Oro-Naso-Sino-Orbital-Cutaneous Fistula From Prolonged Cocaine Use

Presentation We present the case of a 48-year-old man with nasal cellulitis and subsequent oro-naso-sino-orbital-cutaneous fistula from prolonged cocaine use. Diagnosis Initial laboratory investigations reported a raised white cell count (WBC) and C-Reactive Protein (CRP) and subsequently a positive atypical anti-neutrophil cytoplasm antibodies (ANCA) and positive anti-proteinase (PR3). Perihilar lung nodularity on chest imaging raised the possibility of a systemic autoimmune response. His urinalysis was positive for cocaine. Treatment He was commenced on Augmentin, Amphotericin B and Prednisolone. An obturator was created to manage the oro-nasal fistula. A subsequent naso-cutaneous defect was re-approximated. Daily nasal saline douche and abstinence of cocaine were recommended. Discussion Cocaine use in the community is rising and poses a challenge to multiple facets of our health care system.

POS0140 URATE-LOWERING THERAPY REDUCES NON-EPISODIC FOOT PAIN IN PATIENTS WHO FAIL TO MEET ACR/EULAR 2015 GOUT CLASSIFICATION CRITERIA: AN EFFECT PREDICTED BY ULTRASOUND

Background:

Emerging evidence that the joints of asymptomatic hyperuricaemic individuals contain monosodium urate (MSU) deposits and that alternative presentations of foot pain occur in hyperuricaemia suggests that preclinical phases may occur prior to a first episodic gout attack. (1) This case–control study evaluates urate deposition in hyperuricaemic individuals not fulfilling the current gout classification criteria, as well as a potential therapeutic role for urate lowering therapy (ULT).

Objectives:

To investigate whether ULT reduces non-episodic foot pain in patients who fail to meet ACR/EULAR 2015 gout classification criteria.

Methods:

Following informed consent, hyperuricaemic individuals with persistent, non-episodic foot pain (n=53) not fulfilling ACR/EULAR 2015 gout classification criteria, were compared with asymptomatic hyperuricaemic controls (n=18). Ultrasound (US) of bilateral first metatarsophalangeal (MTP) joints and features of MSU deposition including double contour (DC) sign, tophus and juxta-articular erosion were recorded. Cases only were treated with febuxostat or allopurinol daily for 6 months. Serum urate, 24-hour and 7-day visual analogue score (VAS) 0–100 mm pain scales and the Manchester Foot Pain and Disability Index (MFPDI) were recorded before treatment and after 3 and 6 months. MTP Ultrasound was repeated after a minimum of 6 months on treatment.

Results:

53 hyperuricaemic individuals with persistent, non-episodic foot pain not meeting the ACR/EULAR 2015 gout classification criteria were recruited. At baseline MTP US DC sign, erosion and tophus occurred in 62.5%, 20.8% and 49% of cases, respectively. No US features of gout occurred in controls. No significant difference was seen in baseline serum urate between cases (481±14 mg/dL) versus controls (437±14; p=NS). Serum urate in cases fell at 3 months (325±25; p<0.01) and 6 months (248±19; p<0.01). For cases, baseline 24-hour pain VAS (46±3.9) reduced at 3 months (32±4.1; p<0.05) and 6 months (21±5.2; p<0.05) of ULT. The 7-day pain VAS (59±3.9) decreased at 3 months (35±4.5; p<0.05) and 6 months (30±5.3; P<0.05). MFPDI (17±1.4) decreased at 3 month (13±1.8; p=<0.05) and 6 months (11±2.2; p=<0.05). When cases were grouped according to the presence (N=33) or absence (N=18) of DC sign on baseline US, no differences were observed for baseline pain scores. Following ULT however, 24-hour pain VAS were significantly lower in DC positive patients at 3 months (22±4.48 DC positive vs 42±6.14 DC negative; p<0.05) and 6 months (12.±5.4 vs 33±8.4; p<0.05). The 7-day pain VAS were significantly lower in DC positive patients at 3 months (23±4.6 vs 47±6.6; p<0.05) and MFDPI were significantly lower in DC positive patients at 3 months (10±1.9 DC positive vs 19±2.9 DC negative; p<0.05).

Conclusion:

These findings indicate that persistent, non-episodic foot pain in hyperuricaemia is both associated with US features of MSU deposition and is responsive to ULT. Symptomatic hyperuricaemia occurring prior to episodic gout therefore represents an earlier or alternative disease presentation. Changes to the ACR/ EULAR classification criteria to include non-episodic foot pain in the presence of US features of gout may increase the sensitivity of disease classification at an early stage, leading to improved future treatment strategies and long-term outcomes.

References:

[1]Stewart S, Dalbeth N, Vandal AC, Rome K. Characteristics of the first metatarsophalangeal joint in gout and asymptomatic hyperuricaemia: A cross-sectional observational study. J Foot Ankle Res. 2015;8(1):1–8.

Disclosure of Interests:

None declared

Type 2 diabetes continuing medical education for general practitioners: what works? A systematic review

AIMS

To perform a systematic review of studies that have assessed the effectiveness of interventions designed to improve healthcare professionals' care of patients with diabetes and to assess the effects of educational interventions targeted at general practitioners' diabetes management.

METHODS

A computer search was conducted using the Cochrane Library, PubMed, Ovid MEDLINE, Scopus, EMBASE, Informit, Google scholar and ERIC from the earliest date of each database up until 2013. A supplementary review of reference lists from each article obtained was also carried out. Measured changes in general practitioners' satisfaction, knowledge, practice behaviours and patient outcomes were recorded.

