Properties of APTES-Modified CNC Films

Sulfated cellulose nanocrystals' (CNCs') facile aqueous dispersibility enables producing films, fibers, and other materials using only water as a solvent but prevents using sulfated CNCs in applications that require water immersion. We report that modifying CNCs with 3-aminopropyl-triethoxysilane (APTES) via a simple, single-pot reaction scheme dramatically improves the hydrolytic stability of CNC films. The effects of APTES modification on CNCs' properties were studied using attenuated total reflectance Fourier transform infrared spectroscopy, atomic force and optical microscopy, thermogravimetric analysis, dynamic light scattering, and ultimate analysis. Substituting a mere 12.6% of the CNCs' available hydroxyl groups with APTES dramatically increased the hydrolytic stability of shear cast films while only having minor impacts on their mechanical properties. In addition, quartz crystal microbalance with dissipation monitoring (QCMD) and multiparametric surface plasmon resonance (MP-SPR) studies showed that the CNC-APTES films also had a greater irreversible binding with carbofuran, a pesticide and emerging contaminant. These results highlight that APTES modification is a promising method for increasing the utility of sulfated CNCs in sensors, adsorbents, and other applications requiring water immersion.

Microbiological diagnostics of bloodstream infections in Europe-an ESGBIES survey

OBJECTIVES

High-quality diagnosis of bloodstream infections (BSI) is important for successful patient management. As knowledge on current practices of microbiological BSI diagnostics is limited, this project aimed to assess its current state in European microbiological laboratories.

METHODS

We performed an online questionnaire-based cross-sectional survey comprising 34 questions on practices of microbiological BSI diagnostics. The ESCMID Study Group for Bloodstream Infections, Endocarditis and Sepsis (ESGBIES) was the primary platform to engage national coordinators who recruited laboratories within their countries.

RESULTS

Responses were received from 209 laboratories in 25 European countries. Although 32.5% (68/209) of laboratories only used the classical processing of positive blood cultures (BC), two-thirds applied rapid technologies. Of laboratories that provided data, 42.2% (78/185) were able to start incubating BC in automated BC incubators around-the-clock, and only 13% (25/192) had established a 24-h service to start immediate processing of positive BC. Only 4.7% (9/190) of laboratories validated and transmitted the results of identification and antimicrobial susceptibility testing (AST) of BC pathogens to clinicians 24 h/day. Matrix-assisted laser desorption/ionization time-of-flight mass spectrometry from briefly incubated sub-cultures on solid media was the most commonly used approach to rapid pathogen identification from positive BC, and direct disc diffusion was the most common rapid AST method from positive BC.

CONCLUSIONS

Laboratories have started to implement novel technologies for rapid identification and AST for positive BC. However, progress is severely compromised by limited operating hours such that current practice of BC diagnostics in Europe complies only partly with the requirements for optimal BSI management.

Methodology of Niyantrita Madhumeha Bharata Abhiyaan-2017, a Nationwide Multicentric Trial on the Effect of a Validated Culturally Acceptable Lifestyle Intervention for Primary Prevention of Diabetes: Part 2

Background

The rapidly increasing diabetes burden, reaching epidemic proportions despite decades of efforts, reflects our failure to translate the proven evidence for prevention of diabetes. Yoga, with its holistic approach, alters the habituated patterns of lifestyles and behaviour. Motivated by the accumulating evidence, the Government of India funded a large randomized controlled trial.

Aims and Objectives

The twin objectives were: (a) estimate the prevalence of prediabetes and diabetes through a parallel multisite stratified cluster sampling method and (b) implement NMB 2017 (niyantrita madhumeha bharata abhiyaan), a randomized control trial using yoga based lifestyle program.

Materials and Methods

Screening for Indian Diabetes Risk score(IDRS) was conducted in randomly selected clusters in all 7 zones (65 districts from 29 states/union territories) of India. This was followed by detailed assessments in those with known diabetes and high risk (≥60) on IDRS. Those who satisfied the selection criteria and consented were recruited for the two armed waitlisted randomized control trial. A validated remedial diabetesspecific integrated yoga lifestyle module was taught to the experimental arm by certified volunteers of Indian Yoga Association. Followup assessments were done after 3 months in both groups. In this article, we report the methodology of the trial.

Results

Response to door to door visits (n-240,968 adults >20yrs) in randomly selected urban and rural households for screening was 162,330; detailed assessments (A1c, lipid profile, BMI, stress, tobacco etc) were performed on 50,199 individuals. Of these 12466 (6531 yoga 5935 control) consented and for the RCT; 52% females, 48% males; 38% rural, 62% urban; BMI 21.1 ± 3.8; waist circumference 91.7 ± 11.9. A1c in diabetes subjects in yoga group was 7.63 ± 2.17 and 7.86 ± 2.13 in control group.

