Vicia sativa subsp. sativa native to the Middle East comprises Pea Albumin1 b-like homologs: A promising natural biopesticide

The extensive and indiscriminate use of chemical pesticides in agriculture has led to adverse effects on human health, environmental pollution, and the emergence of pesticide-resistant pests. To mitigate these challenges, the development of environmentally friendly alternatives is crucial, with biopesticides emerging as promising solutions such as peptides. Legume seeds naturally contain diverse insecticidal peptides or proteins to combat pest attacks. One such peptide is PA1b (Pea Albumin 1, subunit b), a 37 amino acid extracted from pea seeds (Pisum sativum). PA1b has shown significant potential in controlling cereal weevils (Sitophilus spp.), a major pest of stored cereals. Here, we screened PA1b-like peptides in five wild seeds of vetches (Vicia sativa subsp. sativa) from the Middle East. Using a comprehensive set of biochemical, biological, and molecular techniques, we characterized different PA1b homologs and assessed their toxicity and expression profiles. Our results reveal that PA1b homolog from Vicia sativa subsp. sativa originating from turkey displays outstanding insecticidal activity against Sitophilus oryzae through binding to the receptor site found in the midgut of the insect. Moreover, it exhibits a strong cytotoxic effect against Sf9 cells. This cysteine-rich peptide shows sequence identity and the same hydrophobic pole as AG41, a tenfold more toxic isoform of PA1b from Medicago truncatula. Such observations pave the way for the development of bioinsecticides, with PA1b-like peptides as lead compounds.

Advanced spectroscopic investigation of colour centres in LiF crystals irradiated with monochromatic hard x-rays

Nominally-pure lithium fluoride (LiF) crystals were irradiated with monochromatic hard x-rays of energy 5, 7, 9 and 12 keV at the METROLOGIE beamline of the SOLEIL synchrotron facility, in order to understand the role of the selected x-ray energy on their visible photoluminescence (PL) response, which is used for high spatial resolution 2D x-ray imaging detectors characterized by a wide dynamic range. At the energies of 7 and 12 keV the irradiations were performed at five different doses corresponding to five uniformly irradiated areas, while at 5 and 9 keV only two irradiations at two different doses were carried out. The doses were planned in a range between 4 and 1.4 × 103Gy (10.5 mJ cm-3to 3.7 J cm-3), depending on the x-ray energy. After irradiation at the energies of 7 and 12 keV, the spectrally-integrated visible PL intensity of the F2and F3+colour centres (CCs) generated in the LiF crystals, carefully measured by fluorescence microscopy under blue excitation, exhibits a linear dependence on the irradiation dose in the investigated dose range. This linear behaviour was confirmed by the optical absorption spectra of the irradiated spots, which shows a similar linear behaviour for both the F2and F3+CCs, as derived from their overlapping absorption band at around 450 nm. At the highest x-ray energy, the average concentrations of the radiation-induced F, F2and F3+CCs were also estimated. The volume distributions of F2defects in the crystals irradiated with 5 and 9 keV x-rays were reconstructed in 3D by measuring their PL signal using a confocal laser scanning microscope operating in fluorescence mode. On-going investigations are focusing on the results obtained through thisz-scanning technique to explore the potential impact of absorption effects at the excitation laser wavelength.

Rifampicin-resistant TB: discordance between Xpert® MTB/RIF and MTBDRplus results

BACKGROUND: South Africa´s diagnostic algorithm for TB diagnosis from 2011 to 2017 employed the Xpert^® MTB/RIF assay as the initial screening test for TB diagnosis and rifampicin (RIF) susceptibility, followed by submission of a specimen for GenoType^® MTBDRplus. This study aimed to determine the concordance between the two assays in terms of RIF susceptibility and explore reasons for discordance.METHODS: This was a retrospective laboratory-based study that included all MTBDRplus results of tests performed at the Braamfontein Mycobacteriology Referral Laboratory between 1 September 2014 and 31 August 2015. The patient´s Xpert RIF result was linked with the MTBDRplus result.RESULTS: The overall concordance between RIF susceptibility results was 96.4%. There were 68 discordant RIF results. The most common reasons for discordance identified were possible false Xpert RIF-resistant results (22%), mixed infection/heteroresistance (16%), transcription errors (7%) and erroneous manual interpretation of the MTBDRplus strip (7%). Xpert RIF resistance detected using delayed hybridisation was associated with discordance.CONCLUSIONS: The overall concordance between the MTBDRplus and Xpert RIF results were very good. Management of discordance should include repeat specimens for Xpert and MTBDRplus and rpoB sequencing. All variables should then be considered before treatment regimens are altered.

Sustainable laser-based technology for insect pest control

Aphids damage directly or indirectly cultures by feeding and spreading diseases, leading to huge economical losses. So far, only the use of pesticides can mitigate their impact, causing severe health and environmental issues. Hence, innovative eco-friendly and low-cost solutions must be promoted apart from chemical control. Here, we have investigated the use of laser radiation as a reliable solution. We have analyzed the lethal dose required to kill 90% of a population for two major pest aphid species (Acyrthosiphon pisum and Rhopalosiphum padi). We showed that irradiating insects at an early stage (one-day old nymph) is crucial to lower the lethal dose without affecting plant growth and health. The laser is mostly lethal, but it can also cause insect stunting and a reduction of survivors' fecundity. Nevertheless, we did not notice any significant visible effect on the offspring of the surviving irradiated generation. The estimated energy cost and the harmless effect of laser radiation on host plants show that this physics-based strategy can be a promising alternative to chemical pesticides.

Biological treatment of produced water coupled with recovery of neutral lipids

Produced water (PW) is the largest waste stream generated by oil and gas industry. It is commonly treated by physical-chemical processes due to high salt content and poor biodegradability of water insoluble compounds, such as n-alkanes. N-alkanes can represent a major fraction of organic contaminants within PW. In this study the possibility of simultaneous n - alkane biodegradation and production of neutral lipids in a concentrated PW stream with A. borkumenis SK2 as the sole reactor inoculum was investigated. N-alkane removal efficiency up to 99.6%, with influent alkane COD of 7.4 g/L, was achieved in a continuously operated reactor system. Gas chromatography results also showed that the majority of other non-polar compounds present in the PW were biodegraded. Biodegradation of n-alkanes was accompanied by simultaneous production of neutral lipids, mostly wax ester (WE)-alike compounds. We demonstrate, that under nutrient limited conditions and 108.9 ± 3.3 mg/L residual n-alkane concentration the accumulation of extracellular WE-alike compounds can be up to 12 times higher compared to intracellular, reaching 3.08 grams per litre of reactor volume (g/L_reactor) extracellularly and 0.28 g/L_reactor intracellularly. With residual n-alkane concentration of 311.5 ± 34.2 mg/L accumulation of extracellular and intracellular WE-alike compounds can reach up to 6.15 and 0.91 g/L_reactor, respectively. To the best of our knowledge simultaneous PW treatment coupled with production of neutral lipids has never been demonstrated before.

SOLEIL shining on the solution-state structure of biomacromolecules by synchrotron X-ray footprinting at the Metrology beamline

Synchrotron X-ray footprinting complements the techniques commonly used to define the structure of molecules such as crystallography, small-angle X-ray scattering and nuclear magnetic resonance. It is remarkably useful in probing the structure and interactions of proteins with lipids, nucleic acids or with other proteins in solution, often better reflecting the in vivo state dynamics. To date, most X-ray footprinting studies have been carried out at the National Synchrotron Light Source, USA, and at the European Synchrotron Radiation Facility in Grenoble, France. This work presents X-ray footprinting of biomolecules performed for the first time at the X-ray Metrology beamline at the SOLEIL synchrotron radiation source. The installation at this beamline of a stopped-flow apparatus for sample delivery, an irradiation capillary and an automatic sample collector enabled the X-ray footprinting study of the structure of the soluble protein factor H (FH) from the human complement system as well as of the lipid-associated hydrophobic protein S3 oleosin from plant seed. Mass spectrometry analysis showed that the structural integrity of both proteins was not affected by the short exposition to the oxygen radicals produced during the irradiation. Irradiated molecules were subsequently analysed using high-resolution mass spectrometry to identify and locate oxidized amino acids. Moreover, the analyses of FH in its free state and in complex with complement C3b protein have allowed us to create a map of reactive solvent-exposed residues on the surface of FH and to observe the changes in oxidation of FH residues upon C3b binding. Studies of the solvent accessibility of the S3 oleosin show that X-ray footprinting offers also a unique approach to studying the structure of proteins embedded within membranes or lipid bodies. All the biomolecular applications reported herein demonstrate that the Metrology beamline at SOLEIL can be successfully used for synchrotron X-ray footprinting of biomolecules.

