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The CYP4F2 gene is known to influence mean coumarin dose. The aim of the present study was to undertake a meta-analysis at individual patients' level to capture the possible effect of ethnicity, gene-gene interaction or other drugs on the association and to verify if inclusion of CYP4F2*3 variant into dosing algorithms improves the prediction of mean coumarin dose. We asked the authors of our previous meta-analysis (30 articles) and of 38 new articles retrieved by a systematic review to send us individual patients' data. The final collection consists 15,754 patients split into a derivation and validation cohort. The CYP4F2*3 polymorphism was consistently associated with an increase in mean coumarin dose (+9% (95%CI 7-10%), with a higher effect in females, in patients taking acenocoumarol and in Whites. The inclusion of the CYP4F2*3 in dosing algorithms slightly improved the prediction of stable coumarin dose. New pharmacogenetic equations potentially useful for clinical practice were derived. This article is protected by copyright. All rights reserved.

Excepting host genetic factors, other influences on the pharmacokinetic and pharmacodynamic behavior of warfarin are subject to variations during the treatment despite attempts to stabilize the INR. In 214 Omani patients on warfarin therapy, we evaluated the extent of influence of known genetic predictors of warfarin dose variability, namely CYP2C9, CYP4F2 and VKORC1 gene polymorphisms in a genetically heterogeneous patient population. When patients were stratified according to their daily warfarin maintenance dose (to maintain INR between 2 and 3) into “low dose” (sensitive), “medium dose” (intermediate) and “high dose” (resistance) groups, overall, seven patients with three or four mutant alleles fell in the sensitive group and consequently 25% (7 out of 28) of at risk patients for over anticoagulation can be recognized by prospective pharmacogenetic testing in this patient population. Pre-prescription genotyping of these loci prior to therapy initiation will therefore benefit a small fraction of this population.

L’empreinte parentale est un marquage epigenetique des alleles parentaux et se manifeste par une expression monoallelique de certains genes dits genes soumis a empreinte. Le marquage epigenetique des alleles d’un gene soumis a l’empreinte differe en fonction de l’origine parentale de l’allele. Ces modifications epigenetiques parents-specifiques sont necessaires au developpement normal de l’embryon. Elles surviennent dans la lignee germinale et sont transmises par les gametes. Pour que l’empreinte soit etablie selon le sexe de l’individu, le marquage gametique-specifique (epigenotype gametique) doit etre reversible et effacable. L’effacement des modifications epigenetiques survient dans les cellules germinales primordiales (PGCs). Apres cette etape d’effacement, une nouvelle empreinte parentale sexe-specifique est etablie dans les lignees germinales mâles et femmelles. Aussi, parmi les nombreuses questions posees par l’utilisation de gametes immatures lors de tentatives d’assistance medicale a la procreation (AMP), la question de l’utilisation de gametes “epigenetiquement immatures” est primordiale. En particulier, les consequences epigenetiques a long terme pour le fœtus de l’utilisation de gametes epigenetiquement immatures ne sont pas connues.

A comparative study of the appropriateness of hospitalization was conducted in the medical departments of two university hospitals in Israel. A cross-section of 297 patients on one hospitalization day was analyzed using the Appropriateness Evaluation Protocol (AEP). Data were independently collected by two reviewers (R1 and R2). The study revealed a significant difference in the percent of inappropriate hospitalization between the two hospitals, i.e. 13.3% (R1) or 19.3% (R2) for hospital B, and 24.5% (R1) or 32% (R2) for hospital A. The reviewers were in agreement regarding evaluation (92.6%, Kappa 0.78) of 275 index days. A multivariate analysis of the index days with agreed appropriateness correlated with occupancy and length of stay. Routine monitoring of appropriateness of hospital stay should, therefore, be targeted to medical departments with relatively low occupancy rates and/or prolonged average stay.

