Similarly increased congenital anomaly rates after intrauterine insemination and IVF technologies: a retrospective cohort study

BACKGROUND

While intrauterine insemination (IUI), a simple, inexpensive and non-invasive technique, is the most used assisted reproduction technology (ART) worldwide, the risk of major birth defects following IUI is paradoxically not well documented.

METHODS

Retrospective cohort study performed in Burgundy, France, over a 9-year period which consisted of the cross analysis of two prospective databases, the Burgundy perinatal network database and the database of the assisted conception units in Burgundy. A total of 1348 ART singletons [in vitro fertilization technologies (IVFT): n= 903; IUI: n= 445] matched with 4044 infants conceived naturally, 552 ART twins (IVFT: n= 362; IUI: n= 190) matched with 1656 twins who were conceived naturally. The major birth defects were categorized according to the European Surveillance of Congenital Anomalies classification EUROCAT.

RESULTS

Compared with naturally conceived singletons, singletons born after IUI and IVFT had a higher prevalence of major congenital malformations, with adjusted odd ratios (AOR) of 2.0 [95% confidence interval (CI) 1.0-3.8] and 2.0 (CI 1.3-3.1); 3.6 and 4.2% of infants born, respectively. All twins and unlike-sex twins born after IVFT but not IUI, have an increased prevalence of major birth defects compared with naturally conceived twins; AOR of 3.0 (CI 1.6-5.6) and 3.7 (CI 1.1-16.9), respectively. When comparing IUI with IVFT, no differences were observed for singletons (AOR 1.0; CI 0.4-2.2), all twins (AOR 0.4; CI 0.1-1.2) and unlike-sex twins (AOR 0.3; CI 0.1-4.5).

CONCLUSIONS

The risk of major birth defects in singletons conceived through IUI was increased over naturally conceived singletons. This risk was no different from that observed after IVFT.

Asthma programmes in diverse regions of the world: challenges, successes and lessons learnt

International surveys have demonstrated that asthma is still underdiagnosed and undertreated in many parts of the world. Despite improvements in the standard of asthma care delivered in many areas, as evidenced by improved global asthma mortality data, much information on projects and programmes undertaken in resource-limited regions of the world is not in the public domain. The aim of this report is to review projects and programmes in diverse regions around the world so that health care providers, planners and consumers may draw on the successes, failures and lessons learnt. Such real world experiences may contribute to achieving Global Initiative for Asthma goals of asthma control. Asthma projects and programmes in Argentina, Australia, Brazil, China, Japan, Mexico, Philippines, Russia, South Africa and Turkey were discussed by a group of experts in asthma care, the Advancing Asthma Care Network, from their respective countries, over a course of three satellite meetings in 2010. Collective analyses consistently identified low rates of dissemination and implementation of national and international treatment guidelines, low levels of continuing medical education and training of primary health care professionals and access and distribution of inhaled corticosteroids to be major barriers that are critical to the overall success of a national asthma management programme. In the less developed asthma programmes, under-recognition and undertreatment further limited the success of the programmes. Evidence from well-established national asthma management programmes suggests that establishment of a successful programme entails a logical progression through specific developmental stages, starting with political/stakeholder endorsement and commitment, followed by epidemiological evaluation, evaluation of disease burden, evaluation of access to care and best therapy, and finally optimisation and maintenance therapy for individual patients.

Inhibition of growth hormone receptor activation by pegvisomant may increase bone density in acromegaly

Treatment of acromegaly with pegvisomant lowers serum IGF-1 and raises serum growth hormone. As both IGF-1 and GH are important for bone growth and remodeling, we were concerned that lowering of IGF-1 could cause loss of bone. To evaluate the effects of treatment of acromegaly with pegvisomant on bone mineral density (BMD) we developed an observational, prospective study. 7 acromegaly patients participated in the study. Male and female subjects aged 18 years or more were eligible to participate. Patients were eugonadal or on adequate gonadal replacement therapy for at least 3 years before participating in the study. These patients were treated with a mean dosage of 20 mg of pegvisomant daily for up to 7 years. Bone mineral density (BMD) was evaluated by dual X-ray absorbtiometry (DXA) at baseline, 8, and 18 months as a part of a prospective trial and periodically thereafter. Baseline mean serum insulin-like growth factor-1 (IGF-1) concentration±SD was elevated in all patients (679.86±138.21 ng/ml). The IGF-1 concentrations at 18 months decreased significantly from baseline (p=0.016). Wilcoxon signed-rank tests showed significant increases in the spine BMD from baseline to 18 months (p=0.016) and significant increases in the right hip BMD from baseline to 18 months (p=0.032). The range of the increases was 4.3-17.8% at 7 years. It is concluded that successful treatment of acromegaly with pegvisomant increases BMD.

