Individual variability in concentrations of urinary sulindac sulfide

Among 70 patients with arthritis who were receiving satisfactory maintenance therapy with sulindac (300 to 400 mg daily), 64% had no detectable sulindac sulfide (active metabolite) in one to four random urine specimens. However, 36% had 1.0 to 7.8 (mean, 2.2 +/- 1.4) micrograms/ml sulindac sulfide in urine, similar to the therapeutically effective concentrations found in 24 concurrent plasma specimens (1.4 to 9.0 micrograms/ml). Ten patients had sulindac sulfide in only one or two of two to four urine specimens. Thus, 36% of the patients had pharmacodynamically significant concentrations of sulindac sulfide in urine, presumably capable of suppressing the cyclooxygenase pathway responsible for prostaglandin synthesis in the kidney and elsewhere. The findings suggest individual variability in the capacity for renal oxidation of sulindac sulfide to inactive metabolites, perhaps related to genetic or environmental factors or both. These findings may help to explain conflicting reports on the effects of sulindac on urinary prostaglandins and renal function.

Microinjection of human oocytes: a technique for severe oligoasthenoteratozoospermia

OBJECTIVE

To determine outcome after microinjection with very poor quality sperm and after failed fertilization.

DESIGN

Group 1, fresh oocytes from patients with very low sperm density and motility on the day of oocyte recovery; Group 2, 1-day-old oocytes that failed to fertilize.

SETTING

All material was obtained from the National University Hospital.

PATIENTS

One hundred and thirty-one from group 1; 35 from group 2.

INTERVENTIONS

Sperm was injected subzonally or directly into the ooplasm.

MAIN OUTCOME MEASURE

Normal and abnormal fertilization and pregnancy.

RESULTS

Subzonal transfer was done on 771 oocytes in group 1 and 188 oocytes in group 2. Multiple sperm were transferred [mean of 6.6 for group 1 and 7.3 for group 2]. Monospermic fertilization occurred in 16.6% and 14.9%, respectively. Polyspermy and parthenogenetic activation were low at 2.3% and 2.8%, respectively. Five pregnancies were obtained, but only one delivered. Ooplasmic injection (single sperm heads) was done in 38 oocytes from three patients with extremely severe oligozoospermia; only four two-pronuclear zygotes were obtained and replaced into two patients, without any resulting pregnancy.

CONCLUSIONS

Subzonal transfer may be a viable technique for patients with severe sperm problems.

Approach to joint pains

Aches and pains are common clinical problems. There are many causes of rheumatic pains and a simple classification is given in this article. The approach to the problem should be clinical, and starts with careful history, physical examination and some simple investigations. Most of the common rheumatic problems can be diagnosed easily using the clues to diagnosis given here. Those which are unresolved and problematic can then be referred for further evaluation.

Improved fertilization rates of human oocytes in coculture

Passaged human tubal ampullary epithelial cells from cell lines were used to evaluate fertilization rates and the support of early human embryonic cleavage in vitro. A total of 225 mature oocytes from 32 patients was used in this study. Oocytes from each patient were equally allotted at random to two groups. One hundred thirty-two oocytes were inseminated in the presence of passaged human ampullary cells, while 123 oocytes were inseminated in culture medium alone. Fertilized oocytes were transferred to tubal ampullary cell monolayers and monitored for up to 48 hr. Eighty-five percent of oocytes fertilized in coculture, as compared to 67% in medium alone (P less than 0.01). A higher percentage of good-quality embryos was observed in cocultures than in controls (79 vs 67%; P less than 0.05). Binding of sperm to ampullary monolayer cells was observed. Human ampullary-cell cocultures may be useful to improve fertilization rates and embryonic viability and thus increase take-home baby rates for in vitro fertilization programs.

