Sonography of the normal scapholunate ligament and scapholunate joint space

PURPOSE

The aims of this study were to assess the visibility of the normal scapholunate ligament on sonography and to establish the normal scapholunate joint space width in the neutral position and radial and ulnar deviation.

METHODS

Two hundred normal wrists in 100 subjects (55 men and 45 women; mean age, 40 years; range, 19-83 years) were examined with high-resolution sonography (5-12-MHz linear-array transducer). The visibility and thickness of the scapholunate ligament were recorded. The width of the scapholunate joint space, or interval, was measured in the neutral position and radial and ulnar deviation. The width of the distal radius was recorded as a comparative standard for the patients' body habitus.

RESULTS

The dorsal scapholunate ligament was completely (100%) visible in 95 wrists (48%), partially (> or = 50%) visible in 60 (30%), barely (< 50%) visible in 15 (8%), and not visible in 30 (15%). The volar scapholunate ligament was completely visible in 13 wrists (7%), partially visible in 17 (9%), barely visible in 15 (8%), and not visible in 151 (76%). The proximal component of the ligament was not visible in any subject. Measurement of the scapholunate interval was limited by the lack of identifiable anatomic marks for reference. The mean width of the dorsal scapholunate interval was 4.2 mm (range, 2.3-6.3 mm) in the neutral position. The interval did not differ more than 2.5 mm between the left and right wrists. No predictable change in width on ulnar or radial deviation was evident. The mean scapholunate intervals and mean distal radial width were significantly wider in men than in women and on the right side than on the left side.

CONCLUSIONS

The dorsal scapholunate ligament is completely or partially visible in 78% of normal wrists. Its detection following injury may help to exclude the possibility of scapholunate dissociation. There is a quite wide variation in scapholunate interval widths on sonography and an unpredictable response with stress testing. The absence of a visible scapholunate ligament on sonography does not indicate injury.

Measurement of serum CA-125 concentrations does not improve the value of Chlamydia trachomatis antibody in predicting tubal pathology at laparoscopy

Chlamydia antibody testing (CAT) has been used to predict tubal pathology associated with Chlamydia infection, the leading cause of pelvic inflammatory disease (PID). Tubal pathology not related to C. trachomatis is unlikely to be identified by CAT alone. A correlation between serum CA-125 concentrations and the severity of adnexal inflammation during acute PID was demonstrated. The objectives of this study were to determine the prevalence of C. trachomatis infection in an Asian infertile population and to assess the role of a combination of serum CA-125 and CAT in the prediction of tubal pathology as shown by laparoscopy. A total of 110 consecutive women attending an infertility clinic for work-up were recruited. Blood was taken for CAT and CA-125 on the day of hospital admission and an endocervical swab was taken for culture of C. trachomatis prior to laparoscopy. Two (1.8%) women had C. trachomatis found in the endocervix and 28 (25.5%) women had CAT of > or = 1:32. Serum CA-125 concentrations were > 35 IU/ml in 11 (10%) women. The discriminative capacity of CAT in the diagnosis of tubal pathology including both proximal and distal obstruction was not improved by measuring serum CA-125, regardless of the threshold values of serum CA-125 concentration.

Paracervical block with and without conscious sedation: a comparison of the pain levels during egg collection and the postoperative side effects

OBJECTIVE

To compare the pain levels during egg collection and the subsequent postoperative side effects in patients receiving a paracervical block (PCB) with and without conscious sedation.

DESIGN

A prospective, randomized, double-blind, and placebo-controlled study.

SETTING

A tertiary assisted reproduction unit.

PATIENT(S)

150 patients undergoing egg collection.

INTERVENTION(S)

Randomized to receive PCB only (control group) and PCB in conjunction with conscious sedation (sedation group).

MAIN OUTCOME MEASURE(S)

Vaginal and abdominal pain levels; severity of postoperative side effects.

RESULT(S)

The median pain levels during vaginal punctures were 12.0 (2.5th--97.5th centiles: 0--84.3) and 30.0 (2.5th--97.5th centiles: 0--100) in the sedation and placebo groups, respectively. The corresponding median abdominal pain levels were 16.5 (2.5th--97.5th centiles: 0--100) and 43.0 (2.5th--97.5th centiles: 0--100). The pain levels were significantly higher in the placebo group than the sedation group. There were no significant differences between the two groups in the severity of nausea, vomiting, dizziness, and drowsiness.