Conclusion

This unique methodology provides the evidence to implement a validated yoga life style module using yoga volunteers in all parts of the country which is an urgent need to prevent India from becoming the global capital for diabetes.

Niyantrita Madhumeha Bharata 2017, Methodology for a Nationwide Diabetes Prevalence Estimate: Part 1

Background:

Type 2 Diabetes Mellitus (T2DM) poses an ever-increasing threat to people's health worldwide. India has reported high rates of incidence of T2DM. The dangers make accurate assessment of its burden and intervention of lifestyle change, an urgent necessity.

Aims and Objectives:

The aim of the study was to estimate the nationwide prevalence of prediabetes and diabetes, followed by a translational lifestyle trial.

Methodology:

The Indian Yoga Association was commissioned in 2016–2017 by the Government of India to conduct this study which was undertaken in two phases: Phase 1 was to estimate the prevalence of prediabetes and diabetes across the country, and Phase 2 was to conduct a randomized controlled trial using a validated yoga lifestyle protocol. This paper highlights the unique methodology of Phase 1 of the study. The first stage was screening (February to April 2017) for adults (>20 years) with high risk for diabetes on Indian diabetes risk score (IDRS) on mobile app, using a random cluster sampling survey method. All households in the rural (4 villages with about 500 adult population/village) and urban (2 census enumeration blocks [CEBs] of about 1000 adult population/block) sectors of 65 districts (one per ten districts in the entire country) from 29 out of 35 states of India were approached. In the second stage, detailed assessments (sociodemographic, clinical details, A1c, lipid profile, body mass index, stress, and tobacco) were carried out on those with high risk on IDRS and on all self-reported diabetes individuals.

Results:

In the first stage of door-to-door visit, 240,968 adults in all households of the selected clusters of villages and CEBs were approached. Of these, 162,330 responded. The respondents in the second stage for detailed assessments in the selected cohort were 50,199 (48% rural and 52% urban) adults. Of these, 7472 were self-reported known diabetes adults and the remaining were 42,737. Prevalence estimates for the country will follow in the future publications.

Conclusion:

This rapid survey completed within 3 months in the entire country using trained volunteers offers the methodology to obtain a quick estimate of diabetes and high-risk population to implement any lifestyle program.

Risk factors, clinical course and outcomes of pregnancy-related group A streptococcal infections: retrospective 13-year cohort study

OBJECTIVES

To investigate the incidence, risk factors, clinical course and outcomes of pregnancy-related group A streptococcus (GAS) infection.

METHODS

A retrospective 13-year cohort study of culture-proven pregnancy-related GAS infection was performed at two university hospitals serving heterogeneous, multicultural, urban and rural populations.

RESULTS

Of 124 women diagnosed with pregnancy-related GAS infection, 115 (93%) were in the puerperium, an incidence of 0.8 cases per 1000 live births (95% confidence interval, 0.7-0.9). A multivariate analysis showed primiparity and cesarean delivery to be independent protective factors against puerperal GAS infection (adjusted odds ratios (95% confidence interval), 0.60 (0.38, 0.97) and 0.44 (0.23, 0.81), respectively). Of the nine remaining patients, eight were diagnosed after first trimester abortions and one had an infected ectopic pregnancy. Among the entire cohort (n = 124), the predominant manifestations were fever and abdominal tenderness. Twenty-eight patients (23%) had severe GAS infections. All were treated with β-lactams, and most (n = 104, 84%) received clindamycin. Only four (3%) required surgical intervention; the rest fully recovered with conservative medical treatment including antibiotics. No recurrences, maternal deaths or neonatal complications were noted.

CONCLUSIONS

Pregnancy-related GAS infection is not rare; it lacks specific signs and still carries significant morbidity. Primiparity, a presumable surrogate for diminished exposure to children and thus less GAS carriage, and cesarean delivery in which perioperative antibiotic prophylaxis was uniformly provided, appear as protective factors against puerperal GAS infection. This hints to the importance of community-acquired GAS and may support shifting efforts from infection-control-oriented nosocomial investigations to screening and prevention-driven policies.

Modified anchor shaped post core design for primary anterior teeth

Restoring severely damaged primary anterior teeth is challenging to pedodontist. Many materials are tried as a post core but each one of them has its own drawbacks. This a case report describing a technique to restore severely damaged primary anterior teeth with a modified anchor shaped post. This technique is not only simple and inexpensive but also produces better retention.