Cocultures: a new lead in embryo quality improvement for assisted reproduction

One of the contributory causes to poor PRs in assisted reproduction has been the decreased viability of transferred embryos and the transfer of four-cell embryos into an environment that naturally would be receptive only to 5-day-old blastocysts. In this paper, we have reviewed our own work and that of others on the role of tubal ampullary cells (cocultures) to mimic the in vivo environment to bring about improved embryo quality and an increased number of blastocysts for replacement in IVF patients. The establishment, maintenance, and behavior of human tubal cell lines is first presented, followed by their use as cocultures for fertilization and cleavage of embryos. The mode of action, specificity, and cryopreservation of ampullary cells are also discussed. The currently available results of pregnancies after cocultures are presented together with future aspects of research that are necessary to refine the coculture system. The ultimate aim is to mimic in vivo conditions in vitro, so that at least the PRs of assisted conception can be parallel to normal fecundity in the human. Therefore, a very attractive future includes the freezing of blastocysts generated from coculture, thawing, and replacing them in natural cycles.

Preimplantation genetics: chromosomes of fragmented human embryos

STUDY OBJECTIVE

To examine the chromosome makeup of fragmented human embryos.

DESIGN

Prospective.

SETTING

Assisted reproductive technology (ART) program.

PATIENTS

One hundred twenty-one poor-quality embryos from 58 patients 31 to 40 years of age admitted for an ART program were examined for chromosome makeup.

RESULTS

Chromosome anomalies were observed in 31.9% (29/91) of poor-quality embryos, 19.8% (18/91) displayed mosaicism (diploid/haploid, diploid/triploid, diploid/aneuploid), 5.5% (5/91) showed polyploidy, 2.2% (2/91) had pulverized chromosomes, 2.2% (2/91) revealed aneuploidy, 1.1% (1/91) had prematurely condensed chromosomes, and 1.1% (1/91) had structural rearrangements involving chromosome number 2. The mean age of patients showing anomalies (36.5 years) was not significantly higher than the mean for the entire group (35.5 years).

CONCLUSIONS

The incidence of chromosome anomalies in fragmented human embryos is high. These anomalies originate either in the gametes or through mitotic nondisjunction within the embryos. It is not advisable to replace such embryos into patients going through in vitro fertilization.

Centrioles in the beginning of human development

We demonstrate the presence of centrioles in fertilized human oocytes at syngamy. Single or double centrioles within centrosomes were detected by transmission electron microscopy at one pole of the first cleavage spindle in normal and dispermic embryos (25-26 hr after insemination). Sperm centrioles were also closely associated with the male pronucleus (16-20 hr after insemination) in pronuclear stage embryos. A tripolar spindle derived from a tripronuclear embryo is also demonstrated with two centrioles at one pole. The data provide evidence that human centrioles, as those in most other animals, and unlike the mouse, are paternally derived, thus supporting Boveri's classical theory. Furthermore, this study provides insights to the proposed mechanisms of aberrant cleavage patterns of dispermic human embryos.

A retrospective study on malaria cases admitted to the University Hospital, Kuala Lumpur, 1984-1988

A review of malaria cases over a five year period from 1984-1988 at the University Hospital, Kuala Lumpur, Malaysia is presented. A total of 64 cases were recorded; 50% of which were due to Plasmodium falciparum, 40.6% were due to Plasmodium vivax, 6.2% due to Plasmodium malariae and 3.1% due to a mixed infection of Plasmodium falciparum and Plasmodium vivax. The breakdown of species type compared similarly with other studies conducted in the region. Of this total, sixteen cases were imported from Pakistan, India, Thailand, Indonesia, Sri Lanka, Vietnam, Madagascar and Mali. The presenting symptoms and the clinical findings were typical of a malaria infection. The main problem in the future will be the increase in imported cases of malaria.

Cocultures in human assisted reproduction. Support of embryos in vitro and their specificity

