Predicting birth weight in fetuses with gastroschisis.

OBJECTIVE: To determine the accuracy of commonly utilized ultrasound formulas for estimating birth weight (BW) in fetuses with gastroschisis. STUDY DESIGN: A retrospective review was conducted of all inborn pregnancies with gastroschisis within the five institutions of the University of California Fetal Consortium (UCfC) between 2007 and 2012. Infants delivered at ⩾28 weeks who had an ultrasound within 21 days before delivery were included. Prediction of BW was evaluated for each of the five ultrasound formulas: Hadlock 1 (abdominal circumference (AC), biparietal diameter (BPD), femur length (FL) and head circumference (HC)) and Hadlock 2 (AC, BPD and FL), Shepard (AC and BPD), Honarvar (FL) and Siemer (BPD, occipitofrontal diameter (OFD), and FL) using Pearson's correlation, mean difference and percent error and Bland-Altman analysis. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for the ultrasound diagnosis of intrauterine growth restriction (IUGR) were assessed. RESULTS: We identified 191 neonates born with gastroschisis within the UCfC, with 111 neonates meeting the inclusion criteria. The mean gestational age at delivery was 36.3±1.7 weeks and the mean BW was 2448±460 g. Hadlock (1) formula was found to have the best correlation (r=0.81), the lowest mean difference (8±306 g) and the lowest mean percent error (1.4±13%). The Honarvar and Siemer formulas performed significantly worse when compared with Hadlock 1, with a 13.7% (P<0.001) and 3.9% (P=0.03) difference, respectively, between estimated and actual BW. This was supported by Bland-Altman plots. For Hadlock 1 and 2, sensitivity was 80% with a NPV of 91%. CONCLUSION: The widely used Hadlock (1) and (2) formulas provided the best estimated BW in infants with gastroschisis despite its inclusion of abdominal circumference. Furthermore, this formula performs well with diagnosis of IUGR.

The cost-effectiveness of cardiac computed tomography for patients with stable chest pain.

OBJECTIVE: To assess the cost-effectiveness of cardiac CT compared with exercise stress testing (EST) in improving the health-related quality of life of patients with stable chest pain. METHODS: A cost-utility analysis alongside a single-centre randomised controlled trial carried out in Northern Ireland. Patients with stable chest pain were randomised to undergo either cardiac CT assessment or EST (standard care). The main outcome measure was cost per quality adjusted life year (QALY) gained at 1 year. RESULTS: Of the 500 patients recruited, 250 were randomised to cardiac CT and 250 were randomised to EST. Cardiac CT was the dominant strategy as it was both less costly (incremental total costs -£50.45; 95% CI -£672.26 to £571.36) and more effective (incremental QALYs 0.02; 95% CI -0.02 to 0.05) than EST. At a willingness-to-pay threshold of £20 000 per QALY the probability of cardiac CT being cost-effective was 83%. Subgroup analyses indicated that cardiac CT appears to be most cost-effective in patients with a likelihood of coronary artery disease (CAD) of <30%, followed by 30%-60% and then >60%. CONCLUSIONS: Cardiac CT is cost-effective compared with EST and cost-effectiveness was observed to vary with likelihood of CAD. This finding could have major implications for how patients with chest pain in the UK are assessed, however it would need to be validated in other healthcare systems. TRIAL REGISTRATION NUMBER: (ISRCTN52480460); results.

A comparison of cardiac computerized tomography and exercise stress electrocardiogram test for the investigation of stable chest pain: the clinical results of the CAPP randomized prospective trial.

AIMS: To determine the symptomatic and prognostic differences resulting from a novel diagnostic pathway based on cardiac computerized tomography (CT) compared with the traditional exercise stress electrocardiography test (EST) in stable chest pain patients. METHODS AND RESULTS: A prospective randomized controlled trial compared selected patient outcomes in EST and cardiac CT coronary angiography groups. Five hundred patients with troponin-negative stable chest pain and without known coronary artery disease were recruited. Patients completed the Seattle Angina Questionnaires (SAQ) at baseline, 3, and 12 months to assess angina symptoms. Patients were also followed for management strategies and clinical events. Over the year 12 patients withdrew, resulting in 245 in the EST cohort and 243 in the CT cohort. There was no significant difference in baseline demographics. The CT arm had a statistical difference in angina stability and quality-of-life domains of the SAQ at 3 and12 months, suggesting less angina compared with the EST arm. In the CT arm, there was more significant disease identified and more revascularizations. Significantly, more inconclusive results were seen in the EST arm with a higher number of additional investigations ordered. There was also a longer mean time to management. There were no differences in major adverse cardiac events between the cohorts. At 1 year in the EST arm, there were more Accident and Emergency (A&E) attendances and cardiac admission. CONCLUSION: Cardiac CT as an index investigation for stable chest pain improved angina symptoms and resulted in fewer investigations and re-hospitalizations compared with EST. CLINICAL TRIAL REGISTRATION: http://www.controlled-trials.com/ISRCTN52480460.

Laparoscopic management of bile peritonitis after liver biopsy.

Bile peritonitis is an infrequent complication of liver biopsy and is usually treated by supportive care or laparotomy. Fever, peritoneal signs, and hemoconcentration developed in a 56-year-old man 7 hr after biopsy. At laparoscopy, a large amount of cloudy, bilious fluid was aspirated using a suction-irrigation device. No liver injury or bile leak was seen. The patient gradually improved and, although he required percutaneous drainage of the subhepatic bile collection, did well. This case illustrates the new use of laparoscopy to manage bile peritonitis after liver biopsy. Compared with conventional laparotomy, this procedure has the advantages of lower intraoperative risk, shorter recovery time, and superior visualization of peritoneal contents.

