Two- and three-dimensional transesophageal echocardiographic localization of a right atrial lipoma: importance of orienting echocardiographic images to the surgeon's view.

We present a patient in whom the exact location of a right atrial lipoma identified with two- and three-dimensional transesophageal echocardiography (2-D and 3-D TEE) was correlated with the surgical findings. By orienting the 3-D TEE images to conform to the view of the surgeon from the right side of the patient and referencing the site of attachment of the tumor to the surrounding structures, this lipoma was correctly localized to a 7 o'clock position in the right atrium.

Transpharyngeal echocardiographic imaging of the right and left carotid arteries.

We present a technique for transpharyngeal imaging of the bilateral carotid arteries completed towards the end of a transesophageal echocardiogram. To our knowledge, this is the first report that demonstrates the bifurcation of the right common carotid artery into the right internal and external carotid arteries with a transesophageal echocardiographic probe.

Recurrence of the acute HIV syndrome after interruption of antiretroviral therapy in a patient with chronic HIV infection: A case report.

BACKGROUND: Clinical and virologic consequences of temporary interruption of HIV therapy are incompletely understood. OBJECTIVE: To describe a febrile illness that was consistent with the acute HIV syndrome and occurred after interruption of antiretroviral therapy. DESIGN: Case report. SETTING: University clinic. PATIENT: HIV-infected man. MEASUREMENTS: Plasma viral load, lymphocyte subsets, diagnostic evaluation (including cultures and serologic tests), and analysis of lymph node tissue. RESULTS: The patient began antiretroviral therapy 3 months after initial HIV exposure and had sustained viral suppression, except during a brief scheduled treatment interruption. One hundred sixty-nine days after resuming therapy, the patient discontinued it again immediately following an influenza vaccination. Eleven days later, he presented with a febrile mononucleosis-like syndrome associated with dramatic shifts in plasma HIV RNA level (<50 to >1 000 000 copies/mL) and CD4 cell count (0.743 x 10(9) cells/L to 0.086 x 10(9) cells/L). Evaluation for alternative causes of fever was unrevealing. Symptoms resolved rapidly with resumption of HIV therapy. CONCLUSION: Therapeutic interruption may be associated with profound viral rebound and recurrence of the acute HIV syndrome.

Transesophageal echocardiographic identification of left subclavian artery stenosis with steal phenomenon.

In this report, we present the first case of the transesophageal echocardiographic identification of left subclavian artery stenosis and steal phenomenon.

Genomic organization of the UGT2b gene cluster on human chromosome 4q13.

The UDP-glucuronosyltransferases (UGTs) comprise a large family of proteins capable of detoxifying a wide variety of both endogenous and exogenous substrates. The primary function of this gene superfamily is to catalyze the glycosylation of substrates such as biogenic amines, steroids, bile acids, phenolic compounds and various other pharmacologically relevant compounds, including numerous carcinogens, toxic environmental pollutants and prescription drugs. This conjugation increases the solubility of these compounds, allowing them to be excreted more readily through hepatic or renal mechanisms. This paper describes the genomic characterization and chromosomal localization of three UGT2B genes which together comprise part of a large cluster of related sequences, including pseudogenes found on human chromosome 4q13. A genomic map spanning approximately 500-1000 kb of this region reveals the presence of three previously described UGT2B genes, at least two previously uncharacterized pseudogenes and a significant number of remnant gene fragments and places UGT2B4 between UGT2B7 and UGT2B15. Additionally, access to a large reference DNA bank allowed us to calculate allele frequencies for two UGT2B SNPs: D85R in UGT2B15 and Q458D in UGT2B4 amongst 803 unrelated individuals representing five ethnic populations. The data presented here suggest a recent evolutionary history of gene duplication, mutation and rearrangement. Furthermore, they suggest that a re-evaluation of the current description of the UGT2B gene family with respect to the number of specific genes, degree of allelic diversity and molecular evolution may be necessary.

Simultaneous preservation of orchid seed and its fungal symbiont using encapsulation-dehydration is dependent on moisture content and storage temperature.