Emergence of an HIV-1 cluster harbouring the major protease L90M mutation among treatment-naïve patients in Tel Aviv, Israel

OBJECTIVE

Drug resistance-associated mutations (DRMs) among HIV-1 treatment-naïve patients have increased in recent years. Their incidence and prevalence in various exposure risk categories (ERCs) were evaluated.

DESIGN

Plasma samples of HIV-1 treatment-naïve patients diagnosed between 2001 and 2009 at the Tel Aviv Medical Center were screened for DRMs.

METHODS

Samples obtained from patients following the HIV diagnosis were analysed retrospectively. Genotyping was carried out using the Trugene HIV-1 genotype kit (Siemens, Berkeley, CA, USA). Phylogenetic relationships among viral sequences were estimated using the maximum likelihood method.

RESULTS

Thirty-eight of the 266 analysed sequences (14.3%) had DRMs, all occurring exclusively in the group of men who have sex with men (MSM). The rate of DRMs has constantly risen, reaching a peak of 21.9% in 2009. Notably, protease inhibitor (PI) DRMs became the most frequent DRMs in 2009. Phylogenetic analysis showed a tight cluster comprising 13 of 14 viruses harbouring the L90M major PI resistance mutation, suggesting a single infection source.

CONCLUSION

There was an unexpectedly high rate of the major L90M PI resistance mutation in the MSM group. The clustered transmission of this mutation might be related to a high-risk sexual behaviour. Added to nonnucleoside reverse transcriptase inhibitor and nucleoside reverse transcriptase inhibitor resistance mutations, such a PI mutation may limit future therapeutic options for this particular patient population.

High susceptibility to bacterial infection, but no liver dysfunction, in mice compromised for hepatocyte NF-kappaB activation

Based on the essential involvement of NF-kappaB in immune and inflammatory responses and its apoptosis-rescue function in normal and malignant cells, inhibitors of this transcription factor are potential therapeutics for the treatment of a wide range of diseases, from bronchial asthma to cancer. Yet, given the essential function of NF-kappaB in the embryonic liver, it is important to determine its necessity in the liver beyond embryogenesis. NF-kappaB is normally retained in the cytoplasm by its inhibitor IkappaB, which is eliminated upon cell stimulation through phosphorylation-dependent ubiquitin degradation. Here, we directed a degradation-resistant IkappaBalpha transgene to mouse hepatocytes in an inducible manner and showed substantial tissue specificity using various means, including a new method for live-animal imaging. Transgene expression resulted in obstruction of NF-kappaB activation, yet produced no signs of liver dysfunction, even when implemented over 15 months. However, the transgene-expressing mice were very vulnerable both to a severe immune challenge and to a systemic bacterial infection. Despite having intact immunocytes and inflammatory cells, these mice were unable to clear Listeria monocytogenes from the liver and succumbed to sepsis. These findings indicate the essential function of the hepatocyte through NF-kappaB activation in certain systemic infections, possibly by coordinating innate immunity in the liver.

Evaluation of hexaflumuron for controlling the subterranean termite Coptotermes curvignathus (Isoptera: Rhinotermitidae) in Malaysia

Cellulosic bait matrices containing 0.5% hexaflumuron were tested against field colonies of the subterranean termite Coptotermes curvignathus Holmgren in Malaysia. Foraging activities of the termites were first monitored for several months by using survey stakes and wood bundles placed in underground monitoring traps. Infested stakes were replaced with bait devices. Termite workers to act as recruits were collected from infested stakes and placed in the bait devices. Subsequent activities of the termites were monitored by examining and weighing the wood in the monitoring traps. Data show that the four colonies had populations of 166,288-709,052 foragers and mean wood consumption rates of 305.9-508.2 g/mo per trap. These colonies ceased their activities at all monitoring devices 25-44 d after baiting had commenced. Colonies consumed approximately 27-79 g of bait matrix or 137.5-395 mg of hexaflumuron. Thus, C. curvignathus colonies could be monitored, characterized, baited, and foraging eliminated by using a bait matrix containing hexaflumuron.