A current review of the etiology, diagnosis, and treatment of pediatric pheochromocytoma and paraganglioma

CONTEXT

Pheochromocytomas and paragangliomas (PHEO/PGL) are neuroendocrine tumors that arise from sympathetic and parasympathetic paraganglia. Diagnosed rarely during childhood, PHEO/PGL are nonetheless important clinical entities, particularly given our evolving understanding of their pathophysiology.

EVIDENCE ACQUISITION

We identified articles through the U.S. National Library of Medicine by using the search terms pheochromocytoma and paraganglioma. Results were narrowed to manuscripts that included children and studies related to the genetics of PHEO/PGL. Web-based resources for genetic disorders were also used. For all articles, we performed subsequent reference searches and verification of source data.

EVIDENCE SYNTHESIS

Up to 20% of PHEO/PGL are diagnosed in children. Most are functional tumors, and clinical presentation includes symptoms related to catecholamine hypersecretion and/or tumor mass effect. Increasingly, PHEO/PGL are identified during presymptomatic screening in children with genetic syndromes associated with PHEO/PGL (multiple endocrine neoplasia type 2, von Hippel-Lindau disease, and the paraganglioma syndromes). Plasma and/or urine metanephrines are the best diagnostic test for a functional tumor, and the management of pediatric patients is similar to adults. Genetic counseling should be undertaken in all cases. Although most pediatric PHEO/PGL are benign, these tumors can occasionally metastasize, a condition for which no curative treatment exists.

CONCLUSIONS

Although PHEO/PGL are rarely diagnosed during childhood, the pediatric provider should be able to recognize and screen for such tumors, particularly in the context of a known genetic predisposition. Optimal care of these children includes a multidisciplinary team approach at centers experienced in the evaluation and treatment of these uncommon yet fascinating endocrine neoplasms.

How to demonstrate that eSET does not compromise the likelihood of having a baby?

BACKGROUND

In several randomized studies, elective single embryo transfer (eSET) has proven its effectiveness in reducing twin pregnancy rates while obtaining acceptable overall pregnancy rates. However, there is no outcome measurement consensus to evaluate the effectiveness of eSET versus double-embryo transfer (DET).

METHODS

This study evaluated whether or not adopting an eSET strategy instead of a DET strategy lowers the probability of having at least one live-born infant in good prognosis couples. Seven hundred and twenty-six couples were divided into two groups. The retrospective arm of the study was undertaken on the first group of couples (n = 483, DET group) and the prospective arm performed on the second group of couples (n = 243, SET group). In these specific populations, the probability of a woman having at least one live-born infant and the probability that one embryo utilized leads to a child were the main outcome measures.

RESULTS

The probability of a woman having at least one live-born infant was 60.5% in the DET group compared with 60.8% in the SET group. The probability of a live-born child per embryo utilized was not significantly different between the SET and the DET groups, 18.9% and 17.6%, respectively. In addition, the cumulative multiple live birth rate was significantly lower in the SET compared with the DET group.

CONCLUSIONS

In this observational study, using appropriate cryopreservation techniques, the chance of delivering a live baby, per utilized embryo, in an elective SET strategy is as good as that for DET.

Factors related to withholding life-sustaining treatment in hospitalized elders

OBJECTIVES

To look for predictors in the clinical records of orders for "limitation of life sustaining treatment" (LLST) or "do not attempt resuscitation" (DNAR) in hospitalized elders and to assess the relationship between the presence of these orders and the quality of end-of-life (EOL) care.

DESIGN

Retrospective clinical record review.

SETTING

Inpatients of an inner city elderly acute care unit (EACU) in Spain.

PARTICIPANTS

Of 103 hospitalized patients who died in the EACU during one year, 90 dying an expected death either from acute or chronic disease were included.