RESULTS

Thirteen out of 1255 studies met the eligibility criteria, but none was specifically conducted in rural or remote areas. Ten studies were randomized trials. Fewer than half of the studies (5/13, 38.5%) reported a significant improvement in at least one of the following outcome categories: satisfaction with the programme, knowledge and practice behaviour. There was little evidence of the impact of general practitioner educational interventions on patient outcomes. Of the five studies that examined patient outcomes, only one reported a positive impact: a reduction in patient HbA1c levels.

CONCLUSIONS

Few studies examined the effectiveness of general practitioner Type 2 diabetes education in improving general practitioner satisfaction, knowledge, practices and/or patient outcomes. Evidence to support the effectiveness of education is partial and weak. To determine effective strategies for general practitioner education related to Type 2 diabetes, further well designed studies, accompanied by valid and reliable evaluation methods, are needed.

Management of type 2 diabetes: Australian rural and remote general practitioners' knowledge, attitudes, and practices

BACKGROUND

The gap between current and evidence-based best practice management of chronic diseases in Australian general practice is widely acknowledged. This study seeks to explore some of the factors underpinning this gap in relation to type 2 diabetes management in rural and remote general practice settings.

METHODS

A cross-sectional survey of 854 general practitioners (GPs) currently practising in rural and remote Australian communities with populations between 10 000 and 30 000.

RESULTS

A total of 209 completed surveys were returned for an overall response rate of 24.5%. GPs reported on their education preferences, knowledge, attitudes and practices relating to type 2 diabetes. GPs indicated a strong preference for face-to-face education options such as conferences and seminars (75.2%). Whilst structured online education activities were less utilised than face-to-face options, GPs reported a desire to undertake more of their education online in the future. Survey findings revealed gaps in GP knowledge around the medical management of diabetes. The most prevalent self-reported learning needs related to pharmacological management (n=87, (45.5%)). Correspondingly, in the GP knowledge test, GPs received the lowest mean score for the section on medical management. GPs also reported having the least confidence in providing effective insulin treatment, compared with other aspects of diabetes management. GPs identified an array of difficulties encountered in providing best practice diabetes care, which were classified into three main categories: GP clinical management problems, patient-related challenges and health system-related difficulties.

CONCLUSIONS

This national survey highlights a number of barriers to GP provision of best practice diabetes care in rural and remote Australia. Despite the availability of education programs and clinical practice guidelines, GPs revealed deficits in knowledge and confidence in type 2 diabetes management. GPs identified numerous challenges to effective patient care, some but not all of which can be addressed through continuing professional development. GP preferences for continuing medical education and information may inform future activities, to specifically address the needs of GPs in rural and remote locations.

Influence of environmental parameters on the accuracy of nitrogen dioxide passive diffusion tubes for ambient measurement

Two studies at three sites in the UK provided confirmation that systematic positive bias in NO2 diffusion tube measurement occurred because of changes to "within-tube" chemistry, rather than eddy diffusion at the mouth of the tube. In the first study in Cambridge, UK, sampler overestimation for 1 and 2 week exposures was compared to corresponding time-averaged monitor measurements (NO-NO2-NOx, O3) and weather variables. Noninearity between sampler and monitor NO2 measurements was interpreted in terms of spatial and temporal variations in relative and absolute availability of NO, NO2 and O3 at the site. A maximum overestimation occurred for an exposure mean NO2/NOx approximately 0.5. The separate contributions of reduced NO2 photolysis and eddy diffusion were compared in Study II using samplers of two materials, acrylic and quartz, and of different lengths (40, 55, 71 and 120 mm) at three sites: Norwich background, Cambridge intermediate, London kerbside. For compared sites, NO2 measured by acrylic samplers was significantly higher than for equivalent quartz samplers. For quartz samplers [NO2]mean was only just above the monitor at Norwich and London; sampler/monitor NO2 = 1.04 (P = 0.59) and 1.01(P = 0.76), respectively. For acrylic samplers the order of [NO2]mean was 40 mm > 120 mm > 71 mm > or = 55 mm. Excepting 40 mm samplers, this accords with a chemical bias where co-diffusing NO and 03 molecules in longer tubes have more time to react to form excess NO2. Bias in 40 mm samplers is discussed. Eddy diffusion is negligible for standard samplers because [NO2]mean was equivalent for 55 mm and 71 mm acrylic samplers and close to monitor NO2 for 71 mm quartz tubes. Both studies showed that sampler accuracy was dependent on location. Significantly, overestimation was greatest (approximately 3-4 ppb) where the NO2 annual mean was approximately 20 ppb, close to the UK and EU air quality standard of 21 ppb.

Reliability of nitrogen dioxide passive diffusion tubes for ambient measurement: in situ properties of the triethanolamine absorbent

Factors concerning NO2 uptake by the absorbent triethanolamine (TEA) in NO2 diffusion tubes are examined. Although the nominal freezing point of TEA is 17.9-21.2 degrees C, we show that, for a range of aqueous TEA solutions (0-20%, H2O), no freezing occurs even at -10 degrees C. Therefore NO2 collection efficiency is unlikely to be impaired by low temperature exposure. The recovery of TEA from the meshes of exposed samplers is determined as approximately 98%, even after 42 days, showing that the stability in situ of TEA is unaffected by long-term exposure. A model of a diffusion tube sampling array for simultaneous exposures, with a 0.1 m sampler spacing, shows that NO2 uptake by individual samplers is not affected by the presence of neighbouring tubes in the array. This is confirmed by sampler precision at two Cambridge sites. Four sampler preparation methods are compared for differences in NO2 uptake of exposed samplers. All methods employ TEA as absorbent, transferred by either dipping meshes in a TEA-acetone solution or pipetting aliquots of a TEA-H2O solution onto the meshes. For samplers prepared by three of the methods, no difference in NO2 uptake is found, but for samplers prepared using a 50% v/v TEA-H2O solution, a mean reduction of 18% is found. Student's t-tests show that the difference is highly significant (P < or = 0.001). Reasons for the difference are discussed.

