Scanning electron microscopy of the zona pellucida of human oocytes during intracytoplasmic sperm injection (ICSI)

During intracytoplasmic sperm injection (ICSI) approximately 10% of all injected oocytes degenerate. The reason for this process is unknown. It has been speculated that the mechanical procedure of the insertion of the ICSI needle induces injuries to the zona pellucida which lead to the death of the cell. By scanning electron microscope (SEM), it could be shown that the surface structure of mature oocytes is extremely elastic so that the injection needle penetrates the zona pellucida without destroying the mesh-like or more compact surface. No tissue pieces or zona fragments were detectable. After a culture time of 15 min the penetration site on the zona was no longer easily visible. We believe that oocyte degeneration is not caused by the penetration of a glass needle into the ooplasm but by an injury to the meiotic spindle or by an excessive dose of fluid [polyvinylpyrrolidone (PVP) or medium] during sperm injection.

Tumors of the respiratory tract observed at the German Primate Center, 1978-1994

Eight spontaneous pulmonary tumors (four bronchiolar tubular adenomas, two bronchiolar adenocarcinomas, two squamous-cell carcinomas) occurred in a total of 54 adult tree shrews (Tupaia belangeri) of the GPC colonies between 1978 and 1994. The adenomas and adenocarcinomas consisted of tubularly or trabecularly arranged cuboidal to cylindrical cells interspersed with some PAS-positive goblet cells, thus resembling the epithelial lining of respiratory bronchioles of tree shrews. The two squamous-cell carcinomas probably originated from the pulmonary alveoles. Three more pulmonary tumors (one small-cell carcinoma, one bronchial adenoma, one squamous-cell carcinoma) developed in 409 adult callitrichids of the GPC colonies during the same period, and one more bronchial adenoma was observed in a common marmoset (Callithrix jacchus) of another colony located in Göttingen. With regard to the adenomas and squamous-cell carcinomas, a similar cellular origin with the three shrews is assumed. The small-cell carcinoma possibly developed from the bronchial epithelium, provided a pathogenesis parallel to that of human small-cell carcinoma is suggested. Four of the tree shrew pulmonary adenomas/adenocarcinomas and the small-cell Ca were macroscopically visible as yellowish-grey nodules of 1 mm x 1 mm to 15 mm x 15 mm diameter, predominantly involving the main lobes (2 x right main lobes, 2 x left main lobes, 1 x all lobes). The pulmonary tumors of the other animals were below macroscopical detectability.

False aneurysm of the popliteal artery complicating acupuncture

This is the first reported case in which acupuncture needle injury of the popliteal artery caused the development of a false aneurysm. The patient presented with rupture of the aneurysm and was successfully managed by arterial repair.

[Surgery in patients with organ transplants]

Patients after successful transplantation with immunosuppressive therapy form a "new circle of surgical patients" who can develop various surgical diseases, or injuries which bring about an inevitable urgent or planned surgical treatment. The authors present the results in three patients with transplanted organs (1993-1995) who were subdued to various surgical treatments. The first patient underwent a classical cholecystectomy, choledochotomy, and extraction of concrement from the choledochus after orthotopic transplantation of the heart. The second patient underwent transplantation of the kidneys precedingly to bilateral subtotal resection of both lobes of the thyroid gland due to marked bilateral nodal goitre intervening deeply retrosternally with a severe pressure syndrome on trachea and oesophagus. The immediate and long-term results were excellent. Orthotopic transplantation of the heart in the third patient preceded to intercostal drainage of the thorax and evacuation of pus due to an extensive empyema of the thorax and septic state, and later thoracotomy and decortication with extirpation of the substantial part of the empyema sack was performed with an excellent immediate and long-term effect. The authors present the principles which must be inevitably fulfilled in coincidence with successive surgical treatment in patients with transplanted organs in a permanent immunocomplex regime. (Fig 2, Ref. 11.)

