A resonant sextuplet of sub-Neptunes transiting the bright star HD 110067

Planets with radii between that of the Earth and Neptune (hereafter referred to as 'sub-Neptunes') are found in close-in orbits around more than half of all Sun-like stars1,2. However, their composition, formation and evolution remain poorly understood3. The study of multiplanetary systems offers an opportunity to investigate the outcomes of planet formation and evolution while controlling for initial conditions and environment. Those in resonance (with their orbital periods related by a ratio of small integers) are particularly valuable because they imply a system architecture practically unchanged since its birth. Here we present the observations of six transiting planets around the bright nearby star HD 110067. We find that the planets follow a chain of resonant orbits. A dynamical study of the innermost planet triplet allowed the prediction and later confirmation of the orbits of the rest of the planets in the system. The six planets are found to be sub-Neptunes with radii ranging from 1.94R⊕ to 2.85R⊕. Three of the planets have measured masses, yielding low bulk densities that suggest the presence of large hydrogen-dominated atmospheres.

Extreme oxidant amounts produced by lightning in storm clouds

Lightning increases the atmosphere's ability to cleanse itself by producing nitric oxide (NO), leading to atmospheric chemistry that forms ozone (O₃) and the atmosphere's primary oxidant, the hydroxyl radical (OH). Our analysis of a 2012 airborne study of deep convection and chemistry demonstrates that lightning also directly generates the oxidants OH and the hydroperoxyl radical (HO₂). Extreme amounts of OH and HO₂ were discovered and linked to visible flashes occurring in front of the aircraft and to subvisible discharges in electrified anvil regions. This enhanced OH and HO₂ is orders of magnitude greater than any previous atmospheric observation. Lightning-generated OH in all storms happening at the same time globally can be responsible for a highly uncertain, but substantial, 2 to 16% of global atmospheric OH oxidation.

A nearby transiting rocky exoplanet that is suitable for atmospheric investigation

Spectroscopy of transiting exoplanets can be used to investigate their atmospheric properties and habitability. Combining radial velocity (RV) and transit data provides additional information on exoplanet physical properties. We detect a transiting rocky planet with an orbital period of 1.467 days around the nearby red dwarf star Gliese 486. The planet Gliese 486 b is 2.81 Earth masses and 1.31 Earth radii, with uncertainties of 5%, as determined from RV data and photometric light curves. The host star is at a distance of ~8.1 parsecs, has a J-band magnitude of ~7.2, and is observable from both hemispheres of Earth. On the basis of these properties and the planet's short orbital period and high equilibrium temperature, we show that this terrestrial planet is suitable for emission and transit spectroscopy.

Shooting up? Analysis of 182 gunshot injuries presenting to a London major trauma centre over a seven-year period

Introduction Metropolitan Police data, and those from the emergency department at a London major trauma centre show a resurgence in gun crime. The aim of this study was to collect data on all gunshot injuries over a seven-year period at South-East London's trauma hub. Materials and methods This was a retrospective observational study of all gunshot injuries between 1 January 2010 and 31 December 2016 at a London major trauma centre. Information regarding patient demographics, morbidity and mortality was collected. Data from the English indices of multiple deprivation were reviewed in relation to shooting locations and socioeconomic status in South-East London. Results A total of 182 patients from 939,331 emergency admissions presented with firearm injuries. Males comprised 178 (97.8%) victims and 124 (68.1%) were documented as being Black or Afro-Caribbean. The median age was 22 years. Some 124 (71.7%) victims were shot within a 4 km radius of the hospital. The mean indices of multiple deprivation decile ranking in shooting locations compared with non-shooting locations was 2.6 (± 0.1384) and 3.8 (± 0.1149), respectively. A total of 122 (67.0%) patients underwent specialist operative intervention and 111 (61.0%) suffered only superficial or musculoskeletal injuries. Six patients required emergency thoracotomies; three (50.0%) survived to discharge. The median length of stay was 4 days (interquartile range 2-9 days) and 35 (24.0%) were admitted to intensive care. Ten (5.5%) patients died. Discussion and conclusion Firearms injuries are increasing and place a significant burden on hospital resources. Care provided to gunshot victims has improved as a result of recent trauma management initiatives at South-East London's major trauma centre.

Understanding the Role of Mass-Unloading in a Filament Eruption

We describe a partial filament eruption on 11 December 2011 that demonstrates that the inclusion of mass is an important next step for understanding solar eruptions. Observations from the Solar Terrestrial Relations Observatory-Behind (STEREO-B) and the Solar Dynamics Observatory (SDO) spacecraft were used to remove line-of-sight projection effects in filament motion and correlate the effect of plasma dynamics with the evolution of the filament height. Flux cancellation and nearby flux emergence are shown to have played a role in increasing the height of the filament prior to eruption. The two viewpoints allow the quantitative estimation of a large mass-unloading, the subsequent radial expansion, and the eruption of the filament to be investigated. A 1.8 to 4.1 lower-limit ratio between gravitational and magnetic-tension forces was found. We therefore conclude that following the loss-of-equilibrium of the flux-rope, the radial expansion of the flux-rope was restrained by the filamentary material until 70% of the mass had evacuated the structure through mass-unloading.

ELECTRONIC SUPPLEMENTARY MATERIAL

The online version of this article (10.1007/s11207-017-1224-y) contains supplementary material, which is available to authorised users.

Effects of assisted hatching method and age on implantation rates of IVF and ICSI

The objective of this study was to investigate whether a change in assisted hatching (AH) technique from total to partial penetration of the zona pellucida improved the outcome of IVF and intracytoplasmic sperm injection cycles where AH was indicated. This was an observational study conducted from the beginning of January 2000 to the end of April 2005. Total AH was performed in 312 cycles, while partial AH was performed in 592 cycles. In women of all ages, implantation, clinical pregnancy and live birth rates were higher in the partial AH group than in the total AH group (12.6 versus 7.2%, P = 0.0001; 22.3 versus 15.7%, P = 0.02; 18.2 versus 12.5%, P = 0.03 respectively). The benefit of partial AH was most marked in women under 38 years old (i.e. the recurrent implantation failure group). The authors conclude that partial AH is associated with higher implantation and pregnancy rates than total AH, especially in women under 38 years old who suffer from recurrent implantation failure.