Genome-wide analysis identifies gain and loss/change of function within the small multigenic insecticidal Albumin 1 family of Medicago truncatula

BACKGROUND

Albumin 1b peptides (A1b) are small disulfide-knotted insecticidal peptides produced by Fabaceae (also called Leguminosae). To date, their diversity among this plant family has been essentially investigated through biochemical and PCR-based approaches. The availability of high-quality genomic resources for several fabaceae species, among which the model species Medicago truncatula (Mtr), allowed for a genomic analysis of this protein family aimed at i) deciphering the evolutionary history of A1b proteins and their links with A1b-nodulins that are short non-insecticidal disulfide-bonded peptides involved in root nodule signaling and ii) exploring the functional diversity of A1b for novel bioactive molecules.

RESULTS

Investigating the Mtr genome revealed a remarkable expansion, mainly through tandem duplications, of albumin1 (A1) genes, retaining nearly all of the same canonical structure at both gene and protein levels. Phylogenetic analysis revealed that the ancestral molecule was most probably insecticidal giving rise to, among others, A1b-nodulins. Expression meta-analysis revealed that many A1b coding genes are silent and a wide tissue distribution of the A1 transcripts/peptides within plant organs. Evolutionary rate analyses highlighted branches and sites with positive selection signatures, including two sites shown to be critical for insecticidal activity. Seven peptides were chemically synthesized and folded in vitro, then assayed for their biological activity. Among these, AG41 (aka MtrA1013 isoform, encoded by the orphan TA24778 contig.), showed an unexpectedly high insecticidal activity. The study highlights the unique burst of diversity of A1 peptides within the Medicago genus compared to the other taxa for which full-genomes are available: no A1 member in Lotus, or in red clover to date, while only a few are present in chick pea, soybean or pigeon pea genomes.

CONCLUSION

The expansion of the A1 family in the Medicago genus is reminiscent of the situation described for another disulfide-rich peptide family, the "Nodule-specific Cysteine-Rich" (NCR), discovered within the same species. The oldest insecticidal A1b toxin was described from the Sophorae, dating the birth of this seed-defense function to more than 58 million years, and making this model of plant/insect toxin/receptor (A1b/insect v-ATPase) one of the oldest known.

Levels and trends of smokeless tobacco use among youth in countries of the World Health Organization South-East Asia Region

BACKGROUND

At least two rounds of the Global Youth Tobacco Survey (GYTS) have been completed in most of the countries in the World Health Organization South-East Asia region. Comparing findings from these two rounds provides trend data on smokeless tobacco (SLT) use for the first time.

METHODS

This study uses GYTS data from Bangladesh, Bhutan, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand, and Timor-Leste during 2006-2013. GYTS is a nationally representative survey of 13-15-year-old students using a consistent and standard protocol. Current SLT use is defined as using any kind of SLT products, such as chewing betel quid or nonbetel quid or snuffing any other products orally or through the nasal route, during the 30 days preceding the survey. Prevalence and 95% confidence intervals were computed using SAS/SUDAAN software.

RESULTS

According to most recent GYTS data available in each country, the prevalence of current use of SLT among youth varied from 5.7% in Thailand to 23.2% in Bhutan; among boys, from 7.1% in Bangladesh to 27.2% in Bhutan; and among girls, from 3.7% in Bangladesh to 19.8% in Bhutan. Prevalence of SLT was reported significantly higher among boys than girls in Bhutan (boys 27.2%; girls 19.8%), India (boys 11.1%; girls 6.0%), Maldives (boys 9.2%; girls 2.9%), Myanmar (boys 15.2%; girls 4.0%), and Sri Lanka (boys 13.0%; girls 4.1%). Prevalence of current SLT use increased in Bhutan from 9.4% in 2009 to 23.2% in 2013, and in Nepal from 6.1% in 2007 to 16.2% in 2011.

CONCLUSION

The findings call for countries to implement corrective measures through strengthened policy and enforcement.

X-ray phase contrast imaging and noise evaluation using a single phase grating interferometer

In this paper we present some quantitative measurements of X-ray phase contrast images and noise evaluation obtained with a recent grating based X-ray phase contrast interferometer. This device is built using a single phase grating and a large broadband X-ray source. It was calibrated using a reference sample and finally used to perform measurements of a biological fossil: a mosquito trapped in amber. As phase images, noise was evaluated from the measured interferograms.

Influence of progesterone supplementation during the first third of pregnancy on fetal and placental growth in overnourished adolescent ewes

Overnourishing adolescent ewes throughout pregnancy promotes maternal tissue synthesis at the expense of placental growth, which in turn leads to a major decrease in lamb birth weight. As maternal dietary intakes are inversely related to peripheral progesterone concentrations in these adolescent dams, it was hypothesized that sup-optimal progesterone concentrations in overnourished dams may compromise the growth of the differentiating conceptus resulting in fewer uterine caruncles being occupied and, hence, fewer placentomes formed. This hypothesis was tested by supplementing overnourished adolescent dams with exogenous progesterone during early pregnancy and determining the impact on pregnancy outcome at term. Embryos recovered from superovulated adult ewes inseminated by a single sire were transferred in singleton to the uterus of peripubertal adolescent recipients. After transfer of embryos, ewes were offered a moderate or high amount of a complete diet (n=11 per group). A further high intake group received a progesterone supplement each day from day 5 to day 55 of gestation (term=145 days) to restore circulating progesterone concentrations to moderate values throughout the first third of pregnancy (n=11). For ewes establishing pregnancies (n=7 per group), live weight gain during the first 100 days of gestation was 66+/-4, 323+/-17 and 300+/-7 g per day, body condition score at term was 2.1+/-0.05, 3.0+/-0.08 and 3.1+/-0.07 units and the duration of gestation after spontaneous delivery was 148+/-1.7, 144+/-0.8 and 143+/-0.8 days for the moderate intake, high intake and high intake plus progesterone groups, respectively. At delivery, fetal cotyledon mass (136+/-12.1 versus 57+/-8.2g, P<0.001) and lamb birth weight (5164+/-151 versus 2893+/-381 g, P<0.001) were higher in moderate intake than in high intake dams. Progesterone supplementation restored circulating concentrations to moderate values during the first third of gestation. Lamb birth weight in the high intake plus progesterone group (4150+/-389 g) was intermediate between the high intake (P<0.02) and moderate intake (P<0.05) groups, but this change in birth weight was not associated with corresponding changes in fetal cotyledon mass (76+/-10.3 g). Moreover, the number of fetal cotyledons was similar in all three groups. Thus, progesterone did not directly affect the growth of the fetal cotyledon but may have influenced placental vascularity, blood flow or nutrient transfer capacity or alternatively the development of the embryonic inner cell mass.