Background ‘Beterem in the City’ is a model developed in 2008, based on criteria established by Safe Communities, to promote and manage child safety in municipalities. The model incorporates components of public health, organisational consultation and safety management and is tailored to unique characteristics of municipalities in Israel. A formative and summative evaluation of program effectiveness was conducted. Methods The three year evaluation process comprised various methods. Quantitative tools included: 1. Surveys with program directors and managers in 23 cities 2. Surveys with organisational consultants; 2. Surveys of safe behaviour in four cities. Qualitative tools included: 1. Interviews with program developers and stakeholders; 2. In-depth review of program implementation in four cities, based on interviews and program documentation Results The evaluation indicates that the implementation of the model is incomplete and demands improvement. Those components that are implemented in full demand less time, resources, and expertise as compared to the components that were not implemented. Program components that were found to be correlated with positive outcomes include effective management and utilisation of the organisational consultation hours. While ‘Beterem in the City’ has potential to lead organisational change and increase child safety over time, the current model is ambitious and may not be suitable for the organisational culture and management in most municipalities in Israel. In spite of these results, the evaluation points to success in implementing the model and better outcomes over time and in cities with stronger and more evolved management structures. Conclusions ‘Beterem in the City’ needs to be adapted to different types of municipalities in Israel, including Arab cities and cities with a low socio-economic population. In order to implement the model effectively additional resources, from national bodies, will need to be directed to the program.

International audience; The objective of our present study was to develop a warfarin dosing algorithm for the Omani patients, as performances of warfarin dosing algorithms vary across populations with impact on the daily maintenance dose. We studied the functional polymorphisms of CYP2C9, CYP4F2 and VKORC1 genes to evaluate their impact on the warfarin maintenance dose in an admixed Omani patient cohort with Caucasian, African and Asian ancestries. We observed a 64-fold inter-patient variability for warfarin to achieve stable international normalized ratio in these patients. Univariate analysis revealed that age, gender, weight, atrial fibrillation, deep vein thrombosis/pulmonary embolism and variant genotypes of CYP2C9 and VKORC1 loci were significantly associated with warfarin dose in the studied patient population. However, multiple regression model showed that only the atrial fibrillation, and homozygous CYP2C9 variant genotypes (*2/*3 and *3/*3) and VKORC1 GA and AA genotypes remained significant. A multivariate model, which included demographic, clinical and pharmacogenetic variables together explained 63% of the overall inter-patient variability in warfarin dose requirement in this microgeographically defined, ethnically admixed Omani patient cohort on warfarin. This locally developed model performed much better than the International Warfarin Pharmacogenetics Consortium (IWPC) model as the latter could only explain 34% of the inter-patient variability in Omani patients. VKORC1 3673G>A polymorphism emerged as the single most important predictor of warfarin dose variability, even in this admixed population (partial R(2)=0.45).

The survival rate of very low birthweight infants (weighing less than 1500 gm) has dramatically increased over the past two decades. Consequently, high-tech intensive care is offered to an increasing number of infants with borderline viability, previously considered as miscarriages. We reviewed the most recent literature on the results of intensive care used in the subgroup of extremely low birthweight infants, weighting less than 750 gm or 800 gm. Since definitions, management policies, and follow-up reports in this group of newborns are not consistent, the important statistical variables of incidence, mortality, and morbidity are incomplete and severely biased. In the past decade there was a growing tendency toward using a more active approach in caring for these infants. Most of the success is among the infants weighing 750 to 800 gm, with a survival rate in the range of 33 to 62%. However, the overall improvement in survival is small, with an extremely poor outlook for infants below 600 gm. The morbidity rate in the survivors is alarmingly high, reaching 70% and most common in infants with birthweight less than 600 gm. The available data show that virtually for every "healthy" surviving extremely low birthweight infant there is also at least one surviving child who is moderately to severely handicapped. The overall consequences and implications of high-tech care of these borderline viability infants, once considered as nonviable, are not necessarily improved over those of the former, less aggressive, approach. Since these results have grave consequences for the involved families and society, we urgently need to involve these parties more actively in decision making.

The incidence of triplet pregnancies has increased with the introduction of ovulation induction agents and is expected to further increase with the implementation of multiple embryo transfer in the in vitro fertilization programs. We review our experience with 29 triplet pregnancies in the last 10 years. Despite early sonographic diagnosis, close follow-up, increased use of tocolytics, and prophylactic cervical suture, we could not document prolongation of pregnancy, increased infants' weight, or a significantly decreased perinatal mortality, which still remains about 14%. Furthermore, the use of cesarean section as the delivery method of choice did not change the well-documented unfavorable relationship between birth order and fetal outcome. There is an urgent need for prospective assessment of the value of different treatment modalities, which nowadays becomes possible with the increasing incidence of triplet pregnancies. The prevention of triplet pregnancies or treatment by selective fetal reduction deserves a second thought.