Leukocyte origin and profile in follicular aspirates at oocyte retrieval

BACKGROUND

Follicular aspirates represent a snapshot in time of conditions within the follicle at oocyte retrieval in women undergoing in vitro fertilization and embryo transfer. This clinical material has been much investigated and yet its cellular composition remains unclear. In this study we investigated the origin and profile of leukocytes found within follicular aspirates.

METHODS

We performed morphological and immunohistochemical analyses of follicular aspirates and peripheral blood obtained concurrently at oocyte retrieval.

RESULTS

There was no correlation between erythrocyte and leukocyte numbers in follicular aspirates. The profile of leukocyte subtypes within follicular aspirates was variable and differed significantly from the peripheral circulation in a significant proportion of the analysed samples. A subset of follicular aspirates displayed a marked increase in monocytes/macrophages and an apparent concomitant reduction in polymorphonuclear leukocytes compared with peripheral blood.

CONCLUSIONS

Leukocytes within follicular aspirates cannot be accounted for solely as a result of blood vessel damage during oocyte retrieval. The variation in leukocyte subtypes observed in some follicular aspirates may reflect a coordinated infiltration of these cells, characteristic of progressive inflammatory responses in other systems. The possibility that leukocyte variation is indicative of follicular maturation deserves further investigation due to its potential relevance in optimizing oocyte selection.

Defining poor ovarian response during IVF cycles, in women aged <40 years, and its relationship with treatment outcome

BACKGROUND

Poor ovarian response limits IVF success but assessing interventions is difficult because of the wide variation in definition. This study attempts to derive objective definitions of poor response.

METHODS

A retrospective study of a consecutive series of 1190 patients aged <40 years undergoing their first IVF/ICSI cycle was undertaken. Factors adversely affecting implantation, including advanced female age, were excluded. Clinical outcome in cycles reaching oocyte retrieval (n = 1036) were evaluated with respect to gonadotrophin dose used and oocyte number. Cancelled cycles (n = 154) were analysed in relation to the stimulation dose at cancellation and outcome of their subsequent cycle.

RESULTS

Cycle cancellation for patients on >/=300 IU FSH/day compared to those on a lower dose was associated with a significantly worse outcome in the subsequent cycle. If <3000 IU FSH/cycle were administered, clinical pregnancy rates remained favourable if <4 eggs were recovered (29 versus 33% for >/=5 eggs). By contrast, if >/=3000 IU FSH was required, the pregnancy rate was 25% if >/=5 eggs were recovered but declined to 7% if <4 were obtained.

CONCLUSIONS

Definitions of poor response should include the degree of ovarian stimulation used. A low oocyte number is only detrimental if the cumulative dose is >3000 IU FSH. Cancellation at >/=300 IU FSH/day is associated with a significantly worse prognosis and could define poor response.

Serum IGF-1 concentrations following pituitary desensitization do not predict the ovarian response to gonadotrophin stimulation prior to IVF

BACKGROUND

Insulin-like growth factor-1 (IGF-1) is known to play a role in ovarian follicular development augmenting the action of FSH. Low intrafollicular concentrations have been detected in women who respond poorly to gonadotrophins. This study addresses the relationship between serum IGF-1 levels following pituitary desensitization and ovarian response to gonadotrophin stimulation.

METHODS

This is a case-control study of 78 patients undergoing IVF-embryo transfer treatment. Thirty-nine strictly-defined poor responder patients requiring 50 or more ampoules (75 IU FSH) to reach oocyte retrieval were compared with 39 age-matched normal responders, requiring fewer than 50 ampoules. IGF-1 concentrations were determined by extraction radioimmunoassay on serum samples obtained after pituitary desensitization but prior to gonadotrophin stimulation.

RESULTS

Despite highly significant differences in measures of ovarian response between groups, the mean serum IGF-1 concentration was not statistically significantly different between poor and normal responders [(31.5 nmol/l [95% confidence interval (CI) 28.5-34.5] versus 34.5 nmol/l (95% CI 31.8-37.2)] respectively. No correlation between oocyte number or total gonadotrophin used and serum IGF-1 concentration was observed.

CONCLUSION

Whilst IGF-1 influences ovarian follicular development this study suggests that serum IGF-1 does not predict ovarian response and does not differentiate between critically-defined poor and normal responders.

Higher cortisol:cortisone ratios in the preovulatory follicle of completely unstimulated IVF cycles indicate oocytes with increased pregnancy potential

BACKGROUND

Conception following gonadotrophin-stimulated IVF and embryo transfer has been associated with a higher intrafollicular cortisol:cortisone ratio and decreased metabolism of cortisol to cortisone. The role of glucocorticoids in human oocyte maturation is not fully understood, but active glucocorticoid (cortisol) may be important. This study relates intrafollicular cortisol and cortisone concentrations to oocyte fertilization and embryo implantation in unstimulated cycles.

METHODS

Patients aged <40 years with favourable sperm underwent unstimulated IVF-embryo transfer. Study 1 related intrafollicular cortisol levels to oocyte and IVF outcome: (i) fertilized, pregnant (n = 9); (ii) fertilized, not pregnant (n = 21); and (iii) unfertilized (n = 12). Study 2 was a case-control study of 27 patients (same outcome groups of equal size) which measured intrafollicular cortisol, cortisone and the cortisol:cortisone ratio.