Assisted reproductive techniques (ART) have contributed tremendously to alleviating infertility in childless couples. However, the "take-home baby" rate for in vitro fertilization (IVF) has been much below the rate for normal fertile couples and for the other tubal procedures such as gamete intrafallopian transfer (GIFT) and tubal embryo transfer (TET). It was therefore speculated that the tubal environment might be playing an important role towards the viability of the embryo and that, in IVF, 4-6 cell stage embryos that were usually replaced directly into the uterus might not be receiving the beneficial effects of the tubal environment. Pronuclear stage human and mouse embryos were thus cocultured with reproductive and other somatic cell types to evaluate the quality of the various cleaving stages and the percentage yield of blastocysts. Human ampullary cell cultures were established in 6 to 7 days and kept alive through one menstrual cycle. Cleavage to the compacted and cavitating stages was achieved in 78% and 69%, respectively, of human embryos cocultured in 24-48 hour human ampullary subcultures as compared to 50% and 33%, respectively, for embryos grown in culture medium alone. The percentages of expanded blastocysts and hatching stages in such cocultures were not significantly different from those of controls. However, human ampullary and cumulus and mouse ampullary and muscle fibroblast cultures supported cleavage and development of mouse embryos up to the hatching stages as well as or better than controls. It thus appears that there is no absolute specificity for a reproductive tract source of cocultured cells and that the beneficial effects of ampullary and cumulus cells are not species-specific. The coculture system also appears to overcome the embryonic blocks of the human and mouse, which may be mediated via growth factors that activate the embryonic genome.

Recognition of pernicious syndromes in malaria infections

The case records of 64 patients with malaria over a five year period admitted to the University Hospital, Kuala Lumpur were examined. There were 32 cases of P. falciparum, 26 cases of P. vivax and two cases of mixed infections. Four cases of P. malariae were recorded. The clinical findings, biochemical and haematological parameters were examined for any indication of a pernicious syndrome. A high index of suspicion of a malarial infection may be based on the findings of anaemia, thrombocytopaenia, hyponatraemia, renal failure and abnormal liver function tests in the face of a negative blood film. These pernicious syndromes occur more often in malignant tertian malaria (anaemia 50%, hyponatraemia 39.1%) but a high percentage of the other malarial species show these abnormalities (P. vivax anaemia 57.7%, hyponatraemia 19.2%). When these abnormalities are present but blood films for malaria parasites are negative, repeat blood films are warranted until a parasitological diagnosis is achieved and correct treatment may be started.

Hereditary spherocytosis: a study of 16 patients from University Hospital, Kuala Lumpur

Hereditary spherocytosis is a rather uncommon disease in Malaysia as only 16 patients were seen in our hospital over a 13 year period. Pallor, jaundice and splenomegaly were common physical signs. Clinical severity of the disease was variable and more than half of them needed splenectomy. Complications including haemolytic crisis and cholelithiasis were encountered but not aplastic crisis. All 10 patients who underwent splenectomy had uniformly good results and none of them had post-operative complications.

Thrombotic thrombocytopenic purpura with terminal pancytopenia

A 27 year old housewife developed thrombotic thrombocytopenic purpura during the twelfth week of pregnancy. She had partial response to initial plasma infusion and subsequent plasmapheresis. However, her clinical course was complicated by the development of severe pancytopenia the consequence of a hypocellular marrow. She succumbed to septicaemic shock one month after diagnosis. The development of hypocellular marrow in thrombotic thrombocytopenic purpura has not been reported before.

Co-cultures: their relevance to assisted reproduction

Assisted reproductive techniques have contributed significantly to alleviating subfertility in the childless couple. However, the take-home baby rates have been very low throughout the world. One of the contributory causes has been the reduced viability of replaced embryos brought about by suboptimal in vitro conditions. The culture of human embryos in the presence of passaged human tubal ampullary monolayers (co-cultures) is an attractive approach to improving the viability of embryos for assisted reproduction. Seventy per cent of blastocysts can be produced in human ampullary co-culture as compared to 33% in standard culture media. This paper discusses the various roles of human co-cultures in assisted reproduction and provides an opinion as to how the transfer of blastocysts produced via the co-culture system could enhance pregnancy rates. Particular emphasis is placed on human oviductal characteristics, the various co-culture systems, screening of co-cultures for microbes, freezing of ampullary cells, growth factors and embryonic blocks, specificity of co-cultures, sperm hyperactivation in co-culture and pregnancy rates. The first patient on a clinical trial who had four of her oocytes fertilized and grown in human ampullary co-culture and then replaced into her uterus became pregnant. The co-culture system may have tremendous potential in supporting human embryonic growth via embryotrophic factors.