Medical ethics under managed care

"Managed Care" is having a profound effect on medical ethics and the patient/physician relationship. Historically, the patient (the first party) contracted with a physician (the second party) to provide medical care. The physician had ethical and legal obligations to the patient. In the "new health care," an employer or the government (the fourth party) or infrequently, the patient (the first party) purchases health care from the HMO, PPO, or similar organization (the third party). The third party then contracts with the physician (the second party) to provide that care. The physician has agreed to two, at times competing and possibly immutably conflicting obligations--one to the patient and one to the third party. The ethical and legal problems that arise from conflict between "the bottom line" and "desired" (appropriate) health care will be difficult to solve. The incompatible duality of physician roles both as patient advocate and manager of limited resources will be further explored, with attention to the enormous pressure being applied to this conflict by society, the law, and the third party. Potential resolutions will be offered. Other ethical problems created by the health care system's conversion to managed care include: CONFIDENTIALITY--Information management is a fundamental underpinning of managed care. With patients switching health care programs frequently, and their enormous size and complexity, careful attention to confidentiality is necessary. INFORMED CONSENT--In addition to informed consent relative to the health care being offered, the patient has a right to know what alternatives might be offered independent of her insurance and payment plan. The patient also has a right to know the economic pressures and arrangements between the second and third parties that could influence the quantity and quality of her health care. QUALITY OF CARE--Managed care contends to be religiously attentive to quality of care. If this is so, the very definition of quality of care may be changing.

d-Cycloserine enhances implicit memory in Alzheimer patients

We tested the ability of d-cycloserine, a partial glycine agonist acting at the N-methyl-D-aspartate (NMDA) receptor complex, to improve implicit memory in Alzheimer patients in a parallel-group, placebo-controlled, double-blind study. One-hundred eight patients with probable Alzheimer's disease of mild to moderate severity received d-cycloserine (5, 15, or 50 mg) or placebo twice daily for 10 weeks. We then evaluated their ability to identify perceptually degraded words, some of which were repeated over multiple trials across 3 days. Implicit memory performance of words repeated across trials was significantly enhanced for the patients who received 15 mg d-cycloserine compared with those who received placebo. These findings support development of NMDA receptor-mediated glutamatergic interventions for the treatment of Alzheimer-related memory disorders.

Quantitative in vivo 1H nuclear magnetic resonance spectroscopic imaging of neuronal loss in rat brain

The aim of this research was to determine whether in vivo nuclear magnetic resonance spectroscopic measurement of N-acetyl aspartate, a neuron specific brain marker, provides a quantitative index of neuronal loss. Five rats were injected unilaterally in the corpus striatum with kainic acid, an analogue of glutamate that causes excitotoxic degeneration of intrinsic neurons, and were subjected to nuclear magnetic resonance imaging and spectroscopic imaging. Measurements of N-acetyl aspartate were determined in vivo and compared to post mortem nuclear magnetic resonance spectroscopic measures of N-acetyl aspartate and choline acetyl transferase and glutamate decarboxylase activities, biochemical markers for striatal intrinsic neuronal integrity. Mean per cent neuronal survival of hemispheres with lesion versus the contralateral hemispheres measured 72 for glutamate decarboxylase and 71 for N-acetyl aspartate (in vivo), 74 for N-acetyl aspartate (in vitro), and 62 for choline acetyl transferase, respectively. Our studies in rats have shown that estimates of neuronal loss through nuclear magnetic resonance spectroscopic measurements of N-acetyl aspartate are equivalent to traditional neuronal enzyme activity assays. The results unequivocally demonstrate that N-acetyl aspartate is a valid and sensitive neuronal marker with the capability of providing accurate assessments of neuronal loss in vivo.