Identification of the receptor component of the IkappaBalpha-ubiquitin ligase

NF-kappaB, a ubiquitous, inducible transcription factor involved in immune, inflammatory, stress and developmental processes, is retained in a latent form in the cytoplasm of non-stimulated cells by inhibitory molecules, IkappaBs. Its activation is a paradigm for a signal-transduction cascade that integrates an inducible kinase and the ubiquitin-proteasome system to eliminate inhibitory regulators. Here we isolate the pIkappaBalpha-ubiquitin ligase (pIkappaBalpha-E3) that attaches ubiquitin, a small protein which marks other proteins for degradation by the proteasome system, to the phosphorylated NF-kappaB inhibitor pIkappaBalpha. Taking advantage of its high affinity to pIkappaBalpha, we isolate this ligase from HeLa cells by single-step immunoaffinity purification. Using nanoelectrospray mass spectrometry, we identify the specific component of the ligase that recognizes the pIkappaBalpha degradation motif as an F-box/WD-domain protein belonging to a recently distinguished family of beta-TrCP/Slimb proteins. This component, which we denote E3RSIkappaB (pIkappaBalpha-E3 receptor subunit), binds specifically to pIkappaBalpha and promotes its in vitro ubiquitination in the presence of two other ubiquitin-system enzymes, E1 and UBC5C, one of many known E2 enzymes. An F-box-deletion mutant of E3RS(IkappaB), which tightly binds pIkappaBalpha but does not support its ubiquitination, acts in vivo as a dominant-negative molecule, inhibiting the degradation of pIkappaBalpha and consequently NF-kappaB activation. E3RS(IkappaB) represents a family of receptor proteins that are core components of a class of ubiquitin ligases. When these receptor components recognize their specific ligand, which is a conserved, phosphorylation-based sequence motif, they target regulatory proteins containing this motif for proteasomal degradation.

Neonatal assessment of babies conceived by in vitro fertilization

PROBLEM

Neonatal outcome of in vitro fertilization (IVF) pregnancies has been described by different authors, but several issues have yet to be resolved. The aim of the present study was to evaluate neonates conceived in vitro and to direct special attention to neonatal morbidity and prevalence of minor abnormalities. The information that has been accumulated so far is scant.

METHOD

The first 100 babies conceived in vitro, and subsequently born in our institute, were investigated and compared with the general, spontaneously conceived newborn population. All infants were examined by a senior neonatologist, and the data that were recorded included gestational age at delivery, birth weight, gender, major malformations, minor congenital abnormalities, neonatal mortality, and neonatal morbidity (including asphyxia, jaundice, meconium aspiration, hypoglycemia, and hypocalcemia).

RESULTS AND CONCLUSIONS

The data indicate that the IVF neonates assessed had a higher rate of low birth weight (37%), twinning (30%), and preterm birth (20%) in comparison with the general reference population (p < 0.05). However, no differences were encountered either in the rate of small for gestational age infants or the incidence of major malformations and minor abnormalities between these groups of newborns. The overall neonatal morbidity in IVF babies was found to exceed that of the general population. Nevertheless, at birth, there were no clinical pathognomonic signs typical of IVF babies, although more detailed metabolic, endocrine, and neurobehavioral studies are still required to confirm that newborns conceived in vitro do not differ from those conceived spontaneously in any of these respects.

Treatment variables in relation to oocyte maturation: lessons from a clinical micromanipulation-assisted in vitro fertilization program

OBJECTIVE

In an effort to understand the mechanism underlying the improved pregnancy rate observed in IVF cycles when gonadotropin-releasing hormone analogues (GnRH-a) are applied, we investigated a possible relationship between treatment variables and oocyte nuclear maturity.

DESIGN

Nuclear maturity was retrospectively assessed in cumulus-free, denuded oocytes, obtained from women undergoing micromanipulation-assisted IVF treatment following controlled ovarian hyperstimulation with GnRH-a and menotropins.

SETTING

The setting was the infertility and IVF unit of a tertiary academic medical center.

PARTICIPANTS

Two hundred twenty-one patients underwent 435 treatment cycles.

MAIN OUTCOME MEASURE

This was the proportion of germinal vesicle-intact immature (GVII) oocytes.

RESULTS

One hundred fifty-four of the 3520 oocytes studied (4.4%) were in the GVII stage. These oocytes were found in 66 of the treatment cycles (15.2%) and in 54 of the patients (24.4%). Cycles in which GVII oocytes were detected did not differ from those in which all the aspirated oocytes were mature in the following respects: patient age, type and duration of infertility, controlled ovarian hyperstimulation protocol and time of ovum pickup. However, the GVII group was characterized by a significantly higher peak estradiol level, as well as a higher number of mature follicles visualized sonographically (diameter, > 14 mm) and oocytes retrieved.