Future of assisted reproductive technologies

Within a decade, from the birth of Louise Brown in 1978, there has been tremendous advances in the field of assisted reproduction. These advances are the collective result of techniques known as Assisted Reproductive Technologies (ART). ART is defined as techniques in which the oocyte is handled in-vitro before replacement either as oocytes or embryos. The techniques in ART include in-vitro fertilisation and embryo replacement (IVF-ER), gamete intra-fallopian transfer (GIFT), tubal embryo (TET), donor oocytes and embryos, and freezing of embryos and oocytes. The most recent has been assisting fertilisation by micro-manipulation, including zonal procedures and micro-insemination, e.g. micro-insemination sperm transfer (MIST). There has also been many ethical issues in ART, and little advance in the "take home" baby rate. There is now major interest in co-culture of embryos with ampullary, endometrial and fibroblast mono-layers, to improve the quality of these embryos before their return into the mother. Because of the public's interest in ART, its usefulness has been "oversold". In time to come, ART may be limited to patients who really need it.

A review of patients with deep vein thrombosis diagnosed at University Hospital, Kuala Lumpur

In this retrospective study, 81 patients were diagnosed to have deep vein thrombosis (DVT) at the University Hospital, Kuala Lumpur over a ten year period from 1977 to 1986. Fifty-six patients had their DVT confirmed by venograms. The left side was affected in 79.5% of venographically proven cases of DVT of the lower limbs above the popliteal vein. The incidence of clinically apparent DVT following surgery was 0.21 per 1,000 operations. The incidence of pregnancy-related DVT was 0.039%. DVT was 3 times more frequent in the puerperium than in the antenatal period. The overall incidence of symptomatic pulmonary embolism was 13.6% of the cases of DVT.

Autoimmune haemolytic anaemia in pregnancy: a case report

A young primigravida had idiopathic warm antibody (IgG) autoimmune haemolytic anaemia (AIHA) occurring in the third trimester of pregnancy. Her haemolytic process was responsive to steroid therapy and no transfusion was needed. She delivered a healthy baby with no evidence to haemolysis, though his red cells were coated with IgG which was probably of maternal origin.

Heavy and light chain contributions to antigen binding in an anti-digoxin chain recombinant antibody produced by transfection of cloned anti-digoxin antibody genes

We used immunoglobulin gene transfection to study the effect that substituting an homologous light (L) chain for a parental L chain has on antigen fine specificity and affinity. High-affinity monoclonal anti-digoxin antibodies 26-10 and 40-100 were selected for study because their L chains are 92% homologous (although the H chains differ), and their binding with digoxin and digoxin analogs show very different properties. In order to generate a recombinant transfectoma, the genes encoding the 26-10 H and L chains were cloned. After the sequenced clones had been shown to contain the V gene and the transcriptional control elements, the H and L chain V region genes were subcloned into different expression vectors. Both constructs were transfected into myeloma J558L, a lambda 1 chain producer, to verify that the genetic constructs expressed correctly. The recombined 26-10 antibody was identical to parental 26-10 antibody in fine specificity and affinity. The 26-10 L chain construct was then transfected into a cell line, CR-101, that expresses the 40-100 H chain and a lambda 1 chain. The transfectoma 1E6, secreting 40-100 H chain and 26-10 L chain, was selected. Appropriate gene expression in 1E6 was proven by polymerase chain reaction cloning and sequencing. The fine specificity properties of the 1E6 recombinant derive from both the 40-100 and 26-10 antibodies; however, the affinity of 1E6 is 130 times less than that of the parental antibodies. We conclude that, in 1E6, the H and L chains are codominant in their influence on antigen specificity and that homologous pairing of H and L chains is required for optimal affinity.