Effect of maternal overnutrition during pregnancy on pituitary gonadotrophin gene expression and gonadal morphology in female and male foetal sheep at day 103 of gestation

The aim was to determine whether nutritionally mediated restriction of placental growth alters foetal body growth, pituitary gonadotrophin gene expression and gonadal development at Day 103 of gestation. Embryos recovered from adult ewes inseminated by a single sire were transferred, singly, into the uteri of adolescent recipients. After transfer, adolescent ewes were offered a high (H, n=16) or moderate (M, n=12) level of a complete diet. Ewes were slaughtered at 103+/-0.2 days of gestation and foetal blood, brain, pituitary and gonads were collected. Mean placental weight was lower (P< 0.01) in H than in M groups but foetal weight and reproductive organ weights were similar. Maternal nutrition did not influence LHbeta or FSHbeta mRNA expression in either sex but FSHbeta mRNA expression was higher (P< 0.001) in female (n=11) than in male (n=17) foetal pituitaries. Mean foetal plasma gonadotrophin concentrations were not influenced by dietary intake in either sex. Plasma progesterone concentrations were lower (P=0.001) in foetuses derived from H compared with M intake dams. Compared with M foetuses (n=5), ovaries from H foetuses (n=6) had fewer primordial follicles (P< 0.05) and fewer follicles in total (P< 0.005). In contrast, maternal nutritional status did not influence either seminiferous cord or Sertoli cell numbers in male foetuses (H, n=10; M, n=7). It is concluded that high maternal nutrient intakes restricted placental growth and altered foetal ovarian follicular development prior to the end of the second third of gestation. The latter effect was independent of gonadotrophin secretion.Crown

Impact of maternal nutrition during pregnancy on pituitary gonadotrophin gene expression and ovarian development in growth-restricted and normally grown late gestation sheep fetuses

The influence of maternal nutrition during pregnancy on anterior pituitary gonadotrophin gene expression and ovarian development in sheep fetuses during late gestation was investigated. Embryos recovered from superovulated adult ewes that had been inseminated by a single sire were transferred, singly, into the uteri of adolescent recipients. After embryo transfer, adolescent ewes were offered a high or moderate amount of a complete diet. Pregnancies were terminated at day 131 +/- 0.6 of gestation and the fetal brain, anterior pituitary gland and gonads were collected. Gonadotrophin gene expression (LHbeta and FSHbeta subunits) in the fetal pituitary gland was examined using in situ hybridization. Ovarian follicular development was quantified in haematoxylin- and eosin-stained ovarian sections embedded in paraffin wax. Six dams that were offered a high nutrient intake carried normal-sized fetuses (weight within +/- 2 SD of mean weight for control fetuses from dams fed a moderate level of complete diet) and 13 dams carried growth-restricted fetuses (weight <or= +/- 2 SD of mean weight for control fetuses from dams fed a moderate level of complete diet). Mean placental masses in these groups were 354 +/- 24.5 and 230 +/- 21.1 g, respectively, compared with 442 +/- 54.3 g in the dams that were offered a moderate nutrient intake (n = 6). Growth-restricted fetuses from dams offered a high nutrient intake showed higher pituitary LHbeta mRNA expression (P < 0.05) than normal-sized fetuses from dams offered a moderate nutrient intake (252 +/- 21.6 and 172 +/- 23.6 nCi g(-1), respectively). FSHbeta mRNA expression was not influenced by growth status. Fewer follicles (primarily in the resting pool) were observed in the ovaries of both growth-restricted (P < 0.002) and normal-sized fetuses from dams offered a high nutrient intake (P < 0.01) compared with normal-sized fetuses from dams offered a moderate nutrient intake. Irrespective of nutritional treatment, the total number of follicles was positively associated with placental mass (P < 0.01). Thus, a high maternal nutrient intake during adolescent pregnancy had a negative influence on ovarian follicular development in fetuses as determined during late gestation.

Impact of maternal nutrition during pregnancy on pituitary gonadotrophin gene expression and ovarian development in growth-restricted and normally grown late gestation sheep fetuses

The influence of maternal nutrition during pregnancy on anterior pituitary gonadotrophin gene expression and ovarian development in sheep fetuses during late gestation was investigated. Embryos recovered from superovulated adult ewes that had been inseminated by a single sire were transferred, singly, into the uteri of adolescent recipients. After embryo transfer, adolescent ewes were offered a high or moderate amount of a complete diet. Pregnancies were terminated at day 131 +/- 0.6 of gestation and the fetal brain, anterior pituitary gland and gonads were collected. Gonadotrophin gene expression (LHbeta and FSHbeta subunits) in the fetal pituitary gland was examined using in situ hybridization. Ovarian follicular development was quantified in haematoxylin- and eosin-stained ovarian sections embedded in paraffin wax. Six dams that were offered a high nutrient intake carried normal-sized fetuses (weight within +/- 2 SD of mean weight for control fetuses from dams fed a moderate level of complete diet) and 13 dams carried growth-restricted fetuses (weight +/- 2 SD of mean weight for control fetuses from dams fed a moderate level of complete diet). Mean placental masses in these groups were 354 +/- 24.5 and 230 +/- 21.1 g, respectively, compared with 442 +/- 54.3 g in the dams that were offered a moderate nutrient intake (n = 6). Growth-restricted fetuses from dams offered a high nutrient intake showed higher pituitary LHbeta mRNA expression (P < 0.05) than normal-sized fetuses from dams offered a moderate nutrient intake (252 +/- 21.6 and 172 +/- 23.6 nCi g(-1), respectively). FSHbeta mRNA expression was not influenced by growth status. Fewer follicles (primarily in the resting pool) were observed in the ovaries of both growth-restricted (P < 0.002) and normal-sized fetuses from dams offered a high nutrient intake (P < 0.01) compared with normal-sized fetuses from dams offered a moderate nutrient intake. Irrespective of nutritional treatment, the total number of follicles was positively associated with placental mass (P < 0.01). Thus, a high maternal nutrient intake during adolescent pregnancy had a negative influence on ovarian follicular development in fetuses as determined during late gestation.

Nutrient partitioning during adolescent pregnancy

Human adolescent mothers have an increased risk of delivering low birth weight and premature infants with high mortality rates within the first year of life. Studies using a highly controlled adolescent sheep paradigm demonstrate that, in young growing females, the hierarchy of nutrient partitioning during pregnancy is altered to promote growth of the maternal body at the expense of the gradually evolving nutrient requirements of the gravid uterus and mammary gland. Thus, overnourishing adolescent dams throughout pregnancy results in a major restriction in placental mass, and leads to a significant decrease in birth weight relative to adolescent dams receiving a moderate nutrient intake. High maternal intakes are also associated with increased rates of spontaneous abortion in late gestation and, for ewes delivering live young, with a reduction in the duration of gestation and in the quality and quantity of colostrum accumulated prenatally. As the adolescent dams are of equivalent age at the time of conception, these studies indicate that nutritional status during pregnancy rather than biological immaturity predisposes the rapidly growing adolescents to adverse pregnancy outcome. Nutrient partitioning between the maternal body and gravid uterus is putatively orchestrated by a number of endocrine hormones and, in this review, the roles of both maternal and placental hormones in the regulation of placental and fetal growth in this intriguing adolescent paradigm are discussed. Impaired placental growth, particularly of the fetal component of the placenta, is the primary constraint to fetal growth during late gestation in the overnourished dams and nutritional switch-over studies indicate that high nutrient intakes during the second two-thirds of pregnancy are most detrimental to pregnancy outcome. In addition, it may be possible to alter the nutrient transport function of the growth-restricted placenta in that the imposition of a catabolic phase during the final third of pregnancy in previously rapidly growing dams results in a modest increase in lamb birth weight.

Influence of placentally mediated fetal growth restriction on the onset of puberty in male and female lambs

The onset of puberty in prenatally growth-restricted versus normally grown lambs of both sexes, born in April and housed under natural photoperiod, was examined. Singleton pregnancies were established and adolescent ewes were offered a high or moderate nutrient intake throughout gestation. Placental mass was reduced (P < 0.001) in high compared with moderate intake dams and resulted in the birth of growth-restricted and normal birth weight offspring, respectively. At birth, female lambs weighed 3.43 kg versus 5.03 kg (P < 0.001; n = 14 per group) and male lambs weighed 2.75 kg versus 5.18 kg (P < 0.001; n = 7 per group) in growth-restricted and normal birth weight groups, respectively. Lambs suckled for 12 weeks and thereafter were fed ad libitum until week 43 of age. Growth-restricted lambs had lower preweaning live weight gains and this difference was more pronounced in male (P < 0.05) than in female lambs (P = 0.07). Thereafter, live weight remained lower (P < 0.05) in growth-restricted than in normally grown lambs of both sexes until week 25 of age. In females, the time of onset of puberty was similar in the two groups. All females ovulated and there were no differences in the number of ovarian cycles recorded or in the incidence of aberrant ovarian function. In males, testosterone concentrations and testicular volume were lower in growth-restricted compared with normally developed lambs from birth until weeks 28 and 35 of age, respectively (P < 0.05). The seasonal increase in plasma testosterone concentrations occurred later in growth-restricted than in normally developed lambs (P < 0.01) but the timing of maximum peak concentrations was similar. Peak testosterone concentrations were lower (P < 0.05) in growth-restricted than in normal male lambs.

