Early or late menarche is associated with reduced fecundability in the Norwegian Mother, Father and Child Cohort Study

STUDY QUESTION

Is age at menarche associated with fecundability?

SUMMARY ANSWER

Both early (<11 years) and late (>15 years) menarche is associated with decreased fecundability.

WHAT IS KNOWN ALREADY

Previous studies on age at menarche and fecundability have been inconclusive. Women with early or late menarche are at increased risks of gynaecological and autoimmune diseases that may affect their ability to conceive.

STUDY DESIGN, SIZE, DURATION

We conducted a retrospective cohort study including 67 613 pregnant women, participating in the Norwegian Mother, Father and Child Cohort Study between 1999 and 2008, with self-reported information on age at menarche and time to pregnancy. We included planned pregnancies that were conceived either naturally or with the help of assisted reproductive technologies.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We calculated fecundability ratios (FRs) with 95% CIs representing the cycle-specific probability of conception by categories of age at menarche. FRs were adjusted for participants' pre-pregnancy body mass index, highest completed or ongoing education level, and age at initiation of trying to conceive.

MAIN RESULTS AND THE ROLE OF CHANCE

We observed a 7% lower probability of conceiving during any given menstrual cycle up to 12 cycles in women with early or late menarche. Among women with menarche >15 years, the adjusted FR was 0.93 (95% CI: 0.90-0.97), and among women with menarche <11 years, the adjusted FR was 0.93 (95% CI: 0.89-0.99), when compared to women with menarche between 12 and 14 years.

LIMITATIONS, REASONS FOR CAUTION

The study-population consisted of women pregnant in their second trimester, excluding those with persistent infertility. Recall of age at menarche and time to pregnancy may be inaccurate.

WIDER IMPLICATIONS OF THE FINDINGS

Both early (<11 years) and late (>15 years) menarche was associated with decreased fecundability. Women experiencing early menarche or late menarche may be counselled accordingly.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by the Norwegian Institute of Public Health, Oslo, Norway, and by Telemark Hospital Trust, Porsgrunn, Norway and was partly supported by the Research Council of Norway through its centres of excellence funding scheme (project number 262700) and the Research Council of Norway (project no. 320656). The project was co-funded by the European Union (ERC, BIOSFER, 101071773). Views and opinions expressed are however those of the author(s) only and do not necessarily reflect those of the European Union or the European Research Council. Neither the European Union nor the granting authority can be held responsible for them. M.C.M. has received funding from the European Research Council (ERC) under the European Union's Horizon 2020 research and innovation program (grant agreement no. 947684). The authors report no competing interests.

TRIAL REGISTRATION NUMBER

N/A.

288 Forage mineral and nutrient element concentrations on sheep winter range

Supplementation strategies and nutritional management of ewes during critical production periods of breeding and gestation is an important consideration, particularly when ewes are on winter range. Clinical and subclinical trace mineral deficiencies at these times limit ewe productivity in these extensive environments. The objectives of this study were to (1) quantify mineral element concentrations of common forages on winter range, and (2) evaluate producer supplementation strategies using a survey. We hypothesized that mineral element concentrations in winter forages were inadequate to meet ewe requirements during critical production stages and shrub species would contain higher levels of macro- and micro-mineral element concentrations than grass species. Forage samples were collected from 25 ranches across Wyoming winter range and were compiled by species and analyzed for nutrient and mineral element composition; however, data presented herein represents the first year of data collection (12 of 25 ranches). Nutrient and mineral element concentration results indicated an effect in CP, Ca, P, K, Mg, S, Na, Zn, Cu, Se, Mn, and Mo concentrations between grass and shrub species (P &lt; 0.05). Specifically, Mg and Mo concentrations were higher in grasses while the other mineral element concentrations were higher in shrubs. No effect was observed for Fe and Co concentrations between grass and shrub species (P = 0.37 and P = 0.29). Survey results revealed that 80% of ranches had more than 1000 sheep, and 47% of respondents utilized winter range for 131 to 170 day periods throughout production year. While on winter range the majority of producers (47%) supplement with a protein source. Additionally, 58% do not supplement white salt, while 47% supplement a complete trace mineral mix.