Characterization of monoclonal antibodies specific to the activated ras p21 with aspartic acid at position 13

The ras proto-oncogenes encode membrane bound proteins (p21) which are structurally distinct from the proteins encoded by the activated transforming ras genes. These activated ras genes have been identified in various human tumors as well as their preneoplastic lesions such as colorectal tumors (20-40%), pancreatic carcinomas (95%), lung carcinomas (20-30%), myelodysplasia (40%) and acute myeloid leukemia (30%). The activation of ras p21 is due to amino acid substitutions at positions 12, 13 or 61 of the p21 protein. This report describes two monoclonal antibodies designated D129 and D146 raised against a synthetic peptide corresponding to amino acids 5-16 of ras p21 activated by the substitution of aspartic acid for glycine at position 13. D129 and D146 react specifically with the peptide with the aspartic acid substitution at position 13, but not with the peptide with valine at position 13 or the peptide containing the normal glycine at position 13. Western blot analysis demonstrates that D129 and D146 react specifically with p21 extracted from transformed NIH3T3 fibroblast lines containing aspartic acid at position 13. These studies also demonstrate that D146 is able to detect the activated p21 with aspartic acid at position 13 that is shed into the culture media. Studies demonstrate that MAb D146 specifically immunoprecipitates the cellular p21 with aspartic acid at position 13 from transformed NIH3T3 cells, whereas D129 cannot immunoprecipitate the activated p21. Using a sandwich ELISA format, D146 is able to detect the p21 with position 13 aspartic acid from cell extracts and culture fluids. The ability of D146 to function in the ELISA format raises the possibility that this assay maybe a quick and effective way of determining the presence of activated p21 with aspartic acid at position 13 in human fluids and tissues.

Skin score. A semiquantitative measure of cutaneous involvement that improves prediction of prognosis in systemic sclerosis

Cutaneous sclerosis, assessed yearly by a semiquantitative skin scoring technique (sum of 10 body areas, each scored on a scale of 0-3 for tethering, by clinical palpation), and outcome at 10 years were evaluated in 90 systemic sclerosis patients enrolled in a 3-year, prospective drug trial. The inverse relationship of survival to the skin score at study entry (increasing skin score associated with decreasing survival) (P less than 0.003) was more significant than was the relationship found by using classification schemata that rely only on distribution of cutaneous sclerosis. Six-year survival was 40% in patients with entry skin scores greater than or equal to 15 and 73% when skin scores were less than 15 (P less than 0.005). An entry skin score greater than or equal to 15 was associated with a high risk of early fatal renal and cardiac complications.

Expression of the potent vasoconstrictor endothelin in the human central nervous system

Endothelin is a potent vasoconstrictive peptide initially characterized as a product of endothelial cells. To examine the potential role of endothelin as a neuropeptide, we studied its distribution in the human central nervous system. RNA blot hybridization provided evidence of endothelin gene transcription in a variety of functional regions of the brain. In situ hybridization confirmed the widespread pattern of endothelin transcription and indicated that the highest density of cells containing endothelin mRNA is in the hypothalamus. This technique localized endothelin transcription to cells of the nervous system as well as the vascular endothelium. Immunocytochemical studies detected endothelin immunoreactivity in neurons, providing evidence of the synthesis of the peptide in this cell type and confirming that endothelin is a neuropeptide. Although the prominent expression of endothelin in the hypothalamus may indicate a central vasoregulatory role for the peptide, the widespread distribution of endothelin in neurons in other areas of the brain implies a more fundamental role in the regulation of nervous system function.

Subzonal transfer of multiple sperm (MIST) into early human embryos

Microinsemination sperm transfer (MIST) is a technique whereby sperm are transferred into the perivitelline space (PVS) with the aid of a micromanipulator. MIST is now used to investigate whether blastomere membranes of early human embryos are capable of fusing with the sperm as in the metaphase II oocyte. Between 10 and 30 sperm were transferred into 11 donated human embryos between pronuclear and 16 cell stage. After culture for 6-24 hr in vitro, the embryos were fixed for transmission electron microscopy (TEM). Both acrosome-intact and acrosome-reacted sperm were located in the PVS and between blastomeres. Sperm in the PVS were sometimes penetrating the inner regions of the zona. Sperm-blastomere membrane fusion was not observed, but sperm tail incorporation by phagocytosis was occasionally evident. Sperm heads incorporated into blastomeres were often located in membrane-bound vesicles. Both acrosome-intact and acrosome-reacted sperm heads were found in vacuoles. Acrosome-reacted sperm heads were lying passively in vacuoles or were undergoing degenerative changes at their surfaces. Sperm chromatin decondensation was not observed in any of the sperm heads that were detected in the blastomeres. The evidence presented clearly shows that sperm heads are incapable of expanding their chromatin to form typical male pronuclei following MIST into early human embryos.