Crystal structures of mutant monomeric hexokinase I reveal multiple ADP binding sites and conformational changes relevant to allosteric regulation

Hexokinase I, the pacemaker of glycolysis in brain tissue, is composed of two structurally similar halves connected by an alpha-helix. The enzyme dimerizes at elevated protein concentrations in solution and in crystal structures; however, almost all published data reflect the properties of a hexokinase I monomer in solution. Crystal structures of mutant forms of recombinant human hexokinase I, presented here, reveal the enzyme monomer for the first time. The mutant hexokinases bind both glucose 6-phosphate and glucose with high affinity to their N and C-terminal halves, and ADP, also with high affinity, to a site near the N terminus of the polypeptide chain. Exposure of the monomer crystals to ADP in the complete absence of glucose 6-phosphate reveals a second binding site for adenine nucleotides at the putative active site (C-half), with conformational changes extending 15 A to the contact interface between the N and C-halves. The structures reveal distinct conformational states for the C-half and a rigid-body rotation of the N-half, as possible elements of a structure-based mechanism for allosteric regulation of catalysis.

An overview of Medicaid managed care litigation

Since the enactment of Medicaid in 1965, states have had the option of offering beneficiaries enrollment in managed care arrangements. With the advent of mandatory managed care reaching millions of beneficiaries (including a growing proportion of disabled recipients), the amount and scope of litigation involving Medicaid managed care plans can be expected to grow. A review of the current litigation regarding Medicaid managed care reveals two basic types of lawsuits: (1) those that challenge the practices of managed care companies under various federal and state laws that safeguard consumer rights, protect health care quality, and prohibit discrimination; and (2) suits that assert claims arising directly under the Medicaid statute and implementing regulations, as well as claims related to Constitutional safeguards that undergird the program. Lawsuits asserting claims arising under Medicaid tend to raise two basic questions: (1) the extent to which enrollment in a Medicaid managed care plan alters existing Medicaid beneficiary rights and state agency duties under federal or state Medicaid law; and (2) the extent to which managed care companies, as agents of the state, act under "color of law" (i.e., undertaking to perform official duties or acting with the imprimatur of state authority). Additionally, states might see an increase in litigation brought by prospective and current contractors who assert that they have been wrongfully denied contracts or improperly penalized for poor performance. These assertions may involve claims that are grounded in federal and state law, the Medicaid statute, and the Constitution. Moreover, in light of the consumer protection elements of the managed care reforms contained in the Balanced Budget Act, future managed care litigation may focus on the manner in which companies carry out states' obligations toward managed care enrollees. Resolution of Medicaid managed care cases involves the application of general principles of administrative and regulatory law. Thus, Medicaid managed care cases have implications for other public purchasers of managed care arrangements, including state mental health and alcohol and substance abuse agencies.

Serotonergic agents that activate 5HT2A receptors prevent NMDA antagonist neurotoxicity

Phencyclidine, ketamine, and other agents that block NMDA glutamate receptors trigger a schizophrenia-like psychosis in humans and induce pathomorphological changes in cerebrocortical neurons in rat brain. Accumulating evidence suggests that a complex network disturbance involving multiple transmitter receptor systems is responsible for the neuronal injury, and it is proposed that a similar network disturbance is responsible for the psychotomimetic effects of NMDA antagonists, and might also be involved in the pathophysiology of schizophrenia. In the present study we present evidence that serotonergic agents possessing 5HT2A agonist activity prevent NMDA antagonist neurotoxicity in rat brain. It is proposed that 5HT2A agonists may also prevent the psychotomimetic effects of NMDA antagonists. Among the 5HT2A agonists examined and found to be neuroprotective are LSD and related hallucinogens. The apparent contradiction in proposing that these agents might have antipsychotic properties is resolved by evidence linking their hallucinogenic activity to agonist action at 5HT2C receptors, whereas antipsychotic activity would be attributable to agonist action at 5HT2A receptors.

Reduced pregnancy rates following the transfer of human embryos frozen or thawed in culture media supplemented with normal serum albumin

Over a 26 month period 17% of couples having treatment in our clinical programmes selected a commercially available protein (normal serum albumin, NSA) prepared from pooled human sera instead of using their own serum as a supplement for their embryo culture media. In a retrospective analysis of >2000 gonadotrophin-stimulated cycles and 1000 cycles where frozen/thawed embryos were transferred, fertilization, embryo quality and pregnancy rates following in-vitro fertilization (IVF), gamete intra-Fallopian transfer (GIFT) or intracytoplasmic sperm injection (ICSI) were unaffected by the type of protein used to supplement the culture medium. When embryos were thawed in medium containing NSA, both pregnancy (PR) and implantation rates (IR) were significantly lower (P <0.05) than if the medium was supplemented with serum (PR 8.3% and 17.5%; IR 4.6% and 10.5%). Inclusion of NSA before freezing reduced the IR of thawed embryos. To further test this observation all cycles where embryos were cultured and frozen in medium containing NSA (173 cycles) were matched to cycles where serum was used and the outcome was compared. At the end of 1995 just over half of the embryos in both groups had been thawed. No statistical difference was noted in the pregnancy rates (NSA, 5.6% versus serum, 11.3%) but the IR per embryo was significantly lower when embryos were cultured and frozen in medium supplemented with NSA (2.2%) than when serum was used as the supplement (6.6%).