CONCLUSIONS

Comparing the present findings with previously published data, it appears that the inclusion of GnRH-a in the stimulation regimen is associated with a lower proportion of immature oocytes. A higher occurrence of oocyte-nuclear immaturity is apparently associated with a significantly better ovarian response to stimulation. The high incidence of immature oocytes observed in patients with normospermic partners and low fertilization rates in previous cycles may suggest that the fertilization failure in some of these cases is due to oocyte, rather than sperm, dysfunction.

Viscosity and refractive index of follicular fluid in relation to in vitro fertilization

PURPOSE

To set the standard values of follicular fluid viscosity and refractive index, and to investigate a possible relationship between these physiological parameters and the outcome of in vitro fertilization treatment.

DESIGN AND RESULTS

128 samples of follicular fluid were collected from 40 in vitro fertilization patients. Viscosity determinations (centipoise; mean +/- SD) for shear rates of 23, 46, 115, and 230 were 2.04 +/- 0.86, 1.84 +/- 0.49, 1.48 +/- 0.27, and 1.38 +/- 0.22, respectively. The average (+/- SD) refractive index was 1.030 +/- 0.002. There was no significant difference between the values of thawed frozen fluids and fresh samples of the same specimens. The data showed no correlation between follicular fluid viscosity or refractive index and the presence of oocytes, their maturation grade or their fertilizing capacity.

CONCLUSIONS

For the first time, values of the viscosity and refractive index of follicular fluid obtained during in vitro fertilization have been determined. However, these preliminary results did not reveal any relationship between the physiological parameters examined and the outcome of in vitro fertilization treatment.

Intranasal nafarelin versus buserelin (short protocol) for controlled ovarian hyperstimulation before in vitro fertilization: a prospective clinical trial

The aim of this study was to compare the effect of nafarelin acetate with that of buserelin acetate nasal spray, when administered in a 'short' protocol, as an adjunct to human menopausal gonadotropin (hMG) for controlled ovarian hyperstimulation before in vitro fertilization (IVF). Twenty-two IVF subjects were randomly recruited. Each underwent two consecutive treatment cycles; one with buserelin (900 micrograms/day) and another with nafarelin (400 micrograms/day). The treatment protocol included transnasal gonadotropin-releasing hormone (GnRH) analog from the second cycle day and hMG from the fourth day of the cycle. The buserelin and nafarelin cycles did not differ significantly in the following parameters: baseline hormone profile, duration of GnRH analog treatment, mean hMG dose required, peak estradiol levels, number of preovulatory follicles, number of aspirated oocytes, fertilization rate and number of transferred or frozen embryos. No side-effects or cancellations of treatment were recorded. The average dose required was lower for nafarelin and, because this analog was given only twice a day, it was more convenient to administer. These findings suggest that nafarelin is as effective as buserelin (when administered in a "short' protocol) in achieving controlled ovarian hyperstimulation. It even offers advantages over buserelin with respect to the total dose required (which probably reflects its relatively high potency) and the subjects' compliance.

The initial flare-up induced by gonadotropin releasing hormone agonist may serve as a predictor of ovarian response in the current IVF-ET treatment cycle in normogonadotropic women aged 40-48 years

OBJECTIVE

Our purpose was to assess the potential role of the baseline hormone profile in combination with the initial pattern of response to gonadotropin releasing hormone (GnRH) analogue in predicting ovarian function and hence reproductive outcome in normogonadotropic patients aged 40 years or older undergoing IVF treatment.

PATIENTS AND METHODS

A retrospective analysis of 394 controlled ovarian hyperstimulation (COH) cycles that reached the stage of oocyte retrieval was conducted. The study included 163 normogonadotropic (serum FSH < or = 15 IUIL) patients aged between 40 and 48 years who had regular menstrual cycles. Superovulation was achieved using menotropins in combination with GnRH analog (short protocol, beginning on menstrual day 2). The ovarian response was monitored on the third cycle day, the day following the first GnRH analogue administration.

RESULTS

Cycle distribution by patient age was 175 (44.4%), 122 (30.9%), and 97 (24.7%), while the patient distribution was 85 (52.2%), 48 (29.5%), and 30 (18.3%) for age groups 40-41, 42-43, and 44-48 years, respectively. The mean total dose of menotropins needed for optimal COH was 1787 IU (range, 600-6000 IU). This dose increased with age, while the yield of oocytes and embryos declined (P < 0.05; ANOVA). A positive correlation was demonstrated between the E2 level on day 3 (GnRH analogue flare effect) and the outcome of the treatment cycle (number of oocytes and embryos). Using multiple stepwise regression analysis, it was demonstrated that the initial (day 3) serum E2 levels, combined with baseline FSH levels, patients's age and body mass index enabled early prediction of the ovarian response in the current IVF-ET treatment cycle (oocytes = 8.2 - 0.18 x Age + 0.17 x BMI - 0.12 x FSH + 0.0042 x E2).