CONCLUSION(S)

Patients who received only a PCB during the egg collection experienced 2.5 times higher levels of vaginal and abdominal pain as compared to those who received both PCB and conscious sedation. The use of PCB along is not recommended for all patients but it may be considered with selected patients after they have been given extensive counseling.

Haemodynamic evaluation of tubal and male factors of infertility in natural and ovarian stimulation cycles

PURPOSE

To determine the haemodynamic parameters in women with tubal and male factors of infertility and to investigate the effect of ovarian stimulation on the blood flow indices of the uterine and ovarian arteries.

METHODS

Prospective evaluation of the pulsitility index (PI) and resistance index (RI) of the uterine and ovarian arteries in the tubal and male factors of infertility was done. Comparisons were made between the natural and ovarian stimulation cycles.

RESULTS

In natural cycles, uterine PI was 3.55 +/- 1.39 and RI was 0.95 +/- 0.05 in tubal infertility. These were significantly lower (uterine PI = 4.13 +/- 0.08; uterine RI = 0.99 +/- 0.06) than the corresponding indices in patients with male factor infertility. After ovarian stimulation in tubal factor, uterine PI and RI were 2.62 +/- 0.73 and 0.88 +/- 0.08 and were similar (PI = 2.55 +/- 0.62, RI = 0.87 +/- 0.06) to male factor infertility.

CONCLUSIONS

The data points to measurable differences in the uterine PI and RI between the tubal infertility and male infertility in the natural cycles. These differences were abolished after ovarian stimulation.

Morphometric analysis of peri-implantation endometrium in patients having excessively high oestradiol concentrations after ovarian stimulation

The present study investigated whether high oestradiol concentrations after ovarian stimulation in infertile women affect endometrial development around the time of implantation. The glandular and stromal components of the endometrium were assessed by morphometric criteria. Endometrial biopsies were taken on day 7 (+/-1) after the ovulating dose of human chorionic gonadotrophin in stimulation cycles and on day 7 after the LH surge in natural cycles. Women (n = 38) undergoing assisted reproduction treatment were evaluated: 12 women in natural cycles, 11 women in stimulation cycles with oestradiol <20,000 pmol/l and failed fertilization after oocyte collection (moderate responders) and 15 women with an oestradiol concentration of > or =20,000 pmol/l in stimulation cycles (high responders). High responders showed delayed glandular maturation and advanced stromal morphology, whereas moderate responders demonstrated synchronous development of glandular and stromal features. In natural cycles, the glands were in phase. The effect of excessively high oestradiol concentrations could be explained by quantitative evaluation of the endometrial biopsies as gland--stromal dyssynchrony, which indicates a deficient secretory transformation of the endometrium that represents a suboptimal endometrial environment for implantation. This substantiates our previous clinical observation of significantly lower pregnancy rates in IVF cycles of women with high oestradiol concentrations (> or =20,000 pmol/l).

HMG is as good as recombinant human FSH in terms of oocyte and embryo quality: a prospective randomized trial

Previous studies have demonstrated that the use of recombinant human follicle stimulating hormone (rhFSH) for ovarian stimulation may be associated with a better outcome than human menopausal gonadotrophin (HMG), probably due to the absence of LH, higher FSH bioactivity and better quality of oocytes and embryos when rhFSH is used. Very few studies have examined the effects of different gonadotrophins on oocyte and embryo quality. In this prospective study, 40 women undergoing ovarian stimulation for intracytoplasmic sperm injection were randomized to receive a standard protocol of either HMG or rhFSH in down-regulated cycles. Prior to microinjection, each denuded oocyte was videotaped to assess nuclear maturity, morphology of zona pellucida, oocyte and polar body and the zona thickness, and diameters of oocyte and ooplasma. Fertilization and subsequent embryo development of each oocyte were followed. The embryologists were blind to the type of gonadotrophin each patient had received for stimulation. No significant differences were found between the two groups with regard to the demographic data, the ovarian responses and pregnancy/implantation rates. The percentage of metaphase II oocytes in the HMG and rhFSH groups were similar (86.9 versus 87.4% respectively). All other parameters assessing oocyte and embryo quality were also comparable between the two groups.