Prevention of trauma-induced neurodegeneration in infant rat brain

Recent evidence implicates the endogenous excitatory neurotransmitters, glutamate (Glu) and aspartate, in the pathophysiology of traumatic injury in the adult CNS, but it is not known whether similar excitotoxic mechanisms mediate traumatic injury in the immature CNS. Therefore, we developed a model of brain contusion injury in infant rats and used this model to study the nature and evolution of the acute cytopathologic changes and to evaluate the ability of Glu receptor antagonists to protect the immature brain against such changes. Seven-day-old rat pups were subjected to contusion injury and were killed 0, 0.5, 1, 2, 4, and 6 h later for histologic evaluation of the brain. Physical tearing of the dura and minor disruption of underlying brain tissue was noted at 0 h. At 30 min a discrete zone of neuronal necrosis began to appear at the border of the trauma site; this zone progressively expanded over a period of 4 h. The cytopathologic changes closely resembled the type of changes Glu is known to cause; these changes consisted of swollen dendrites, degenerating neurons with pyknotic nuclei and markedly swollen cytoplasm, and dark cells with vacuolated cytoplasm. The noncompetitive N-methyl-D-aspartate (NMDA) antagonist, dizocilpine maleate, when administered 30 min before or 1 h after trauma, significantly attenuated the lesion. The competitive NMDA antagonist, 3-((-2)-carboxypiperazine-4-yl)-propyl-1-phosphonate, was also neuroprotective. The alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionate/kainate receptor antagonist 2,3-dihydro-6-nitro-7-sulfamoyl-benzo(f)quinoxaline did not significantly suppress the lesion when given as three treatments (30 mg/kg each) 30 min before plus 15 and 75 min after the insult. These findings suggest that traumatic injury in the infant rat brain is mediated by endogenous excitotoxins (Glu and aspartate) acting at NMDA receptors and can be substantially mitigated by timely treatment with NMDA receptor antagonists.

Morphological observations on the fate of liposomes in the regional lymph nodes after footpad injection into rats

Multilamellar liposomes composed of equimolar egg phosphatidylcholine and cholesterol and containing carboxyfluorescein or colloidal gold were injected subcutaneously into the footpad of the hind-leg of rats. The draining popliteal lymph nodes of animals killed at time intervals after injection were then dissected and sections examined by fluorescence microscopy (carboxyfluorescein), light microscopy using an immunogold silver kit to enhance gold particles or by transmission electron microscopy. Morphological observations confirmed that subcutaneously injected liposomes accumulate in large numbers in the draining lymph node. The majority of liposomes arrived at the subcapsular sinuses, probably via afferent lymphatic vessels, as such, i.e., in a non-cell bound form. Subsequently, liposomes were dispersed throughout the lymph node either by permeation as free vesicles along the sinuses or by cells involved in vesicle uptake. The majority of such cells were free macrophages, littoral cells and reticular cells (fixed macrophages). Once within cells, liposomes were seen digested by the lysosomal apparatus with varying loss of their lamellar structure, leaving free gold particles within the lysosomes.

The Boston Teacher Questionnaire. 2. Assessments of validity

We assessed the validity of the Boston Teacher Questionnaire in a sample of 3451 9-year-old children. Those identified by the questionnaire as having a learning difficulty syndrome were compared to those without any characteristic of that syndrome. The validity reference measures were individually administered neuropsychological assessments at age 7 years and a group-administered reading achievement test at age 9 years. Girls and boys with the reading syndrome had much lower reading scores at age 9 years than did their peers. Boys, but not girls, with the arithmetic syndrome were much more likely than their peers to have arithmetic scores more than one grade below the expected level at age 7 years. Girls and boys with the tasks syndrome, characterized by impersistence, dependence, and inflexibility, were more likely than those without any features of the syndrome to be classified as having little or no goal orientation by a neuropsychologist who assessed the children in an office setting. Similarly, the neuropsychologist was much more likely than expected to have classified children with the attention syndrome as having a short attention span, and to have classified boys, but not girls, with the hyperactivity syndrome as having an unusual/extreme level and nature of overactivity. Children with any syndrome were more likely than others to have low scores on components of the Wechsler Intelligence Scale for Children, items of the Bender-Gestalt Test that assessed integration and distortion, and measures of reading comprehension. We conclude that the Boston Teacher Questionnaire validly identifies children with learning problems.

The effects of cooling mouse oocytes

The effects of cooling and warming on meiotic spindles of mouse oocytes have been assessed by transmission electron microscopy. Intact cumulus-oocyte complexes were immediately cooled from 37 to 15, 4, 0, and -7 degrees C (seeding temperature) for 15 min in a programmed biological freezer and fixed at these temperatures. Other complexes, cooled to these temperatures, were rapidly warmed to 37 degrees C and incubated for 2 hr before fixation at 37 degrees C. Of 334 oocytes assessed at various temperatures, at least 100 were examined for metaphase II spindles. Spindle microtubules completely disappear at 0 and -7 degrees C, while complete or partial depolymerization of microtubules was observed at 4 degrees C. Cooling to 15 degrees C did not cause major disruptions of spindle structure in most oocytes. Chromosomes tended to rotate or clump at lower temperatures but chromosome scatter outside the spindle zone was rarely observed. Centrosomal material was fragmented at 4 degrees C and occasionally at 15 degrees C and was not evident at the spindle poles at 0 and -7 degrees C. Kinetochores were seen at all temperatures. Spindle structure was evidently restored in the majority of oocytes on rewarming at 37 degrees C. Changes in the ooplasm induced by cooling were elongation and disruption of vesicular smooth endoplasmic reticulum, especially between lipid globules and disappearance of fibrillar inclusions. Cortical granule exocytosis was not observed on cooling, while microfilaments were intact. Swelling of membranous organelles was also observed in cumulus cells. Most of the cytoplasmic changes were also reversed on rewarming. The response of mouse oocytes to cooling is compared to that of human oocytes, reported previously.