424 WS Young Scholar Talk PHD: Effect of increasing dietary zinc during late gestation and early lactation on ewe and lamb body weights, serum and milk minerals, and somatic cell count

The objectives of the current research are to quantify the effects that increased dietary Zn during late gestation and early lactation has on ewe and progeny body weights, serum and milk minerals, and somatic cell count. Within Rambouillet (WF) and Hampshire (BF) breeds, ewes were ranked by BW and randomly assigned down the rank into 1 of 2 treatment groups: Control (n = 34, 37 mg Zn/kg DM, ≈1×NRC) and Zn treatment (n = 37, 113 mg Zn/kg DM, ≈3×NRC). Treatments were delivered via a ZnSO4-fortified alfalfa pellet fed at a rate of 0.45 kg/d DM from a RFID-activated automated feeder from d 108 ± 10 of gestation to d 30 post-lambing. Ewe BW were recorded at d 0, 29, lambing, 30 post-lambing, and weaning. Lamb BW was recorded at lambing, d 15, 30, and weaning. Serum samples were taken from ewes and lambs at 18 ± 4 h post-lambing and analyzed for mineral concentrations. Maternal trace mineral transfer efficiency were calculated by dividing lamb serum values by their respective dam’s serum value and expressed as a percentage. Ewe milk was collected twice weekly. Milk was analyzed for mineral content (d 0, 10, and 30 of lactation) and SCC (d 3–5, 6–9, 10–12, 13–16, 17–19, 20–23, 24–26, 27–29, or 30–32). Ewe and lamb BW was not influenced by Zn treatment (P &gt; 0.19). Ewe serum Zn and maternal transfer efficiency did not differ between control and Zn treatment ewes (P ≥ 0.47). There was a treatment × breed type interaction for lamb serum LogZn (P = 0.04), where BF lambs within Zn treatment had greater serum LogZn (0.63 ± 0.32) than WF lambs (-0.37 ± 0.27; P = 0.04), but breeds did not differ within lambs in the Control treatment group. Milk Ni and Zn was greater for Zn treated ewes than control ewes (P &lt; 0.01), but Mg and P concentrations were greater for control ewes (P ≤ 0.02). Control and Zn treated ewes did not differ in LogSCC through the first 30 d of lactation (P = 0.68) nor did they differ at weaning (P = 0.48). White face and BF ewes LogSCC did not differ at weaning (P = 0.09), but for the first 30 d of lactation BF (5.79 ± 0.06) had greater LogSCC than WF ewes (5.54 ± 0.06; P &lt; 0.01). Day of lactation impacted ewe SCC (P &lt; 0.01), with peak SCC between d 6 and 9 which began to decline as lactation progressed. Current Zn recommendations appear to be adequate for ewe and lamb growth during late gestation and early lactation, but results suggest litter size and breed nuances. Milk Zn is also increased with dietary Zn above NRC recommendations, while further interactions with milk Ni, Mg, and P occur. Additionally, longitudinal values of SCC throughout lactation may inform preventative intervention strategies for cases of sub-clinical mastitis since peak SCC is within the first 9 d post-lambing.

290 Impacts of dietary zinc concentrations on lamb feedlot performance

The objectives of this study were to identify the impacts of Zn concentrations in lamb grower pellet on lamb feedlot performance and natural coccidia infection in terms of fecal Eimeria oocyst excretion. Rambouillet lambs (n = 33; 43.9 ± 1.0 kg) were used in a 63 d feeding trial to assess the effect of a diet fortified with a combination of ZnSO4 (80%) and Zn amino acid complex (20%; ZnAA; Zinpro Corp.; Eden Prairie, MN, USA) at three different dietary Zn concentrations (treatment, TRT) which met or exceeded current recommendations. These levels included 1×NRC requirements (450 mg/kg grower pellet; 1NRC), 2×NRC requirements (900 mg/kg grower pellet; 2NRC), and 3×NRC requirements (1350 mg/kg grower pellet; 3NRC). Lamb performance characteristics, including body weight (BW), average daily gain (ADG), average dry matter intake (DMI), feed efficiency (gain:feed, G:F), and residual feed intake (RFI), were quantified. Fecal samples were collected every 2 wk to assess coccidia infection status via fecal oocyst counts. Treatment × period (d 0–10, 11–42, 42–63) interactions were identified for DMI (P &lt; 0.001). No main effect of TRT was identified for BW, ADG, G:F, or RFI (P &gt; 0.36), but was for DMI (P = 0.02). Ten Eimeria species were detected and summed for total fecal oocyst count, but focus was on the most pathogenic species (E. ahsata, E. bakuensis, E. crandallis, and E. ovinoidalis). A statistical tendency for the interaction between TRT × day was detected for E. bakuensis and E. ovinoidalis (P ≤ 0.08). Transformed counts of E. bakuensis and E. crandallis were lower for 1NRC compared to 2NRC and 3NRC lambs (P &lt; 0.05). Results indicate greater dietary Zn concentrations increased DMI and decreased Eimeria oocysts excreted.