Effect of some enhancers on the permeation of haloperidol through rat skin in vitro

The objective of this work is to enhance the permeation of haloperidol through the rat skin in vitro by using various enhancers at a concentration of 1 mg/ml in the saturated drug solution and analysing the dose-dependent diffusion profile for the enhancers which significantly increased permeation at this concentration compared with the control. Enhancers belonging to various chemical classes like the vitamins (ascorbic acid), surfactants (cetrimide, polysorbate 20), sulfoxides (dimethyl sulfoxide), glycols (polyethylene glycol 400, propylene glycol) and amides (urea) were used. Amber glass Franz-type diffusion cells were used for the permeation studies and haloperidol was made soluble in aqueous solution with the aid of lactic acid. Ascorbic acid and cetrimide increased flux and permeability coefficient significantly. From the dose-dependent permeation studies, it was concluded that ascorbic acid enhanced the permeation by increasing the solubility of the drug in the vehicle thus providing a high concentration gradient across the skin, whereas cetrimide enhanced the permeation by increasing the thermodynamic activity which may be due to solubilization of skin lipids by micelles. Polysorbate 20 decreased the enhancer index by decreasing the thermodynamic activity. None of the enhancers changed the lag time except for urea which decreased the lag time probably by its binding with keratin. Dimethyl sulfoxide, polyethylene glycol 400 and propylene glycol did not have a significant effect on haloperidol permeation compared with control.

Effect of grapefruit juice on pharmacokinetics and pharmacodynamics of verapamil enantiomers in healthy volunteers

OBJECTIVES

To determine the effect of grapefruit juice on the pharmacokinetics and pharmacodynamics of S- and R-verapamil (given as racemates) at steady state.

METHODS

Nine healthy male volunteers followed a randomised cross-over study comprising two treatment periods. Pretreatments of 200 ml orange juice (control) or grapefruit juice twice daily for 5 days and 120 mg verapamil (orally) twice daily for 3 days were given. On the study day, the subjects received the morning dose of verapamil with either orange juice (control) or grapefruit juice. Plasma and urine samples were collected for measurement of S- and R-verapamil and the metabolites S- and R-norverapamil. Blood pressure (BP), heart rate (HR) and PR-interval were monitored.

RESULTS

During the grapefruit juice period, the steady-state peak and trough concentrations of S-verapamil were moderately increased (peak 41+/-25 ng ml(-1) versus 26+/-13 ng ml(-1), trough 14+/-7 ng ml(-1) versus 12+/-6 ng ml(-1), P=0.08). Grapefruit juice significantly increased the area under the plasma concentration-time curve during the 12-h dose interval (AUC0-12 h) of S-verapamil by 36% (292+/-146 ng h ml(-1) versus 215+/-102 ng h ml(-1), P=0.04). Similar results were obtained for peak and trough concentrations of R-verapamil. The AUC0-12 h of R-verapamil was increased by 28% (1022+/-412 ng h ml(-1) versus 800+/-316 ng h ml(-1), P=0.04). Elimination half-life and renal clearance of both S- and R-verapamil were not affected. Considerable inter-subject variability in interaction was shown. There were no significant differences in the pharmacodynamic parameters (BP, HR and PR-interval).

CONCLUSIONS

The present study has demonstrated an interaction between verapamil and grapefruit juice, which is likely due to an inhibition of intestinal metabolism resulting in increased oral bioavailability.

Human oviductal cells reduce the incidence of apoptosis in cocultured mouse embryos

OBJECTIVE

To investigate the effect of human oviductal cell coculture on the incidence of apoptosis in mouse embryos.

DESIGN

Experimental laboratory study.

SETTING

University gynecology unit.

PATIENT(S)

Fallopian tubes were obtained from patients undergoing hysterectomy.

INTERVENTION(S)

Mouse embryos were cocultured with human oviductal cells.

MAIN OUTCOME MEASURE(S)

Blastocyst development, allocation of inner cell mass (ICM) and trophectoderm (TE) in blastocyst, and apoptosis in embryos.

