Interrater variability with the Expanded Disability Status Scale (EDSS) and Functional Systems (FS) in a multiple sclerosis clinical trial. The Canadian Cooperation MS Study Group

We describe the interrater variability in the Expanded Disability Status Scale (EDSS) and Functional Systems (FS) in a multiple sclerosis clinical trial. Two physicians blinded to their previous assessments and to each other's scores consecutively examined 168 patients (545 paired examinations). Perfect agreement on the assignment of the disability scores ranged from 48% (cerebellar functional group) to 69% (EDSS and pyramidal functional group). Only 31% to 62% of this agreement occurred independently of that expected by chance (kappa). With the exception of the cerebellar and sensory functional groups, agreement within 1 step occurred in at least 92% of cases. These findings suggest that differences of a single step on these scales may not reflect an important functional change. We recommend that at least a 2-step change (1.0 point on the EDSS and 2 points on the FS) is needed to be confident of an important change in the degree of disability or response to treatment in this disease.

Intrauterine insemination as front-line treatment for non-tubal infertility

Eighty-one clinical pregnancies occurred from 508 cycles of intrauterine insemination (IUI) in 242 patients. Following 20 miscarriages 30 pregnancies have been delivered, and 31 remain ongoing at 16 weeks and beyond. This represents a 12% delivered/ongoing pregnancy outcome per cycle of IUI, in women of average age 30.9 years who with their partners had suffered on average 3.65 years of infertility. All forms of non-tubal infertility were treated with pregnancies occurring in all primary categories. No pregnancies occurred in 5 women who underwent IUI in 18 natural cycles. All pregnancies arose in the 237 women who received clomiphene citrate, human menopausal gonadotropin, or a combination of both with ovulation triggered by human chorionic gonadotropin. Dependent upon patient age and duration of infertility, we implement IUI as a frontline treatment for all cases of non-tubal infertility prior to subjecting patients to the more costly and invasive tubal transfer techniques.

Effects of dibutyryl cyclic guanosine monophosphate on human spermatozoal motility and penetration of zona-free hamster oocytes

The possible effects of N2,2'-O-dibutyryl 3'-5'-cyclic guanosine monophosphate (dbcGMP), imidazole (IM) or their combination on human spermatozoal motility and penetration of zona-free hamster oocytes were investigated. Motility of human spermatozoa was assessed at 0, 0.5, 2, 3, 5 and 8 h over an 8-h incubation period with various concentrations of dbcGMP, IM or dbcGMP plus IM. Both percentage motile spermatozoa and progression of human spermatozoa decreased with increasing concentrations of dbcGMP (12-96 mM) and IM (10-80 mM). This inhibitory effect on motility was more pronounced when dbcGMP was added with IM. For assessment of human spermatozoal penetration into zona-free hamster oocytes, spermatozoa were treated for 30 min with either dbcGMP, IM or both after 5 h of capacitation pre-incubation at 37 degrees C. Alternatively, the compounds were only added during the capacitation preincubation period. At concentrations of dbcGMP less than or equal to 24 mM, neither of the treatments had a significant effect on the penetration rate of zona-free hamster oocytes in comparison with the controls. However, a higher concentration of dbcGMP (48 mM) inhibited the penetration rate. A similar trend was observed when dbcGMP plus IM were added. IM alone had no significant effect on the penetration rate at the concentrations tested (10-40 mM). Our data indicated an inhibitory effect of dbcGMP on both human spermatozoal motility and penetration into zona-free hamster oocytes.

Post-operative artificial insemination--does it improve GIFT outcome?

Based on a retrospective study of our gamete intra-Fallopian transfer (GIFT) programme we have analysed 102 cycles where a standard GIFT procedure was implemented and 92 cycles where a post-operative intrauterine and intracervical insemination (post-operative IUI/ICI) was performed, in addition to GIFT. Our comparison suggests that the pregnancy outcome has been significantly improved (P less than 0.05) by this additional post-operative IUI/ICI. The standard GIFT group (102 cycles) yielded 38 clinical pregnancies and, ultimately, 29 delivered pregnancies (37.2/28.4%), whilst the post-operative IUI/ICI group (92 cycles) gave 48 clinical pregnancies initially and, currently, 38 pregnancies are ongoing or delivered (52.2/41.3%). The possible implications of the 'normal' presence of spermatozoa in the human female tract as an explanation for this improvement is discussed, and the adoption of IUI/ICI after GIFT is proposed, following a prospective controlled study.