Mutations in the par genes of Caenorhabditis elegans affect cytoplasmic reorganization during the first cell cycle

A dramatic reorganization of cytoplasm occurs during the first cell cycle in embryos of the nematode, Caenorhabditis elegans. We present here the results of a quantitative study of some of the events during this reorganization in wild-type embryos and in par mutant embryos. The par mutations define a set of genes required for cytoplasmic localization in early embryos. We show that par mutations lead to defects in several events of the reorganization. Mutations in all four of the par genes we studied lead to defects in pseudocleavage and asymmetric redistribution of cortical microfilaments. In addition, some of the par mutations affect streaming of cytoplasm, migration of the pronuclei, and asymmetric shortening of the embryo. We propose that the major function of the par genes might be to orchestrate this initial reorganization of cytoplasm.

Problems in the cryopreservation of unfertilized eggs by slow cooling in dimethyl sulfoxide

The survival, fertilization, development, and viability in vitro and in vivo of unfertilized mouse eggs frozen by slow cooling to -36 degrees C or -80 degrees C in 1.5 M dimethyl sulphoxide (DMSO) was examined in a series of experiments which explored some of the problems in freezing the egg. DMSO was added to the eggs at either room temperature or at 0 degrees C. Maximum success rate (42% of frozen eggs developing to two cells) was obtained when DMSO was added at 0 degrees C and the eggs slow cooled to -80 degrees C. Removal of cumulus failed to improve freezing success rates. Addition of DMSO at temperatures above 0 degrees C significantly reduced the fertilizing capacity of eggs. Excessive exposure of eggs to temperatures around 15 degrees C also caused a significant reduction in fertilization rates. The effects of DMSO and cooling on fertilization are likely to be due to zona hardening by cortical granule release and to disorganization of the egg cytoskeleton and plasma membrane. These problems will be difficult to overcome if cryopreservation of the unfertilized human egg is preferred to the fertilized egg or early cleavage stage embryo in clinical in vitro fertilization.

Vitrification of mouse oocytes results in aneuploid zygotes and malformed fetuses

Vitrification of mouse oocytes adversely affected the subsequent developmental potential of embryos and fetuses derived from the fertilization of such oocytes after thawing. Only 5% of oocytes vitrified formed viable fetuses on the 15th day of gestation as compared to 47% in the controls. The incidence of chromosomally aneuploid zygotes, derived from cryopreserved oocytes, was approximately threefold higher than the controls irrespective of whether the oocytes were cryopreserved by vitrification or DMSO slow-freezing. Malformed fetuses were obtained from oocytes that had been vitrified as well as those that had been exposed to vitrification solutions only, whereas no malformed fetuses were obtained in oocytes slow-frozen by DMSO or fresh controls--thus demonstrating that the exposure of oocytes to the vitrification chemicals was responsible for the fetal malformations. The data in this study suggest that the vitrification technique should be cautiously applied to human oocyte cryopreservation. Furthermore, the data also demonstrate that the exposure of female gametes to carcinogenic and/or teratogenic chemicals may result in malformed embryos when such oocytes are subsequently fertilized.

Ultrarapid freezing of early cleavage stage human embryos and eight-cell mouse embryos

Early cleavage stage human embryos and 8-cell mouse embryos were snap-frozen after a brief exposure to high concentrations of dimethyl sulfoxide (DMSO; 2 or 3.5 M) and 0.25 M sucrose and thawed in a warm water bath. Eleven of 12 3- to 8-cell human embryos survived freezing and thawing with more than 50% of their original blastomeres intact. However, pregnancy was not initiated when the 11 embryos were transferred to six patients. It was shown that continuation of embryonic development in vitro and in vivo was significantly better when 8-cell mouse embryos were snap-frozen in 3.5 M DMSO than in 2 M DMSO. When frozen in 3.5 M DMSO, 78% of 8-cell embryos survived on thawing, 84% developed to blastocysts in vitro, 63% implanted, and 42% developed to fetuses. Ultrarapid freezing is a quick and inexpensive method for mouse embryo cryobanking, but further studies are required to confirm the viability of frozen human embryos.

Ultrarapid freezing: a new low-cost and effective method of embryo cryopreservation

The authors describe a rapid freezing method (ultrarapid freezing) that has been developed for cryopreservation of early cleavage stage embryos. In the present experiments, 2-cell mouse embryos were frozen under a wide range of conditions in an attempt to optimize their survival and viability in vitro and in vivo. The experiments show that embryos exposed briefly (2 to 2.5 minutes) to relatively high concentrations of dimethyl sulfoxide (3 to 4 M) and 0.25 M sucrose survive and develop when plunged directly into liquid nitrogen and thawed in a 37 degrees C waterbath when sealed in 0.25-ml plastic pailettes. Survival and viability rates of ultrarapidly frozen embryos after thawing were comparable to those obtained with conventional slow-freezing techniques. The authors believe that this freezing technique can be further improved and that the speed, ease, and low cost of the method make it a very attractive alternative to more conventional methods for freezing early cleavage stage embryos.

