia. A retrospective analysis was conducted on incidence of complications and presence of dysplasia on the specimen edges after classical conization compared to conization with loop diathermy. The possibilities for analyzing specimen edges were reviewed. RESULTS: A significantly higher incidence of complications was found among patients who underwent classical conization compared to those who had the loop diathermy procedure. The loop procedure is sufficient for treatment of cervical dysplasias. CONCLUSION: The authors suggest loop diathermy conization as the method of choice for treatment of cervical dysplasia.

Molecular profiling of cervical cancer progression.

Most cancer patients die of metastatic or recurrent disease, hence the importance to identify target genes upregulated in these lesions. Although a variety of gene signatures associated with metastasis or poor prognosis have been identified in various cancer types, it remains a critical problem to identify key genes as candidate therapeutic targets in metastatic or recurrent cancer. The aim of our study was to identify genes consistently upregulated in both lymph node micrometastases and recurrent tumours compared to matched primary tumours in human cervical cancer. Taqman Low-Density Arrays were used to analyse matched tumour samples, obtained after laser-capture microdissection of tumour cell islands for the expression of 96 genes known to be involved in tumour progression. Immunohistochemistry was performed for a panel of up- and downregulated genes. In lymph node micrometastases, most genes were downregulated or showed expressions equal to the levels found in primary tumours. In more than 50% of lymph node micrometastases studied, eight genes (AKT, BCL2, CSFR1, EGFR1, FGF1, MMP3, MMP9 and TGF-beta) were upregulated at least two-fold. Some of these genes (AKT and MMP3) are key regulators of epithelial-mesenchymal transition in cancer. In recurrent tumours, almost all genes were upregulated when compared to the expression profiles of the matched primary tumours, possibly reflecting their aggressive biological behaviour. The two genes showing a consistent downregulated expression in almost all lymph node metastases and recurrent tumours were BAX and APC. As treatment strategies are very limited for metastatic and recurrent cervical cancer, the upregulated genes identified in this study are potential targets for new molecular treatment strategies in metastatic or recurrent cervical cancer.

Survival rate and prognostic factors for patients who underwent surgical procedures for invasive carcinoma of the vulva in Serbia.

OBJECTIVES: To determine five-year survival rate and prognostic factors for patients who underwent radical surgery for carcinoma of the vulva. MATERIAL AND METHOD: 94 women were operated on from 1989 to 1996 at the Clinical Centre of Serbia. RESULTS: Five-year survival was 78.56% for Stage I, 73.5% for Stage II, for Stage III--14.28%, and for Stage IV--7.14%. Five-year survival rate for tumor size between 2 cm and 5 cm was 57.14%, and for tumors larger than 5 cm, 28.57%. Five-year survival rate was 64.28% if no lymph nodes were involved, 21.43% if there were unilateral metastatic lymph nodes and 14.28% if bilateral lymph nodes had metastatic disease. Histologic grades of the tumor showed that for grade 1, five-year survival was 64.28%, for grade 2, 35.71% and there were no survivors five years after surgery among patients with grade 3 tumor. CONCLUSION: FIGO stage, size of tumor, lymph node involvement and grade of tumor are significant prognostic factors for survival of patients after surgery.

[Antenatal homeostasis of insulin and glucose in the fetus with cytomegalovirus infection]. / Antenatalna homeostaza insulina i glukoze kod fetusa sa citomegalovirusnom infekcijom.

Factors of effect on the fetal glucose level can be of maternal, placental or fetal origin. The level of fetal insulin during gestation is regulated by the potentials of the endogenous fetal production on one hand and on the other by the factors (primarily glucaemia) that stimulate or inhibit its production. The aim of this paper was to analyze in which way and to what extent the congenital infection with the Cytomegalovirus disturbs the metabolism of the fetal glucose and insulin. Umbilical venous cord blood was obtained by cordocentesis at 22 to 29 weeks gestation from 52 women referred to our clinic for fetal karyotyping and scatological analysis of fetal CMV infection. To determine the effect of Cytomegalovirus (CMV) infection on insulin and glucose fetal homeostatis, we performed cordocentesis in 18 patients (group A) with proved congenital CMV fetal infection. Control group (B) consisted of 34 patients in whom blood samples were taken for fetal karyotyping. Maternal and fetal glucose levels were 3.95 mmol/l and 3.15 mmol/l in group A and 4.00 and 3.62 mmol/l in group B, respectively. Maternal average insulin level in group A was 14.45 mU/ml and in fetuses 10.64 mU/ml, while in group B maternal and fetal insulin levels were 12.85 mU/ml and 15.35 mU/ml, respectively. Maternal/fetal (M/F) insulin ratio was in group A 1.35, and in group B 0.84. Statistical analysis showed significantly lower glucose and insulin levels and also higher maternal/fetal insulin ratio in fetuses affected by CMV infection (t = 1.4, p < 0.001). Consequences of congenital CMV infection were fetal hypoglucaemia and hypoinsulinemia.