The use of human follicular fluid in gamete intra-fallopian transfer

We undertook a prospective study to compare our gamete intra-Fallopian transfer (GIFT) procedure with or without the use of human follicular fluid (FF) as a constituent for the final spermatozoal suspension and as the tubal transfer medium for both eggs and spermatozoa. We routinely perform an intrauterine and intracervical insemination (IUI and ICI) following GIFT, and FF or culture medium was used accordingly as a constituent in this spermatozoal suspension also. When FF was used (26 cycles), clear FF taken from the first egg-bearing follicle was sterilized by micropore filtration, gassed with 5% CO2 in air and warmed to 37 degrees C. This FF was then used to dilute the spermatozoal suspension (50:50, v/v) for both tubal, uterine and cervical inseminations at least 30 min before transfer, and all transferable eggs were placed into this FF before transfer. Alternatively (30 control cycles), eggs and spermatozoa were prepared and transferred in Earle's medium supplemented with 10% pooled fetal cord serum. The FF and control patient groups were relatively homogeneous, with no statistically significant differences in ovarian response, oocyte retrieval or transfer or seminal profiles. The outcome of the GIFT procedures using FF or culture medium showed no significant advantage of the use of FF. The clinical pregnancy rate was similar in both groups: 50% (15/30) control; 46.2% (12/26) FF.

Routine gamete intrafallopian transfer (GIFT): a highly successful option for treatment of non-tubal infertility

Gamete intrafallopian transfer (GIFT) is increasingly accepted as a realistic alternative to in vitro fertilization (IVF), or intrauterine insemination (IUI) for treatment of non-tubal infertility. The lack of information on fertilization capacity of the gametes, the greater cost relative to IUI, and the partly unsubstantiated claims of higher success rates, caused us some concern with the readiness with which GIFT had been accepted as a standard infertility treatment. So we undertook a provisional GIFT programme with these considerations in mind, and we report on the first 91 GIFT cycles performed in our clinic. Sixty of the patients (62 cycles) treated suffered from idiopathic infertility, 12 from minimal endometriosis, 9 from male factor infertility, and 8 from ovulatory dysfunction. An initial clinical pregnancy rate of 41% (38/91) was achieved; pregnancy loss was 23% (9/38), giving a continuing pregnancy rate of 32% (29/91). Given this undeniably encouraging result, and the potential for diagnostic IVF, embryo freezing, and ovum donation with surplus oocytes collected from this GIFT programme, we now have adopted GIFT permanently as a treatment to complement our IVF and IUI programmes.

Fallopian replacement of eggs with delayed intrauterine insemination (FREDI): an alternative to gamete intrafallopian transfer (GIFT)

This report contains details of what is the first group of patients with nontubal infertility to undergo fallopian replacement of eggs with delayed intrauterine insemination (FREDI). Twenty-three patients suffering from idiopathic or immune infertility, polycystic ovarian disease (PCOD), or mild endometriosis underwent follicular stimulation with human menopausal gonadotropin and/or pure follicle-stimulating hormone plus human chorionic gonadotropin prior to laparoscopic pickup of eggs of varying maturity. Eggs without spermatozoa were transferred at the time of laparoscopy. Subsequent high intrauterine insemination (IUI) of washed spermatozoa at a time when egg maturation within the tubes was judged to be complete enabled a cohort of fully capacitated spermatozoa to meet fully mature eggs in a totally physiological manner. Eight clinical pregnancies arose from this group, one healthy, male infant has been delivered, and four pregnancies remain ongoing. Although based on a small population of patients, it does seem that in vivo egg maturation following replacement in the fallopian tube is an effective alternative to in vitro maturation and, with the increased control over timing of egg insemination, leads us to propose FREDI as a flexible new therapeutic approach for the treatment of nontubal infertility.

Local-regional recurrence in breast cancer after mastectomy and adriamycin-based adjuvant chemotherapy: evaluation of the role of postoperative radiotherapy

In an attempt to determine whether patients treated for breast cancer with radical or modified radical mastectomy and adjuvant chemotherapy benefit from postoperative radiotherapy, 400 women with Stages II-III breast cancer who received adjuvant chemotherapy based on the combination of Adriamycin and Cytoxan were analyzed retrospectively. Prognostic features which predicted a high risk of isolated local-regional relapse were identified. Thirty-eight percent of these patients were also treated with postoperative radiation in addition to adjuvant chemotherapy and were compared to those patients treated only with adjuvant chemotherapy. With a median follow-up of 60 months, 15% of the patients reviewed developed local-regional disease as the first site of relapse without concommitant systemic relapse. When examined univariately, stage of disease, tumor size, nodal status, and estrogen receptor status were strong prognostic variables. Age, cell type, location of tumor within the breast, menstrual status, radiation dose, and type of treatment were not significantly related to isolated local-regional relapse. However, patients who received postoperative radiation were significantly more advanced in their disease condition. When the factors were examined multivariately, the type of treatment along with stage of disease were found to be statistically significant prognostic indicators. About half of the patients were tested for estrogen receptor status. Multivariate analysis performed on this subset of patients showed that estrogen receptor status, type of treatment, and axillary nodal status were significant predictors of the risk of isolated local-regional relapse. This study suggests that patients treated with mastectomy and Adriamycin and Cytoxan-based adjuvant chemotherapy may benefit from postoperative radiation in reducing the risk of isolated local-regional recurrence.