Effect of growth factors in culture medium on the rate of mouse embryo development and viability in vitro

The development of mouse embryos from two cells to blastocysts in Whittingham's T6 medium containing the growth factor insulin or the serum replacement Nu-Serum was studied and compared with development in vivo. The rate of embryo development to blastocysts was increased by the addition of Nu-Serum to T6 and there was a significant increase in the implantation rate of embryos grown in T6 + Nu-Serum compared with T6 alone or with insulin. However, the rate of embryo development in vitro was retarded compared with that in vivo and the number of normal fetuses following transfer to recipients of blastocysts grown in T6 + Nu-Serum was not different from the number for those grown in T6 alone or with insulin. The addition of neither insulin nor Nu-Serum to T6 optimizes embryo development or viability.

Tracking of mouse cell lineage using microinjected DNA sequences: analyses using genomic Southern blotting and tissue-section in situ hybridizations

We examined the feasibility of applying DNA microinjection to label cells for lineage studies of mouse embryos. Tissues from three transgenic mice mosaic due to the insertion of an exogenously introduced mouse beta-major globin gene were analyzed by genomic Southern-blotting and in situ hybridization. These studies allowed the direct quantification and localization of lineage descendants derived from the marked or transformed founder cells. The results of these studies suggested an early segregation of cells in the somatic vs. germ-cell lineages. The in situ hybridization data further demonstrated that cells of the transformed lineages were usually finely dispersed, indicative of extensive cell-cell mixing during mouse development. However, a notable exception to this was the patchy distribution of cells in the kidney (corresponding to individual nephrons), the clustering of transformed cells in individual villi of the small intestine, and the segregation of positive and negative seminiferous tubules in the testis. These data suggest a clonal basis for the organization of development in organs like the kidney, intestine, and testis.

Development of mouse embryos cryopreserved by vitrification

Eight-cell mouse embryos were cryopreserved by vitrification in a concentrated solution of dimethylsulphoxide, acetamide, propylene glycol and polyethylene glycol. This solution (designated VS1) does not crystallize when cooled to subzero temperatures but instead forms a glassy transparent solid. Embryos were exposed in three steps to a stock VS1 solution or a saline solution containing 90% of the cryoprotectants in the stock VS1 (90% VS1) and then the suspensions were vitrified by rapid cooling in liquid nitrogen. Of 568 embryos vitrified in 90% VS1, 80% developed in vitro and 98 normal fetuses or young (17% of the total) were produced after transfer to pseudopregnant recipients. By contrast, 22% of 153 embryos vitrified in the stock VS1 developed in vitro, but only one normal fetus was obtained after transfer. These results demonstrate that normal fetuses and young can be produced from embryos cryopreserved by the simple and rapid method of vitrification.

Incidence of chromosome anomalies in first-cleavage mouse embryos obtained from frozen-thawed oocytes fertilized in vitro

To assess the effect of low temperature storage on mouse oocytes we (1) examined the capacity for normal development of embryos derived from frozen oocytes fertilized in vitro after transfer to pseudopregnant foster mothers and (2) analyzed the chromosome complement at the first cleavage division. Fewer frozen than control oocytes were fertilized (36% vs 66%), but after embryo transfer the proportion of fertilized eggs that implanted (67-68%) and formed normal foetuses (50-53%) was similar in the two groups. Freezing did not affect the observed incidence of aneuploidy (1.5-3.3%). The frequency of polyploid embryos derived from frozen oocytes was almost double that of controls (15.8% vs 8.5%), but it is unclear whether this is a real effect of freezing or is an artifact produced by the chromosome preparation technique.

Mouse interferon produced in vivo does not inhibit the development of preimplantation mouse embryos

Mouse embryos were cultured in vitro in medium with serum containing interferon which had been induced in vivo by intravenous administration of polyinosine-polycytidylic acid. Two-cell and blastocyst-stage embryos were incubated for 72 and 24 h respectively before embryo transfer, or fixation to determine cell number. Further, blastocysts were outgrown on coverslips in embryo culture medium with fetal calf serum and interferon. Expression of an intermediate filament protein (Mr 55 000) in blastocyst outgrowths was examined with a monoclonal antibody. Embryos appeared morphologically normal and after treatment the mean cell number did not differ from that of controls. Implantation was unaffected by any of the treatments, but culture before transfer in medium containing mouse serum reduced the number of normal fetuses recovered on Day 14 of gestation compared to those cultured in medium without serum. Exposure to interferon did not modify the expression of filaments in the outgrown blastocyst. It is therefore unlikely that interferon induced by viral infection during pregnancy is responsible for preimplantation embryonic loss.

Cryopreservation of human embryos: progress on the clinical use of the technique in human in vitro fertilization

Embryo cryopreservation has been studied at Monash University since 1981 and has been available to patients since mid-1983. Of approximately 1200 patients' cycles of in vitro fertilization (IVF), 445 have had excess embryos which they requested to be frozen. To date 205 patients have requested thawing of their embryos and 144 have had frozen-thawed embryos replaced in utero, resulting in 16 pregnancies. Four of these pregnancies aborted, four are ongoing, and eight deliveries have resulted, including one stillbirth at 26 weeks and one set of twins. Analysis of the data collected to date shows that patients with three or more embryos frozen have a significantly higher pregnancy rate than patients with one or two embryos frozen (23 versus 4%, respectively). Embryo viability, but not embryo survival, following freeze-thawing is related to the degree of embryonic fragmentation and the cell stage at freezing. Eight-cell embryos had a significantly higher viability than other cleavage stages. Those resulting in pregnancy tended to be the faster-dividing eight-cell embryos and were undamaged after freezing and thawing. However, when considering all cleavage stages, there was little effect of freezing damage on embryo viability, providing that at least 50% of the cell complement of embryos were intact and the zona pellucida was undamaged. Nor was there any marked effect of the age of embryos postinsemination. It is also possible that patients who were pregnant following the initial embryo replacement on the cycle of IVF treatment are more likely to conceive following replacement of their frozen-thawed embryos.

