Biomedical subjects
Publications and source records attributed to K E Morton.
The cause of vaginal bleeding in girls of 10 years and under is reviewed. Of the 52 patients seen, in 28 (54%) bleeding was caused by a local lesion and 11 (21%) of these had malignant genital tumours. Eleven (21%) children presented with some form of precocious puberty, and in 13 (25%) patients no cause could be found.
Radical transsphenoidal surgery in 58 patients with large non-functioning pituitary tumours relieved pressure symptoms and disconnection hyperprolactinaemia without loss of pituitary function, and verified the diagnosis. Pre-operative bromocriptine did not cause any shrinkage of non-functioning tumours (n = 8), even up to 48 weeks. Thirty-two patients not given postoperative radiotherapy are being followed-up, and although two show minor CT scan evidence of tumour regrowth, for the others the delay in radiotherapy is enabling reproduction where required. In 20 patients with non-invasive macroprolactinomas radical surgery caused no loss of pituitary function but cured eight, of whom one has relapsed; none of eight invasive prolactinomas was cured by surgery. Pre-operative bromocriptine caused marked size reduction in seven of seven macroprolactinomas, but if continued beyond 6 weeks induced tumour fibrosis and uneven shrinkage which made surgery dangerous and unproductive. Selective transsphenoidal surgery relieved hyperprolactinaemia in 70% of patients with meso- (n = 15) or microprolactinoma (n = 24) usually without loss of pituitary function: the relapse rate was 1 per 88 patient years of follow-up. Invasive prolactinomas, and macroprolactinomas showing uneven shrinkage with a short (up to 4 weeks) course of bromocriptine should have radiotherapy rather than surgery, while the patients most suited to surgery are those with mesoprolactinomas, or some macroprolactinomas with compact intrasellar shrinkage after short-term bromocriptine. Microprolactinomas generally did not benefit from surgery as compared to conservative therapy. In none of the tumour groups were the surgical findings an accurate predictor of postoperative pituitary function.
Plasma anticardiolipin antibody (ACA) was measured in 83 patients having coronary artery bypass graft surgery and results were correlated with the incidence of early (1-2 weeks) and late (12 months) graft occlusion, as judged by angiography. There was an association between preoperative ACA level and the incidence of late graft occlusion in relation to both number of patients with an occlusion and number of distal anastomoses occluded. 8 of 15 patients (53.3%) whose maximum ACA level exceeded 4 SD of the mean of controls had a late graft occlusion. When the ACA titre was 2-4, 0-2, or less than 0 SD above the mean of the controls, the occlusion rates were 3 of 13 (23.1%), 3 of 33 (9.1%), and 1 of 15 (6.7%), respectively (p less than 0.03). The incidence of a postoperative rise in ACA level was higher in patients who had had a myocardial infarction in the past than in those with a history of angina only (chi 2 = 4.08, p less than 0.05). This observation supports the notion that one mechanism of ACA production is an immune response to myocardial injury. These results raise the further possibility that the ACA, or related antiphospholipid antibodies, may play a part in progressive coronary vessel disease.
Vaginoplasty using human amnion has been performed in 27 patients aged from 13 to 28 years. Excellent epithelialization occurred with good functional results; the technique appears to be preferable to other surgical methods.
Vaginoplasty in two girls with severe vaginal stricturing due to congenital adrenal hyperplasia is described. The strictures were so tight and long that conventional flap techniques were inappropriate, and long fasciocutaneous flaps from redundant labioscrotal tissue were used. This technique has gained wide usage in plastic surgery, but has not been described previously in this site.
Fifteen patients with various developmental and acquired abnormalities of the vagina were treated by the application of human amnion over a mold after surgical dissection of a space for the new vagina or enlargement of an existing but strictured one. Excellent results were achieved in cases of complete and partial vaginal agenesis, and there was improvement in all of the patients with vaginal strictures.
Forty women in whom ketonuria was detected during the first stage of labour were allocated randomly to intravenous treatment with one litre of either normal saline, Hartmann's solution, 5% dextrose or 10% dextrose. The solutions were administered over 1 h and blood was taken immediately beforehand and thereafter at 30-min intervals for 90 min to assess their effect on intermediary metabolism, plasma osmolality and acid-base status. Although both the 5 and 10% dextrose infusions caused a rapid decline in whole blood D-3-hydroxybutyrate concentrations, they also produced pathological degrees of maternal hyperglycaemia and hyperinsulinaemia and a marked elevation in the mean blood lactate and pyruvate concentrations. Administration of 10% dextrose was also associated with a significant increase in serum osmolality. Hartmann's solution produced significantly higher mean whole blood lactate and pyruvate concentrations than did normal saline. There was a significant increase in the venous base deficit in the group infused with 10% dextrose, indicating that the buffering capacity of the blood had been exceeded. It is concluded that rapid infusions of dextrose or Hartmann's solution should not be administered during labour. Normal saline should be used for rehydration and if dextrose therapy is deemed necessary the dose administered should not exceed physiological requirements.
To further understand the mechanism by which in vivo prostaglandin synthesis may be orchestrated, plasma levels of endogenous inhibitor(s) of prostaglandin synthase (EIPS) in the human fetus, neonate and adult have been measured. In general, a reciprocal relationship was found between plasma EIPS levels and previously reported plasma prostaglandin concentrations. This result supports a role for EIPS in the control of prostaglandin biosynthesis in the human.
The management of 56 pregnancies in 54 patients is presented, 52 with systemic lupus erythematosus and two patients with primary antiphospholipid syndrome. All underwent serial Doppler blood flow studies of the umbilical and uterine arteries from 14 weeks of gestation. Drug therapy was directed at disease activity and the fetus and mother monitored intensively to identify optimum time for delivery. End diastolic blood flow (EDF) studies were compared with anticardiolipin antibodies (aCL) and the lupus anticoagulant (LAC) to predict outcome of pregnancy in terms of mortality, Caesarian delivery, hypertension, and gestation. The absence of end-diastolic blood flow predicted Caesarian delivery more accurately. The presence of EDF and the absence of aCL was consistent with a normotensive pregnancy. The presence of LAC was the best of the three in predicting fetal demise.
Certain subgroups of lupus patients and those with circulating antiphospholipid antibodies (aPL) in particular, suffer a high rate of fetal loss. Over the past 4 years, we have prospectively studied 100 pregnancies in patients with systemic lupus erythematosus (SLE) and primary antiphospholipid syndrome. In addition to conventional methods of monitoring SLE and fetal development, we have also used Doppler flow assessment of placental perfusion from the 14th wk of pregnancy onward. Patients with the antiphospholipid syndrome and previous history of thrombotic events were treated with daily heparin (10,000 IU) and low-dose aspirin (75 mg). Those without a history of thrombosis were treated with low-dose prednisolone, azathioprine, or hydroxychloroquine. Pregnancy loss was reduced from 81.3% in 101 previous pregnancies to 36.8% in 100 pregnancies managed by us. None of the patients who received hydroxychloroquine throughout the pregnancy presented fetal malformations. Careful management and close monitoring of the lupus pregnancy has substantially improved fetal outcome.