Pregnancies from fallopian replacement of immature eggs with delayed intrauterine insemination

Gamete intrafallopian transfer requires that a woman should not only have patent tubes but should also have had mature eggs collected for replacement. Eggs must be collected as close to ovulation as possible, to give them a good chance of fertilizing upon replacing them directly into the tubes with the spermatozoa. Preliminary results from three patients who received Fallopian replacement of immature eggs followed by delayed intrauterine insemination indicate that maturation of eggs can occur in vivo in the Fallopian tubes. Intrauterine insemination at a later time when the eggs were judged to be mature has given rise to two pregnancies from the three patients with whom this procedure was adopted.

Comparative study of combined GIFT and IVF-ET with GIFT alone

Twenty-eight couples with unexplained infertility, or with suboptimal spermatozoa were divided into two groups. One group underwent gamete intra-Fallopian transfer (GIFT), and the other had combined GIFT and in-vitro fertilization--embryo transfer (IVF-ET) (GET). There was a marked difference in pregnancy rates between the two groups, with the pregnancy rate surprisingly being less in the combined GET group; 10% for GET, as compared with 39% for GIFT alone. The results suggest that GIFT and IVF-ET are incompatible. Differences in the pregnancy rates may be explained by limitations in implantation, whereby the embryo-endometrium interaction that allows for implantation and continued embryonic development has a 'single event capacity', and once this interaction is initiated, the 'implantation window' is closed to other embryos that may arrive later in the uterus.

MD 240928 and harmaline: opposite selectivity in antagonism of the inactivation of types A and B monoamine oxidase by pargyline in mice

In mice treated 24 hrs earlier with pargyline (20 mg/kg i.p), both type A and type B monoamine oxidase (MAO-A and MAO-B) were partially inactivated in brain, heart and liver. The abilities of two short-acting, reversible inhibitors of MAO to antagonize that inactivation were compared. Pretreatment with MD 240928 at doses of 10, 20 or 30 mg/kg i.p. antagonized the inactivation of type B MAO but did not alter the inactivation of type A MAO in all three tissues. In contrast, pretreatment with harmaline at a dose of 10 mg/kg i.p. antagonized the inactivation of type A MAO but did not alter the inactivation of type B MAO. Antagonism of the pargyline-induced inactivation is interpreted as being due to the transient selective inhibition of MAO-A by harmaline and of MAO-B by MD 240928, preventing the mechanism-based inactivation of those enzymes by pargyline. The selective protection by harmaline is in agreement with earlier results with that compound in rats; the selective protection by MD 240928 is the first report of selective protection against MAO-B inactivation.

Duration of chest pain associated with acute myocardial infarction: a predictor of long-term prognosis

This paper describes 109 patients who had their first myocardial infarction and were then followed up for 3 to 8 years. The following data were collected at the time of the infarction: duration and severity of chest pain, type of infarction and peak SGOT (serum glutamic oxaloacetic transaminase) level. The duration of chest pain has previously been shown to correlate with infarct size. Duration of chest pain, age and peak SGOT level were found to be the most important predictors of survival. None of the other independent variables contributed further to survival when the effects of duration of pain, age and SGOT level were taken into account. However, there was a significant association between pain duration and functional status. These data suggest that the duration of chest pain during first myocardial infarctions is a predictor of long-term prognosis and probably of functional status.

Early determinants of outcome in blunt injury

A critical set of 135 patients and a validation set of 202 patients who sustained blunt injury were examined for indices of outcome based on blood chemistry and the Glasgow coma scale. In both sets the nonsurvivors had significantly lower scores on the coma scale, higher levels of plasma glucose and increased leukocyte counts. Hypokalemia was also noted and a trend towards lower serum levels with increasing injury severity. Logistic discriminant analysis demonstrated that the most important variables were the coma scale score (as a continuous variable from 3 to 14) and the plasma glucose level (as a dichotomized variable with normal being defined as less than 10 mmol/L [i.e., the renal threshold] and abnormal as being above this level). A coma scale score cut-off at 10 with an abnormal plasma glucose level, and a cut-off at 8 with a normal plasma glucose level produced a maximum correct classification rate (into survivals and deaths) of 87%. Lower scores were associated with an increasing probability of death. Serum potassium levels and the leukocyte count did not contribute significantly to the discriminant function, although both were related to outcome. The reasons for the detected abnormalities are discussed. Metabolic markers, such as plasma glucose and serum potassium, in association with the coma scale score are simple and early determinants of outcome in blunt injury and may be useful indices of injury severity.