264 Harvest season, carcass weight, and fat measurement effects on lamb carcass characteristics and economic comparison of moderate and heavy weight lamb carcasses in the Western lamb processing industry

Carcass characteristics and economic impact estimates of over-finished lambs on the processing sector were evaluated in two commercial Intermountain West abattoirs. Lamb carcasses were surveyed throughout the year using digital images and imaging software (n = 9,532). Estimations of abattoir costs and returns included loading labor, downtime cost, price of fat, live and carcass trucking costs from the two largest lamb processors in the Intermountain West. Profitability comparisons were made using Monte Carlo simulation models replicating live and carcass prices for distributions based on historical pricing data to assess overall profitability of a carcass in an ideal weight range (29.5 - 39.0 kg) and a carcass that exceeds ideal weight (&gt; 39.0 kg). Overall means show that the average lamb carcass exceeded packer preferred hot carcass weight (40.76 ± 9.29 kg) and industry acceptable 12th rib fat thickness (8.17 ± 3.79 mm). There were seasonal differences in hot carcass weight and fat measurements with carcasses being lighter weight (P = 0.05) and trimmer (P = 0.05) in the summer months. Monte Carlo simulation found that the additional yield from heavier carcasses offset costs of harvesting them. However, factors such as machine wear and increased labor turnover rates should be considered, although difficult to quantify. Collectively, the current study shows that U.S. lamb carcasses are too heavy and excessively fat but have minor effect on processor profitability.

289 Effects of dietary Zn on ewe milk minerals and somatic cell count

The objectives of the current study were to evaluate the effects of dietary Zn fed at approximately 3 times NRC recommendations on milk Zn concentrations and mammary health. Within Rambouillet (WF) and Hampshire (BF) breeds, ewes were ranked by BW and randomly assigned down the rank into 2 treatment groups: Control (n = 45, 37 mg Zn/kg DM) and Zn treatment (n = 44, 113 mg Zn/kg DM). Treatments were delivered via a ZnSO4-fortified alfalfa pellet fed at a rate of 0.45 kg/d DM from a RFID-activated automated feeder from approximately 6 wk before to 4 wk after lambing. Ewe milk was collected twice weekly, and analyzed for mineral content (d 0, 10, and 30 of lactation) and somatic cell count (SCC; d 3–5, 6–9, 10–12, 13–16, 17–19, 20–23, 24–26, 27–29, or 30–32). Single-bearing ewes had greater Ca, Mg, and P (P ≤ 0.04) than multiple-bearing ewes. Day of lactation influenced milk Mg, P, and Zn (P &lt; 0.01), and values generally decreased as lactation progressed. Milk Zn was 1.7-fold greater (P &lt; 0.01) for Zn treatment than Control ewes. Milk Ca, Mg, and P were greater for Control than Zn treatment (P ≤ 0.02) ewes. A breed × litter size effect was detected for LogSCC (P = 0.02). Single-bearing WF ewes had lower LogSCC than multiple-bearing WF ewes (5.36 ± 0.09 vs 5.74 ± 0.07; P &lt; 0.01) but litter size did not affect BF ewe LogSCC (5.80 ± 0.08 vs 5.79 ± 0.09; P = 0.92). Day of lactation impacted ewe SCC (P &lt; 0.01), with peak SCC between d 6 and 9, which began to decline as lactation progressed. In conclusion, dietary Zn above NRC recommendations increased milk Zn.