RESULTS

Conception cycles demonstrated higher cortisol concentrations compared with the fertilized group (study 1) [median (95% confidence interval): 299 (249-330) versus 227 nmol/l (185-261); P < 0.05] and higher cortisol:cortisone ratios when compared with the unfertilized group (study 2) [7.38 (5.23-9.19) versus 3.56 (1.75-7.46) respectively; P = 0.02]. Of the women with cortisol:cortisone ratios greater than the outcome independent mean of 5.90, 58% conceived compared with only 13% with ratios <5.90 (P < 0.02).

CONCLUSION

Higher cortisol:cortisone ratios in conception cycles suggest that active glucocorticoid may be important for final oocyte maturation and embryo implantation in unstimulated cycles.

Biological versus chronological ageing of oocytes, distinguishable by raised FSH levels in relation to the success of IVF treatment

BACKGROUND

The present study addresses the issue of biological ageing of the oocyte (as indicated by basal serum FSH levels) versus chronological ageing.

METHODS

1019 infertile but ovulating women were studied in their first cycle of IVF treatment. A series of logistic regression models were developed to assess statistical significance of effects of age and FSH on implantation rates and live babies born.

RESULTS

The number of oocytes retrieved and embryos available for transfer declined with increasing age and basal serum FSH concentrations. Fertilizing ability of oocytes increased with advancing age but was not affected by FSH concentrations. Although the number of oocytes or embryos available for transfer had no independent effect on implantation rates, the implanting ability of fertilized oocytes (embryos) was inversely related to increasing age and independently to FSH. The chance of a baby being born, however, was determined more by age than by serum FSH.

CONCLUSIONS

Ovarian ageing affecting oocyte quality and fecundity can occur independently of chronological age. This has important practical implications whereby serum basal FSH measurement may be a valuable prognostic index, though chronological age remains important.

Low-dose dexamethasone augments the ovarian response to exogenous gonadotrophins leading to a reduction in cycle cancellation rate in a standard IVF programme

BACKGROUND

Cancellation of assisted conception cycles because of poor ovarian response to gonadotrophins is a significant problem in assisted reproduction. Various adjuvant treatments have been suggested to improve responsiveness. This study reports on the potential benefits of low dose dexamethasone.

METHODS

Patients <40 years of age were invited to participate in a twin centre prospective double blind randomized placebo controlled study. A total of 290 patients were recruited and computer randomized using sealed envelopes to receive either 1 mg dexamethasone (n = 145) or placebo tablets (n = 145) in addition to a standard long protocol gonadotrophin-releasing hormone analogue with gonadotrophin stimulation regime.

RESULTS

A significantly lower cancellation rate for poor ovarian response was observed in the dexamethasone group compared with controls (2.8 versus 12.4% respectively, P < 0.002). Further comparisons between the dexamethasone group and controls were made of median fertilization rates (60 versus 61% respectively, NS), implantation rates (16.3 versus 11.6% respectively, NS) and pregnancy rate per cycle started (26.9 versus 17.2%, NS). The benefit was apparent in patients both with polycystic and normal ovaries.

CONCLUSION

Low dose dexamethasone co-treatment reduces the incidence of poor ovarian response. It may increase clinical pregnancy rates and should be considered for inclusion in stimulation regimes to optimize ovarian response.

Family settings and children's adjustment: differential adjustment within and across families

BACKGROUND

Children in stepfamilies and single-parent families exhibit elevated levels of behavioural and emotional problems compared with children in intact (biological) families, but there is variation within and across these family types.

AIMS

To examine the sources of variation in children's behavioural and emotional problems across diverse family settings.

METHOD

Levels of behavioural and emotional problems in children from diverse stepfamilies and single-parent families were compared with children living with both biological parents. Psychosocial risks were measured at the individual child and family levels.

RESULTS

Behavioural and emotional problems were elevated in children in stepmother/complex stepfamilies and single-parent families, but not in simple stepfather families, relative to 'biological' families. Psychopathology associated with family type was explained by compromised quality of the parent-child relationship, parental depression and socio-economic adversity. Sibling similarity in behavioural and emotional problems was most pronounced in high-risk family settings.

CONCLUSIONS

Family type is a proxy for exposure to psychosocial risks; the extent of family-wide influence on children's development may be strongest in high-stress settings.

Medical education with the Internet: a pilot training programme in reproductive medicine

Following a detailed information technology survey in the South West Deanery, an Internet educational programme in reproductive medicine was constructed, delivered and assessed. The course followed a problem-based approach using case studies, using an education website and electronic mail (e-mail) to communicate between trainees and trainers. Independent evaluation revealed a high level of satisfaction for both trainees and trainers with an increase in trainees' confidence to deal with patients following the course. This study suggests that the Internet may be used effectively to deliver postgraduate medical education, if the training programme is designed appropriately to computer infrastructure and the computer literacy of the users.

A study of the pharmacokinetic interaction between lamivudine and alpha interferon

OBJECTIVE

This study was designed to investigate any possible pharmacokinetic interaction between lamivudine and alpha interferon as potential candidates for combination therapy for the treatment of hepatitis B virus (HBV).

METHODS

Nineteen healthy male, Caucasian volunteers, aged 20-41 years and weighing 60.5-83.5 kg completed this open, non-randomised study. They each received a single, abdominal, deep s.c. injection of 10 mIU alpha interferon on day 1, followed by a wash-out period of at least 1 week. Subjects then began a 7-day course of lamivudine (100 mg) followed by a further 10-mIU alpha-interferon injection directly after oral lamivudine dosing. Blood and urine samples were taken pre- and post-dose for alpha-interferon and/or lamivudine assay.

RESULTS

Lamivudine was safe and well tolerated in all subjects. No adverse events were reported in subjects on lamivudine, whereas 106 adverse events considered attributable to alpha interferon were recorded. Statistical analysis of pharmacokinetic parameters indicated no significant effect of lamivudine on alpha-interferon pharmacokinetics. There was a small statistically significant reduction (approximately 10%) in the area under the lamivudine concentration time curve on co-administration with alpha interferon and a concomitant increase in clearance, which is not considered clinically relevant.