Effects of a pediatric emergency department febrile infant protocol on time to antibiotic therapy

The purpose of this study was to examine the effect of an Emergency Department (ED) protocol to reduce time to antibiotic administration in the febrile infant less than 3 months of age with a rectal temperature > or =38.0 degrees C. We conducted a before-after study of a febrile infant quality improvement initiative in an urban pediatric ED with approximately 35,000 patient visits per year. Records of infants less than 3 months of age presenting with a rectal temperature > or =38.0 degrees C, who underwent a full septic work-up (blood, urine, and cerebrospinal fluid studies, and possibly chest radiography), were identified by using daily ED logs. This review was performed in the month before and then 12 months after institution of the "Septic Infant Work-up Sheet" and a set of interventions (Febrile Infant Protocol) designed to streamline care of the febrile infant and to reduce the time to antibiotic administration. Data were analyzed by using the Kaplan-Meier survival estimate and the log-rank test. Patient demographic characteristics and severity of illness were similar across months; however, ED process of care was significantly changed. Initial analysis revealed a median time to antibiotics of 142 min. Subsequent analysis after implementation of the Febrile Infant Protocol revealed a median time to antibiotics of 105 min. This represents an overall time reduction of 25% from time of presentation to antibiotic administration. In conclusion, a guideline-based ED febrile infant protocol changed clinical practice and improved time to antibiotics.

Foster parents of medically fragile children can improve their BLS scores: results of a demonstration project

OBJECTIVES

1) To assess performance and comfort level with cardiopulmonary resuscitation (CPR), foreign body removal (FBR), and seizure management in foster parents of medically fragile children; 2) To determine if the parents' performance and comfort levels increase with an individual teaching session with a medical professional to review CPR and FBR.

METHODS

In this single cohort pilot study, 18 foster parents of medically fragile children were asked to rate their comfort level with pediatric CPR and FBR on a 5-point scale (1 = very uncomfortable, 5 = very comfortable). They then underwent five mock code scenarios and were evaluated using a 5-point scale (1 = poor performance, 5 = outstanding performance). A 6-month follow-up evaluation using similar scenarios was conducted.

RESULTS

At visit 1, the percentage of parents demonstrating adequate performance of CPR, FBR, and seizure management was: 1) CPR: infant (78%); child (78%); 2) Foreign body removal: age <1 year (17%); age >1 year (65%); 3) Seizures (94%). At visit 2, performance improved in all areas, especially FBR, where the percentage of parents demonstrating adequate performance increased to 71% for children <1 year and 82% for children >1 year. As measured by the 5-point scales, CPR and FBR performance and parent comfort level with CPR improved significantly (Wilcoxon signed-ranks test, P < 0.004), but parent comfort level with FBR did not (P = 0.12).

CONCLUSIONS

Based on this pilot study, foster parents of medically fragile children benefit from an individual teaching session by a medical professional. CPR instruction for this group of foster parents should include adequate review and assessment of foreign body removal procedures.

Intrathoracic petechiae in sudden infant death syndrome: relationship to face position when found

Previous studies have not addressed the relationship of intrathoracic petechiae (IP) to the position of the face when a caretaker finds a victim of sudden infant death syndrome (SIDS). The aims of this retrospective study were to determine (1) the rate of the facedown position in SIDS (not to be confused with the prone body position), (2) if the facedown position occurred more frequently among SIDS victims with intrathoracic petechiae than those without petechiae, and (3) if the facedown position occurred more frequently among cases with more severe petechial hemorrhage of the thymus. We selected 199 SIDS cases from the San Diego SIDS Research Project database and grouped them as IP-present and IP-absent. Each case was analyzed with regard to the face position when found unresponsive or dead. Among these 199 cases, 37% were found face-down, which represents 51% of the 142 cases found prone. The two groups were similar with respect to age, sex, and rate of premature birth. Thirty-nine percent (39%) of the IP-present group and 9% of the IP-absent group were found in the facedown position (P = 0.057; 95% confidence interval for the difference = 0.3%, 40%). Cases were also grouped by severity of thymic petechiae and analyzed regarding face position. Neither age nor the facedown position was associated with greater severity of thymic petechiae. The wide confidence interval yielded by our analysis of IP limits our ability to clarify the precise pathophysiologic role of external oronasal obstruction in SIDS. While it remains possible that a subset of SIDS cases occur as a result of external obstruction, we are unable to generalize its importance. Internal airway obstruction and rebreathing with terminal gasping, both of which have been documented in sudden infant death, remain other possible scenarios leading to the production of IP.

Neck extension and rotation in sudden infant death syndrome and other natural infant deaths

It has been hypothesized that some cases of sudden infant death syndrome (SIDS) are a result of neck extension and/or rotation that causes vertebral artery (VA) compression and brain stem ischemia. There is a paucity of relevant literature on this topic. Therefore, our aim was to compare neck rotation and extension in SIDS and other natural infant deaths. Cases of SIDS and other natural infant deaths within the San Diego SIDS Research Project database were analyzed retrospectively with respect to neck and body position as reported by the trained, experienced scene investigators and/or the caretakers who discovered the infants. Information was used from 246 SIDS cases and 56 cases of other natural deaths. Simultaneous neck extension and rotation was not reported in either group. When data regarding neutral/flexed/extended position and rotation of the neck were combined, no significant differences were found between the two groups (P = 0.94); 40% of the SIDS cases and 41% of the other natural death cases were found with the neck either extended or rotated (odds ratio [OR] 0.97, [reference group = neck either neutral or flexed, and not rotated], 95% confidence interval [CI] 0.45, 2.11). There were also no significant differences between the groups when neck rotation and neck extension were analyzed independent of one another. Neck rotation among cases found in the prone position was common and was not significantly different between the two groups (49% of 146 SIDS cases, 58% of 24 other natural death cases, P = 0.38, OR 0.68, 95% CI 0.28, 1.62). Neck rotation among infants found in the supine position occurred one-third as often in the SIDS group (9% of 33 cases) as in the other natural death group (29% of 14 cases); however, the difference was not significant (P = 0.17; OR 0.25, 95% CI 0.05, 1.31). Although our analysis does not exclude VA compression and brain stem ischemia in some cases of SIDS, we found no evidence to affirm its importance. This study demonstrates the importance of meticulous scene descriptions, including neck position.

Successful treatment of retrograde ejaculation with sperm recovered from bladder washings. A report of two cases

BACKGROUND

Retrograde ejaculation causes < 2% of male infertility but is the leading cause of aspermia. The incidence of retrograde ejaculation is increasing due to the aggressiveness of modern urologic cancer surgery and an increase in diabetes mellitus. Generally, the only adverse effect is on fertility. Various approaches have been proposed for treatment, ranging from insemination with sperm-rich urine obtained after masturbation to intracytoplasmic sperm injection (ICSI). We used a protocol involving bladder washing.

CASES

Case 1 involved a man with retrograde ejaculation secondary to a successful right orchiectomy and retroperitoneal lymph node dissection for stage B1 embryonal cell carcinoma. He was treated with bladder washing and intrauterine insemination. He fathered three children from six insemination cycles. Case 2 involved a man with idiopathic retrograde ejaculation and a wife with ovulatory dysfunction. He received treatment similar to that in case 1 and fathered one child from two insemination cycles.

CONCLUSION

Larger studies need to be done specifically comparing treatments. Our method resulted in four normal infants in two couples over eight total insemination cycles and, taken together with other results from the literature, seems a good choice for clinicians who are treating retrograde ejaculation for the first time. We agree with others who have recommended that in vitro fertilization/ICSI not be the first step for treating the usual couples with retrograde ejaculation.