CONCLUSIONS

Multiple-parameter analysis demonstrated that the use of the initial E2 response to GnRH analogue stimulation combined with basic clinical data may assist in the prediction of ovarian function and hence the reproductive outcome in normogonadotropic IVF patients aged 40 years or older. This may serve as a clinical tool for improving patient selection and treatment outcome in IVF-ET.

Assisted hatching by partial zona dissection of human pre-embryos in patients with recurrent implantation failure after in vitro fertilization

OBJECTIVE

To examine the potential of the partial zona dissection technique to promote successful implantation by assisting embryo hatching after IVF.

DESIGN

The study and the control group included 72 and 82 patients, respectively, each had undergone at least three failed IVF-ET attempts. Assisted hatching was performed on four- to six-cell stage embryos by creating a slit in the zona pellucida using the partial zona dissection technique. After 90 minutes incubation (5% CO2, 37 degrees C), the embryos were transferred to the uterus.

SETTING

Infertility and IVF Unit of an academic tertiary referral medical center.

RESULTS

In the assisted hatching group, 230 micromanipulated embryos were replaced (3 or 4 treated embryos per patient) compared with 295 nonmanipulated embryos in the control group. Clinical pregnancy rates (PRs) were similar in the assisted hatching and control groups (n = 15; 20.8% and n = 12; 14.6%, respectively). However, the contribution of assisted hatching by partial zona dissection to successful implantation was related to the patients's age: patients older than 38 years showed a markedly higher PR after assisted hatching: 23.9% in the study group compared with only 7% of the controls.

CONCLUSIONS

These results demonstrate that assisted hatching by partial zona dissection is a quick and efficient method that does not induce any visible damage to the embryos replaced. In a selected group of patients (aged over 38 years, who have failed to conceive in at least three previous IVF attempts) it significantly increases the chances for pregnancy after ET.

[Tendon interposition arthroplasty vs Kessler silicone prosthesis for basal joint arthritis of the thumb]

Of 86 patients with osteoarthrosis of the trapeziometacarpal or pantrapezial joint operated on during 1978-1988, 52 cases (14 males, 38 females) were reviewed. 32 had undergone interposition of the flexor carpi radialis tendon and 18 Kessler's silicone prosthesis technique. 2 had silicone prosthesis replacement in 1 hand and tendon interposition in the other. The average age of all patients was 65.5 years (range 56-74). Average follow-up was 7.0 years for the 32 after the interposition procedure (range 8-14), and 10.5 years (range 8-14) after prosthesis implantation. A greater proportion of those after tendon interposition reported alleviation of pain. There was no statistically significant difference between the groups with regard to patient satisfaction, need for job change, range of abduction and opposition, grip and pinch power, thumb length and ability in activities of daily living. Tendon interposition arthroplasty is simple and relatively inexpensive compared to silicone prosthesis insertion, which has inherent complications, such as breakage of the prosthesis and synovitis. Tendon interposition has therefore been our standard procedure since 1988.

Dizygotic triplet pregnancy following in-vitro fertilization

We present a case of dizygotic triplet pregnancy (mono-amniotic twins and a singleton) that, as far as we know, is the first reported one induced by artificial reproductive technology. It ended in the delivery of three healthy normal babies: two monozygotic twin boys and a girl. It appears that zygote splitting is significantly more common in patients treated with ovulation-inducing agents than in the general population. Also, in-vitro conditions of embryonic growth might influence the chances of multifetal gestation and the incidence of identical twinning. This may be due to changes in the physical properties of the zona pellucida and subsequent partial hatching of the pre-embryo. Evaluation of similar cases in the future may shed more light on the mechanism underlying their occurrence following in-vitro fertilization.

[Thumb reconstruction with microsurgical wrap-around neurovascular flap from big toe]

A 27-year-old man had his right dominant thumb amputated, together with skin from the dorsal area of the first metacarpal. Reconstruction was performed using a neurovascular flap taken from his right big toe. It consisted of skin and two-thirds of the distal phalanx, including the nail bed and digital plantar nerves. The vascular pedicle of the flap was formed by branches of the dorsalis pedis artery and the greater saphenous vein. The flap was wrapped around a bony scaffold formed by an iliac bone graft and inserted into the thumb. The revascularization of the flap was performed by connecting the end of the dorsalis pedis artery to the side of the radial artery, and the end of the greater saphenous vein to the end of cephalic vein. Reinnervation was achieved by connecting the plantar digital nerves to the stumps of the digital nerves of the thumb. 1 year later, the patient expressed full satisfaction with the appearance and good function of his reconstructed thumb.