CONCLUSIONS

Alpha interferon and lamivudine can be co-administered with no requirement for dose modification, as there was no clinically significant difference in the pharmacokinetics of either drug.

Distinction between early and late ovarian hyperstimulation syndrome

OBJECTIVE

To compare patient and cycle characteristics among three study groups: early ovarian hyperstimulation syndrome (OHSS), late OHSS, and non-OHSS.

DESIGN

Prospective observational study.

SETTING

University assisted conception service.

PATIENT(S)

Women undergoing in vitro fertilization, intracytoplasmic sperm injection or gamete intrafallopian transfer treatment at Bristol University In Vitro Fertilization Service between January 1, 1995, and December 31, 1998.

INTERVENTION

None.

MAIN OUTCOME MEASURE(S)

Patient age, prevalence of polycystic ovaries, gonadotropin requirement, peak serum estradiol (E(2)) concentration, number of oocytes retrieved, clinical pregnancy rate, number of gestation sacs, and severity of OHSS.

RESULT(S)

Women with early OHSS had significantly higher serum E(2) levels and lower gonadotropin requirements than did the other groups. Cycles with either early or late OHSS had significantly more oocytes collected than those without OHSS. Serum E(2) and oocyte numbers did not accurately predict the risk of developing late OHSS. Clinical pregnancies occurred in all cycles with late OHSS, and multiple pregnancies were significantly more frequent in the late OHSS group than in the other groups. Late OHSS was more likely than early OHSS to be severe.

CONCLUSION(S)

Early OHSS relates to "excessive" preovulatory response to stimulation, whereas late OHSS depends on the occurrence of pregnancy, is likelier to be severe, and is only poorly related to preovulatory events.

Psychopathology and short-term emotion: the balance of affects

In this study, the relationship between short-term emotion expressions and dimensional ratings of internalizing and externalizing symptomatology was examined. Short-term emotions, defined as facial or vocal displays of emotion generally lasting less than 10 seconds and elicited by a specific and proximal event, were observed during recess in 71 children from diverse socioeconomic backgrounds, who were between 4 and 8 years old. Internalizing and externalizing symptomatology was assessed through parent and teacher questionnaire. Sociometric ratings were obtained from peers on children's anger and aggression. It was hypothesized following Tomkins (1979) and others that one affect becomes predominant in the emotional experience of the individual. Different operationalizations of this concept were examined. Using regression analyses, externalizing symptomatology was found to be predicted by higher levels of anger, lower levels of happiness, and lower levels of sadness. Internalizing symptomatology was found to be predicted by higher levels of sadness and lower levels of anger. It was concluded on the basis of these data that the relationship between short-term emotion and internalizing and externalizing psychopathology is best understood as the balance between different short-term emotions. Results are discussed in the context of theories of emotion and their functions.

Periovulatory human oocytes, cumulus cells, and ovarian leukocytes express type 1 but not type 2 11beta-hydroxysteroid dehydrogenase RNA

OBJECTIVE

To further elucidate cortisol metabolism in the follicular microenvironment at the time of oocyte retrieval, the presence of 11beta-hydroxysteroid dehydrogenase (HSD) messenger (m)RNA transcripts in oocytes; cumulus cells; granulosa cells; and CD45(+), CD15(+) leukocytes was assessed semiquantitatively.

DESIGN

Controlled study using semiquantitative assessment of 11beta-HSD mRNA.

SETTING

University IVF center.

PATIENT(S)

Twenty-six patients undergoing controlled ovarian hyperstimulation for assisted conception.

INTERVENTION(S)

Metaphase II oocytes; cumulus cells; granulosa cells, and CD45(+), CD15(+) leukocytes from individual follicular fluid aspirates.

MAIN OUTCOME MEASURES

Semiquantitative analysis of PCR products after total RNA extraction and complementary DNA synthesis.

RESULT(S)

Periovulatory human oocytes; cumulus cells; CD45(+), CD15(+) leukocytes; and granulosa cells consistently express type 1 but not type 2 11beta-HSD mRNA. Expression of mRNA is greatest in cumulus cells. Type 1 11beta-HSD mRNA expression varies considerably in all cell types and among individual follicles and patients.

CONCLUSION(S)

These studies of mRNA expression suggest that the enzymes present both in and around the periovulatory oocyte will favor a high-cortisol environment.

Anterior ischemic optic neuropathy: a complication after systemic inflammatory response syndrome

BACKGROUND

Patients are surviving previously fatal injuries. Unique morbidities are occurring in these survivors. Anterior ischemic optic neuropathy represents a previously unrecognized cause of blindness in the trauma victim. We hypothesize that this phenomenon is caused by unique characteristics of optic edema/ pressure or decreased blood flow associated with massive resuscitation.

METHODS

Between November of 1991 and August of 1998, there were 18,199 admissions to our trauma center. Of this group, 350 patients required massive volume resuscitation (>20 liters infused over first 24 hours). Patients having closed head injuries, facial fractures or direct orbital trauma were excluded from study. The following variables were studied: demographics, injury severity (Injury Severity Score, highest lactate, worst base deficit, and lowest pH) crystalloid and transfusion requirements, ventilator requirements (PEEP) RESULTS: Of the 350 patients with massive resuscitation, 9 patients were diagnosed with anterior ischemic optic neuropathy (2.6%). Of these, seven patients required celiotomy (78%). Six of the seven celiotomy patients had damage control celiotomies and abdominal compartment syndrome (86%). One patient had a repair of a subclavian artery; one had a complex acetabular repair. Blindness was unilateral in five patients and bilateral in four. All nine patients had evidence of global hypoperfusion, systemic inflammatory response, massive resuscitation, and high ventilatory support; one patient required cardiopulmonary resuscitation.