Evaluation of cycloserine in the treatment of Alzheimer's disease

This multicenter study evaluated the efficacy and safety of cycloserine and measured its effects on explicit and implicit memory tests in patients with Alzheimer's disease (AD). Four hundred ten patients with AD, aged 50 years or older, were enrolled in this parallel-group, double-blind, placebo-controlled, randomized trial of 5, 15, or 50 mg cycloserine or placebo twice daily, and 403 entered the double-blind treatment phase. Two hundred sixty-five patients completed the entire 26-week treatment phase. There were no baseline differences among the four treatment groups. Cognitive Drug Research (CDR) efficacy assessments showed no differences between active treatments and placebo from baseline to study weeks 2, 6, 14, or 26. Patients receiving 15 mg of cycloserine improved significantly on one section of an implicit memory test. No differences among treatments were observed for any other assessment scales evaluated. The incidence and severity of adverse events were similar across treatment groups. Cycloserine was well tolerated but did not demonstrate consistent evidence of efficacy during the course of therapy. Higher doses may be necessary to achieve efficacy in the AD population and do not appear to be precluded by the adverse event profile seen in this study.

HEp-2 cell-adherent Escherichia coli in patients with human immunodeficiency virus-associated diarrhea

Diarrhea occurs commonly in African human immunodeficiency virus (HIV) infections. A case-control (HIV-positive vs. -negative) study of adults with diarrhea was done in Lusaka, Zambia, to determine the prevalence of intestinal infection by HEp-2 cell-adherent Escherichia coli. Adherent E. coli were more common in HIV-positive patients with acute diarrhea than among HIV-negative controls (60% vs. 33%) and were found significantly more often in HIV-positive patients with chronic diarrhea than among HIV-negative controls with chronic diarrhea (79% vs. 17%, P < .002). Adherent strains were found significantly more often among HIV-positive patients (69%) than in 22 asymptomatic subjects (36%, P < .02). The HEp-2 cell adherence of the E. coli strains did not show a common pattern. Adherent bacteria were also observed in colonic biopsies from 32% of Zambians with chronic diarrhea who underwent endoscopy. Adherent E. coli may be an important cause of HIV-associated diarrhea in Zambia.

[Latent hypothyroidism--a minor laboratory variation or a disease?]

Latent hypothyreosis is a state which is characteristic by normal values of thyroid hormones (T3, T4) and moderately increased values of thyroid-stimulating hormone (TSH), or extensive response of TSH after stimulation with thyrotrophin-releasing hormone (TRH-test). The characteristic symptoms include goitre, symptoms of mammary glands (galactorrhea, benign mammary dysplasia), impairment of menstruation cycle and fertility and psychic disturbances (depressive symptomatology, deterioration of memory). The characteristic laboratory alterations include increased basal or stimulated values of prolactin and impairment of lipoprotein metabolism (significant decrease of HDL, increase of LDL). This aspect often makes the indication of substitution therapy justified in spite of normal concentrations of peripheral hormones. (Ref. 26).

Clinical stage I endometrial carcinoma: pitfalls in preoperative assessment with MR imaging. Work in progress

PURPOSE

To identify potential pitfalls in using magnetic resonance (MR) imaging to determine the depth of myometrial invasion in patients with clinical stage I endometrial carcinoma.

MATERIALS AND METHODS

Forty women with clinical stage I endometrial carcinoma underwent preoperative pelvic MR imaging. Uterine length, tumor signal intensity, appearance of the junctional zone, presence of large polypoid tumors, leiomyomata, and congenital uterine anomalies were analyzed. Univariate logistic-regression analysis was performed to identify associations between incorrect MR staging and these variables.

RESULTS

MR staging of IA, IB, and IC disease was 55% accurate (22 of 40 cases); MR differentiation of deep myometrial invasion (stage IC) from superficial disease (stages IA and IB) was 78% accurate (31 of 40 cases). Older age (P = .025), presence of polypoid tumors (P = .025), and difficulty in pathologic staging (P < .005) were significantly associated with incorrect MR assessment.

CONCLUSION

When present, large polypoid tumors, leiomyomata, congenital anomalies, small uteri, and indistinct zonal anatomy may make it difficult to assess myometrial invasion at MR imaging.