MEASUREMENTS

Demographic, functional, cognitive, clinical, and end-of-life (EOL) parameters. The influence of identifying closeness to death and the number of LLST suborders on the quality of EOL-management were considered simultaneously using structural equation modelling with LISREL 8.30 software.

RESULTS

LLST and specific DNAR orders were registered in 91.1% and 83.3% of patients, respectively. Failure of acute treatment, discussions with the patient/family, recognizing the presence of common EOL symptoms, and prescribing specific symptomatic treatment were recorded in 88.9%, 93.3%, 94.4%, and 86.7% of patients, respectively. LLST-orders were more likely to be documented if there was severe functional impairment prior to admission (p < 0.001), advanced organ disease criteria were met (p=0.006), or closeness to death was acknowledged in writing (p < 0.001). The quality of the EOL-management was better in patients for whom there were LLST-orders (p =0.01) and written acknowledgement of closeness to death (p < 0.001).

CONCLUSIONS

LLST-orders were more likely to be written in an EACU for patients with previous severe impairment, co-morbidity, or advanced disease. Written acknowledgement of closeness to death and LLST-orders were predictors of better EOL-management.

Zoledronic acid for the prevention of bone loss in patients with previously untreated lymphoma undergoing chemotherapy

e20611

Background: Treatment of lymphoma with alkylating agents and steroids causes bone loss and increased fracture risk. In addition, over half of all untreated lymphoma patients are osteopenic or osteoporotic at diagnosis. Pamidronate reduces bone loss and risk of vertebral fractures in lymphoma patients undergoing chemotherapy (CT). However, the effects of the more potent bisphosphonate (BP) zoledronic acid (ZA) in this setting are unknown. Therefore, we report on a phase III trial evaluating the effect of ZA on bone mineral density (B) in patients with newly-diagnosed lymphoma undergoing CT. Methods: In total, 72 patients will be randomized to either the control arm [calcium carbonate (1,200 mg orally/day) plus vitamin D (400 IU orally/day)], or the BP arm [calcium carbonate and vitamin D as in the control arm plus ZA (4 mg IV at baseline and at 6 months)]. The primary endpoint is the absolute change in B of the lumbar spine (LS) and femoral neck (FN) at baseline and 12 months. Results: Thus far, 112 patients have been screened for enrollment. Twenty-seven patients (24.1%) failed screening due to periodontal disease, a predetermined exclusion criterion of the study. To date, 14 patients in the control arm and 9 patients in the BP arm have completed the one-year follow up period including baseline and one-year B evaluations. Comparing patients in the control arm to those in the BP arm, the average absolute change in B at the LS was -0.048 g/cm2 vs. 0.0093 g/cm2 (p=0.005), at the left FN was -0.039 g/cm2 vs. 0.0074 g/cm2 (p=0.01), and at the right FN was -0.043 g/cm2 vs. 0.0211 g/cm2 (p<0.001), respectively. There have been no therapy-related serious adverse events or skeletal fractures in either arm. Conclusions: ZA in combination with calcium carbonate and vitamin D improves the B of patients with lymphoma undergoing CT. Given the incidence of below-average pre-treatment B and the known deleterious effects of lymphoma therapy on bone density, baseline B evaluation is warranted in all lymphoma patients. The high rate of periodontal disease in this patient population emphasizes the need for careful dental evaluation prior to BP therapy given the well-described, albeit rare, risk of osteonecrosis of the jaw from ZA.

[Table: see text]

[Spermiogenesis: histone acetylation triggers male genome reprogramming]

During their post-meiotic maturation, male germ cells undergo an extensive reorganization of their genome, during which histones become globally hyperacetylated, are then removed and progressively replaced by transition proteins and finally by protamines. The latter are known to tightly associate with DNA in the mature sperm cell. Although this is a highly conserved and fundamental biological process, which is a necessary prerequisite for the transmission of the male genome to the next generation, its molecular basis remains mostly unknown. We have identified several key factors involved in this process, and their detailed functional study has enabled us to propose the first model describing molecular mechanisms involved in post-meiotic male genome reprogramming. One of them, Bromodomain Testis Specific (BRDT), has been the focus of particular attention since it possesses the unique ability to specifically induce a dramatic compaction of acetylated chromatin. Interestingly, a mutation was found homozygous in infertile men which, according to our structural and functional studies, disrupts the function of the protein. A combination of molecular structural and genetic approaches has led to a comprehensive understanding of new major actors involved in the male genome reprogramming and transmission.