[Metabolism of amino acids in fetuses with cytomegalovirus infection and growth retardation]. / Metabolizam amino-kiselina kod fetusa sa citomegalovirusnom infekcijom i zastojem u rastu.

Aim of the study was to evaluate correlation between valine and glycine, representatives of essential and nonessential amino acids, in fetuses appropriate and small for gestational age with congenital cytomegalovirus infection. Umbilical venous cord blood was obtained by cordocentesis at 22 to 29 weeks' gestation from 18 women (11 in appropriate for gestational age--A, and seven in small for gestational age--B) fetuses with CMV infection. Plasma amino acids were measured with an Beckman M 121 amino acid analyzer. Maternal valine level was 136.0 mmol/l; fetal valine in AGA and SGA fetuses: 219 and 189 mmol/l respectively. Fetomaternal valine ratio was significantly lower in SGA group (1.39 mmol/l-SGA, 1.61 mmol/l AGA, t = -6.9, p < 0.001). Glycine level in maternal blood was 139.0 mmol/l; fetal in SGA and AGA fetuses 137 mmol/l and 176 mmol/l, respectively. Fetomaternal glycine ratio was also significantly lower in SGA group than in AGA, 1.01 and 1.27 respectively (t = -2.96, p < 0.001). Valine/Glycine maternal and fetal ratio did not show any difference between groups. In congenitally CMV infected fetuses with intrauterine growth retardation there is a decreased valine and glycine level, compared to the congenitally CMV infected fetuses with normal intrauterine growth. There is a lower fetal concentration of these amino acids compared to the maternal level in SGA fetuses. A decreased glycine level compared to the valine level has also been found in congenitally CMV infected fetuses with intrauterine growth retardation.

Selenium and malondialdehyde content and glutathione peroxidase activity in maternal and umbilical cord blood and amniotic fluid.

Placenta tissue may be a major source of lipid peroxidation products in pregnancy. It was proven that placental peroxidation activity increases with gestation. Selenium (Se), as an essential constituent of glutathione peroxidase (GSH-Px), takes part in the reduction of hydrogen peroxides and lipid peroxides. Malondialdehyde (MDA) is a major breakdown product split off from lipid peroxides. In this study, Se and MDA content and GSH-Px activity were measured in blood and plasma taken from 20 apparently healthy nonpregnant women between 19 and 38 yr of age and from 115 unselected pregnant women between 17 and 45 yr of age (35 in the first trimester, 22 in the second trimester, 38 in the third trimester, and 20 within 2 d of delivery). Samples of umbilical cord blood and amniotic fluid were taken from women in the second and third trimesters and at delivery. The Se content was measured by atomic absorption spectrometry (AAS), plasma MDA concentration by thiobarbituric acid reaction, and Se-dependent GSH-Px spectrometrically. Blood and plasma Se contents of nonpregnant women were below those considered adequate, indicating low selenium intake. In comparison to nonpregnant women, pregnant women had significantly decreased whole-blood and plasma Se levels in the second and third trimesters and at delivery. The significant drop of whole-blood SeGSH-Px activity was observed in the first trimester of pregnancy and its lower activity was maintained until delivery. A significant drop in plasma SeGSH-Px activity occurred in the second trimester and attained the minimal level at delivery. The Se level and SeGSH-Px activity in maternal and umbilical cord blood were at similar levels. Amniotic-fluid SeGSH-Px activity was nondetectable or exceptionally low and its Se content remained unchanged during pregnancy. Plasma levels of MDA were significantly decreased in the second and third trimesters and at delivery. The fetal blood plasma at birth had a lower MDA level compared to the levels of MDA of their mothers at delivery. A low, but significant inverse correlation existed between blood SeGSH-Px activity and plasma MDA content and between plasma Se and plasma MDA contents during pregnancy. A significant decrease of Se and SeGSH-Px activities (antioxidant enzyme) in both blood and plasma suggests a possible drop in total antioxidant status during pregnancy. Elevated MDA plasma levels might be the result of increased lipid peroxidation in placental tissue during pregnancy. Index Entries: Selenium; glutathione peroxidase; malondialdehyde; pregnancy; umbilical cord blood; amniotic fluid.