RESULT(S)

Oviductal cells significantly enhanced the blastulation (38%) and hatching rate (22%) of the cocultured zygotes. The corresponding values in medium alone culture were 21% and 9%, respectively. The cocultured embryos also had higher blastomere count at blastocyst stage (P<0. 005). This was due to increase in both the cell count of ICM (P<0. 05) and TE (P<0.001). Coculture reduced the incidence of apoptosis in the cultured morula and blastocyst from 38% and 48% to 16% (P<0. 001) and 27% (P<0.05), respectively. The number of apoptotic blastomeres per morula (1.5 +/- 0.6; P<0.005) and blastocyst (2.3 +/- 0.7; P<0.005) after coculture was also significantly lower than that of the corresponding control (morula, 2.1 +/- 0.8; blastocyst, 3.5 +/- 1.1).

CONCLUSION(S)

Human oviductal cells improved mouse embryo development partly by decreasing the incidence of apoptosis.

Comparison of two dosages of recombinant human follicle-stimulating hormone in Chinese women undergoing controlled ovarian stimulation: prospective randomised double-blind study

OBJECTIVE

To compare two dosages of recombinant human follicle-stimulating hormone for controlled ovarian stimulation.

DESIGN

Prospective, randomised double-blind study.

SETTING

Tertiary assisted reproduction unit, Hong Kong.

PARTICIPANTS

Forty subfertile Chinese women aged 24 to 38 years undergoing in vitro fertilisation. Entry criteria included good physical and mental health, and a body mass index between 18 and 29 kg/m2. Exclusion criteria were subfertility caused by an endocrine abnormality, polycystic ovarian syndrome, or absent ovarian function; previous assisted reproduction treatment in which fewer than three oocytes were retrieved; prior hospitalisation due to severe ovarian hyperstimulation syndrome; chronic cardiovascular, hepatic, renal, or pulmonary disease; alcohol or drug abuse; and the administration of investigational drugs within the previous 3 months.

INTERVENTION

Injection of recombinant follicle-stimulating hormone, 100 IU/d or 200 IU/d.

MAIN OUTCOME MEASURES

The number of oocytes, total dose of drug used, and pregnancy rates.

RESULTS

Compared with the 20 women receiving 200 IU/d, the 20 who received 100 IU/d had a significantly lower median number of oocytes retrieved and median total dose of drug used (7.5 versus 15.0 [P<0.001] and 1200 IU versus 2000 IU [P<0.001], respectively). The pregnancy rates in the fresh cycles were similar (20%) in both groups, but the cumulative pregnancy rates in the 100 IU/d and 200 IU/d groups were 20.0% and 45.0% per stimulated cycle, respectively. The incidence of ovarian hyperstimulation syndrome in the 100 IU/d and 200 IU/d groups was 5.0% and 20.0%, respectively.

CONCLUSIONS

Use of 100 IU/d of recombinant follicle-stimulating hormone requires a lower total dose but results in the harvest of half the number of oocytes compared with when a dosage of 200 IU/d is used.

Population pharmacokinetics of tacrolimus in Asian paediatric liver transplant patients

AIMS

The purpose of this study was to describe the population pharmacokinetics of intravenous and oral tacrolimus (FK506) in 20 Asian paediatric patients, aged 1-14 years, following liver transplantation and to identify possible relationships between clinical covariates and population parameter estimates.

METHODS

Details of drug dosage histories, sampling times and concentrations were collected retrospectively from routine therapeutic drug monitoring data accumulated for at least 4 days after surgery. Before analysis, patients were randomly allocated to either the population data set (n = 16) or a validation data set (n = 4). The population data set was comprised of 771 concentration measurements of patients admitted over the last 3 years. Population modelling using the nonlinear mixed-effects model (NONMEM) program was performed on the population data set, using a one-compartment model with first-order absorption and elimination. Population average parameter estimates of clearance (CL), volume of distribution (V) and oral bioavailability (F) were sought; a number of clinical and demographic variables were tested for their influence on these parameters.