Multiple myeloma in the University Hospital: a retrospective study of biodata, clinical, laboratory and radiological profiles, 1980-1987

A retrospective study of 37 cases of multiple myeloma admitted from 1980 to 1987 to the University Hospital Kuala Lumpur, Malaysia, was carried out to analyse the biodata, clinical presentation, laboratory and radiological profiles. The cases were selected after they had satisfied preset diagnostic criteria. The mean age was 60 years. There was no sex or ethnic preponderance. The most common symptom was bone pain. Pallor was detected in 73% of the patients. Haemoglobin was less than 120 g/L in 95%, and ESR was greater than 100 mm/hr in 70% of cases. Bone marrow and trephine biopsies were diagnostically important. Hypercalcaemia occurred in seven cases out of which three were IgA myelomas. Either serum creatinine or blood urea was raised in nearly 50% of cases. The most common heavy chain paraprotein was IgG while Kappa light chain was the commoner light chain type. 86% of cases had osteolytic lesions. These findings are, in general, similar to those of larger studies on multiple myeloma.

Management of systemic sclerosis--a review

Establishing a correct diagnosis is the first step in the management of this condition. The ARA (American Rheumatism Association) diagnostic criteria is a useful guideline. Next, a multisystem evaluation is needed to define the extent of visceral involvement. Patient education is important to enable them to understand and participate in the management of their disease. Skin care and protection from trauma and cold and physiotherapy to retard contractures are taught. Raynaud's phenomenon may be helped by topical nitrates, ketanserin, nifedipine and vasodilatory prostaglandins. D-penicillamine may be tried for patients with generalised scleroderma of less than 3 years' duration. Colchicine may help but other drugs like N-acetylcysteine and chlorambucil have tested and found ineffective. Cyclosporin seems promising. Finally, all visceral complications should be managed accordingly.

Bilateral spontaneous pneumothorax in systemic sclerosis--report of two cases

We describe 2 patients with systemic sclerosis who developed bilateral spontaneous pneumothoraces. Though unilateral spontaneous pneumothorax has been described, the problem has not been emphasized recently and the complication of bilateral spontaneous pneumothoraces has not been documented. Treatment of the pneumothorax is difficult and reexpansion of the lung is slow. This complication is associated with a poor prognosis as both patients had severe respiratory impairment and one died shortly afterwards.

Ultrastructure of preimplantation human embryos co-cultured with human ampullary cells

Ova with two pronuclei were co-cultured with established human ampullary cell lines and various stages of preimplantation embryonic development were monitored by Nomarski optics and then assessed by transmission electron microscopy (TEM). Fifteen embryos ranging from the 2-cell stage to blastocyst hatching were examined for normal and abnormal features. Their ultrastructure was similar to that of embryos cultured in Whittingham's T6 medium, reported previously. Seven embryos were evidently morphologically normal and showed good organization of fine structure. Most cellular organelles underwent progressive changes during early development. There was evidence of enhanced embryonic genome activation at the 8-cell stage. Invariably, all embryos had few too many fragments, some internalized, which were later segregated into the blastocoele or found outside the trophoblast of the late morula and blastocysts. Six grossly 'normal' embryos assessed by Nomarski had multiple nuclei of various dimensions, which highlights the subjectivity of embryo assessment in the IVF laboratory. Incomplete incorporation of chromatin into nuclei and formation of micronuclei were evident in some blastomeres. The results are discussed in relation to early embryonic loss, prevalent in IVF. Significant events reported include the detection of centrioles at the 8-cell stage, cavitation of the early blastocyst and the initiation of blastocyst hatching visualized by TEM.