Relationship between nutritionally-mediated placental growth restriction and fetal growth, body composition and endocrine status during late gestation in adolescent sheep

The aim was to investigate the consequences of nutritionally-mediated placental growth restriction on fetal organ growth, conformation, body composition and endocrine status during late gestation. Embryos recovered from superovulated adult ewes inseminated by a single sire were transferred in singleton to the uterus of peripubertal adolescent recipients. Post-transfer, adolescent dams were offered a high (H) or moderate (M) level of a complete diet to promote rapid or moderate maternal growth rates, respectively (n=7 per group). After day 100 of gestation the feed intake of the M dams was adjusted weekly to maintain body condition score. Liveweight gain during the first 100 days of gestation was 301+/-24 and 90+/-4.6 g/day for the H and M groups, respectively. Maternal plasma concentrations of insulin, IGF-I and urea were significantly higher and non-esterified fatty acid concentrations significantly lower in H compared with M dams prior to slaughter on day 128 of gestation. At this stage of gestation, total placentome weight was 50 per cent lower in H compared with M groups (P< 0.001) and was associated with a 37 per cent reduction in fetal weight (P< 0.01). All variables of fetal conformation and absolute fetal organ weights, with the exception of the adrenal glands, were lower (P< 0. 05) in the fetuses from H intake dams. However, relative fetal organ weights expressed as g/kg fetal body weight, with the exception of the gut, were not influenced by maternal dietary intake. Furthermore, fetal weight but not maternal nutritional group were predictive of individual organ weight for all organs dissected. Together these results imply that growth restriction in the fetuses derived from H intake dams was largely symmetrical. Fetal plasma concentrations of insulin, IGF-I and glucose were attenuated (P< 0.05) in fetuses from H compared with M groups. The lower fetal body weight in the former group was associated with a reduction in absolute but not relative crude protein (P< 0.01) and fat content (P< 0.05). Total fetal liver glycogen content but not concentration was (P< 0.05) reduced in H versus M groups. The lower mass of both the placenta and fetal liver was due to a reduction in cell number rather than an alteration in cell size. Thus, over-nourishing adolescent sheep is associated with a major restriction in placental growth which mediates a gradual slowing of fetal growth during the final third of pregnancy.

Laparoscopic removal of a perforated intrauterine device from the perirectal fat

BACKGROUND

The intrauterine device (IUD) was a very common form of birth control in the United States. The most serious potential complication of IUD use is uterine perforation. Uterine perforation is common among women with "lost" IUDs and can cause severe morbidity and mortality and should be carefully managed. The recommended treatment is removal of the perforating IUD. This can usually be managed laparoscopically unless bowel perforation or other severe sepsis is present.

METHODS

An intra-abdominal IUD was removed laparoscopically from the perirectal fat of a 49-year-old woman who had been diagnosed over 20 years earlier with an "expelled" IUD.

CONCLUSIONS

It is important that the possibility of uterine perforation be considered in anyone who has had a diagnosis of an expelled IUD without actual confirmation that the IUD is no longer present in the body. In any woman who presents with pelvic pain and a history of a "lost" IUD, the surgeon should have a high index of suspicion and obtain radiological studies. It may be advisable to question women about possible IUD use when they present with pelvic pain of unknown origin.

The effect of valproic acid on blood loss in patients with cerebral palsy

Valproic acid (VPA) is used in the treatment of seizure disorders often present in patients with cerebral palsy. The charts of 114 patients with cerebral palsy were reviewed to evaluate the effect of VPA on blood loss during spine surgery. Forty-one patients had seizure disorders. Of these, 18 were taking VPA as monotherapy (group III) and the remaining 23 patients were taking other antiseizure medications, including two taking VPA (group II). There was a significant increase in the number of patients with abnormal bleeding times and a significant difference (p < 0.001) in blood loss (ml/kg) in patients taking VPA as monotherapy (38.6 ml/kg vs. 30.0 ml/kg). There was also increased blood-product administration postoperatively in the VPA monotherapy patients. Physicians should be aware of this potential association between VPA use and increased blood loss. The routine laboratory tests of complete blood count, prothrombin time, and partial thromboplastin time will not adequately screen for the platelet-mediated effects of VPA.

Impact of lifestyle choices on female infertility

OBJECTIVE

To inform physicians who are involved in the primary care of reproductive-age women of the specific relationships between lifestyle choices and infertility so that they can use this knowledge to educate their patients and encourage changes in behavior.

STUDY DESIGN

A review of the relevant literature, performed via Medline search.

RESULTS

Prevention of chlamydial and gonorrheal infections; maintenance of the proper body weight; increased individual awareness about the effects of age on fecundity; and reduced intake of caffeine, tobacco and alcohol are all possible avenues for primary prevention of infertility.

CONCLUSION

Lifestyle choices can be made that influence the reproductive capability of women. It may be worthwhile for primary care physicians to use information on lifestyle to encourage their patients to improve their overall health while positively affecting their ability to reproduce.

Translocation of protein kinase C isoforms in rat muscle in response to fasting and refeeding

Weanling rats were offered food ad libitum, or fasted for 18 h, or fasted and refed for times ranging from 5 to 30 min. Five protein kinase C (PKC) isoforms (alpha, epsilon, zeta, theta and mu) were detected in the hindlimb muscles by Western immunoblotting. PKC forms epsilon and theta were abundant in plantaris, but not in soleus muscle, and no difference in localization was detected between fed rats and those fasted for 18 h. PKC forms alpha and mu were affected by fasting and refeeding. PKC-mu was found only in the cytosolic fraction of the plantaris muscle of the fasted animal, but in the fully-fed animals it was also associated with the membrane fraction. The pattern of localization observed in the fully-fed state was restored in the fasted rats by 20 min refeeding. In contrast, PKC-alpha was not detected in the cytosolic fraction of the plantaris in fasted animals but rapidly reappeared there on refeeding, being restored to 20% and 80% of the fed value within 5 and 30 min of refeeding respectively. The timing of these changes was correlated with the increase in serum insulin concentration, which was significantly elevated above the fasted value by 5 min and at subsequent times. These data suggest a possible role for PKC isoforms alpha and mu in the metabolic changes that occur in skeletal muscle on transition between the fasted and the fed state.

Gamete intrafallopian transfer. A cost-effective alternative to donor oocyte in vitro fertilization in women aged 40-42 years

OBJECTIVE

To investigate whether gamete intrafallopian transfer (GIFT) may be a cost-effective alternative to donor oocyte procedures in women 40 and older with good ovarian reserve.

STUDY DESIGN

Retrospective review of records at an infertility clinic in a large multispecialty group practice. Twenty two consecutive women aged 40 and older underwent 24 stimulation cycles for laparoscopic GIFT procedures from 1988 to 1997.

RESULTS

The mean GIFT cycle cost was $5,731. The delivery rate per stimulation cycle was 25.0%. The patients who gave birth were 40-42 years of age. The mean cost per delivered infant was $22,924. A previously reported value for mean cost per pregnancy for donor oocyte in vitro fertilization (IVF) was $30,457. Theoretical costs per delivery, generated from Society for Assisted Reproductive Technology outcome data for anonymous donor oocyte IVF in 1994 (delivery rate per transfer, 34.4%) for $8,000, $9,000 and $10,000 cycle costs were $23,256, $26,163 and $29,070, respectively.

CONCLUSION

In women with good ovarian reserve, GIFT may be a cost-effective alternative to donor oocyte IVF at age 40-42.

Ice-cream truck-related injuries to children

Few studies exist on the cause and nature of injuries to children from ice-cream truck-related accidents. We reviewed the medical records of 11 children with orthopedic injuries treated at Children's Hospital-San Diego from 1985 to 1995 for injuries in such accidents. Of nine children on their way to or from an ice-cream truck who were struck by an oncoming vehicle, all were girls; eight had pelvic or lower-extremity fractures. When ice-cream trucks park on the street, they pose a danger to children, because children are drawn to them, and the trucks' large size blocks the vision of oncoming drivers.