Culture factors affecting the success rate of in vitro fertilization and embryo transfer

The development of one-cell mouse zygotes to the blastocyst stage in vitro has been used as a quality control for the media and handling procedures employed for human in vitro fertilization and embryo transfer (IVF/ET). One-cell mouse zygotes were placed in culture in medium containing bovine serum albumin. Aliquots of the same batch of medium containing female patients' homologous serum were used for the fertilization and culture of human oocytes. The following procedures were associated with high rates of mouse embryo development and human pregnancies following IVF/ET: adequate gassing and equilibration of the medium, double-rinsing of pipets and catheters used to handle embryos, use of a HEPES-buffered medium for manipulating embryos in the absence of an atmosphere containing 5% CO2, control of excessive temperature in the vicinity of the embryos, and ET using medium containing 50% patient's serum. The institution of these procedures gave more consistent pregnancy rates. However, there was no obvious association between fertilization and cleavage of human oocytes and the quality of the medium ascertained by the mouse embryo development test. In a continuing trial, we are comparing two culture media (modified Tyrode's and a medium formulated on the composition of human fallopian tube fluid [HTF]) and two culture techniques (culture in medium under oil in petri dishes and in loosely capped tubes). Significantly more mouse zygotes developed in HTF medium compared to Tyrode's medium. In a randomized 2 X 2 factorial trial with human IVF/ET, the highest pregnancy rate occurred when fertilization and culture were carried out in HTF medium under oil, but numbers are not yet sufficient to show any statistical difference between treatments.

The effect of porcine relaxin vaginally applied at human embryo transfer in an in vitro fertilization programme

It has been suggested that the polypeptide hormone relaxin is an early pregnancy factor which facilitates implantation and pregnancy maintenance. To test this hypothesis a double blind randomized placebo controlled trial was conducted where 2 mg purified porcine relaxin or distilled water was given in a vaginal gel on the day of embryo transfer and again 3 days later in a human in vitro fertilization (IVF) programme. There were 96 patients in the randomized trial and 73 patients who were treated concurrently in the same IVF programme acted as a further control group. Of the 51 patients who received relaxin, 10 pregnancies were confirmed and 8 continued successfully. In the 45 patients treated with placebo 10 pregnancies were also confirmed and 6 continued successfully. Amongst the 73 patients concurrently treated outside the trial 14 achieved a pregnancy and 10 continued to term. Thus, porcine relaxin given in these circumstances in a human IVF programme did not appear to improve or interfere with the pregnancy rate. Possible factors that affected the implantation rates in this trial are discussed.

Pathogenicity of mouse hepatitis virus for preimplantation mouse embryos

Mouse embryos which were hatched from the zona pellucida in vitro in the presence of mouse hepatitis virus (MHV) or outgrown on coverslips and then exposed to MHV were shown by immunohistochemical staining to have virally infected trophoblast cells. Zona-intact embryos incubated with MHV for 48 h (2-cell embryos) or 1.5 h (blastocysts) were resistant to infection. Morulae and early blastocysts collected from donor mice experimentally infected with MHV were not infected, but the medium in which they were flushed from the uterine horns was contaminated with virus. No virus was detected after embryos were washed through three changes of uncontaminated medium. MHV was transmitted to foster mothers when embryos were transferred in medium contaminated with the virus. Fetal and decidual tissues were not infected. We suggest that embryo transfer is an effective and simple alternative to Caesarian rederivation of MHV-contaminated mice.

Endocrinology of ovarian stimulation for in vitro fertilization

Understanding of the endocrinology of in vitro fertilization has advanced rapidly in the past 5 years. Despite a multitude of ovarian stimulation regimens a particular regimen has not demonstrated a marked superiority. In principle the achievement of high FSH levels during the early follicular phase to recruit a maximum number of follicles with a tolerable degree of asynchrony for final maturation is confined to a limited time span or 'FSH window' of about 3 to 4 days before negative E2 feedback induces below-threshold FSH levels, thereby condemning all subsequent follicles in that cycle to atresia. It appears that one can widen and/or amplify the 'FSH window' too far from gross hyperstimulation resulting in the recruitment of many follicles with an intolerable degree of asynchrony. This may lead to a defective endocrine environment for the oocytes contained within these follicles or an abnormal luteal environment and an increased frequency of fertilization, cleavage and implantation failure. Whichever regimen is used, the stimulation should ideally be sufficient to promote the development of at least 3 follicles beyond 18mm diameter at the time of OPU. This can be expected to result in at least 2 embryos to be available for transfer. Monitoring of follicular response by a combination of E2 and ultrasonic parameters is recommended so that the administration of HCG is given close to the anticipated endogenous rise of LH. This can be achieved by detecting a reduction in the rate of E2 rise (to plateau).(ABSTRACT TRUNCATED AT 250 WORDS)

Improved conception rate after intrauterine insemination of washed spermatozoa from men with poor quality semen

The efficacy of high intrauterine insemination of a washed motile fraction of spermatozoa from men with poor quality semen on the day after the luteinising hormone (LH) surge was compared with that of natural intercourse based on symptothermal methods and a single act of intercourse timed on the day after the LH surge in the same 35 couples in a controlled and randomised trial of the three types of cycle. Each couple had been trying to conceive for at least 3 years, the woman being potentially fertile and the only detectable defect related to poor semen quality. After 39 intrauterine insemination cycles, 8 women conceived (all in their first insemination cycle); this procedure was significantly more successful than LH-timed intercourse (0/38; p less than 0.05) and natural intercourse timed by symptothermal methods (1/34; p = 0.022). The technique of intrauterine AIH, with a 'Tomcat' catheter, was simple, painless, and uncomplicated.