RESULTS

The final optimal population models related clearance to age, volume of distribution to body surface area and bioavailability to body weight and total bilirubin concentration. Predictive performance of this model evaluated using the validation data set, which comprised 86 concentrations, showed insignificant bias between observed and model-predicted blood tacrolimus concentrations. A final analysis performed in all 20 patients identified the following relationships: CL (l h-1) = 1.46 *[1 + 0. 339 * (AGE (years) -2.25)]; V (l) = 39.1 *[1 + 4.57 * (BSA (m2)-0. 49)]; F = 0.197 *[1 + 0.0887 * (WT (kg) -11.4)] and F = 0.197 *[1 + 0.0887 * (WT (kg) -11.4)] * [1.61], if the total bilirubin > or = 200 micromol l-1. The interpatient variabilities (CV%) in CL, V and F were 33.5%, 33.0% and 24.1%, respectively. The intrapatient variability (s.d.) among observed and model-predicted blood concentrations was 5.79 ng ml-1.

CONCLUSIONS

In this study, the estimates of the pharmacokinetic parameters of tacrolimus agreed with those obtained from conventional pharmacokinetic studies. It also identified significant relationships in Asian paediatric liver transplant patients between the pharmacokinetics of tacrolimus and developmental characteristics of the patients.

High-performance liquid chromatographic assay for catecholamines and metanephrines using fluorimetric detection with pre-column 9-fluorenylmethyloxycarbonyl chloride derivatization

A convenient HPLC-fluorescent assay of norepinephrine (NE), epinephrine (E), dopamine (DA) and their 3-O-methylated metabolites, normetanephrine (NM) and metanephrine (MN) was developed. These analytes were coupled to 9-fluorenylmethyloxycarbonyl chloride (FMOC-Cl) before assays. Results showed that using a linear gradient elution, peaks of FMOC-NE, FMOC-E, FMOC-DA, FMOC-NM, FMOC-MN and FMOC-DHBA (3,4-dihydroxybenzylamine, internal standard) were simultaneously resolved within 40 min. Optimization of the chromatographic and derivatization conditions, and validation of the assay were further discussed in the paper. The structures of these derivatives were confirmed by atmospheric pressure chemical ionization mass spectrometry (APCI-MS). The molecular ions [M+H]- of FMOC-NE, FMOC-E, FMOC-DA, FMOC-NM and FMOC-MN were m/z 836, 850, 820, 628 and 642, respectively. Based on these findings, the FMOC-derivatives of metanephrines and catecholamines were confirmed to be bi-substituted and tri-substituted respectively at the amino and catechol functional groups. Finally, the assay was successfully applied to the measurement of urinary E, DA, NM and MN after direct derivatization and simple cleaning.

Effects of different atrioventricular intervals during dual-site right atrial pacing on left atrial mechanical function

Recent studies have suggested that dual-site right atrial (RA) pacing via the high RA and coronary sinus ostium (CSos) prevents atrial fibrillation (AF). However, the programming of the atrioventricular (AV) interval associated with optimal left atrial (LA) mechanical function during high RA and dual-site RA pacing has not been defined. LA mechanical function was studied by measuring transmitral pulsed Doppler echocardiographic peak A wave velocity and percent A wave filling, in six women and three men, 67 +/- 8 years of age, who had received dual-site RA pacemakers in a randomized study. Serial echocardiographic measurements were performed during high RA or dual-site RA pacing at 80 beats/min with AV intervals of 50, 100, 150, or 200 ms tested in random order. High RA and dual-site RA pacing at an AV interval of 50 ms were associated with significantly lower peak A wave velocity and percent A wave filling, compared to the other AV intervals (all P < 0.05). Compared with high RA pacing, dual-site RA pacing was associated with significantly higher peak A wave velocity (85 +/- 12 vs 72 +/- 17 cm/s, P = 0.04) and percent A wave filling (24 +/- 3 vs 20 +/- 4%, P = 0.02) at an AV interval of 100 ms, but a lower peak A wave velocity at an AV interval of 200 ms (77 +/- 10 vs 84 +/- 8 cm/s, P = 0.004). In conclusion, variations in the AV interval during atrial pacing have significant effects on LA function. As a consequence of altered atrial activation, the AV interval associated with optimal LA mechanical function during dual-site RA pacing was significantly shorter than that during RA pacing. This observation has important implications with respect to the programming of dual-site RA pacemakers implanted to prevent AF for hemodynamic purpose.