Etiology of supracondylar humerus fractures

The specific etiology of supracondylar humerus fractures in children is not well known. All supracondylar humerus fractures treated at Children's Hospital and Health Center, San Diego (CHSD) over an 8-year period (n = 391) were reviewed to determine specific information about the manner in which the injury occurred. Girls tended to sustain these fractures more often, and the nondominant arm was more often injured. Falls from a height accounted for 70% of the fractures. Children < or = 3 years old tended to fall off of household objects (beds, couches, other objects 3-6 feet high), and children 4 years and older tended to fall from playground equipment such as monkey bars, slides, and swings. Safety precautions should be implemented in homes of young children and at playgrounds to avoid these fractures.

Maternal endocrine status in relation to pregnancy outcome in rapidly growing adolescent sheep

It has previously been reported that high nutrient intakes which promote rapid maternal growth throughout pregnancy are associated with poor pregnancy outcome when compared with normally growing adolescent animals. The present study examined the maternal plasma concentrations of a number of putative endocrine regulators of nutrient partitioning between the maternal and fetal compartments in relation to placental and fetal growth in this novel experimental paradigm. Embryos were recovered on day 4 after oestrus from superovulated adult ewes that had been inseminated using semen from a single sire and synchronously transferred, in singleton, to the uterus of peripubertal adolescent recipients (n = 38), which had been induced to ovulate at 32 weeks of age (live weight 47.4 +/- 0.4 kg). Post-transfer, the adolescent recipients were offered a high (n = 21) or moderate (n = 17) level of a complete diet calculated to achieve rapid (RMG) or normal (NMG) maternal growth rates. After day 100 of gestation, the feed intake of the NMG group was adjusted weekly to meet the increasing nutrient demands of the gravid uterus. Pregnancy rate following embryo transfer was higher (P < 0.05) in the RMG (90%) than in the NMG (59%) group. For ewes delivering live young at term, liveweight gain during the first 100 days of gestation was 294 +/- 12.9 and 84 +/- 4.7 g/day for the RMG (n = 16) and NMG (n = 10) groups respectively, and body condition score immediately prior to parturition was higher in RMG than in NMG ewes (2.9 +/- 0.04 vs 1.9 +/- 0.15 score units respectively, P < 0.001). For the RMG and NMG groups respectively, mean placental weight was 327 +/- 18.1 and 485 +/- 16.6 g with lamb birth weights of 3.49 +/- 0.13 and 4.82 +/- 0.21 kg (P < 0.001). The reduction in placental mass in the RMG group reflected a decrease in the number (P < 0.001) and size (P < 0.01) of the fetal cotyledons. The duration of gestation was shorter (P < 0.001) and colostrum yield at parturition lower (P < 0.001) in the RMG group. Maternal insulin concentrations, determined three times weekly, were higher (P < 0.001) throughout gestation in the RMG group and irrespective of treatment group were negatively correlated (P < 0.01) with placental weight and lamb birth weight. High glucose levels throughout gestation and a decreased response to an exogenous insulin challenge on day 95 of gestation implied a degree of insulin resistance in the RMG group but, in spite of these high maternal glucose concentrations, the reduced size of the placenta probably constrained fetal growth. Maternal IGF-I levels determined weekly, were elevated (P < 0.001) during the second and third trimester in RMG versus NMG groups and a sustained elevation in maternal tri-iodothyronine and thyroxine concentrations was evident in the RMG group from mid-gestation. In contrast, GH pulse frequency and mean GH concentrations, determined on day 68 and 122 of gestation, were lower (P < 0.05) in the RMG group, and irrespective of treatment group, were correlated negatively with feed intake and positively with placental weight and colostrum yield at parturition. Progesterone concentrations were lower in the RMG group during the second and third trimesters (P < 0.001) and, irrespective of treatment group, were positively associated (P < 0.001) with placental weight, gestation length and colostrum yield. These results suggest that in pregnant adolescent sheep on high dietary intakes, elevated insulin and IGF-I levels ensure that the anabolic drive to maternal tissue synthesis is established during early gestation at the expense of placental growth. The consequent restriction in placental transport capacity is the primary limitation to fetal growth and reduced GH and placental progesterone secretion may impair colostrum production.

Laparoscopic removal of virilizing hilar cell tumor in a postmenopausal patient

A postmenopausal woman experienced rapidly progressing hirsutism and signs of virilization. Hormone evaluations showed markedly elevated serum testosterone levels and no evidence of excess cortisol or dehydroepiandrosterone sulfate production. A computerized tomographic scan of the adrenals and ovaries was normal, and transvaginal ultrasound revealed a left ovary with a maximum diameter of 3.2 cm. At outpatient laparoscopic bilateral oophorectomy, the left ovary had a benign, 2.5-cm Leydig cell tumor, hilar cell variant. Laparoscopy may be useful in the diagnosis and treatment of select cases of virilizing tumors of the ovary.

Improving the cost-to-benefit ratio of in-vitro fertilization

In-vitro fertilization (IVF) has been criticized for being too costly to permit ready access to needy patients, either through their own funds or through those of third party providers. European groups have managed to offer these procedures at a fraction of the cost incurred by their United States counterparts by streamlining their protocols. Accordingly, we present our methods for reducing the cost of IVF. The main modification was made by performing the IVF procedures in the clinic under i.m. analgesia, avoiding the costs of a surgery suite and anaesthesia. In addition, donor, oocyte, micromanipulation, and cryopreservation services were not offered, reducing overall personnel and equipment costs. Overall costs were reduced from customary levels of $7,000--$11,000 in the United States to $3,409 per cycle initiated, while maintaining good ongoing/delivered pregnancy rates (30.0% versus 18.6% nationally) per cycle reaching aspiration. We conclude that, through the elimination of less necessary and/or utilized procedures, IVF may be performed in a more cost-effective manner while maintaining good success rates. For the patients who desire IVF services not offered under such a system, referral to a more specialized IVF center is appropriate.

High-frequency pressure-control ventilation with high positive end-expiratory pressure in children with acute respiratory distress syndrome

OBJECTIVE

Animal models suggest that high-frequency ventilation with low tidal volumes and high positive end-expiratory pressure (PEEP) minimize secondary injury to the lung. We hypothesized that using a high-frequency pressure-control mode of ventilation with high PEEP in children with severe acute respiratory distress syndrome (ARDS) would be associated with improved survival.

DESIGN

The study was a retrospective and prospective clinical study at a 24-bed tertiary care pediatric critical care unit. Fifty-three patients with severe ARDS were studied during a 37-month period, 30 prospectively and 23 retrospectively. Severe ARDS was defined as (1) rapid onset of severe bilateral infiltrates of noncardiac origin, (2) partial pressure of oxygen (arterial)/fraction of inspired oxygen less than 200 on PEEP of 6 cm H2O or more for 24 hours or longer, and (3) Murray disease severity score greater than 2.5. All patients meeting these criteria underwent ventilation in the pressure-control mode; the protocol for ventilation had the following general guidelines: (1) fraction of inspired oxygen limited to 0.5, (2) mean airway pressure titrated with PEEP to maintain arterial partial pressure of oxygen of 55 mm Hg or greater (7.3 kPa), (3) peak inspiratory pressure minimized to allow hypercapnia (arterial partial pressure of carbon dioxide, 45 to 60 mm Hg (6.0 to 8.0 kPa), and (4) ventilator rates of 40 to 120/min. Percutaneous thoracostomy and mediastinal tubes were placed for treatment of air leak.

RESULTS

The survival rate was 89% (47/53) in children with severe ARDS. Nonsurvivors had significantly higher peak inspiratory pressures (75 vs 40 cm H2O, p = 0.0006), PEEP (23 vs 17 cm H2O, p = 0.0004), mean airway pressure (40 vs 28 cm H2O, p = 0.04), alveolar-arterial oxygen gradient (579 vs 540 mm Hg, p = 0.03), and oxygenation index (43 vs 19, p = 0.0008) than survivors. Air leak was present in 51% of patients; there was no difference in the incidence of air leak between survivors and nonsurvivors (p = 0.42).

CONCLUSIONS

The high-frequency positive-pressure mode of ventilation was safe and was associated with an improved survival rate (89%) for children with severe ARDS. Limitation of both inspired oxygen and tidal volume, along with aggressive treatment of air leak, may have contributed to the improved survival rate.