Fertilisation and pregnancy outcome after ICSI in globozoospermic patients without assisted oocyte activation

The successful outcome of intracytoplasmic sperm injection (ICSI) with globozoospermic sperm and non-activated oocytes is reported. Three couples underwent ICSI treatment and two of the patients were siblings. Forty-four non-activated oocytes were injected, 26 oocytes fertilised normally and 17 good quality embryos were obtained. Six embryo transfers were carried out, three with fresh embryos and three with frozen-thawed embryos. Three pregnancies resulted from the fresh embryo transfers and additionally two pregnancies were obtained after the transfer of frozen-thawed embryos. Two healthy babies were born. One twin pregnancy is ongoing. Our case reports demonstrate that in some ICSI attempts undertaken with globozoospermic sperm cells from two of our patients, high fertilisation rates, pregnancies and live births can be achieved, without artificially activated oocytes. Our data also suggest that in some cases, round-headed spermatozoa lack the capacity to activate the oocyte. Therefore, it cannot be excluded that artificial oocyte activation could be of help in globozoospermic patients with complete fertilisation failure.

Immune cells from pleural fluids of patients with inflammatory breast cancer are immunocompetent

Abstract #5044

Background: Malignant pleural effusion is a debilitating complication of metastatic breast cancer (MBC), including inflammatory breast cancer (IBC). The cellular components in pleural effusion are important indicators of pathologic process. Although pleural fluids from patients with IBC contain tumor cells and immune cells, little is known about the phenotype and function of the immune cell infiltrate. The objective of the study was to determine the immunophenotype and function of the cellular immune cells in pleural effusion of patients with pleural metastases.&#x2028; Methods and Patients: Pleural effusions from 9 women with MBC, 6 with IBC, median age 56 years (range 44-75 yrs), were submitted for pathological review. Mononuclear cells (MNC) were reacted with a cocktail of monoclonal antibodies to detect surface antigens by 8-parameter flow cytometry. In addition, MNC were activated through the T-cell receptor (TCR) with immobilized anti-CD3 and soluble anti-CD28 to assess intracytoplasmic syntheses of pro-inflammatory [interleukin (IL)-2, tumor necrosis factor (TNF)-a and interferon-gamma (IFN-γ)] and anti-inflammatory (IL-10) cytokines by TCR-activated CD4+ and CD8+ T cells. Data are presented as the mean (±SEM) of TCR-activated CD4+ and CD8+ T-cells that synthesized inflammatory and anti-inflammatory cytokines.&#x2028; Results: Upon pathological review, the mean (±SEM) number of tumor cells, MNC, and neutrophils were 20.2% ± 7.4% (range, 2%-72%), 62.4% ± 7.7% (range, 25%-96%), and 17.3% ± 5.9% (range, 0%-50.0%), respectively. The MNC consisted of 83.1% ± 8.2% CD3+ pan-T, 58.2% ± 7.0% CD4+ T, 24.2% ± 5.2% CD8+ T, 2.8% ± 0.9% CD19+ B, 4.0% ± 0.7% natural killer (NK), 3.4% ± 1.8% NKT, and 0.9% ± 0.2% dendritic cells, respectively. The CD4/CD8 T-cell ratio was 3.62 ± 0.78. The percentages of CD4+ and CD8+ T cells that synthesized inflammatory and anti-inflammatory cytokines following activation through the TCR-activated are listed in Table 1.&#x2028; &#x2028; Conclusion: There were no statistically significant differences between pleural fluids of IBC and non-IBC subjects with respect to tumor cell involvement, MNC phenotype, or T-cell function. Moreover, the function of pleural fluid T cells of MBC patients were similar to that of normal peripheral blood T cells (historical data, not shown). These data suggest that T-cells in the pleural fluids of patients with MBC are immune competent and can be activated through the TCR to synthesize pro- and anti-inflammatory cytokines.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5044.