Pilot study on the use of repeated doses of misoprostol in termination of pregnancy at less than 9 weeks of gestation

Pregnancy was terminated by repeated doses of vaginal misoprostol in 20 women at a gestational age of less than 9 weeks. The women were given 800 microg of vaginal misoprostol as an initial dose followed by 400 microg of vaginal misoprostol every 3 h for 4 doses. Fourteen women (70%, 95% confidence interval: 48 85%) had a complete abortion. Two women (10%) had a missed abortion, and two (10%) had an ongoing pregnancy. Two women ( 10%) had an incomplete abortion. The interval between the first dose of misoprostol and the passage of tissue mass was 25.3 +/- 34.4 h (median: 15 h). The duration of vaginal bleeding was 23.6 +/- 20.4 days (median: 14 days). Side-effects were mild and there was no significant drop in hemoglobin level. Repeated doses of vaginal misoprostol may be an alternative for women who do not want surgical abortion and who live in an area where mifepristone is not available.

Comparison of two different doses of lignocaine used in paracervical block during oocyte collection in an IVF programme

We have recently demonstrated the efficacy of paracervical block (PCB) used in conjunction with conscious sedation during egg collection. The dosage of lignocaine used in various studies ranges from 50 mg to 200 mg. There are, however, no studies evaluating the efficacy of different doses of local anaesthetic agents used in PCB. In this prospective, double-blind and placebo-controlled study, 150 women undergoing egg collection in their first IVF cycle were randomized to receive 200 mg and 150 mg lignocaine in PCB. No differences were seen in the demographic data, the ovarian responses, the duration of egg collection and the number of follicles punctured. The fertilization, implantation and pregnancy rates were similar when either 150 mg or 200 mg lignocaine was employed. The median pain levels during vaginal punctures were 14.0 (2.5th-97.5th centiles: 0-75.4) and 14.0 (2.5th-97.5th centiles: 0-86.5) in patients receiving 200 mg and 150 mg lignocaine respectively, whereas the corresponding median abdominal pain levels were 14.0 (2.5th-97.5th centiles: 0-85.6) and 14.0 (2.5th-97.5th centiles: 0-99.1). These pain levels during egg collection were not significantly different between the two groups. The use of 200 mg lignocaine in PCB is not justified, even in the absence of toxic effects.

Randomized comparison of vaginal (200 microg every 3 h) and oral (400 microg every 3 h) misoprostol when combined with mifepristone in termination of second trimester pregnancy

It is known that when misoprostol is given at 200 microg every 3 h after mifepristone pretreatment, the vaginal route is more effective than the oral route. However, women prefer the oral route. This randomized study was to test our hypothesis that oral misoprostol 400 microg is as effective as vaginal misoprostol 200 microg when given every 3 h in termination of second trimester pregnancy after priming with mifepristone. A total of 142 patients was randomly assigned to group 1 (200 mg mifepristone + 400 microg oral misoprostol every 3 h up to five doses) or group 2 (200 mg mifepristone + 200 microg vaginal misoprostol every 3 h up to five doses). The incidence of side-effects and the preference study were assessed through a standardized questionnaire during and after the abortion. For the oral group, both the incidence of diarrhoea (40.0 versus 23.2%, P = 0.03) and the amount of drug used (1734 compared with 812 microg, P < 0.0001) were significantly higher than that of the vaginal group but the incidence of fever appeared to be lower (not significant). There was no significant difference in complete abortion rate: 81.4% in the oral group and 75.4% in the vaginal group. The median induction-abortion interval was similar in the two groups (10.4 versus 10.0 h). The percentage of women who aborted in 24 h was also similar: 57/70 (81.4%) in the oral group and 58/69 (87.0%) in the vaginal group. Overall, 82.0% of women preferred the oral route. Oral misoprostol (400 microg) given every 3 h up to five doses, when combined with mifepristone, was as effective as the vaginal (200 microg) route in second trimester termination of pregnancy. This regimen could also be offered to those women who found repeated vaginal administration unacceptable.