Seeds of Dactylorhiza fuchsii (common spotted orchid) and Anacamptis morio (green-winged orchid) were encapsulated in alginate beads with hyphae of the basidomycete fungus Ceratobasidium cornigerum. Pre-treatment of beads for 18 h with sucrose at an optimum concentration of 0.75 M decreased the desiccation rate in a flow of sterile air (c. 23 degree C, 30% RH) and increased seed and fungal survival after up to 16 h drying. Pre-treated and 16-h dried beads were transferred to cryo-vials and subsequently stored at a range of low temperatures for up to 30 d. Neither embryo growth of both orchids nor fungal development was detrimentally affected by 1 d storage at -196 degree C when the beads were pre-dried to c. 20% moisture content. Encapsulated D. fuchsii seed and compatible fungus had < 5% and < 45% viability when beads of the same moisture content were stored for 1 d at -20 degree C and -70 degree C respectively. In contrast, viability of the seed and the fungus remained unchanged during 30 days storage at -196 degree C but was progressively lost at 16 degree C over the same interval. The results indicate opportunities for the use of simultaneous cryopreservation as a conservation tool for diverse taxa.

Curriculum reform at the University of Otago Medical School.

The University of Otago Medical School, the older of the two medical schools in New Zealand, identified during the 1980s many of the same problems with its undergraduate curriculum as were reported in the United States, Canada, and the United Kingdom. An early, overly ambitious attempt to introduce a full problem-based learning curriculum at Otago failed; however, many piecemeal changes that embodied some of the principles of problem-based learning were successfully implemented. Subsequently, as desire for more coordinated and substantive change grew, Otago's faculty used what they had learned from their first effort to successfully introduce a modular systems-based preclinical curriculum in 1997. The authors describe the features of the new curriculum and discuss two components (a systems-integration course and a large-scale program of computerized in-course testing) that are particularly innovative. The new curriculum is already achieving one of its main goals (increasing the perceived relevance of preclinical teaching) and other outcomes are being evaluated.

Clinical outcomes of the Otago-Southland Breast Cancer Screening Programme 1991-1996.

AIM: To document the clinical outcome of the Otago-Southland Breast Cancer Screening Programme through its first two rounds of screening, from 1991-1996. METHODS: Review and analysis of clinical and pathological records. RESULTS: In the first round of screening, 13,876 women were screened, giving 75% uptake; 12.2% were referred for assessment and 126 cancers detected, 9.1 per thousand women screened. For the 9946 incidence screens in the second round, 3.9% of women screened were referred to assessment and 50 cancers detected, 5.0 per thousand women screened. The uptake and cancer detection rates exceed the targets and exceed other published results; the size distribution of the cancers detected was comparable to the Swedish two-counties study, showing that the results should produce an ultimate mortality reduction. The referral rate to assessment was higher than expected in the first round of screening, but within the targeted range in the second round. The benign to malignant ratio for all biopsies was 1.4:1 for the prevalence screen of the first round and 1.2:1 for the incidence screens in the second round, both exceeding the targets set. CONCLUSIONS: The results show that the uptake and clinical results of the programme exceed expectations and that a large number of small invasive tumours have been successfully detected. These results are comparable to the best of overseas studies, and give confidence that mortality reductions will ultimately occur.

Chromosomal basis of X chromosome inactivation: identification of a multigene domain in Xp11.21-p11.22 that escapes X inactivation.

A number of genes have been identified that escape mammalian X chromosome inactivation and are expressed from both active and inactive X chromosomes. The basis for escape from inactivation is unknown and, a priori, could be a result of local factors that act in a gene-specific manner or of chromosomal control elements that act regionally. Models invoking the latter predict that such genes should be clustered in specific domains on the X chromosome, rather than distributed at random along the length of the X. To distinguish between these possibilities, we have constructed a transcription map composed of at least 23 distinct expressed sequences in an approximately 5.5-megabase region on the human X chromosome spanning Xp11.21-p11.22. The inactivation status of these transcribed sequences has been determined in a somatic cell hybrid system and correlated with the position of the genes on the physical map. Although the majority of transcribed sequences in this region are subject to X inactivation, eight expressed sequences (representing at least six different genes) escape inactivation, and all are localized to within a region of less than 370 kb. Genes located both distal and proximal to this cluster are subject to inactivation, thereby defining a unique multigene domain on the proximal short arm that is transcriptionally active on the inactive X chromosome.

Lidocaine's effect on defibrillation threshold are dependent on the defibrillation electrode system: epicardial versus endocardial.