Zinc AA supplementation alters yearling ram rumen bacterial communities but zinc sulfate supplementation does not

 Despite the body of research into Zn for human and animal health and productivity, very little work has been done to discern whether this benefit is exerted solely on the host organism, or whether there is some effect of dietary Zn upon the gastrointestinal microbiota, particularly in ruminants. We hypothesized that (i) supplementation with Zn would alter the rumen bacterial community in yearling rams, but that (ii) supplementation with either inorganically sourced ZnSO4, or a chelated Zn AA complex, which was more bioavailable, would affect the rumen bacterial community differently. Sixteen purebred Targhee yearling rams were utilized in an 84-d completely randomized design, and allocated to one of three pelleted dietary treatments: control diet without fortified Zn (~1 × NRC), a diet fortified with a Zn AA complex (~2 × NRC), and a diet fortified with ZnSO4 (~2 × NRC). Rumen bacterial community was assessed using Illumina MiSeq of the V4 to V6 region of the 16S rRNA gene. One hundred and eleven OTUs were found with > 1% abundance across all samples. The genera Prevotella, Solobacterium, Ruminococcus, Butyrivibrio, Olsenella, Atopobium, and the candidate genus Saccharimonas were abundant in all samples. Total rumen bacterial evenness and diversity in rams were reduced by supplementation with a Zn AA complex, but not in rams supplemented with an equal concentration of ZnSO4, likely due to differences in bioavailability between organic and inorganically sourced supplement formulations. A number of bacterial genera were altered by Zn supplementation, but only the phylum Tenericutes was significantly reduced by ZnSO4 supplementation, suggesting that either Zn supplementation formulation could be utilized without causing a high-level shift in the rumen bacterial community which could have negative consequences for digestion and animal health.

Are women with obesity and infertility willing to attempt weight loss prior to fertility treatment?

OBJECTIVE

To assess attitudes towards weight loss interventions in patients seeking infertility treatment.

METHODS

We evaluated prior weight loss experiences, attitudes towards future interventions by body mass index (BMI), and willingness to delay fertility treatment for weight loss interventions stratified by BMI using logistic regression amongst women ≤45years old with infertility over three months or recurrent pregnancy loss.

RESULTS

The average age of our convenience sample of respondents (148 of 794 eligible women, 19%) was 34.5 years old, with a mean BMI of 26.7±7.4kg/m², including 37 with a BMI >30kg/m² (25%). Most women had attempted conception over 1year. The majority of women with overweight or obesity were attempting weight loss at the time of survey completion (69%). While 47% of these women reported interest in a supervised medical weight loss program, 92% of overweight women and 84% of women with obesity were not willing to delay fertility treatment more than 3 months to attempt weight loss.

CONCLUSION

Most women with obesity and infertility in our population are unwilling to postpone fertility treatment for weight loss interventions.

Prediction of gestational age based on genome-wide differentially methylated regions

Background

We explored the association between gestational age and cord blood DNA methylation at birth and whether DNA methylation could be effective in predicting gestational age due to limitations with the presently used methods. We used data from the Norwegian Mother and Child Birth Cohort study (MoBa) with Illumina HumanMethylation450 data measured for 1753 newborns in two batches: MoBa 1, n = 1068; and MoBa 2, n = 685. Gestational age was computed using both ultrasound and the last menstrual period. We evaluated associations between DNA methylation and gestational age and developed a statistical model for predicting gestational age using MoBa 1 for training and MoBa 2 for predictions. The prediction model was additionally used to compare ultrasound and last menstrual period-based gestational age predictions. Furthermore, both CpGs and associated genes detected in the training models were compared to those detected in a published prediction model for chronological age.

Results

There were 5474 CpGs associated with ultrasound gestational age after adjustment for a set of covariates, including estimated cell type proportions, and Bonferroni-correction for multiple testing. Our model predicted ultrasound gestational age more accurately than it predicted last menstrual period gestational age.

Conclusions

DNA methylation at birth appears to be a good predictor of gestational age. Ultrasound gestational age is more strongly associated with methylation than last menstrual period gestational age. The CpGs linked with our gestational age prediction model, and their associated genes, differed substantially from the corresponding CpGs and genes associated with a chronological age prediction model.

Electronic supplementary material

The online version of this article (doi:10.1186/s13059-016-1063-4) contains supplementary material, which is available to authorized users.