Outpatient minilaparotomy ovarian cystectomy for benign teratomas in teenagers

Benign cystic teratomas are the most common ovarian neoplasms in adolescents. An ovary-conserving method was developed for outpatient surgical removal of benign cystic teratomas by minilaparotomy in teenagers. The technique requires no specialized training, laser devices, or expensive disposable instrumentation. As a precaution, the first teenager in whom the technique was used was observed as an inpatient for 3 days. Following this, the method was used as an outpatient procedure in three further cases. No complications occurred in any of the four patients, and the mean operating time of 85 minutes (range, 60 to 95 minutes) was similar to the reported time for removal of benign cystic teratomas by laparotomy. Although a randomized controlled study with many more patients would be necessary for a definitive conclusion, considerable cost savings and reduction in morbidity over traditional laparotomy are suggested by this experience.

Laparoscopic diagnosis and treatment of an infarcted epiploic appendage

A patient experienced acute abdominal pain that was diagnosed at laparoscopy as being due to an infarcted epiploic appendage. To our knowledge, this is the second report of laparoscopic diagnosis and treatment of an epipolic disorder. Infarcted epiploic appendages may be associated with bowel obstruction and abscess formation. Therefore, they should be looked for at the time of diagnostic laparoscopy for acute abdominal pain of unclear etiology, and removed if present.

Peripheral joint laxity increases in pregnancy but does not correlate with serum relaxin levels

OBJECTIVE

Our purpose was to evaluate peripheral joint laxity during pregnancy and to determine whether serum relaxin levels are associated with increased joint laxity.

STUDY DESIGN

A prospective observational study was performed.

RESULTS

A significant increase in joint laxity was found in five of seven peripheral joints over the course of the pregnancy and post partum. There was no correlation with serum relaxin levels. There were no significant differences in joint laxity on the basis of parity, age, or prepregnancy exercise levels.

CONCLUSIONS

Peripheral joint laxity is noted to increase as pregnancy progresses. The cause of this change is undetermined.

Equal effectiveness of electrical and volitional strength training for quadriceps femoris muscles after anterior cruciate ligament surgery

Neuromuscular electrical stimulation and voluntary muscle contraction are two exercise modes widely used in rehabilitation to strengthen skeletal muscle. Since there is no debate as to which mode is most effective, we compared electrical stimulation with voluntary contraction performed at matched intensities following reconstructive surgery of the anterior cruciate ligament. Forty men and women, aged 15-44, were randomly assigned to either an electrical stimulation or a voluntary contraction group. None of the subjects had a previous history of neuromuscular injury. The subjects received treatment for 30 minutes a day, 5 days a week, for 4 weeks. Knee extension torque was monitored during treatment to try to match the absolute muscular tensions (quantified as "activity") achieved during therapy. To match the activity of the subjects in the electrical stimulation group, who were treated at the highest stimulation intensity they could tolerate, the subjects in the voluntary contraction group were paced at progressively increasing intensities corresponding to 15, 25, 35, and 45% of the injured limb's maximum voluntary torque during weeks 1, 2, 3, and 4, respectively. We found no significant difference between the groups in terms of maximum voluntary knee extension torque throughout the study period. In addition, 1 year after surgery, there was still no significant difference between groups with regard to knee extension torque (p > 0.4). These data suggest that neuromuscular electrical stimulation and voluntary muscle contraction treatments, when performed at the same intensity, are equally effective in strengthening skeletal muscle that has been weakened by surgical repair of the anterior cruciate ligament.

Factors associated with improving success rates with gamete intrafallopian transfer under thin-needle spinal anesthesia

PURPOSE

In order to reduce the risk of major anesthetic complications associated with laparoscopic gamete intrafallopian transfer procedures, we have exclusively used thin-needle spinal anesthesia over the years 1991 - 1994. This paper will review complication rates in order to further establish the safety profile of GIFT under thin-needle anesthesia and report the changes in our GIFT protocol from 1991 to 1994 which have been associated with a statistical improvement in the implantation rate from 11% to 23% (P = 0.01) and an increase in delivery rates from 29% to 42% per transfer procedure.

METHODS

Sixty-eight laparoscopic GIFT procedures were done in women with at least one patent oviduct and failure to respond to less invasive treatment. Clinical variables were analyzed to determine if similar patient populations had been treated over the study period.

RESULTS

The improved delivery rates and implantation rates could not be explained by patient selection. No major perioperative complications occurred. Minor perioperative complications and difficulties included one patient requiring general anesthesia, one patient developing a spinal headache which could be managed conservatively at home, and one patient requiring a minilaparotomy to complete the GIFT procedure. The more serious complications occurred as a result of the superovulation and multiple oocyte transfer rather than the surgical or anesthetic technique. These included two patients with severe ovarian hyperstimulation requiring hospitalization, and five delivered triplet pregnancies. Factors associated with improving success rates included improvements in semen and equipment preparation as well as an increase in the number of sperm transferred from 200,000 to 500,000.

CONCLUSIONS

GIFT can be performed with relative safety under thin needle spinal anesthesia with high implantation and delivery rates if care is made to optimize sperm and equipment preparation. GIFT under thin-needle spinal anesthesia may be an attractive alternative for treatment of longstanding nontubal infertility in couples willing to take the risk of ovarian hyperstimulation and multiple pregnancy.

Relative roles of natural killer- and T cell-mediated anti-leukemia effects in chronic myelogenous leukemia patients treated with interferon-alpha

Potential anti-leukemia effects mediated by T cells or by natural killer (NK) cells were investigated in chronic myelogenous leukemia (CML) patients treated with interferon-alpha. Therapy-associated modulation of T cell and NK reactivity was monitored for one year from initiation in autologous mixed lymphocyte-tumor cell reactions and cytotoxicity directed against autologous CML cells, respectively. During the course of IFN-therapy, NK activity against autologous CML cells increased steadily, whereas T cell reactivity fluctuated randomly. Despite the high level of T cell reactivity to autologous tumor cells in short-term (6 days) culture, 1) they failed to respond to synthetic peptides corresponding to the bcr/abl fusion sequence of the patient, and 2) only one proliferative T cell clone (TCC) was isolated which specifically recognized HLA-DR-matched CML cells. This TCC appeared not to recognize synthetic peptides corresponding to the bcr/abl fusion sequence of the patient; the antigen to which it responds remains unknown. To assess potential immunogenicity of bcr/abl peptides, it was attempted to sensitize T cells from normal donors in vitro. Of 109 cell lines obtained from seven different donors, eleven showed peptide-dependent proliferation. Therefore, although these results show that it is possible to isolate apparently CML-specific T cells from patients, as well as to prime T cells against tumor-specific peptide in vitro, the frequency of such T cell-mediated reactivity appears low and its relevance to anti-leukemic effects questionable. On the other hand, the strong time-dependent enhancement of natural killing of autologous CML blasts during IFN-alpha treatment, a phenomenon not observed for T cell reactivity, suggests that natural immunity may be more important in controlling disease.

Improved combined laparoscopic and minilaparotomy technique to allow for reversal of extensive tubal sterilization

We assessed the efficacy of combined laparoscopic and minilaparotomy for outpatient microsurgical reversal of extensive tubal sterilization in 11 women undergoing the procedure and followed for a mean of 24.7 months. All patients desired reversal of extensive tubal sterilization, and had 4 cm or less of the longer oviduct remaining. The mean operating time was 110 minutes, and the mean total cost was $5067. There were no major complications. Two women were treated for uncomplicated cystitis within 1 month of surgery. Five (45%) of 11 women delivered viable infants; one patient had two ectopic pregnancies. These preliminary data suggest that outpatient combined laparoscopy and minilaparotomy may be effective in patients who desire restoration of fertility after extensive tubal sterilization.

Serum parathyroid hormone-related protein levels during lactation

We measured parathyroid hormone-related protein (PTHrP) in the serum of 15 healthy women within three days of beginning breast-feeding and within one hour of completing nursing. A sensitive immunoradiometric assay that measures N-terminal PTHrP containing at least the first 74 amino acids was used. We found normal PTHrP values in all patients. Values one day before and two days after delivery in a hypoparathyroid woman who chose not to breast-feed were also normal. Since N-terminal PTHrP fragments of 1-36 amino acids or more are biologically active, we believe additional studies using sensitive PTHrP assays that measure smaller fragments and investigations performed under other conditions of breast-feeding are necessary before concluding that PTHrP does not have a role in calcium homeostasis in nursing mothers. Furthermore, additional studies in hypoparathyroid nursing mothers should be performed.