INTRODUCTION: Epicardial and endocardial defibrillation electrode systems affect myocardial electrophysiology and sympathetic function differently. Thus, we postulate that antiarrhythmic drugs will interact with these electrode systems differently. METHODS AND RESULTS: Defibrillation energy requirements (DER) at 20% (ED20), 50% (ED50), and 80% (ED80) success were measured at baseline and during lidocaine (10 mg/kg per hour) or D5W treatment for epicardial and endocardial electrodes. Pigs were randomized to treatment (lidocaine or D5W) and electrode system, which resulted in four experimental groups: (1) epicardial electrode + D5W; (2) epicardial electrode + lidocaine; (3) endocardial electrode + D5W; and (4) endocardial electrode + lidocaine. ED50 DER (mean +/- SEM) values at baseline for groups 1-4 were 10.6+/-1, 8.5+/-1, 12.6+/-1, and 12.3+/-1 J, respectively. DER values for groups 1 and 3 during D5W were similar to baseline. Conversely, lidocaine increased ED50 DER values from 8.5+/-1 to 13.5+/-2 J (P < 0.05) in group 2 animals (epicardial electrodes). When lidocaine was administered to group 4 animals (endocardial electrodes), however, ED50 DER values remained similar to baseline values (12.3+/-1 to 14.3+/-2 J, P = NS). Lidocaine increased ED50 DER values by 59% with the epicardial electrode system, which was significantly greater than the 16% increase with the endocardial electrode system (P < 0.05). Electrophysiologic response and electrode impedance were similar between electrode systems. CONCLUSION: Lidocaine increases DER values to a greater extent when using epicardial versus endocardial electrode system. Thus, drug-device interactions are dependent on the electrode system. These data suggest that the electrophysiologic milieu created by endocardial defibrillation mitigates the effects that lidocaine has on DER values.

Autism and multiple exostoses associated with an X;8 translocation occurring within the GRPR gene and 3' to the SDC2 gene.

An X;8 translocation was identified in a 27-year-old female patient manifesting multiple exostoses and autism accompanied by mental retardation and epilepsy. Through molecular analysis using yeast artificial chromosomes (YACs) and cosmid clones, the translocation breakpoint was isolated and confirmed to be reciprocal within a 5'-GGCA-3' sequence found on both X and 8 chromosomes without gain or loss of a single nucleotide. The translocation breakpoint on the X chromosome occurred in the first intron of the gastrin-releasing peptide receptor (GRPR) gene and that on chromosome 8 occurred approximately 30 kb distal to the 3' end of the Syndecan-2 gene (SDC2), also known as human heparan sulfate proteoglycan or fibroglycan. The GRPR gene was shown to escape X-inactivation. A dosage effect of the GRPR and a position effect of the SDC2 gene may, however, contribute the phenotype observed in this patient since the orientation of these genes with respect to the translocation was incompatible with the formation of a fusion gene. Investigation of mutations in these two genes in unrelated patients with either autism or multiple exostoses as well as linkage and association studies is needed to validate them as candidate genes.

Pilot studies of in-course assessment for a revised medical curriculum: I. Paper-based, whole class.

PURPOSE: To test a paper-based method of in-course assessment for a modular, systems-oriented medical curriculum at the University of Otago Medical School. METHOD: In 1996, 193 students took paper-based quizzes on the first four topics of a course in clinical biochemistry. A score of 75% was required for passing, but students could retake quizzes. The subsequent test on these four topics was constructed from questions used in previous years. The next four topics were taught without quizzes. The test on these topics was again constructed from questions used in past years. The authors examined the performances on the quizzes and tests and sought the students' opinions about the program. RESULTS: 72.0-95.3% of the students passed the quizzes the first time and 94.8-99.5% passed by the second version. Performance on the subsequent test items was higher than [corrected] when the items had been used previously; so was performance on three of the four questions for the next four topics, none of which had been accompanied by quizzes. Students valued the quizzes as a stimulus to study and as feedback. They preferred the segment of the course with the quizzes to the segment without them. CONCLUSION: This method of in-course assessment was easy to administer and highly acceptable to the students. Performance on the quizzes was more than satisfactory and a passing score of 75% was reasonable. Such quizzes appeared to be able to replace a test that required explanation of answers while increasing the numbers of questions that could be asked and decreasing the marking time.