25-Hydroxyvitamin D in pregnancy and genome wide cord blood DNA methylation in two pregnancy cohorts (MoBa and ALSPAC)

The aim of the study was to investigate whether maternal mid-pregnancy 25-hydroxyvitamin D concentrations are associated with cord blood DNA methylation. DNA methylation was assessed using the Illumina HumanMethylation450 BeadChip, and maternal plasma 25-hydroxyvitamin D was measured in 819 mothers/newborn pairs participating in the Norwegian Mother and Child Cohort (MoBa) and 597 mothers/newborn pairs participating in the Avon Longitudinal Study of Parents and Children (ALSPAC). Across 473,731CpG DNA methylation sites in cord blood DNA, none were strongly associated with maternal 25-hydroxyvitamin D after adjusting for multiple tests (false discovery rate (FDR)>0.5; 473,731 tests). A meta-analysis of the results from both cohorts, using the Fisher method for combining p-values, also did not strengthen findings (FDR>0.2). Further exploration of a set of CpG sites in the proximity of four a priori defined candidate genes (CYP24A1, CYP27B1, CYP27A1 and CYP2R1) did not result in any associations with FDR<0.05 (56 tests). In this large genome wide assessment of the potential influence of maternal vitamin D status on DNA methylation, we did not find any convincing associations in 1416 newborns. If true associations do exist, their identification might require much larger consortium studies, expanded genomic coverage, investigation of alternative cell types or measurements of 25-hydroxyvitamin D at different gestational time points.

The multiple sclerosis susceptibility genes TAGAP and IL2RA are regulated by vitamin D in CD4+ T cells

Multiple sclerosis (MS) is an inflammatory, demyelinating disorder of the central nervous system that develops in genetically susceptible individuals. The majority of the MS-associated gene variants are located in genetic regions with importance for T-cell differentiation. Vitamin D is a potent immunomodulator, and vitamin D deficiency has been suggested to be associated with increased MS disease susceptibility and activity. In CD4+ T cells, we have analyzed in vitro vitamin D responsiveness of genes that contain an MS-associated single-nucleotide polymorphism (SNP) and with one or more vitamin D response elements in their regulatory regions. We identify IL2RA and TAGAP as novel vitamin D target genes. The vitamin D response is observed in samples from both MS patients and controls, and is not dependent on the genotype of MS-associated SNPs in the respective genes.

Enhancement of bacillus Calmette-Guerin attachment to the urothelium by removal of the rabbit bladder mucin layer

It has been established that the urothelial mucin layer functions as a bacterial anti-adherence factor. Intravesical Bacillus Calmette-Guerin is used to treat patients with superficial bladder cancer. The proposed mechanism of action of Bacillus Calmette-Guerin is adherence to the urothelium with induction of an immunologic and/or inflammatory response. The current study was designed to determine if rabbit bladder mucin removal results in increased Bacillus Calmette-Guerin urothelial adherence. PAS and colloidal iron stains were used to demonstrate that intravesical instillation of 50% acetone renders rabbit bladder urothelium mucin deficient. The urothelium remains mucin deficient at two hours, but by 24 hours the mucin layer has been regenerated. Two hours following intravesical 3H-labeled Escherichia coli administration, bacterial adherence was 29-fold greater in mucin deficient than mucin intact rabbits (p = 0.05). By 12 hours, the difference in adherence was not significant. Two hours following intravesical administration of 3H-labeled Bacillus Calmette Guerin, mucosal adherence was 21-fold greater in mucin deficient compared to mucin intact rabbits (p = 0.002). After mucin removal, Bacillus Calmette Guerin urothelial adherence was significantly increased. The significant increase in Bacillus Calmette Guerin adherence after mucin removal may be clinically exploitable.

Multifocal, synchronous inverted papillomas involving the ureter

Inverted papillomas involving the upper urinary tract remain a rarely diagnosed phenomenon. A case of bilateral ureteral inverted papillomas is presented. The treatment and diagnosis of this lesion remain a challenge.

Variations in WGA-binding proteins in tumours growing in different implantation sites

The protein/glycoprotein composition of Triton X100 extracts of four metastatic tumour lines have been compared by gel electrophoresis after the implantation into different sites of the body. No consistent differences in the patterns were noted after staining with Coomassie Blue or treating with concanavalin A. In contrast, after treating with wheat germ agglutinin (WGA), the patterns varied with site. This was most marked with the ML and M5 tumours, where the overall binding was much lower for some sites. Although WGA binding with the LL and BL6 tumours was generally higher than with the ML and M5, reduced binding was still evident for some sites. Reduced WGA binding was also observed for extracts of secondary tumour growing in the liver or lungs.