Psychiatric Family History in Juvenile Psychiatric Patients

Introduction:

The presence of mental illness in any of the parents can be a stressful factor in the child and be in certain way generator of disease. AIMS describe and quantify the psychiatric family history in patients who were consecutively referred to the outpatient department of children and adolescent psychiatry,mental health community center of collado villalba, Madrid

Material and method:

Obtain data of a series of cases filing a card of the 18-year-old minor patients who in September, October, November and December, 2007 come for the first time to our mental health community center.

Results:

The total number of patients were 114. There were psychiatric family history in 36,8% (N=42), the mother was or had been in psychiatric treatment in 28% (N=31)) of the cases, the father in 15% (N=17) and the brothers in 7 % (N=8), the most frequent diagnoses in mothers it were neurosis in 21 % (N=24), toxic abuse in 3,5% (N=4) and personality disorder in 1,8% (N=2), toxic abuse was the most frequent with 8,8% (N=10) in parents, followed by neurosis diagnosed in 4,4% (N=5), the most frequent diagnoses in brothers was the emotional disorder in 4,4,% (N=5). The mean age of parents was 41,34 (SE =6,34), in mothers was 38,43 (SE=6,59).

Conclusions:

We have to consider the existence of some kind of psychiatric family history in the therapeutic plan of the patient.

Prospective evaluation of the threat related to the use of seminal fractions from hepatitis C virus-infected men in assisted reproductive techniques

BACKGROUND

The risk of hepatitis C virus (HCV) transmission during assisted reproductive techniques (ARTs) is still disputed and no report concerning its prospective evaluation is available.

METHODS

The aim of this 4-year follow-up multicentre study that enrolled 86 HCV-serodiscordant couples was to determine whether a sperm-processing method was able to reduce levels of HCV in semen and the risk of HCV transmission to the newborn. All the men were chronically infected by HCV and 10 of them by human immunodeficiency virus. A total of 181 seminal plasmas and 153 sperm fractions were tested for the presence of HCV RNA.

RESULTS

HCV RNA tested positive in 20.4% of the seminal samples. All of the 153 final sperm fractions tested negative for HCV. The detection of HCV RNA in semen was significantly correlated with a high viral load in blood (P < 0.05). The presence of HCV RNA in seminal plasma impaired neither semen parameters nor ART issue. From the 58 couples enrolled effectively in an ART programme, 24 pregnancies and 28 newborns were obtained. All of them tested negative for HCV RNA in blood.

CONCLUSION

These results emphasize the safety of the semen-processing method. The negligible risk of transmitting HCV reduces the value of the systematic analysis of HCV RNA in seminal fractions prior to ART. Since use of this analytical procedure involves the freezing of semen, its avoidance would result in an increase in sperm quality and reduce the need to perform intracytoplasmic sperm injection techniques.

Starting a new program of split liver transplantation after a low learning curve: a reality in centers with large experience in liver surgery and whole liver transplantation

BACKGROUND/AIMS

Split liver transplantation (SLT) is nowadays, considered an adequate surgical solution to expand the grafts from the existing pool of cadaveric donors.

METHODOLOGY

A total of 897 liver transplantations were performed between 1986 and 2002; 20 were SLTs (2.3%). A 30% were children.

RESULTS

Mean follow up of 15.15 months +/- 13.85. Median age was 42.27 +/- 25.65 yrs. Median recipient weight was 52.29 +/- 20.87 Kg. Mean donor weight was 76.1 +/- 13.11. The majority was "in situ" SLT (65%). There was no primary graft dysfunction. Two patients developed biliary complications (none in situ SLT). Early HAT occurred in 2 patients and delayed HAT in one. Four patients were retransplanted but none were performed because of primary graft dysfunction. Five patients died in the hospital. Fifteen patients (75%) survived the postoperative period and 3 patients died during follow-up. Mean patient survival time was 42 months (95% CI: 31-52). Actuarial patient survival was 93.3%, 84.4%, 84.4% at 6 months, 1 year and 3 years. Mean graft survival was 36 months (95% CI: 25-48). Actuarial graft survival was 87%, 72%, 72% at 6, 12, 36 months. Univariate analysis of risk factors for graft loss showed that the type of splitting technique (p=0.019), and the UNOS (1 and 2a) status of the recipient (p=0.001) were significantly associated with graft loss.

CONCLUSIONS

In the context of large volume full cadaveric liver transplantation, split liver can provide adequate results (even after a short learning curve) mainly in elective cases and with the in situ technique.