CONCLUSION

Prone positioning is known to be associated with an increased intraocular pressure. We postulate that the combination of massive resuscitation and prone positioning will increase the incidence of anterior ischemic optic neuropathy. As such, we recommend that prone positioning for adult respiratory distress syndrome be reserved for only those patients at risk of death.

Children's understanding of martial conflict and the marital relationship

Children's understanding of marital conflict and the marital relationship was investigated in 60 children of 5, 7, and 9 years old. Age differences were hypothesized in four areas of children's understanding of marital conflict and the marital relationship, based on the development between 5 and 9 years of age of children's abilities to (a) analyse complex sequences of behavior in terms of the mental states of protagonists and (b) integrate multiple social roles. The four areas investigated were: conceptions of marital conflict, conflict resolution, family triangulation, and integration of the spousal and parental roles. Children were read stories involving family interactions. Open-ended questions were asked about their understanding of these interactions and a coding scheme was devised that reflected theoretical concepts. Nine-year-olds differed from 5-year-olds on all aspects of their understanding of marital conflict and the marital relationship, and 7-year-olds showed levels of understanding between 5- and 9-year-olds. Younger children were less likely than older children to explain marital conflict in terms of the divergent goals of each parent, to understand conflict resolution as dependent on one person changing their beliefs or goals, to understand that parents were simultaneously spouses and parents and to understand the nature of triangulation. Marital conflict is interpreted very differently by children of different ages.

The influence of bacterial vaginosis on in-vitro fertilization and embryo implantation during assisted reproduction treatment

There is growing evidence that the pathogenic effects of bacterial vaginosis may not be confined to the lower genital tract. Possible associations with infertility and effects on fertilization and implantation were studied in patients undergoing in-vitro fertilization (IVF) treatment. High vaginal swabs taken at the time of oocyte collection were assessed by Gram staining. The prevalence of bacterial vaginosis and of intermediate and normal flora in 301 patients was 25.6, 14.0 and 60.4% respectively. Bacterial vaginosis was more prevalent in patients with tubal (31.5%, n = 149) compared with non-tubal (19.7%, n = 152) infertility (odds ratio (OR) 1.87, CI 1.11-3.18, P = 0.02). Bacterial vaginosis did not have an adverse effect on fertilization rate. Further, no significant difference in implantation rates was seen when comparing bacterial vaginosis (15. 8%, OR 1.03, CI 0.66-1.61) and intermediate flora (13.1%, OR 0.82, CI 0.45-1.52) with normal flora (15.5%). Though confidence intervals around the observations were relatively wide, the findings suggest that routine screening for bacterial vaginosis in the hope of improving the success of IVF treatment is not justified. The prevention of complications in pregnancy associated with bacterial vaginosis might be a more relevant indication for screening at the time of IVF treatment, in particular patients with tubal disease, if treatment were shown to be effective for that particular purpose. However, antibiotic treatment before IVF has been shown to be positively disadvantageous for IVF by encouraging other organisms.

A longitudinal study of the relation between language and theory-of-mind development

Fifty-nine 3-year-olds were tested 3 times over a period of 7 months in order to assess the contribution of theory of mind to language development and of language to theory-of-mind development (including the independent contributions of syntax and semantics). Language competence was assessed with a standardized measure of reception and production of syntax and semantics (the Test of Early Language Development). Theory of mind was assessed with false-belief tasks and appearance-reality tasks. Earlier language abilities predicted later theory-of-mind test performance (controlling for earlier theory of mind), but earlier theory of mind did not predict later language test performance (controlling for earlier language). These findings are consistent with the argument that language is fundamental to theory-of-mind development.

Travel advice given by pharmacists

BACKGROUND

In 1993 more than 1 million Swiss residents traveled to a tropical or subtropical country. Although most pretravel advice is given by general practitioners, a number of travelers also seek advice from pharmacists. Little is known about the quantity and quality of travel advice given or the sources of information used by this group.

METHODS

One-hundred and twenty randomly selected pharmacists from three Swiss cantons were first interviewed in a cross-sectional study on the telephone. All study participants subsequently received a pretested questionnaire, in which most of the questions asked on the phone were repeated, with additional questions regarding the sources of information used for travel advice and the cooperation of general practitioners. Included in both parts of the study were two scenarios of fictive travelers seeking health advice for destinations frequently visited by Swiss tourists (Thailand and Kenya).

RESULTS

Of 136 pharmacists approached, all who said they sometimes gave travel advice, agreed to participate (88%). Fifty-six percent of them give travel advice regularly (mean 2-3 times per month). General knowledge on the main health hazards was good, but for treatment of travelers' diarrhea, only 59% spontaneously mentioned the need for increased fluid intake, whereas 100 % recommended antidiarrheal drugs. Protection from the sun was mentioned only by 10 % of the respondents, and only 8 % said that the traveler should seek advice from a medical doctor. Over 95% could name the three most important measures against mosquito bites, although up to 20% still recommend Vitamin B1 as well. On the telephone, only 19% (for Thailand) and 31% (for Kenya) gave accurate advice on malaria protection, and 13% (for Thailand) and 3% (for Kenya) could make correct recommendations about vaccination. However, more than 50% said that in practice they would consult documentation before giving any advice, with the Bulletin of the Federal Office of Health (BFOH) being the most commonly used source of information. In the questionnaire interview, where documentation was used, the accuracy of advice increased, especially for malaria protection (74% correct for Thailand and 93% for Kenya).

CONCLUSIONS

The overall knowledge of Swiss pharmacists on travel medicine issues is satisfactory. Specific questions need further attention, such as treatment of travelers' diarrhea, sun protection and advice on malaria prophylaxis and vaccinations. For the latter two, clients should also consult a medical doctor. Collaboration between doctors and pharmacists, and the consistency of the advice given, are important in improving compliance. Reliable information sources are available in pharmacies and are used.