Pilot studies of in-course assessment for a revised medical curriculum: II. Computer-based, individual.

PURPOSE: To test a computer-based method of in-course assessment for a modular, systems-oriented medical curriculum at the University of Otago Medical School. METHOD: For the in-course assessment in anatomic pathology, 193 students completed five biweekly (i.e., every two weeks), criterion-referenced, computer-based quizzes incorporating many digitized photographs and a variety of question formats. The students signed up to take quizzes at any of ten available times during each quiz week. A score of 70% was required for passing each quiz, but the students could retake quizzes up to two more times in alternative versions. The students' opinions about biweekly testing and computer-based testing were sought. RESULTS: All 193 students satisfactorily completed the assessment program, with no significant problems with hardware, software, or administration during the more than 1,000 computer-based quizzes. The students valued the bi-weekly quizzes as a stimulus for study and for feedback. They strongly supported computer-based quizzes, identifying a variety of benefits in their responses to the questionnaire. The staff found that development of visually rich quizzes was greatly facilitated by the use of computers. CONCLUSION: The study confirmed the feasibility of using regular, computer-based quizzes for in-course assessment of a large medical school class and demonstrated assessments of a kind that would be difficult to achieve by means other than with computers.

Pituitary lineage determination by the Prophet of Pit-1 homeodomain factor defective in Ames dwarfism.

The gene apparently responsible for a heritable form of murine pituitary-dependent dwarfism (Ames dwarf, df) has been positionally cloned, identifying a novel, tissue-specific, paired-like homeodomain transcription factor, termed Prophet of Pit-1 (Prop-1). The df phenotype results from an apparent failure of initial determination of the Pit-1 lineage required for production of growth hormone, prolactin or thyroid-stimulating hormone, resulting in dysmorphogenesis and failure to activate Pit-1 gene expression. These results imply that a cascade of tissue-specific regulators is responsible for the determination and differentiation of specific cell lineages in pituitary organogenesis.

X inactivation analysis and DNA methylation studies of the ubiquitin activating enzyme E1 and PCTAIRE-1 genes in human and mouse.

Previously reported data on the X inactivation status of the ubiquitin activating enzyme E1 (UBE1) gene have been contradictory, and the issue has remained unsettled. Here we present three lines of evidence that UBE1 is expressed from the inactive X chromosome and therefore escapes X inactivation. First, by RNA in situ hybridization, UBE1 RNA is detected from both the active and inactive X chromosomes in human female fibroblasts. Second, UBE1 is expressed in a large panel of somatic cell hybrids retaining inactive human X chromosomes, including two independent hybrids that did not require UBE1 expression for survival. And third, sites at the 5' end of UBE1 are unmethylated on both active and inactive X chromosomes, consistent with the gene escaping inactivation. In order to address whether other genes that escape inactivation map to the same region of the X chromosome, we have also examined the expression of genes mapping adjacent to UBE1. The gene for PCTAIRE-1 (PCTK1) maps within 5 kb of UBE1 and similarly escapes X inactivation by the somatic cell hybrid assay, whereas six other genes that are within 1 Mb of UBE1 in Xp11.23 are silenced on the inactive X chromosome. Comparative mapping studies of the homologous loci in mouse establish that Ube1-x and Pctk1 are also within close physical proximity on the murine X chromosome, and expression studies of the Pctk1 gene determine that, similar to Ube1-x, it is subject to X inactivation in mouse. Methylation of CpG residues at restriction sites at the 5' end of both genes on the murine inactive X chromosome is consistent with both genes being subject to X inactivation in mouse, in contrast to their expression status in humans.

Molecular definition of breakpoints associated with human Xq isochromosomes: implications for mechanisms of formation.