In vitro fertilization and embryo transfer program, Department of Obstetrics and Gynecology, University of Adelaide at the Queen Elizabeth Hospital, Woodville, South Australia

A review is presented summarizing the in vitro fertilization experience at the University of Adelaide, Australia. Initial attempts utilizing the normal cycle were unsuccessful in obtaining a pregnancy. Since 1982 the overall ongoing pregnancy rate has been 21% per embryo transfer, 16% per laparoscopy, and 12% per treatment cycle. A detailed description of presently utilized methodology is presented.

Culture factors in relation to the success of human in vitro fertilization and embryo transfer

The development of 1-cell mouse zygotes to the blastocyst stage in vitro has been used as a quality control for the media employed for human in vitro fertilization and embryo transfer (IVF-ET). The following procedures were associated with high rates of mouse embryo development and human pregnancies following IVF-ET: adequate gassing and equilibration of the medium, double rinsing of pipettes and catheters used to handle embryos, use of a HEPES-buffered medium for manipulating embryos in the absence of an atmosphere containing 5% CO2, control of excessive temperature in the vicinity of the embryos, and ET using medium containing 50% patient's serum. The institution of these procedures gave more consistent pregnancy rates. However, there was no obvious association between fertilization and cleavage of human oocytes and the quality of the medium ascertained by the mouse embryo development test.

Incidence of the luteinized unruptured follicle phenomenon in cycling women

A prospective study is presented in order to determine the frequency of the luteinized unruptured follicle (LUF) in a population of 66 regularly cycling women. They were monitored by daily ultrasound for a total of 183 cycles, and the LUF was detected in 9 cycles, giving an incidence of 4.9%. The results of daily changes of luteinizing hormone, estradiol, and progesterone provide support for the thesis that the LUF behaves steroidogenically as a corpus luteum and that the luteal phase duration is normal. Continued monitoring in 35 cycles revealed a recurrence in only one case during a fourth subsequent cycle. Thus, the findings indicate that the LUF is a sporadic and infrequent phenomenon. It is therefore an uncommon cause of infertile cycles in potentially fertile women and represents a biologic variable rather than a syndrome. Based on ultrasonic and endocrine observations, a mechanism is proposed for the resolution of the LUF.

Fate of cholesterol-rich liposomes after subcutaneous injection into rats

The fate of small (30-60 nm) and large (about 400 nm diameter) liposomes composed of phosphatidylcholine or sphingomyelin and equimolar cholesterol and containing quenched carboxyfluorescein and 111In-labelled bleomycin after footpad injection of rats was investigated. Judging from the values of latent carboxyfluorescein in the plasma, phosphatidylcholine and sphingomyelin small liposomes entered the blood circulation intact, presumably via the lymphatics to reach 3 h after injection a peak of 16.9 and 23.1% of the dose per total blood, respectively. Of the 111In radioactivity given in phosphatidylcholine liposomes, about 32% was recovered in the liver. Hepatic uptake of 111In for sphingomyelin liposomes was lower (about 9%) reflecting their slower rate of clearance. No latent carboxyfluorescein could be detected in the blood after injection with phosphatidylcholine or sphingomyelin large liposomes and levels of 111In in the liver (and spleen) were very low. A proportionally much greater amount of liposomal 111In was intercepted by the popliteal and to a lesser extent, the lumbar lymph nodes. Such uptake was significantly higher (e.g. 463%) for small than for large (e.g. 195% per g popliteal nodes) liposomes. After foot pad injection of large liposomes into Walker 256 tumour-bearing rats, localization of 111In in the popliteal nodes was similar to that seen with control animals. However, 111In localization in the lumbar nodes was augmented more than 5-fold. These results suggest that large liposomes as used in this study, characterized by efficient drug entrapment, inability to reach the liver and spleen and improved localization in the lymph nodes of tumour-bearing animals may be preferable to vesicles of small size for the local treatment of lymphatic metastases.

Incidence of multiple pregnancy after in-vitro fertilisation and embryo transfer

7 multiple pregnancies occurred in a series of 20 pregnancies after oocyte recovery for in-vitro fertilisation and embryo transfer. After ovarian stimulation with clomiphene alone or with human menopausal gonadotropin, 102 laparoscopies were carried out in 62 women and the ongoing pregnancy rate beyond the first trimester was 17/102 laparoscopies (17%), including 5 sets of twins. 1 triplet and 1 twin pregnancy showed evidence of regression of two sacs and one sac, and both are progressing as singleton pregnancies at 16 and 34 weeks, respectively. 3 abortions occurred at 7, 8, and 9 weeks--a spontaneous abortion rate of 15%. The pregnancy and multiple pregnancy rates after stimulation with clomiphene alone or with human menopausal gonadotropin were comparable, but oocyte pickup based on a knowledge of the duration of the endogenous rise in luteinising hormone, rather than 36 h after administration of human chorionic gonadotropin, increased the pregnancy rate. As the quality and number of embryos transferred to the uterus increased, the risk of multiple pregnancy also rose. Consideration should therefore be given to restricting the number of embryos transferred to limit multiple pregnancies to twins.