Ventriculoatrial conduction metrics for classification of ventricular tachycardia with 1:1 retrograde conduction in dual-chamber sensing implantable cardioverter defibrillators

The introduction of dual-chamber sensing in implantable cardioverter defibrillators (ICDs) has greatly reduced the incidence of false detection due to supraventricular tachycardias. The remaining arrhythmias which serve to confound classification are supraventricular tachycardias (SVTs) with 1:1 anterograde conduction and ventricular tachycardias (VT) with 1:1 retrograde conduction. An algorithm has been designed and tested (28 patients) which employs ventriculoatrial (VA) conduction measurements to separate 1:1 VTs from 1:1 SVTs. A study was conducted to assess realistic VA interval boundaries for classification of arrhythmias with 1:1 retrograde atrial conduction. Intracardiac atrial and ventricular recordings of 7 passages of VT with retrograde conduction, 12 passages of atrioventricular nodal reentrant tachycardia (AVNRT), 3 passages of atrial tachycardia (AT), 8 passages of sinus tachycardia (ST), and 2 passages of orthodromic reentrant tachycardia (ORT) were analyzed. Automated real-time atrial and ventricular waveform recognition was performed on each passage and VA intervals were measured. Separation of VT with retrograde conduction from other 1:1 supraventricular tachycardias was effected by imposing discrete VA interval boundaries. VA boundaries of 80 ms to 234 ms classified 1:1 VT with 100% sensitivity (SENS) and 80% specificity (SPEC). In addition, the lower boundary completely classified AVNRT with 100% SENS and 100% SPEC, and all passages of ST were contained above the upper boundary. These findings could be of importance in algorithms for next-generation implantable cardioverter defibrillators which include two-chamber (atrial and ventricular) sensing and two-chamber interval measurements.

The relation between immunoglobulin G antibodies to Chlamydia trachomatis and poor ovarian response to gonadotropin stimulation before in vitro fertilization

OBJECTIVE

To determine whether a relation exists between previous exposure to Chlamydia trachomatis and impaired ovarian response to gonadotropin stimulation.

DESIGN

Controlled clinical study.

SETTING

Two university IVF centers.

PATIENT(S)

Two hundred forty-two patients receiving IVF treatment and 81 control patients. Ninety-four patients with a poor response to IVF, defined by cycle cancellation in response to a daily stimulation dose of 300 IU of FSH, and 148 patients with a good response were matched for age. Twenty-eight pregnant controls and 53 controls of proven fertility also were included.

INTERVENTION(S)

Serum samples were obtained from patients and controls. Serum levels of immunoglobulin (Ig) G antibodies to C. trachomatis were determined by ELISA.

MAIN OUTCOME MEASURE(S)

The prevalence of serum IgG antibodies to C. trachomatis in critically defined poor responders was compared with that of age-matched good responders.

RESULT(S)

A significantly higher proportion of poor responders had serum IgG antibodies to C. trachomatis compared with good responders (44.7% and 30.4%, respectively). Patients undergoing IVF had a significantly higher prevalence of IgG antibodies to C. trachomatis (36%) than did either pregnant or nonpregnant controls (12%).

CONCLUSION(S)

A significantly higher prevalence of serum IgG antibodies to C. trachomatis was observed in critically defined poor responders, suggesting a possible detrimental effect of C. trachomatis on subsequent ovarian function.

The incidence of lower-pole nephrolithiasis--increasing or not?

OBJECTIVE

To determine if the incidence of lower-pole nephrolithiasis is increasing.

METHODS

A previously published meta-analysis of trends in the location of stones in the kidney, using data from 1984 to 1992, determined the percentage of lower pole stones in 26,722 kidney stones treated by extracorporeal shockwave lithotripsy (ESWL). We performed prospective studies on all patients treated by ESWL for a single renal stone (not manipulated from the ureter) in two organizations: at Lithotripters Inc., 47,303 stones were treated with ESWL by 1000 urologists in private practice from 1989 to 1995. At the Midwest Urologic Stone Unit, 9357 stones were treated with ESWL by 200 urologists in private practice from 1987 to 1995. The distribution of stones in both samples was compared with that reported earlier.

RESULTS

The meta-analysis for stone location trends from the previously published article suggested that the percentage of kidney stones in the lower pole at ESWL increased erratically from 1984 to 1989 but was then stable for 3 years. The Lithotripters Inc. sample showed an essentially constant incidence from 28% in 1990 to 30% in 1995, and the Midwest Urologic Stone Unit sample showed an essentially constant incidence from 35% in 1988 to 36% in 1995.

CONCLUSION

The incidence of lower pole nephrolithiasis has remained stable from 1990.

Elective bedside surgery in critically injured patients is safe and cost-effective

OBJECTIVE

The success of elective minimally invasive surgery suggested that this concept could be adapted to the intensive care unit. We hypothesized that minimally invasive surgery could be done safely and cost-effectively at the bedside in critically injured patients.

SUMMARY BACKGROUND DATA

This case series, conducted between October 1991 and June 1997 at a Level I trauma center, examined bedside dilatational tracheostomy (BDT), percutaneous endoscopic gastrostomy (PEG), and inferior vena cava (IVC) filter placement. All procedures had been performed in the operating room (OR) before initiation of this study.

METHODS

All BDTs and PEGs were performed with intravenous general anesthesia (fentanyl, diazepam, and pancuronium) administered by the surgical team. IVC filters were placed using local anesthesia and conscious sedation. BDTs were done using a Ciaglia set, PEGs were done using a 20 Fr Flexiflow Inverta-PEG kit, and IVC filters were placed percutaneously under ultrasound guidance. Cost difference (delta cost) was defined as the difference in hospital cost and physician charges incurred in the OR as compared to the bedside.