To test the centromere misdivision model of isochromosome formation, we have defined the breakpoints of cytogenetically monocentric and dicentric Xq isochromosomes (i(Xq)) from Turner syndrome probands, using FISH with cosmids and YACs derived from a contig spanning proximal Xp. Seven different pericentromeric breakpoints were identified, with 10 of 11 of the i(Xq)s containing varying amounts of material from Xp. Only one of the eight cytogenetically monocentric i(Xq)s demonstrated a single alpha-satellite (DXZ1) signal, consistent with classical models involving centromere misdivision. The remaining seven were inconsistent with such a model and had breakpoints that spanned proximal Xp11.21: one was between DXZ1 and the most proximal marker, ZXDA; one occurred between the duplicated genes, ZXDA and ZXDB; two were approximately 2 Mb from DXZ1; two were adjacent to ALAS2 located 3.5 Mb from DXZ1; and the largest had a breakpoint just distal to DXS1013E, indicating the inclusion of 8 Mb of Xp DNA between centromeres. The three cytologically dicentric i(Xq)s had breakpoints distal to DXS423E in Xp11.22 and therefore contained > or = 12 Mb of DNA between centromeres. These data demonstrate that the majority of breakpoints resulting in i(Xq) formation are in band Xp11.2 and not in the centromere itself. Therefore, we hypothesize that the predominant mechanism of i(Xq) formation involves sequences in the proximal short arm that are prone to breakage and reunion events between sister chromatids or homologous X chromosomes.

Surgical management of complete atrioventricular septal defects. A twenty-year experience.

Creation of a competent left atrioventricular valve is a cornerstone in surgical repair of complete atrioventricular septal defects. To identify risk factors for mortality and failure of left atrioventricular valve repair and to determine the impact of cleft closure on postoperative atrioventricular valve function, we retrospectively analyzed hospital records of 203 patients between January 1974 and January 1995. Overall early mortality was 7.9%. Operative mortality decreased significantly over the period of the study from 19% (4/21) before 1980 to 3% (2/67) after 1990 (p = 0.03). Ten-year survival including operative mortality was 91.3% +/- 0.004% (95% confidence limit): all survivors are in New York Heart Association class I or II. Preoperative atrioventricular valve regurgitation was assessed in 203 patients by angiography or echocardiography and was trivial or mild in 103 (52%), moderate in 82 (41%), and severe in 18 (8%). Left atrioventricular valve cleft was closed in 93% (189/203) but left alone when valve leaflet tissue was inadequate and closure of the cleft might cause significant stenosis. Reoperation for severe postoperative left atrioventricular valve regurgitation was necessary in eight patients, five of whom initially did not have closure of the cleft and three of whom had cleft closure. Six patients had reoperation with annuloplasty and two patients required left atrioventricular valve replacement. Five patients survived reoperation and are currently in New York Heart Association class I or II. On most recent evaluation assessed by angiography or echocardiography (a mean of 59 months after repair), left atrioventricular valve regurgitation was trivial or mild in 137 of the 146 survivors (94%) examined; none had moderate or severe left atrioventricular valve stenosis. By multiple logistic regression analysis, strong risk factors for early death and need for reoperation included postoperative pulmonary hypertensive crisis, immediate postoperative severe left atrioventricular valve regurgitation, and double-orifice left atrioventricular valve. These results indicate that complete atrioventricular septal defects can be repaired with low mortality and good intermediate to long-term results. Routine approximation of the cleft is safe and has a low incidence of reoperation for left atrioventricular valve regurgitation.

Three genes that escape X chromosome inactivation are clustered within a 6 Mb YAC contig and STS map in Xp11.21-p11.22.

In order to study the distribution of genes that escape X chromosome inactivation, a high density yeast artificial chromosome (YAC) contig and STS map spanning approximately 6 Mb has been constructed in Xp11.21-p11.22. The contig contains 113 YACs mapped with 53 markers, including 10 genes. Four genes have been assayed for their expression status on both the active and inactive human X chromosomes, and these data have been combined with previous results on two other genes in the contig. Three of these genes escape X inactivation and have been localized to a single YAC clone of approximately 1075 kb. The other three genes are subject to inactivation, with two of them lying among the genes that escape inactivation. These results suggest that there are both regional control signals as well as gene-specific elements that determine the X inactivation status of genes on the proximal short arm of the human X chromosome.

The DXS423E gene in Xp11.21 escapes X chromosome inactivation.

The DXS423E gene has been localized to Xp11.21 and is expressed in somatic cell hybrids retaining either the human active or inactive X chromosome, demonstrating that DXS423E escapes X chromosome inactivation. The XE169 (DXS1272E or SMCX) gene that escapes X chromosome inactivation is also located in Xp11.21-11.22 and maps within the same YAC as DXS423E. Thus the DXS423E and XE169 genes define a new region in the proximal short arm of the X chromosome that is not subject to X chromosome inactivation, supporting a regional basis for escape from inactivation.