[Importance of close interdisciplinary cooperation in the treatment of diseases of the thyroid gland]

The authors reflect on the importance of interdisciplinary collaboration when resolving problems of the diagnosis and treatment of diseases of the thyroid gland. In 1989-1993 at the First Surgical Clinic of the Kosice Hospital 189 patients were operated on account of thyroid disease. During the last year the number of operations increased substantially due to better cooperation. In their group eufunctional nodular goitre was indicated most frequently for surgery. In the diagnosis they preferred ultrasonography and needle aspiration cytology. Peroperative biopsy is used in every operation of the thyroid gland. If the USG and cytological finding are not clear, they perform hemothyroidectomy and send the material to a pathologist for evaluation. By intensive interdisciplinary collaboration they achieved a very low number of two-stage operations in carcinoma, 1.05% paralyses of the recurrent nerve and a 1.58% postoperative mortality.

Urinary gonadotropin peptide (UGP) as a marker of gynecologic malignancies

Urinary gonadotropin peptide (UGP) was measured in 866 urines from normal women and women with benign and malignant gynecologic disease using the Triton UGP enzyme immunoassay. The greatest level of overexpression of the marker was observed in patients with ovarian cancer. Using a cutoff of 4 fmol/mg creatinine, UGP was overexpressed in samples from 2% of normal premenopausal women, 15% of normal postmenopausal women, 5% of women with benign gynecologic disease, and 59% of women with ovarian cancer. UGP expression was independent of the histologic type of ovarian cancer. The expression of UGP and CA 125 were not correlated and use of the two markers in tandem increased the sensitivity of detection of disease by greater than 20% over that which was observed using each marker individually. UGP levels were correlated with clinical status, and doubled in value in 67% of patients with progressive disease, and were halved in 93% of patients who were in remission at the time of the study.

Bacteremia associated with operative decompression of a small bowel obstruction

BACKGROUND

Intraoperative decompression of the small bowel has been advocated as a method of aiding recovery of both the patient and the intestine. However, the methods proposed (retrograde stripping or enterotomy) require vigorous handling of bacteria-laden small bowel, possibly giving rise to a bacteremia.

STUDY DESIGN

A small bowel obstruction was created in 31 rats by means of a ligature. Twenty-four hours later, the obstruction was relieved, and the rats were divided into three groups: relief of obstruction alone, relief with retrograde stripping, and relief with enterotomy plus suction. Blood cultures were taken before and after manipulation of the bowel.

RESULTS

In blood cultures taken before and after manipulation there was a significant increase of Escherichia coli bacteremia in the two manipulation groups compared with the relief of obstruction only group.

CONCLUSIONS

Bacteremia may be an effect of operative decompression of obstructed bowel, which at times outweighs its supposed benefits.

Central hypothyroidism--various types of TSH responses to TRH stimulation

Thyrotropin (TSH) levels in serum before and 20 and 60 min after the administration of 0.2 mg TRH i.v. as well as thyroid hormone (T3, T4) levels were studied in 39 patients with organic diencephalo-pituitary lesions and 27 healthy subjects. All participants gave their informed consent with the study. By the type of TSH response to TRH stimulation all patients were divided into 4 groups: 1. Normal response (n = 10): basal TSH 2.31 +/- 1.51, peak TSH 20 min after TRH 12.17 +/- 6.53, TSH 60 min after TRH 8.43 +/- 4.65 microU/ml; T3 2.02 +/- 0.48 and T4 95.9 +/- 27.73 nmol/l; 2. Blunted or absent TSH response (n = 8): basal TSH 0.82 +/- 0.42, peak TSH 20 min after TRH 1.51 +/- 0.66, TSH 60 min after TRH 1.35 +/- 0.51 microU/ml; T3 1.6 +/- 0.49 and T4 86.63 +/- 16.49 nmol/l; 3. Delayed ("diencephalic") TSH response (n = 16): basal TSH 2.69 +/- 1.27, peak TSH 20 min after TRH 7.96 +/- 3.35, TSH 60 min after TRH 10.0 +/- 3.97 microU/ml; T3 1.30 +/- 0.63 and T4 65.85 +/- 21.13 nmol/l; 4. Higher basal or stimulated TSH (n = 10): basal TSH > 10 mU/ml or stimulated values above 25 mU/ml. Mean T3 and T4 values in patients with normal or blunted TSH response did not differ significantly from the controls. Mean T3 and T4 in the group with delayed TSH response were significantly lower (P < 0.01). High TSH and low T3 and T4 levels were found in the patient with large meningioma sellae.(ABSTRACT TRUNCATED AT 250 WORDS)