Cutaneous graft-versus-host-like reaction after paternal lymphocyte immunization for prevention of recurrent abortion

We have presented an immunocompetent patient who, after paternal lymphocyte immunization, developed a GVH-like skin reaction; she recovered spontaneously. This complication is rarely seen. This was the only case observed in our series of over 70 patients immunized. A similar phenomenon was not reported in a larger series by Carp and colleagues (1). However, the case deserves special attention because this reaction can be life-threatening. Therefore, we suggest that paternal lymphocyte immunization should be recommended only for those patients who have undergone a thorough work-up and in whom all causes, other than immunological, for recurrent abortion have been excluded. Even then, this treatment should be given with utmost caution. In view of the above described complication, we believe that more data are still required to justify offering such a treatment modality on a routine basis.

Immunosuppressive activity in culture media containing human oocytes fertilized in vitro

A possible cause for implantation failure following embryo transfer is the rejection of pre-embryos by the maternal immune system. To elucidate the mechanisms underlying the rescue of the pre-embryo from maternal rejection, immunosuppressive activity was investigated in culture media containing human oocytes fertilized in vitro by employing the graft-versus-host reaction and the active rosette test. Normal donor lymphocytes were incubated with culture medium containing either fertilized or nonfertilized oocytes. Control experiments were carried out using lymphocytes incubated in culture medium only, as well as in culture medium containing human sperm. In 67% of the tests (12 out of 18), graft-versus-host reaction was inhibited, as compared to 29% of those performed with medium in which oocytes failed to fertilize (p less than .03), and 33% with medium in which only sperm was present. The frequency of an inhibitory active rosette test was similar in both groups. It is possible that immunosuppressive properties are acquired by the human pre-embryo as it grows in culture. Detection of such substances, which could contribute to the establishment of pregnancy, may improve monitoring of embryo quality prior to transfer.

[Nerve injuries in bicycle riders]

2 cases of damage to peripheral nerves following bicycle riding are described in males aged 13 and 35 years, respectively. In 1 there was injury to the ulnar nerve at the level of the wrist, with hypesthesia of the 2 ulnar digits and paresis of intrinsic muscles. In the other case there was involvement of the pudendal nerves with numbness of the buttocks and genitalia, and with difficulty in achieving erection. After cycling was stopped for a few weeks the symptoms disappeared spontaneously, with full recovery. Once symptoms subside completely cycling can be resumed, although with certain precautions.

The relationship between sperm parameters and fertilizing capacity in vitro: a predictive role for swim-up migration

The relationship between sperm parameters and fertilizing capacity in vitro was examined retrospectively, with the aim of finding predictive criteria for successful in vitro fertilization. Three hundred thirty semen samples were used to inseminate 1462 oocytes. Conventional parameters of sperm concentration and percentage motility in the ejaculate as well as swim-up migration were analyzed in relation to fertilization rate. It was shown that the probability of fertilizing human oocytes in vitro decreases significantly when (a) the sperm concentration is below 20 x 10(6) spermatozoa/ml ejaculate (P = 0.006), (b) motility is lower than 80% (P = 0.002), or (c) less than 4 x 10(6) motile spermatozoa/ml are concentrated in the swim-up fraction (P less than 0.0001). It was also demonstrated that nonfertilizing sperm could not be distinguished from fertilizing sperm by the conventional criteria but rather by the average concentration of motile spermatozoa in the swim-up fraction [12.5 +/- 1.5 and 22.3 +/- 2.3 x 10(6)/ml for the 0 and the 100% fertilization groups, respectively (mean +/- SE; P less than 0.01)]. Thus, the swim-up migration technique can serve as a predictive test for the in vitro fertilizing capacity of sperm.

Autonomic seizures in an infant: unusual cutaneous and cardiac manifestations

An eight-month-old infant developed autonomic seizures, manifested by skin reaction (harlequin-like syndrome) and paroxysmal bradycardia. Interictal EEG showed multifocal spikes, 24-hour EEG/ECG monitoring disclosed episodes of cerebral decremental response associated with cardiac nodal rhythm. Head CT and other laboratory tests were normal. Despite excellent seizure control with carbamazepine, the child has moderate psychomotor retardation.