Primary carcinoma of the fallopian tube is rarely diagnosed preoperatively. We report the case of a 42-year-old woman with primary tubal carcinoma, which was diagnosed preoperatively on the basis of an elevated CA-125 and characteristic features on transvaginal sonography.

In the present study, we have examined the origin and growth pattern of the β cells in pancreatic islets, to determine whether a single progenitor cell gave rise to all the precursors of the islets, or if each of a few progenitor cells is the founder of a different islet, or if each islet is a mixture of cells originating from a pool of progenitor cells. Aggregation mouse chimaeras where the pancreatic β cells derived from each embryo can be identified in the islets on histological sections were analyzed. In two chimaeras, all the islets contained cells from both the aggregated embryo. This clearly demonstrates that each islet resulted from several independent cells. In addition, the β cells derived from either embryo component were in very small clusters in the islets, suggesting that in situ cell division did not account significantly for islet growth.

Vaginal bleeding in childhood is not a common complaint. Serious medical or sociological problems can underly this irregular symptom in young girls. Therefore it requires careful medical investigation followed by appropriate sociologic and psychologic support. The variable etiologies of vulvovaginitis are the most common causes of vaginal bleeding during the prepubertal period. External blood loss can be related to trauma or urologic factors. It can be the presenting sign of relatively rare benign and malignant neoplasms of the genital tract. Precocious menstruation in itself or as a part of precocious puberty must be suspected in these cases. Vaginal bleeding in prepubertal girls is uncommon but warrants careful evaluation because of the special status of the young patient.

A total of 157 consecutive patients were studied in an effort to examine prospectively the incidence of asymptomatic intraamniotic infection in the early phase of the second trimester. All patients were referred for amniotic fluid karyotyping. In addition, the amniotic fluids were examined for Gram stain and were directly cultured on blood agar and MacConkey agar as well as in thioglycollate broth. We found positive amniotic fluid cultures in eight cases (5.09%); however, results of Gram stain examinations were negative in all amniotic fluid samples. The data indicate that there is no correlation between white blood cells in the amniotic fluid and positive amniotic fluid culture results. Only one pregnancy with positive amniotic fluid culture resulted in a septic abortion. Therefore we can suggest that intraamniotic infection can exist early in pregnancy, even with intact membranes, and in most cases without any clinical symptoms.

Free digoxin-like immunoreactive factor(s) (DLIF) which may have a homeostatic role, as documented in different physiological conditions, but is generally undetectable in plasma from normal population. Total digoxin-like immunoreactive factor(s) (protein bound and free) can be estimated after plasma is heated. In this study, total digoxin-like immunoreactive factor(s) as measured in plasma in a well defined control population and compared to healthy term pregnant women and neonates, categories known to be associated with increased free digoxin-like immunoreactive factor(s) concentrations. The mean level of this factor(s) in the control group was 706 +/- 129 pg digoxin equivalent/ml (pg/ml) and was unaffected by age and sex. Significantly increased levels of total digoxin-like immunoreactive factor(s) were found in pregnant women and neonates (928 +/- 127 and 1242 +/- 367 pg/ml, respectively). We conclude that levels of total digoxin-like immunoreactive factor(s) are increased in term pregnancies and neonates, similarly to its free form. However total digoxin-like immunoreactive factor(s) is detected in the normal population as a plasma component, contrary to its free form, which is generally undetectable.

PROBLEM: Immunologic recognition of pregnancy is important for normal gestation. Successful pregnancy is characterized by a Th2 dominance, whereas there is a Th1 dominance in failed pregnancies. We assume that a signal given by the fertilized ovum induces a Th2 shift, necessary for a normal outcome. In vitro fertilization provides a tool for testing this possibility. METHOD OF STUDY: Phytohemagglutinin-stimulated lymphocytes were incubated for 48 hr in the presence of culture media from in vitro fertilized eggs, as well as in follicular fluid (FF) and control supernatants. Total RNA was isolated from the lymphocytes by the guanidine-isothiocyanate method and interleukin (IL)-10 mRNA expression was detected by reverse transcription-polymerase chain reaction. RESULTS: Ten percent of the activated lymphocytes incubated with FF expressed IL-10 mRNA, whereas 88% of the lymphocytes activated with supernatants of sperm + oocytes gave a positive signal. Significantly (P < 0.05) fewer (50%) lymphocytes stimulated in the presence of control supernatants also expressed mRNA for IL-10. In supernatants of activated lymphocytes incubated with the culture medium of spermia + oocytes, the concentration of IL-10 was significantly higher than in the lymphocytes incubated with FF. CONCLUSION: These data suggest that the presence of the fertilized ovum induces a Th2 shift, which enables pregnancy to proceed to term.