New technique for artificial lung maturation. Direct intramuscular fetal corticosteroid therapy.

The aim of this study was to present a new technique of administration of antenatal corticosteroid therapy in order to cause fetal lung maturation. A single dexamethasone dose of 4 mg was applied directly to the fetal gluteal musculature by ultrasound-guided intramuscular injection 48 h before delivery. This technique of fetal corticosteroid therapy was applied in six cases. Our patients had high risk pregnancies (preeclampsia diabetes mellitus, intracranial hemorrhage, epilepsy, hyperthyreosis). The pregnancies were terminated in the mother's vital interest. The lecithin/sphyngomyelin (US) ratio was < 1.5:1. There were no procedure-related complications. The fetuses were delivered by cesarean, 48 hours later except for the vaginal delivery in the patient in which fetal death occurred in utero. In five cases an uneventful outcome of fetuses indicated that direct fetal corticosteroid treatment improved postnatal lung function in preterm fetuses. A new technique of corticosteroid application successfully prevents respiratory distress in preterm infants decreasing the risk of maternal complications. To our knowledge, this is the first report of fetal intramuscular corticosteroid therapy in the human population.

How congenital cytomegalovirus infection changes insulin and glucose homeostasis in affected fetuses.

Factors affecting the fetal glucose level can be of maternal, placental or fetal origin. The level of fetal insulin during gestation is regulated by the potential of the endogenous fetal production on one hand, and on the other, by the factors (primarily glycaemia) that stimulate or inhibit its production. The aim of this paper was to analyze in which way and to what extent congenital infection with the cytomegalovirus disturbs the metabolism of fetal glucose and insulin. Umbilical venous cord blood was obtained by cordocentesis at 22 to 29 weeks gestation from 52 women referred to our clinic for fetal karyotyping and scatological analysis of fetal CMV infection. To determine the effect of cytomegalovirus (CMV) infection on insulin and glucose fetal homeostasis, cordocentesis was performed in 18 patients (group A) with proven congenital CMV fetal infection. The control group (B) consisted of 34 patients in whom blood samples were taken for fetal karyotyping. Maternal and fetal glucose levels were 3.95 mmol/l and 3.15 mmol/l in group A and 4.00 and 3.62 mmol/l in group B, respectively. Maternal average insulin level in group A was 14.45 mU/ml and in fetuses 10.64 mU/ml, while group B maternal and fetal insulin levels were 12.38 mU/ml and 15.35 mU/ml, respectively. Maternal/fetal (M/F) insulin ratio was 1.35 in group A and in group B, 0.84. Statistical analysis showed significantly lower glucose and insulin levels and also a higher maternal/fetal insulin ratio in fetuses affected by CMV infection (t = 1.4 p < 0.001). Consequences of congenital CMV infection were fetal hypoglycaemia and hypoinsulinemia.

Essential and nonessential amino acids in appropriate and small for gestational age fetuses with congenital cytomegalovirus infection.

The aim of the study was to evaluate the correlation between valine and glycine, representatives of essential and nonessential amino acids, in appropriate and small fetuses for gestational age with congenital cytomegalovirus (CMV) infection. Umbilical venous cord blood was obtained by cordocentesis at 22 to 29 weeks' gestation from 18 women (11 in appropriate for gestational age (AGA) -A, and 7 in small for gestational age (SGA) -B) fetuses with CMV infection. Plasma amino acids were measured with a Beckman M 121 amino acid analyzer. Maternal valine level was 136.0 mmol/l; fetal valine in AGA and SGA fetuses: 219 and 189 mmol/l, respectively. Fetomaternal valine ratio was significantly lower in the SGA group (1.39 mmol/l-SGA, 1.61 mmol/l AGA, t = 6.9 p < 0.001). The glycine level in maternal blood was 139.0 mmol/l; fetal in SGA and AGA fetuses 137 mmol/l, and 176 mmol/l, respectively. The fetomaternal glycine ratio was also significantly lower in the SGA group than in AGA. 1.01 and 1.27, respectively (t = -2.96, p < 0.001). Valine/glycine maternal and fetal ratio did not show any difference between groups. In the congenital CMV infected fetuses with intrauterine growth retardation there were decreased valine and glycine levels compared to the congenitally CMV infected fetuses with normal intrauterine growth. There was a lower fetal concentration of these amino acids compared to the maternal level in SGA fetuses. A decreased glycine level compared to the valine level has also been found in congenitally CMV infected fetuses with intrauterine growth retardation.