Laparoscopic treatment of heterotopic pregnancy

The increasing frequency of pelvic inflammatory disease and use of ovulation-induction agents has resulted in a corresponding increase in the frequency of heterotopic pregnancy. In most reported cases the diagnosis was made retrospectively at the time of laparotomy. With improvements in ultrasonography and operative laparoscopy, the diagnosis can be made preoperatively and the disease treated surgically with low morbidity. In a woman who had received clomiphene citrate for ovulation induction, the diagnosis of heterotopic pregnancy was suspected preoperatively based on transvaginal ultrasonography. The patient was treated laparoscopically by partial salpingectomy, and subsequently delivered a normal infant.

Spontaneously acquired, unilateral absence of the adnexa. A case report

A free-floating, calcified cyst was found in the peritoneal cavity in association with unilateral absence of the adnexa. The evidence was that it was due to torsion and separation of the adnexa from their supporting structures. This phenomenon may be a cause of congenital absence of the ovary.

Use of the Edinburgh Postnatal Depression Scale to identify postpartum depression in a clinical setting

The Edinburgh Postnatal Depression Scale (EPDS) is a validated instrument developed specifically to identify women experiencing postpartum depression (PPD). This study sought to determine the extent of postpartum depression in our population and the maternal characteristics associated with it and to also determine if the scale increased practitioner awareness and treatment of PPD. Two hundred eighty-seven women from the total population completing the EPDS in 1991 (n = 1,139) were randomly selected for retrospective chart review to identify relationships between maternal characteristics and elevated EPDS scores. Charts were also reviewed for outcomes related to depression for the six-month period after delivery. Statistical analysis of the data revealed that 17.4% of the total population had an EPDS score of > or = 10, indicating a potential risk of developing PPD. Eight percent scored > or = 13, suggesting that further assessment was necessary. Marital instability, lack of medical insurance and a history of depression were the factors found to correlate most significantly with elevated EPDS scores. The physicians and midwives providing service for our population were interviewed, and 83% reported that the EPDS had increased their awareness of PPD, while 92% reported having referred for treatment patients with high EPDS scores. Use of the EPDS scale can improve practitioner awareness and aid in the diagnosis of PPD. Several easily identifiable variables are associated with PPD.

Reproductive potential after treatment for persistent ectopic pregnancy

We examined the success rate and reproductive outcome of 50 patients who had been treated for persistent EP after initial unsuccessful salpingostomy. All who underwent salpingectomy had successful treatment of their persistent EP. One treatment failure occurred after MTX. Of 50 women, 32 (61.5%) attempted conception after treatment for persistent EP. The cumulative clinical pregnancy rate after treatment for persistent EP was 59% at 36 months. There was a significant association between clinical pregnancy rate after persistent EP and those with normal contralateral fallopian tubes (P < 0.005). The relative risk of having a clinical pregnancy among those who attempted conception was 2.3 for those having a normal contralateral fallopian tube compared with those with a contralateral fallopian tube with obvious pathology. Intrauterine pregnancy rates after treatment of persistent EP were similar to those reported for primary treatment of EP.

Identifying hearing loss in the intensive care nursery: a 20-year summary

The outcome of a study on hearing loss in graduates of one third-level and two second-level intensive care nurseries (ICN) is reported. The goals were to identify, test, and fit hearing aids on those who need them. Initial hearing-threshold estimates were obtained by auditory brainstem response (ABR) analyses at the time of discharge from the hospital; the mean percentage of failures to respond to 30-dB nHL clicks (in one or both ears) was 19.8 percent for the third-level ICN graduates (N = 4374), and 12.0 percent for the second-level graduates (N = 1527). About half of those with hearing loss at the initial Test were returned for a ReTest 6-20 weeks later, at which time 48.7 percent of the third-level and 44.0 percent of the second-level group were judged normal because they delivered 25-dB click ABRs bilaterally. Following conventional audiological work-ups of the ones with unilateral or bilateral hearing loss, hearing aids were fitted to 92 in the third-level group (2.1% of those Tested) and 22 of the second-level group (1.4%). Not quite half of these fittings occurred within 1 year of the hospital Test that initially diagnosed the loss.

Live birth after treatment of severe adenomyosis with a gonadotropin-releasing hormone agonist

A patient with a 10-year history of secondary infertility underwent GnRH-a therapy with LA for 5 months to control symptoms of severe adenomyosis and to avoid an unwanted hysterectomy. Shortly after cessation of treatment, the patient conceived. A healthy male was delivered at term by cesarean section, which makes this the first report of a live birth after treatment of severe adenomyosis with a GnRH-a.

Reproductive outcome after 143 laparoscopic procedures for ectopic pregnancy

OBJECTIVE

To analyze reproductive outcome after laparoscopic procedures for ectopic pregnancy, with particular attention to laparoscopic salpingectomy.

METHODS

In a 260-physician multispecialty clinic in the rural upper midwestern United States, 143 patients were followed prospectively after undergoing laparoscopic procedures for ectopic pregnancy. Ninety-five who sought further pregnancies during the study period were analyzed for reproductive outcome. Intrauterine pregnancy rates were compared by age, parity, size of ectopic gestation, and evidence of prior tubal damage. Life table analysis was also performed.

RESULTS

The overall intrauterine pregnancy rates for laparoscopic salpingostomy (60%) and laparoscopic salpingectomy (54%) were not significantly different from each other. However, intrauterine pregnancy rates differed significantly by history of prior tubal damage. The pregnancy rate was 79% among women without tubal damage and 42% among women with damage.

CONCLUSIONS

Our intrauterine pregnancy rates after both laparoscopic salpingectomy and laparoscopic salpingostomy are similar to those reported in the literature for similar procedures performed at laparotomy. In predicting pregnancy outcome after laparoscopic procedures for ectopic pregnancy, the major variable seemed to be evidence of prior tubal damage. With no evidence of previous damage, we found similarly high pregnancy rates for laparoscopic salpingostomy and salpingectomy.

Gamete intrafallopian transfer with spinal anesthesia

OBJECTIVE

To investigate the feasibility of performing GIFT under spinal anesthesia administered through a thin (27-gauge) needle.

DESIGN

Prospectively studied case series.

SETTING

A tertiary care center staffed by a 260 physician multispecialty group.

PATIENTS

Twenty-seven consecutive fertility patients underwent 28 laparoscopic GIFT procedures, electing to receive spinal anesthesia administered through a thin (27-gauge) needle.

INTERVENTIONS

Laparoscopic GIFT and thin-needle spinal anesthesia.

MAIN OUTCOME MEASURES

Assessment of anesthetic complications and reproductive outcome.

RESULTS

Satisfactory anesthesia was obtained in 27 of the 28 cases (96%). One patient required additional general anesthesia because of failed spinal anesthesia. All patients were discharged from the hospital on the day of surgery and no postdural headache, persistent back pain, meningitis, or neurological deficit was reported on a 7-day follow-up. Of the 12 clinical pregnancies (43%), 9 ongoing/delivered pregnancies occurred (32%). Six patients had livebirths, and three patients have ongoing second or third trimester pregnancies; there were three spontaneous abortions.

CONCLUSIONS

Spinal anesthesia administered through a 27-gauge needle is an attractive option for laparoscopic GIFT. The risk of serious morbidity because of an anesthetic-related complications may be reduced, and the oocytes are not exposed to the potentially deleterious effects of the drugs associated with general anesthesia.

Laparoscopic diagnosis of puerperal ovarian vein thrombophlebitis. A case report

Puerperal ovarian vein thrombophlebitis is a relatively rare postpartum complication that may result in serious complications. The syndrome may be diagnosed through exploratory surgery or diagnostic imaging, although the best method remains unclear. In one case, open laparoscopy yielded a swift diagnosis and ensured prompt treatment without necessitating further diagnostic studies.