RESULTS

Of 16,417 trauma admissions, 379 patients (2%) underwent 472 minimally invasive procedures (272 BDTs, 129 PEGs, 71 IVC filters). There were four major complications (0.8%). Two patients had loss of airway requiring reintubation. Two patients had an intraperitoneal leak from the gastrostomy requiring operative repair. No patient had a major complication after IVC filter placement. Total delta cost was $611,994. When examined independently, the cost was $324,224 for BDT, $164,088 for PEG, and $123,682 for IVC filter. OR use was reduced by 506 hours.

CONCLUSIONS

These bedside procedures have minimal complications, eliminate the risk associated with patient transport, reduce cost, improve OR utilization, and should be considered for routine use in the general surgery population.

A testing system for implantable cardioverter defibrillators

Implantable cardioverter defibrillator (ICD) testing during the implantation process is important in order to avoid repeated induction of arrhythmias, which extends the implantation procedure and poses a risk to the patient. Hence, an in vitro testing system has been designed to assist optimal device programming and avoid repetitive inductions. The system includes a high-speed computer with A/D and D/A subsystems. Software has been designed to eliminate repeated arrhythmia induction by real-time capture and storage of the electrogram. Subsequently, the electrogram can be replayed into ICD software simulators at a variety of settings to determine candidate programming parameters. To validate the simulation system, signals were fed directly to an ICD via an attenuator. Output event markers were captured simultaneously with the signal into a digital file to assess the device performance. Four ventricular tachycardia (VT), three supraventricular tachycardia, (SVT), three atrial flutter (AFL), three atrial fibrillation (AF), and ten ventricular fibrillation (VF) passages were used to verify the system. Test settings were 110-160 beats/min for detection rate and 5 seconds for shock delay. The simulator and ICD detected the episodes for all passages at the 110 beats/min setting. For the setting of 160 beats/min, two VTs, two SVTs, three AFLs, and nine VFs were detected by the device, but no Afb triggered a shock. The simulator detection criteria were met by two VTs, two SVTs, three AFLs, ten VFs, and one AF. The mean detection time was 6,869-7,330 ms (110-160 beats/min) for the simulator and 7,840-8,170 ms for device. Comparison of results showed general agreement between simulator and device. Results demonstrated that device behavior at a variety of settings can be elucidated by the simulator for selection of optimal performance. The automated system can also function as a test bed for evaluation of new algorithms during device development and design.

Comprehensive scheme for detection of ventricular fibrillation for implantable cardioverter defibrillators

Implantable cardioverter defibrillators (ICDs) detect and defibrillate ventricular fibrillation (VF) and ventricular tachycardia (VT). Other therapies which use less energy are also available to terminate VT. Previous studies have shown that ICD rate schemes often misdiagnose VT as VF. In this study, an improved VF classification scheme was designed and tested, which employs the classic rate criteria plus paired signal concordance (PSC); PSC uniquely detects VF where VT and VF rates overlap (220-340 ms). Two signals from a bipolar pair (1 cm) recorded in a unipolar sense exhibit similar signal shape for concordant rhythms, such as sinus rhythm and VT, and disconcordance for VF. Once the rate criterion is met, PSC is measured by the peak normalized cross-correlation coefficient calculated over the depolarization. Variability, measured by a modified range, determined the contextual diagnosis over a passage. Sinus rhythm (20), VT (12), VF (22), atrial fibrillation (10), sinus rhythm with ventricular premature depolarizations (7), and polymorphic VT (4) passages were recorded from 38 patients. Rate-PSC was tested with unfiltered, digitized signals (1-500 Hz, 1,000 samples per second) and with filtered, downsampled signals (1-50 Hz, 100 samples per second). Sensitivity values, or percentage of correct VF detection, and specificity values, or detection of all other rhythms, were generated and compared with simulations of three commercial ICDs programmed to similar settings as rate-PSC and to nominal settings. The sensitivity values for rate-PSC with unfiltered and with filtered signals and for ICDs with 220 ms and with nominal settings were 100%, 100%, 48-80%, and 100%, respectively; the corresponding specificity values were 95%, 83%, 93%, and 7-13%, respectively. It was concluded that the rate-PSC scheme was able to reliably separate VF from other rhythms, even rhythms that have a variable morphology or variable rate. With the confidence of accurate VF detection, use of low-energy therapies for non-VF rhythms will increase device longevity and enhance patient comfort.

Collagen IX: evidence for a structural association between NC4 domains in cartilage and a novel cleavage site in the alpha 1(IX) chain

Collagen IX, a structural component of the extracellular matrix of connective tissues, is synthesized as long and short forms which contain or lack, respectively, a 27 kDa non-collagenous (NC) 4 domain at the N-terminus of the alpha 1(IX) chain of the molecule. The long form occurs in cartilage and developing cornea, but not in vitreous, suggesting a specialized function for the NC4 domain, perhaps by interacting with other macromolecules. To test this hypothesis, embryonic chick cartilage was treated with DTSSP, dissociated with bacterial collagenase, and the NC4-containing DTSSP-cross-linked protein complexes examined and purified. Analysis of cartilage extracts using an anti-NC4 antibody, and of purified NC4-containing complexes, identified a predominant NC4 dimer. A naturally-occurring N-terminal fragment of the alpha 1(IX) chain, whose size is equivalent to the NC4-COL3-NC3 domains of the chain, was identified. Association of collagen IX molecules via NC4 domains and the existence of a cleavage site close to the NC3 domain of the molecule are likely to be of primary importance in the growth and remodeling processes of cartilage, in health and disease.