The significance of the number of antral follicles prior to stimulation in predicting ovarian responses in an IVF programme

Multiple follicular development plays a major role in the successful outcome of IVF and embryo transfer treatment. Prediction of ovarian responses prior to stimulation is useful in counselling patients and helpful in tailoring the dosage of gonadotrophin to individual patients. The objective of this study was to compare age of women, body mass index (BMI), basal FSH concentration, volume of both ovaries and the number of antral follicles of both ovaries in predicting the number of oocytes obtained. A total of 128 consecutive women, who had no history of ovarian surgery, were non-smokers and undergoing the first cycle using a standard regimen of ovarian stimulation were examined. The total number of antral follicles achieved the best predictive value, followed by basal FSH, BMI and age of women. In those women with fewer antral follicles, a longer duration and higher dosage of human menopausal gonadotrophin were required but the number of eggs obtained was significantly less than for those with more antral follicles. Significantly more cycles were cancelled before egg collection in women with < or =6 antral follicles while more cycles of embryo transfer were postponed in order to reduce the risk of ovarian hyperstimulation syndrome in women with >9 antral follicles.

2-hydroxypropyl-beta-cyclodextrin increases aqueous solubility and photostability of all-trans-retinoic acid

BACKGROUND

All-trans-retinoic acid (ATRA, vitamin A acid or tretinoin) is effective in the treatment of acute promyelocytic leukaemia (APL). Unfortunately, the oral absorption of ATRA is highly variable. Its poor aqueous solubility also makes it difficult to be formulated into parenteral formulation. To date, there is no parenteral formulation of ATRA available commercially.

OBJECTIVE

To undertake the preformulation work necessary for developing such a product.

METHOD

We investigated the solubility and stability profile of ATRA in various formulations.

RESULTS

The aqueous solubility of ATRA could be greatly increased by the inclusion of ATRA in 2-hydroxypropyl-beta-cyclodextrin (HP-beta-CD). Adjusting the pH value further improved the water solubility of ATRA. The photostability of HP-beta-CD-based formulation of ATRA was evaluated and it was found that inclusion ATRA into HP-beta-CD did improve the photostability of ATRA.

CONCLUSION

These results showed that it is possible to develop a parenteral formulation and/or an aqueous oral formulation of all-trans-retinoic acid by using 2-hydroxypropyl-beta-cyclodextrin. However, the biopharmaceutical properties of such a formulation would be necessary before its use.

Pharmacokinetics of quinine in obesity

Obesity can modify the pharmacokinetics of lipophilic drugs. As quinine is a lipophilic drug, this study was conducted to determine whether the pharmacokinetics of quinine is altered in obese subjects. Nine obese Thai men were compared with 8 age-matched lean men. After an oral dose of quinine had been given to the men, plasma quinine concentrations were measured up to 48 h after the dosing. Mean peak plasma quinine concentration in the obese group was significantly lower than that observed in the controls (4.0 +/- 0.8 vs 5.0 +/- 0.3 mg/L, P < 0.01). There were no significant differences in time to reach the peak plasma concentration, half-life and total clearance of quinine between the 2 groups. The mean clearances of quinine normalized to the ideal bodyweight (IBW) in the obese and the control groups were not significantly different (0.091 +/- 0.018 vs 0.091 +/- 0.024 L/h/kg IBW, P > 0.05). As there are similarities in the total clearance and the clearance of quinine based on IBW, the maintenance dose of quinine should be given to obese patients on the basis of ideal bodyweight, not on total bodyweight.

Free posterior tibial perforator flap: anatomy and a report of 6 cases

Anatomy of cutaneous perforators of the posterior tibial artery were studied in 20 limbs of 10 cadavers. The majority of the perforators (n = 74, 61%) were located in the middle two quarters of the leg, at an average of 18.6 cm (s.d. 4.5 cm; range 10.5-26 cm) from the medial malleolus, or around 54% (s.d 16%) of the length of the leg. There were usually 3 or 4 perforators in this region, with an average caliber of 1.5 mm (s.d. 0.2 mm; range 1-2 m.m.) and an average length from the posterior tibial artery to the skin of 4.0 cm (s.d. 1.3 cm; range 2.5-6 c.m.). A free fasciocutaneous skin flap based on one of these perforators (the posterior tibial perforator flap, PTP flap) was successfully transplanted in 6 cases. This modified technique of the posterior tibial flap enables the surgeon to retain the posterior tibial artery when the skin of the medial aspect of the leg is chosen to be used as skin flap donor.