The growth and metastasis of four commonly used tumour lines implanted into eight different sites: evidence for site and tumour effects

The growth and metastasis of four commonly used experimental tumour lines have been compared after the implantation of cells into a lobe of the liver, the spleen, the left kidney, the peritoneal cavity, the thorax, the right thigh muscle, subcutaneously into the dorsolumbar region and intravenously into the tail vein or the right femoral vein. This was done to assess the importance of site in affecting metastatic distribution, and to determine whether any general conclusions could be drawn as to the role of this factor. Tumours grew at variable rates in different sites, but this did not affect the extent or distribution of metastasis. Each line gave a characteristic pattern that could be considerably modified by site. For example, in the spleen, metastasis was always extensively to the liver; in the kidney, and to some extent in the muscle, metastasis was similar to that obtained for intravenously injected cells; in the peritoneal cavity or thorax, metastasis was usually lower than from other sites; and in the liver, the metastasis to other lobes of the liver and to the lungs was modified. Many of these findings could be explained by both specific and non-specific factors operating at each site. It is suggested that interactions at the primary site of tumour growth may be very important in affecting metastasis, and that in the future more attention should be given to this factor in order to make progress in understanding tumour spread.

Rehabilitation services in rural communities: delivery by hospital based and local teams

Since rehabilitation services are generally not available on a local basis to rural communities, a rural service delivery approach, the Coordinated Ambulatory Rehabilitation Evaluation Services (CARES) Project, was established. The program demonstrated a local rural rehabilitation capability based on primary care physicians, a local hospital, and nonphysician rehabilitation providers working cooperatively with a rehabilitation specialty hospital 640km away. Service delivery profiles of the hospital and local teams were compared for pediatric and adult clinics. The project was successfully implemented with 281 patients seen in their local areas.

Immunolocalization of the murine monoclonal antibody, 791T/36 within primary human colorectal carcinomas and identification of the target antigen

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The intracellular acid-extractable (acid-soluble) amino acid pool in mammalian cells: 3 Competition for entry and its effects on incorporation into protein synthesis

Competition studies have been carried out between normal and analogue amino acids with suspension cultured mammalian cells incubated, except for the competing amino acid, in normal medium. Although this produces less dramatic changes on uptake and incorporation than experiments performed in Krebs-Ringer solution, it has the advantage of obtaining data under more physiological conditions. A systematic survey with all the amino acids used has shown, in general, a non-specific interference for uptake into the acid-extractable pool, suggesting that a common pool-forming mechanism is involved. Individual differences in competitive behaviour probably arise from varying affinities of amino acids for the pool-forming mechanism, their ability to displace others from the pool, and the rate of their subsequent discharge, among other characteristics. Certain interactions appear exceptional, however, notably glycine and serine, which could be due to their linked metabolism. Incorporation of amino acids into protein of the same cells gave the anticipated high degree of specificity, but evidence is now presented that the amount of a particular labelled amino acid entering into protein depends not only on its absolute concentration in the medium, but also on its relative concentration. The results indicate that the effects of excesses of other amino acid is to reduce the probability with which the labelled species can be loaded by its own tRNA. This inhibition is of a non-specific nature.

Effect of breast-feeding on plasma cholesterol and weight in young adults

The relation between breast-feeding and plasma cholesterol level in adult life was examined in a longitudinal study of a sample of people born in 1946. One hundred and seventy-two subjects whose breast-feeding history had been recorded during infancy were examined when they were 32 years old. Women who had been breast-fed had significantly lower mean plasma cholesterol than women who had been bottle-fed (5.4 mmol/l compared with 5.9 mmol/l). For men the difference was smaller and not significant. An unexpected finding was the higher mean weight and skinfold thickness in men who had been breast-fed. These results support the hypothesis that factors acting very early in life affect the risk of disease in adults.

Removal of metronidazole by haemodialysis

The removal of the anti-anaerobic antibiotic metronidazole has been studied in oliguric patients. The drug and its principal metabolite are rapidly removed by haemodialysis so that the plasma concentration quickly falls below the therapeutic range. Hence a further dose of metronidazole would be needed after dialysis to restore an adequate plasma concentration.

Avascular necrosis of bone after renal transplantation: role of parathyroid hormone and vitamin D

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Survey of Fracture Treatment

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The Development of Orthopædic Surgery: (Section of Orthopædics)

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Case of Carotid Body Tumour with Syncopal Attacks, after Operation

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