Aphthous ulceration in diversion colitis. Clinical implications.

Two cases of aphthous ulceration apparently due to diversion colitis are described. There was no evidence of Crohn's disease initially or at follow-up. Aphthous ulceration of the colon and diversion colitis are reviewed, and the nonspecificity of aphthae for Crohn's disease is stressed. The presence of aphthous ulcers in a diverted colon should not preclude colostomy closure.

Properties and metabolic fate of two very low density lipoprotein subfractions from rhesus monkey serum.

Physical, chemical and physiological approaches were used to examine the properties of two very low density lipoproteins, VLDL-I (slow-beta), and VLDL-II (pre-beta), which were isolated by agarose column chromatography from the serum of rhesus monkeys fed either Purina Chow or one of four hyperlipidemic diets containing 0.5-20% cholesterol suspended in either coconut oil, peanut oil, mixed coconut oil and butter fat or lard. In the coconut oil-fed hyperlipidemic animals, the majority of the apolar lipids of VLDL-I was represented by cholesteryl esters. The small percentage of triacylglycerol (15%) had a fatty acid composition which resembled that of the fatty acid in each of the diets. In turn, VLDL-II had a triacylglycerol-rich core and differed from VLDL-I in apolipoprotein distribution (VLDL-I: low molecular weight apolipoprotein B, 36%; apolipoprotein E, 64%; and VLDL-II: high molecular weight apolipoprotein B, 38%; apolipoprotein E, 3%; and apolipoprotein C, 65%). Both VLDLs were hydrolyzed in vitro by milk lipoprotein lipase by first-order kinetics although VLDL-I exhibited a slightly slower reaction rate. When an oral dose of [3H]retinol was given to one of the animals, both VLDLs became labeled but the specific activity of VLDL-I was six times higher than that of VLDL-II and the other lipoproteins. We conclude that VLDL-I represents a cholesteryl ester-rich lipoprotein probably of intestinal origin, whereas VLDL-II may be a particle of hepatic derivation modified by its interaction with the other plasma lipoproteins.

Lipid interactions with human alpha-fetoprotein (AFP). A study of the role of such interactions in the ability of human AFP to suppress lymphocyte transformation.

The ability of human alpha-fetoprotein (HAFP) isolates to inhibit human lymphocyte transformation varies over 2-3 orders of magnitude. Since HAFP is known to bind fatty acids, we have examined the possible role of lipid binding in producing this variability. While certain oxygenated sterols are potent inhibitors of lymphocyte transformation, and while the kinetics of such inhibition precisely mimic those of HAFP, HAFP is, by contrast, a weak inhibitor of sterol synthesis in mitogen-stimulated human lymphocytes. Fatty acids (18:0, 18:1, 18:2, 18:3, 20:4, 22:6) and 10(-4) M have little or no effect upon lymphocyte transformation. The fatty acid content of seen HAFP isolates ranged from 2.3 to 8.0 mol fatty acid/mol HAFP and included 12:0, 14:0, 16:0 (the most abundant), 18:0, 20:4, and 22:0; no 22:6 was found. There was no correlation between the total or individual fatty acid contents of HAFPs and their ability to inhibit lymphocyte transformation. Lysooleoyl-, lysostearoyl-, and lysopalmitoyl-lecithin at 5 X 10(-5) M all inhibited lymphocyte transformation (30.1%, 52.1%, and 58.1%, respectively) and the latter was active at 6.3 X 10(-6) M. Exposure of HAFP to a 5-fold molar excess of [14C]-lysopalmitoyl lecithin resulted in significant (10%) binding to HAFP, while no significant binding of dipalmitoyl lecithin occurred under similar conditions. Analysis of lipid extracts of potent HAFP isolates by thin-layer chromatography failed to reveal the presence of phospholipids. Although HAFP can bind certain lipids, and although certain lipids inhibit lymphocyte transformation, we conclude that HAFP suppression of lymphocyte transformation cannot be attributed to the binding of hydrocortisone, prostaglandins, fatty acids, lysolecithins, or oxygenated sterol compounds.

Isolation and partial characterization of high-density lipoprotein HDL1 from rat plasma by gradient centrifugation.

The lipoproteins isolated from rat plasma by flotation in the density range 1.019-1.063 g/ml were further characterized. Using rate zonal ultracentrifugation, we isolated two lipoproteins in almost equal proportions from this density range. Similar isolations may be accomplished with density gradients in a swinging-bucket rotor. On isopycnic-density-gradient ultracentrifugation one component banded at rho = 1.031 g/ml and the other at rho = 1.054 g/ml. More that 98% of the apoprotein of the lighter component was B protein, and hence this particle is LD (low-density) lipoprotein. Of the apoproteins of the rho = 1.054 g/ml particles, designated lipoprotein HDL1, over 60% was arginine-rich peptide, and the remainder was A-I, A-IV and C peptides. The molecular weight of these lipoproteins determined by agarose column chromatography was 2.36 x 10(6) for LD lipoprotein and 1.30 x 10(6) for lipoprotein HDL1. On electron microscopy the radius of LD lipoprotein was 14.0 nm and that of lipoprotein HDL1 was 10.0 nm, in contrast with molecular radii of 10.4 nm and 8.4 nm respectively determined from the gel-permeation-chromatography data. The lipid and phospholipid composition of both particles was determined. Lipoprotein HDL1 was notable for both the concentration of its esterified cholesterol, which was similar to that of LD lipoprotein, and the low triacylglycerol content, resembling that of HD lipoprotein. The possible origin of lipoprotein HDL1 is discussed.