The management of cervical adenosarcoma in a 14-year-old girl is described. The tumor had an exceptionally violent biological nature and did not respond to a variety of customary and unorthodox therapeutic measures. These included conventional intravenous chemotherapy, radiation therapy, surgery, intraarterial chemotherapy, colostomy, and peritoneovenous shunt for untreatable ascites. The patient died within 16 months of diagnosis. This is the fifth case of cervical adenosarcoma in the English literature. This tumor usually has a better prognosis and none of the previous four cases succumbed to the disease. The unusual virulence of the present case is discussed and the literature reviewed.

The effect of the maternal postural position on the Nonstress Test (NST) was evaluated in 14 normal pregnancies at 38–40 weeks of gestation. Each woman was studied for two periods of 30 min, each in the standing and left lateral recumbent positions. Comparing both positions no significant difference was found in the number of fetal movements and heart rate accelerations. The total surface area of accelerations (TSAA) was significantly larger in the standing position.

A computerized quantification of fetal heart rate and beat-to-beat variability was performed during and between fetal breathing episodes. Sixteen healthy pregnant women at term participated in the study. The results indicate that fetal breathing is associated with a significant increase in beat-to-beat variability (from 4.48 +/- 1.66 between breathing episodes to 5.80 +/- 2.04 during breathing episodes, p less than 0.01) and a small but significant decrease in fetal heart rate (from 142.7 +/- 8.6 bpm between breathing episodes to 140.4 +/- 8.6 bpm during breathing episodes, p less than 0.05).

This study explores the relationship between fetal heart rate variability and fetal breathing movements in the term fetus. Fourier analysis was applied to fetal heart rate variability during fetal breathing and nonbreathing episodes. A distinct component in the order of 0.7 to 0.95 Hz was demonstrated in fetal heart rate variability during breathing episodes. These frequencies have the same distribution as the corresponding rate of breathing and therefore indicate that respiratory sinus arrhythmia exists in the term fetus.

Bilateral adnexal agenesis (both ovaries and tubes) is not a common finding. Ectopic ovaries are also very rare. A report of the combination of the two, as far as we know, has never been published. Such a case is presented here with its endocrinological evaluation. The literature concerning these entities is reviewed.

Fetal body movements and breathing movements were recorded with a real time ultrasound scanner in 26 fetuses. There were two recording periods of 25 min each, before and half and hour after maternal IV administration of 50 gr glucose. Six fetuses were at 280 days of gestation (Group A), twelve fetuses were at 294 days of gestation (group B), eight fetuses at 294 days gestation were classified as stage I postmature (group C). The incidence of fetal body movements was not significantly different in the three groups. Maternal glucose administration had no significant influence on fetal body movements in any group. On the other hand fetal breathing activity was significantly increased in all three groups after maternal glucose administration. Breathing activity was significantly greater in group A when compared to group C in both recording periods, and when compared to group B in the period which followed maternal glucose administration. It is concluded that fetal breathing activity is reduced in prolonged pregnancies.

The influence of music on fetal behavior was examined in 20 women to whom two different types of music were played via earphones. A real-time ultrasound scanner was used for direct observation of fetal body movements and breathing movements. A significant decrease in breathing activity was observed in fetuses while their mothers listened to a preferred type of music.

Because the clinical diagnosis of coronary artery disease (CAD) in the presence of aortic stenosis (AS) is difficult, the value of exercise gated nuclear angiography in detecting CAD in 33 patients with AS was assessed. Exercise left ventricular (LV) ejection fraction (EF) and wall motion analysis were evaluated after symptom-limited supine cycle ergometer exercise. Sixteen patients had severe AS (valve area 0.8 cm2 or less). Thirteen had significant associated CAD (50% or greater reduction in luminal diameter of 1 major coronary artery). Twenty patients had normal coronary arteriograms. All 10 patients with mild to moderate AS and normal coronary arteries had normal nuclear studies. Patients with CAD, regardless of the severity of AS, had a decrease in LVEF during exercise (12 of 13 patients) and regional wall motion abnormalities (11 of 13 patients). Abnormal exercise gated nuclear ventriculographic studies occurred in the absence of CAD in 10 of 20 patients, and all had severe AS (mean aortic valve area 0.8 cm2 or less, range 0.4 to 0.8). Ten had an abnormal LVEF response to exercise and 7 had exercise-induced abnormal wall motion. These findings suggest that the presence of an abnormal LVEF, whether in conjunction with an abnormal wall motion analysis, is indicative of further invasive evaluation; conversely, in those patients with a normal response of LVEF and normal wall motion during exertion, invasive studies may be safely deferred.