The possible role of the immune system in the aetiopathogenesis of ovarian hyperstimulation syndrome

This review examines recent evidence suggesting a role for the immune system, in particular cytokines, in the pathogenesis of ovarian hyperstimulation syndrome (OHSS). Ovarian tissue is known to contain cells capable of producing a range of immunological mediators and the concentrations of these have been shown to be elevated in serum and ascitic fluid from women with established OHSS. Available evidence points to a role for vascular endothelial growth factor and interleukin-2, possibly acting through other intermediary cytokines, in the pathogenesis of OHSS. However, each individual has a unique cytokine profile and several cytokines may share biological actions, making it difficult to interpret data on isolated cytokine concentrations from relatively small numbers of patients. Improved understanding of the role of the immune system in the development of OHSS may have implications for the prediction, prevention and management of this iatrogenic condition.

Analysis of the intraventricular electrogram for differentiation of distinct monomorphic ventricular arrhythmias

This study investigated the effectiveness of correlation waveform analysis for identifying different ventricular electrogram morphologies of multiple VTs in the same patient. Patients with implantable antitachycardia devices are commonly subject to the occurrence of more than one distinct monomorphic VT. Each of these VTs may have unique therapeutic alternatives for termination. VTs with identical and different monomorphic configurations were recorded (1-500 Hz) using distal bipolar (1 cm) and distal unipolar electrograms from the right ventricular apex. Thirty-six distinct monomorphic VTs induced in 15 patients were analyzed. Nine VTs with identical morphologies (12/12 surface ECGs) were induced twice and used as a control. A template was created for each VT induced. Correlation waveform analysis was used to compare each depolarization of all other VTs induced subsequently in the same patient. The mean correlation coefficient (p mu) of cycle-by-cycle analysis was used as a discriminant function: p mu > or = 0.95 was considered matched; and p mu < 0.95 was considered distinct. From the control population, VTs were successfully classified as identical in 9 of 9 cases (100%) using both bipolar and unipolar electrograms. VTs with different monomorphic configurations were successfully classified as being different in 31 of 33 cases (94%) using bipolar electrogram analysis and in 29 of 33 cases (88%) using the unipolar. Template matching is effective for detecting: (1) the recurrence of VTs, which are identical; and (2) the occurrence of a VT with a different configuration. This method appears effective using either unipolar or bipolar intracardiac waveforms.

Cost-effective method for bedside insertion of vena caval filters in trauma patients

BACKGROUND

The need for patient transport for inferior vena cava (IVC) filter placement impacts patient safety, comfort, charges, and nursing care. Bedside, ultrasound-guided IVC filter placement may offer an acceptable, cost-effective alternative.

METHODS

Prospective cohort study of 55 consecutive trauma patients requiring IVC filter placement. During a 13-month period (August of 1995-September of 1996), patients meeting criteria for IVC filter were evaluated. Complications were recorded, and the potential financial savings were determined.

RESULTS

Of 3,172 trauma admissions, 55 patients met IVC filter criteria and 49 patients had IVC filters placed under ultrasound guidance. In six patients (10.9%), ultrasound guided filter placement failed. There were four complications in four patients (8.2%). Over 13 months, charges were reduced by $69,800 when compared with radiology suite placement and $118,300 when compared with operative placement.

CONCLUSIONS

Ultrasound guided, bedside placement of IVC filters is a safe, cost-effective method of pulmonary embolism prophylaxis in select trauma patients.

The detection and confirmation of 11 beta-hydroxysteroid dehydrogenase type 1 transcripts in human luteinized granulosa cells using RT-PCR and plasmid pUC18

The activity of 11 beta-hydroxysteroid dehydrogenase (11 beta-HSD) in human granulosa cells has been shown to be associated with the outcome of treatment following in-vitro fertilization and embryo transfer. There are two known isoforms of 11 beta-HSD which differ significantly in their actions and co-factor requirements. The net activity of 11 beta-HSD which differ significantly in their actions and co-factor requirements. The net activity of 11 beta-HSD within the human ovary is unclear, but may be of particular importance within the ovarian follicle in regulating possible glucocorticoid influences on the oocyte. This study presents preliminary information regarding establishment of techniques to identify transcripts of the 11 beta-HSD isoforms within human granulosa cells and human cumulus cells using reverse transcription-polymerase chain reaction. In view of the high expression of the type 1 11 beta-HSD isoform and the possibility of other 11 beta-HSD isoforms in the ovary, plasmid technology was used to confirm the technique specifically identifying the known isoforms.

Increased follicular fluid total and free cortisol levels during the luteinizing hormone surge

OBJECTIVE

To determine the changes in follicular fluid (FF) total and free cortisol during the LH surge in naturally ovulating women.

PATIENT(S)

Twenty-six women having diagnostic laparoscopy during the follicular phase of normal menstrual cycles were selected.

INTERVENTION(S)

Blood samples were collected 1 day before, the day of, and 1 day after surgery and the results of serum E2 and LH were used to divide the cycles retrospectively into pre- and post-LH surge groups. Follicular fluid was collected during laparoscopy.

MAIN OUTCOME MEASURE(S)

Serum P, total and free cortisol, and FF volume, E2, P, total cortisol, and free cortisol were measured on the day of surgery.

RESULT(S)

Median serum and FF P levels were significantly higher in the post-LH surge group compared with the pre-LH surge group (0.54 versus 1.54 ng/mL [1.7 versus 4.85 nmol/L] and 5.03 versus 28.0 micrograms/mL [15.8 versus 88.0 mumol/L], respectively). Follicular fluid volume also increased significantly after the surge (2.5 versus 4.5 mL). Median serum total and free and percent free cortisol were higher after the surge, although not significantly. In contrast, FF total, free, and percent free levels increased dramatically between pre- and post-LH surge samples (4.41 versus 43.6 ng/mL [16.0 versus 158 nmol/L], 0.138 versus 6.68 ng/mL [0.5 versus 24.2 nmol/L], and 3.3% versus 15.0%, respectively; P < 0.05).

CONCLUSION(S)

An increase in total and free cortisol occurs in the follicle during the LH surge. Cortisol and its regulation by 11 beta-hydroxysteroid dehydrogenase therefore may exert a physiologic role in oocyte maturation or ovulation.