Cardiovascular reactivity in isometric exercise and mental arithmetic in children

In children, we studied noninvasively the cardiovascular stress responses, including changes over time of systolic blood pressure (SBP), heart rate (HR), and stroke volume (SV) in isometric handgrip (IHG) and mental arithmetic. Specifically, we asked whether 1) these cardiovascular stress responses were different for the two stress conditions in children, 2) these responses differed in boys and girls, and 3) the anthropometric variables related to these stress responses. SV differed significantly between IHG and mental arithmetic over the entire stress period. This may reflect higher systemic vascular resistance during IHG. HR in boys was lower than in girls over the entire period of stress in both stress tests. This observation cannot be attributed to differences in conditioning, because this should not influence responses to isometric or mental stress. A larger left ventricular mass was related to higher SVs. A marked relationship was found between HR and SBP and between HR and SV. No relationship was found between SBP and SV.

The European Myocardial Infarct Amiodarone Trial (EMIAT). EMIAT Investigators

The objective of the European Myocardial Infarct Amiodarone Trial (EMIAT) is to assess the efficacy of amiodarone on mortality of patients with depressed left ventricular (LV) function following myocardial infarction (MI). The rationale for the trial is as follows: patients with poor LV function after acute MI have a high sudden cardiac death (SCD) mortality; amiodarone is a successful prophylactic therapy against SCD in patients with ventricular arrhythmias; a number of small studies (Canadian Amiodarone Myocardial Infarction Arrhythmia Trial [CAMIAT] pilot study, Basel Antiarrhythmic Study & Infarct Survival [BASIS], and the Polish Amiodarone Trial [PAT]) of prophylactic amiodarone post AMI have shown a beneficial response attributable to amiodarone. Patients are enrolled between 5 and 21 days after acute MI if LV ejection fraction (assessed by multiple-gated image acquisition nuclear angiography) is < or = 40%. The study group is stratified according to ejection fraction (stratum 1, 31-40%; stratum 2, < 31%). Amiodarone or placebo treatment (blind, randomized) is initiated prior to the discharge of the patient from the hospital and each patient is followed up for the duration of the study, at least 1 year. Recruitment began on November 30, 1990, and will continue for 4 years; > 700 patients are enrolled from > 60 centers (13 countries). The total study mortality (10% at 500 days) and the differential mortality of both strata are as anticipated. Side effects have been infrequent and very few patients have been withdrawn from the study. Trial conclusion is forecast for October 1995.

Alpha- and beta-adrenergic stimulation of protein synthesis in cultured adult ventricular cardiomyocytes

The effect of the alpha 1-adrenoceptor agonist phenylephrine (PE, 1-10 microM) and the beta-adrenoceptor agonist isoprenaline (ISO, 1-10 microM) on protein synthesis and ultrastructure of ventricular cardiomyocytes from adult rat in culture (6 days in medium 199 plus 20% fetal calf serum) was studied. In these cultures cardiomyocytes were spread, but not spontaneously contractile. ISO and PE significantly increased total cell protein and incorporation of (14C)-phenylalanine within 24 h of exposure. These effects were inhibited by the antagonists propranolol and prazosin, respectively. The incorporation of (14C)-uridine was stimulated only by PE but not ISO. Induction of fetal BB-isoform of cytosolic creatine kinase was also caused only by PE but not ISO. The ultrastructure of PE-treated cardiomyocytes was altered as compared to controls, by a greater number of Golgi complexes, denser myofibrillar structures and the appearance of paracrystalline bands in mitochondrial matrices. In conclusion, in this culture model the protein synthesis of cardiomyocytes can be stimulated, independently of the contractility, by either alpha 1- or beta-adrenoceptor agonists. Catecholamines differ, however, in their effects on specific cellular proteins and structures. Only alpha 1-adrenergic stimulation leads to a "fetal shift" in the expression of CK-isoforms.