A method for detecting ovulation by measuring the concentration of salivary phosphate was assessed. Spontaneously produced samples were obtained from 14 women aged 18-28 years everyday during midcycle and every other day during the early and late stages of the menstrual cycle. All subjects showed significant (p less than .01-.001) phosphate peaks at midcycle. There was also a correlation between the phosphate peak and the midcycle shift in basal body temperature. It is recommended that the possibility of hormonal regulation of the salivary content of phosphate be investigated.

The effect of the delivery method on the short-term and long-term morbidity and mortality of the very low birthweight breech-presenting infants was evaluated. Although some previous studies question the benefit of cesarean section for the premature breech infants, the mortality rate and the incidence of birth injuries were significantly lower in the abdominally delivered group than in those delivered vaginally. The long-term follow-up clearly demonstrates that the vaginally delivered infants had a substantially higher incidence of cerebral palsy, visual damage, deafness, and severe developmental delay. It is concluded that cesarean section may be the preferred delivery method for the breech-presenting infants weighing 1000 to 1999 gm, offering a better quality of life.

500 patients treated by suction evacuation of the gravid uterus are described. There were 80 therapeutic abortions, 375 early incomplete abortions, 21 late incomplete abortions, 18 missed abortions, and 6 cases of hydatidiform mole. The suction method was attempted to avoid the trauma of the curette. The 80 therapeutic abortions were done in Weeks 5-10 of pregnancy. To check results, an immediate curettage was made in 56 cases: this verified that no tissue remained in the uterus. In the 18 cases of missed abortion an adherent and fibrotic placenta was encountered in 9. A curettage was then needed to complete the procedure. The suction method was not used for subsequent cases of missed abortion. In the 375 cases of early incomplete abortion suction evacuation was 100% successful; in these cases the cervix was usually already adequately dilated. In the 21 cases of late incomplete abortion, 17 had the fetus already expelled. However, the remaining placenta tended to block the suction tube. Parts of the placenta were then left to be removed by curettage. In the 4 cases in which the fetus had not been expelled it could not be evacuated through the suction tube. Therefore suction evacuation was no longer done for late incomplete abortion. In all 6 cases of hydatidiform mole suction evacuation was quickly performed with minimal bleeding. Damage to the basal layer of the endometrium and the myocardium is avoided in the separation of the placenta by suction evacuation. The method is recommended as better than curettage for early therapeutic abortion, early incomplete abortion, and hydatidiform mole but not for late incomplete abortion or missed abortion.

Vaginismus is probably a result of a faulty psycho-sexual development and can be successfully treated by hypno-desensitization, which is a therapeutic technique utilizing both hypnosis and desensitization. Hypnosis is used to obtain relaxation. Desensitization is a technique whereby anxiety-producing stimuli are presented in an increasing, step-wise manner (i.e., imagery and visualization of suggested material in the “in vitro” technique and the Hegar dilators in the “in vivo” method). Using the hypno-desensitization technique, complete success was obtained in 37 of the 43 patients. Follow-up for a period of 1–5 years on 35 patients showed that these couples were leading a normal sexual life and no symptom substitution appeared.

This study was undertaken to evaluate the effect of maternal intravenous (IV) administration of glucose on fetal breathing and its associated fetal heart patterns. Sixteen healthy women at term gestation participated in the study. The outcome of each of the pregnancies was normal. Fetal breathing and fetal electrocardiograms were simultaneously recorded by real time sonography and a fetal monitor respectively, and then digitized into a microcomputer. These women were studied for a 25-minute control period, given 50 gm of glucose IV and then, 20 minutes later, restudied for an additional 25-minute period. The results indicate that fetal breathing movements lasted for 24.8 +/- 6.2 percent of the time during the control period (mean +/- SEM) and were increased to 63.2 +/- 11.5 percent following the injection of glucose (P less than 0.01). Fetal heart rate decreased during fetal breathing by 2.3 and 2.1 beats per minute, before and after glucose administration, respectively (NS). Fetal breathing was associated with increased beat-to-beat variability by 1.32 +/- 0.5 and 1.27 +/- 0.3, before and after glucose administration, respectively (NS). This study confirms previous reports that the amount of time the fetus spends making breathing movements is significantly increased following maternal glucose administration, and demonstrates that the injection of glucose does not alter the modulation of fetal heart rate and beat-to-beat variability by fetal breathing.