Emergency contraception: methods and efficacy

A number of effective and safe methods for emergency contraception are now available. High doses of oestrogens, although effective, are seldom used nowadays because of the high incidence of nausea and vomiting, and the need for administration for 5 days. The Yuzpe regimen, consisting of administration of two doses of combined oral contraceptive pills with a 12-h interval, can prevent more than 74% of expected pregnancies, but the incidence of side effects, mainly gastrointestinal side effects, is high. Levonorgestrel and mifepristone are more effective than the Yuzpe regimen and have a lower incidence of side effects. They can prevent about 85% of pregnancies. The efficacy of both the Yuzpe regimen and levonorgestrel decreased with increase in the intercourse-treatment interval. The dose of mifepristone can be reduced to 10 mg without loss of efficacy. Both levonorgestrel or mifepristone are not yet widely available, and the Yuzpe regimen remains the only hormonal method in many countries. The postcoital insertion of an intrauterine contraceptive device is also a highly effective method, which can prevent over 90% of pregnancies.

Deletions within the azoospermia factor subregions of the Y chromosome in Hong Kong Chinese men with severe male-factor infertility: controlled clinical study

OBJECTIVE

To determine the patterns and the prevalence of microdeletions in the azoospermia factor subregions of the Y chromosome in Hong Kong Chinese men with severe male-factor infertility.

DESIGN

Controlled clinical study.

SETTING

Reproductive centre of a university teaching hospital, Hong Kong.

PARTICIPANTS

Fifty-eight men with severe male-factor infertility who participated in the in vitro fertilisation programme from May 1998 through March 1999, and 46 male volunteers with proven fertility.

MAIN OUTCOME MEASURES

Polymerase chain reaction analysis of DNA from peripheral blood lymphocytes using six loci spanning the AZFa, AZFb, and AZFc subregions of the Y chromosome. RESULTS. No microdeletions were detected in the fertile controls or in patients with obstructive azoospermia. Deletions within the AZFc subregion were found in 9% (4/44) of men with non-obstructive azoospermia or severe oligospermia. Neither AZFa nor AZFb deletions were detected in any participants.

CONCLUSION

Deletions within the azoospermia factor subregions of the Y chromosome are associated with severe male-factor infertility in Hong Kong Chinese men.

The effect of ageing on female fertility in an assisted reproduction programme in Hong Kong: retrospective study

OBJECTIVE

To analyse the effect of ageing on female fertility in an in vitro fertilisation programme in Hong Kong.

DESIGN

Retrospective study.

SETTING

University teaching hospital, Hong Kong.

PATIENTS

Seven hundred and seventy-one women in whom 1336 cycles of in vitro fertilisation were initiated between 1 January 1986 and 31 December 1995.

MAIN OUTCOME MEASURES

Patient age and indications for treatment; hormonal response; and the number of cancelled cycles, oocytes retrieved, oocytes fertilised, cleaving embryos, embryos transferred, and clinical pregnancies.

RESULTS

Compared with women aged <or =30 years (n=193), women aged > or =36 years (n=398) had a significantly higher cycle cancellation rate (19.3% versus 10.4%), fewer oocytes retrieved per retrieval cycle (6.6 versus 9.0), fewer oocytes fertilised per retrieval cycle (5.0 versus 7.0), fewer cleaving embryos per retrieval cycle (4.8 versus 6.8), and lower serum oestradiol level (9735 [standard deviation, 5681] pmol/L versus 10 708 [5916] pmol/L) despite a larger amount of human menopausal gonadotrophin having been used (all variables, P<0.01; Chi squared test). The clinical pregnancy rate per initiated cycle (range, 7.5%-13.0%) decreased with advancing age (P<0.01; Chi squared test).

CONCLUSION

Ageing has a significant deleterious effect on women's reproductive capability. Women should be encouraged to seek early medical advice and treatment for subfertility.