The effect of preinsemination interval upon fertilization of human oocytes in vitro

A correlation between oocyte maturity, duration of preinsemination interval (PII) and fertilization rate in vitro has been suggested. Therefore, delayed insemination is being widely practised in many IVF centres. The purpose of this study was to investigate prospectively the effect of PII upon the fertilization rate in vitro. A total of 1474 oocytes were inseminated following incubation for between 30 and 540 min. The duration of the PII was determined randomly. It was found that neither fertilization rate (on average 46.9%) nor pregnancy rate (20.4%, calculated per embryo transfer) were affected by PII for any given degree of oocyte-cumulus maturity. The ability to inseminate oocytes at any time (within 9 h following egg collection) to the convenience of the biologist further simplifies the technology of IVF.

Aquarium-borne Mycobacterium marinum skin infection. Report of a case and review of the literature

A 33-year-old fish fancier developed a protracted skin infection that ultimately was found to be caused by Mycobacterium marinum. The organism was isolated from the lesion as well as from infected fish taken from his home aquarium. The lesion resolved after a six-week course of oral sulfamethoxazole and trimethoprim. Forty-four additional cases of culture-proved M marinum skin infections acquired from aquariums and reported in the English-language literature are reviewed. Almost universally, the lesions remained circumscribed and were either single nodular (14 patients) or multiple sporotrichoid (31 patients). Diagnosis was supported by acid-fast smears (15 patients) and isolation of the organism from skin lesions (43 patients) or from fish (two cases). In vitro studies, as well as clinical outcomes, suggest sulfamethoxazole-trimethoprim or ethambutol hydrochloride plus rifampin to be the drugs of choice.

Cellular hyperreactivity to placenta in toxemia of pregnancy

It is generally assumed that maternal immune response may be involved in some pathological conditions of pregnancy, such as toxemia. The activity of cell-mediated immunity to placenta was studied in women with gestosis. The leucocyte inhibition technique was employed to test reactivity of peripheral blood leucocytes from postpartum women. The results indicated that leucocyte migration was significantly inhibited in the presence of placental microsomal fraction when blood from toxemic women was used. Thus, about 87% out of 30 studied cases of toxemia showed positive results. At the same time, in only 22% of women with uncomplicated pregnancy was such a positive leucocyte migration inhibition test found. There was no correlation between the severity of the toxemic symptoms and the extent of inhibition. In further experiments the leucocyte migration inhibition test with the microsomal fraction antigens from cadaver kidneys was performed; only 1 out of 6 patients showed positive leucocyte migration inhibition. These findings may suggest that the normal status of the mother is altered towards cellular hyperreactivity to placental antigens in toxemic pregnancy.

Osteoarthritis at the base of the thumb. The concept of monoarticular reconstruction

Osteoarthritic affection of the base of the thumb involving 148 hands has been studied. Isolated osteoarthritis of the trapezio-metacarpal joint was found to be the largest group including a total of 111 hands. Reconstruction of this particular joint by a new technique is described and long-term results reported. A small series of isolated osteoarthritis of the trapezio-scaphoid joint is presented and reconstruction by replacing the affected articular surface of the carpal scaphoid is described. Osteoarthritic involvement of more than one of the articular surfaces of the trapezium was found in a group of 31 hands. In all of them the trapezio-metacarpal joint was predominantly affected. The rationale for monoarticular reconstruction of the trapezio-metacarpal joint, regardless of the extent of involvement, is discussed in detail.

Fatigue fractures of tibial and femoral shaft in soldiers

In 136 fatigue fractures in military recruits, 58 were in the femoral shaft and 43 were in the tibia. Fatigue fractures in the long bones of the lower limb can be classified on the extend of the periosteal reaction. Most were grade 1, showing periosteal reaction only on one or two cortices as seen on the anteroposterior and lateral projections of the roentgenograms. Physical activity was discontinued immediately when fatigue fracture of the femur or tibia was suspected on clinical grounds alone. Early clinical diagnosis the long bone fatigue fractures in all patients except one. The injured soldiers were ambulatory without plaster cast immobilization or crutches. The suggested classification was used to select patients with Grade 1 fatigue fracture for early resumption of active military training.

Familial occurrence of Letterer-Siwe disease

Letterer-Siwe disease occurred in 4 infant sibs from two consanguineous families. An identical clinical course and pathological picture was observed in all 4 infants. The occurrence of families with multiple cases supports the hypothesis of genetic causation in Letterer-Siwe disease. The family patterns are in accord with an autosomal recessive inheritance.