Isotope renography was compared to excretory urography, voiding cystourethrography and endogenous creatinine clearances in 52 spinal cord injury patients. Renogram abnormalities were detected in 86 per cent of the cases. The most common abnormality was the delay of isotope excretion from the renal cortex and pelvis. Anticholinergic medication significantly reduced these excretion delays. A subgroup containing 22 newly injured patients was evaluated separately. Renogram abnormalities in this subgroup were associated with normal excretory urography and normal creatinine clearances. We postulate that the defect producing upper tract deterioration in spinal cord injury begins early, is obstructive to renal drainage, does not increase with time and probably requires early intervention with anticholinergic medication or transurethral sphincterotomy to prevent upper tract damage.

Plasma digoxin-like immunoreactive factor(s) (DLIF) have been reported in various pathophysiological conditions associated with volume expansion and linked to the regulation of blood volume and pressure. We hypothesized that DLIF might be present in rapidly expanding gonadotropin-stimulated ovarian follicles. The mean total and free DLIF concentrations in the follicles (n = 9) studied were 4925 nmol/L and 1885 nmol/L, respectively. These concentrations were substantially higher than the plasma total and free DLIF levels in these women: 1216 nmol/L and 158 nmol/L, respectively (p less than 0.0001). The plasma DLIF levels in the gonadotropin-treated women were comparable to those in term pregnant women, which are known to be higher than those in non-pregnant women. The ovary thus may be a source of DLIF in the plasma of gonadotropin-treated women, and DLIF may have a role in ovarian follicular fluid homeostasis.

Ovarian hyperstimulation syndrome was induced in rabbit by administration of human menopausal gonadotropin (HMG) and human chorionic gonadotropin (HCG). In an attempt to establish whether serotonin plays a part in the induction of this syndrome, the hyperstimulated rabbits were divided into two groups and were administered known anti-serotonin drugs, cyproheptadine and methysergide, respectively. The group treated with cyproheptadine, a non-specific serotonin antagonist, exhibited significant acceleration in the regression of the syndrome. Methysergide, a specific serotonin antagonist, administered to the second group, neither prevented the occurrence of the syndrome nor accelerated its regression. The results of this work indicate that serotonin does not seem to be directly involved in the production of the ovarian hyperstimulation syndrome in rabbits.

An inexpensive microcomputer has been devised to analyze fetal heart signals and fetal activity which were simultaneously recorded. Digital techniques were used to provide quantitative analysis of each of these inputs, and the interrelations among them. A parallel graphical presentation of those inputs was also provided.

Fifty obstetric patients with asymptomatic bacteriuria were treated by single-dose antimicrobial therapy. The immediate cure rate was 84% and the recurrence rate was 12%. Seven of the eight patients in whom single-dose treatment failed responded to subsequent 7-day therapy with the same drug, indicating renal involvement. A 50% recurrence rate in the group of patients in whom single-dose treatment failed was compared with a 5% recurrence rate in the group cured by single-dose therapy, which indicates that failure with single-dose antimicrobial therapy can serve as a therapeutic test to identify patients at high risk for recurrent bacteriuria and its sequelae during pregnancy. It is concluded that single-dose antimicrobial therapy is a safe and effective way to treat asymptomatic bacteriuria in pregnant patients without urologic problems in their history.

A rare complication of ovulation induction with clomiphene citrate is presented. The importance of keeping in mind such a serious complication is emphasized in order to achieve early diagnosis and appropriate management. In pregnancies following clomiphene treatment, close supervision is imperative as soon as pregnancy is evident.

Since its introduction six years ago (1,2), the clinical use of 111-In labelled white cells for the detection and localization of inflammatory disease has greatly increased. In the last three years, reports from several centres have confirmed its diagnostic value (3,4,5,6). The growing interest in imaging of labelled white blood cells is due in part to the increasing availability of 111-In-oxinate and the ease of its use. Some commercial sources now have the capacity to carry out the entire white cell labelling procedure (Pharmatopes, Inc., 2944 Corvin Drive, Santa Clara, CA 95051). Nevertheless, white cell labelling with 111-In-oxinate is a relatively easy technique similar in complexity to the red cell labelling with 51-Cr needed for the determination of mass and halflife which is routinely performed in most Nuclear Medicine laboratories. Normally, autologous white cells are used and it has been shown conclusively that the 111-In labelled white cells retain their viability and chemotactic properties, and concentrate specifically in areas of inflammation and abscess following reinjection (7,8,9).