Myelodysplastic syndrome: a review from University Hospital, Kuala Lumpur

Twenty patients with Myelodysplastic Syndrome (MDS) were diagnosed in University Hospital, Kuala Lumpur over a 5 year period. They were subclassified using the French American British (FAB) criteria. 90% of the patients were above 40 years old and the sex ratio was about equal. The predominant presenting symptom was anaemia and there was paucity of physical signs at presentation. Patients with 'aggressive' subtypes of MDS i.e. refractory anaemia with excess blasts (RAEB), refractory anaemia with excess blasts in transformation (RAEB(-)+) and chronic myelomonocytic leukaemia (CMML) had more frequent thrombocytopenia and neutropenia and their marrow pictures frequently had dysmegakaryopoiesis and dysgranulopoiesis as compared to more the "benign" subtypes i.e. refractory anaemia (RA) and refractory leukaemic anaemia with ringed sideroblasts (RARS). Four patients had leukaemic transformation and all of them came from the 'aggressive' subtypes. The current views on treatment of MDS are discussed.

Splenic lymphoma with hypersplenism--a case report

A 47-year old man had hypersplenism from massive splenomegaly, the cause of which was undetermined for 2 years. He was initially asymptomatic though there was mild pancytopenia. However, 18 months after presentation he manifested both clinical and haematological deterioration, almost succumbing to sepsis. Splenectomy finally provided a definite diagnosis of follicular lymphoma and also restored his blood counts to within normal range.

Micro-centrifugation of human spermatozoa: its effect on fertilization of hamster oocytes after micro-insemination spermatozoal transfer

Micro-centrifugation (MC) at 6500 r.p.m. (3352 g) has not been used previously for spermatozoal concentration and subsequent fertilization. We investigated MC for micro-insemination spermatozoal transfer (MIST) of human spermatozoa from normal donors into hamster oocytes. MC resulted in reduced penetration of hamster oocytes, both after MIST [77.4% (41/53) versus 87.8% (43/49) for control; NS] and after exposure to zona-free hamster oocytes [60.8% (79/130) versus 72.7% (88/121) for control; P less than 0.05]. However, MIST under the zona resulted in better incorporation of sperm nuclei when compared with zona-free hamster oocytes, for spermatozoa exposed to micro-centrifugation (77.4 versus 60.8%, P less than 0.05) and controls (87.8 versus 72.7%, P less than 0.05). Polyspermy was higher after MIST [22.0% (9/41) versus 13.9% (11/79); NS] for MC+, and [25.6% (11/43) versus 13.6% (12/88); NS] for MC-. We conclude that MC does have a negative, but minimal effect on the fertility of human spermatozoa with respect to hamster oocytes.

Micro-insemination: genetic aspects

Micro-insemination involves sperm deposition directly into oocytes. This can be by transfer of sperm (Micro-Insemination Sperm Transfer, or MIST) or by micro-injection into the ooplasm (Micro-Insemination Micro-Injection into Cytoplasm, or MIMIC). Micro-insemination is indicated in spermatozoa with no or very poor motility, very low density, multiple defects, or inability to penetrate oocyte vestments. There is a 10% incidence of chromosomal abnormalities in spermatozoa from fertile and normal men. However, there is no increase in sperm chromosomal abnormalities in men with normal peripheral karyotypes and highly abnormal sperm parameters. Preliminary results of karyotypes of human oocytes that failed to become fertilized after MIST and mouse morulae and blastocysts produced after MIST reveal that there was no significant increase in aneuploidy or polyploidy. There is evidence that MIMIC may result in increased abnormal sperm karyotypes. Polyspermy is low in the mouse and human after transfer of multiple spermatozoa into the perivitelline space, thus suggesting an oolemmal block. However, blastomere membranes do not fuse with spermatozoa, as observed in a study of MIST into human embryos. Zona drilling with acid is not advised because of disturbances to chromosomal kinetics. The conclusion of this review is that MIST does not result in an increased risk of chromosomal abnormalities, while caution must be exercised with MIMIC.

Acute organic brain syndrome due to drug-induced eosinophilia

A 72 year old man developed acute organic brain syndrome associated with marked eosinophilia following self medication with a variety of drugs. Investigations revealed no other known causes of eosinophilia. Withdrawal of drugs resulted in dramatic drop in eosinophil count paralleled by clinical resolution of neurological problems. To our knowledge drug-induced eosinophilia has not previously been associated with acute organic brain syndrome.