Five fetuses with cystic hyroma were diagnosed in our department during a period of 5 months. Four of them were identified by an ultrasonic examination. No common causative factor was found to explain the appearance of such a rare anomaly in 5 cases over a very short period of time.

Air embolism was encountered in a patient following induced abortion by means of intra-amniotic hypertonic saline instillation. The only symptom present was isolated cortical blindness. The patient was treated in a high-pressure chamber and a nearly complete recovery was achieved.Air embolism, diagnosed by clinical therapeutic trial in the Navy hyperbaric chamber, occurred in a woman having labor induced by hypertonic saline for intrauterine fetal death at 25 weeks' gestation. 20 hours after saline administration, and 2 hours after 2 mU/minute diluted oxytocin was started, she had a sudden cardiovascular collapse with cyanosis and dyspnea. She was resuscitated by ventilation by mask and iv fluids. When she regained consciousness she was cortically blind. During treatment by the Navy's protocol, 30 minutes of compression at 6 ATA alternating cycles of 100% oxygen and air after rapid decompression to 2.8 ATA for 5 hours 19 minutes, there was a dramatic improvement in vision. After treatment, she showed left hemianopsia with macular damage. A year later only slight loss of left visual field remained. Air embolism can only be differentiated from amniotic fluid embolism by demonstration of amniotic fluid or fetal components in the maternal central circulation, or a therapeutic trial in a hyperbaric chamber. It is safer to try the pressure chamber immediately.

In a prospective, randomized trial, the efficacy of a single-dose, first-generation, long-acting cephalosporin was compared with a three-dose regimen in a group of 100 women undergoing cesarean section who were at high risk for postoperative febrile morbidity. Fifty women received a single 1 gm intravenous dose of cefazolin and 50 received 1 gm of the drug followed by two additional doses, 8 hours apart, to complete a three-dose regimen. Another 50 women, considered to be at low risk for postoperative febrile morbidity, were not given antibiotic prophylaxis. Outcomes of febrile morbidity (18% vs 12%) and particularly morbidity caused by endometritis (6% vs 8%, respectively) were similar for single-dose and three-dose groups. In the untreated low-risk group there were no cases of endometritis and the febrile morbidity was comparable to that of the prophylactically treated groups (14% vs 15%). Single-dose cefazolin prophylaxis appears to be comparable to multidose prophylaxis in reducing febrile morbidity after cesarean section.

Vaginismus (spastic contractions of the vaginal musculature that make intercourse impossible) has long been considered difficult, if not impossible, to treat with traditional psychotherapy. Surgical removal of the hymen is also ineffective, as the problem is a muscle spasm, not an imperforate hymen. In this article, the use of systematic desensitization with sexual imagery is described, as is actual (in vivo) use of a series of graduated dilators. Note that although the authors do not emphasize it, the use of dilators was much more effective. All thirty-one patients who completed dilator therapy (out of thirty-four who began therapy) were cured, while only six of nine desensitization patients were cured. Other clinical work has indicated that use of dilators—with or without the hypnosis these therapists used—is indeed the treatment of choice for vaginismus.

SummaryThe influence of maternal posture on fetal movements as subjectively recorded by women 32 to 41 weeks pregnant was studied. A total of 160 women recorded fetal movements for 90 minutes while standing, sitting and lying in six different sequences. Fetal movements were significantly reduced in the standing position. A standing—sitting—lying sequence caused the highest frequency of fetal movements.

A case of unruptured Ampullary pregnancy in the 7th postmenstrual week is presented, which was diagnosed and treated at the same time by operative culdoscopy. The indication and advantages of this method are discussed.

Many studies concerning the various aspects of cesarean section have recently appeared in the literature. The important issues are the changing indications for the operation and the different management protocols in trial of labor following a previous cesarean section. As the different authors use different ways of presenting their results, comparison of these studies is a complex matter and the conclusions are sometimes misleading. It is proposed that the data presented should be more uniformly used, according to the principles presented in this study.