Hybrid acute leukaemia--a report of 3 cases

The simultaneous expression of both lymphoid and myeloid phenotypic features in acute leukaemia is rare. We report 3 cases of biphenotypic hybrid acute leukaemia seen in our institution. All 3 patients achieved remission with treatment for acute lymphoblastic leukaemia but two subsequently relapsed while on treatment. The hybrid acute leukaemias are important areas for further research both for delineation of basic biology and choice of optimal treatment.

Plasma cell leukemia--a case report

An elderly man developed plasma cell leukemia 7 months after multiple myeloma was diagnosed. Thereafter, he deteriorated rapidly and succumbed to the disease 1 month later despite treatment.

Human micro-insemination by injection of single or multiple sperm: ultrastructure

The process of micro-insemination by single or multiple sperm transfer into the perivitelline space (PVS) or by direct sperm injection into oocytes was examined by transmission electron microscopy. Spermatozoa from normal and oligozoospermic men were injected into oocytes, obtained from consenting IVF patients, mostly by zona-puncture using micromanipulators. Spermatozoa were washed by the Percoll or Ficoll methods and capacitated using Whittingham's T6 or modified Tyrode's medium or incubated in strontium medium before injection. The women were stimulated by three IVF methods and oocytes were recovered by laparoscopy or ultrasonography. Sixty-one oocytes were cultured in T6 or Ham's F-10 media (3-24 h) and were subjected to micromanipulation. Four oocytes were also studied after zona-drilling. Normal 2-pronuclear ova were developed after single-sperm transfer satisfying all morphological criteria of fertilization. Both monospermic and polyspermic fertilization resulted after multiple sperm transfer, indicating that a vitelline block to polyspermy may exist in humans. The majority of oocytes examined were unfertilized. Spermatozoa with intact or reacted acrosomes and those undergoing the acrosome reaction were found in the PVS and in the ooplasm. Abnormal spermatozoa were also seen in these locations. Quantitation of acrosomal status in 16 oocytes after multiple-sperm transfer, revealed that 24% of spermatozoa were acrosome-reacted or reacting in the PVS following Ficoll entrapment, while 76% of spermatozoa were intact (33% of these abnormal). Sperm transfer seemed to be the least invasive, while direct sperm injection was comparatively destructive to oocytes. Drilling with acid made larger breaches in the zona when compared with mechanical perforation and spermatozoa occasionally escaped through breaches. Three 2-pronuclear ova obtained after multiple sperm transfer have resulted in two pregnancies, in cases of severe oligozoospermia, during the course of this study.

Establishment of human ampullary cell cultures

Epithelial cells from the ampulla of healthy oviducts from 16 women aged 33-41 years and at different phases of their menstrual cycles were used to establish primary cultures and the continuation of a cell line. The morphology and behaviour of these cells in vitro were evaluated using Nomarski's inverted optics, scanning and transmission electron microscopy. Cells from all patients produced confluent monolayers in 6-7 days with no significant relationship of cell growth with stage of cycle. Fourteen primary cultures were of the epithelioid type while two showed mixed epithelioid and fibroblast-like growth. Two distinct cell types (ciliated and secretory) were observed in primary culture. Secretory cells showed several microvilli of different lengths and distribution. Secretory cells predominated over ciliated cells in all patients, but maximum ciliation occurred around the time of ovulation. Structural features of the cells in vitro were remarkably similar to those described in vivo. Ampullary cells could be maintained in vitro through four to six passages with 3-4 days of growth between passages. Sub-cultured cells were all secretory and were of two types (I and II) based on ultrastructure. Secretory vesicles containing electron-dense material and lipids were observed in these cells. The method described allows for the use of ampullary cells as feeder layers for IVF and support of cleaving human embryos and the evaluation of the biochemical events surrounding fertilization and ectopic pregnancies.

Transfer of human sperm into the perivitelline space of human oocytes after zona-drilling or zona-puncture

To evaluate the transfer of sperm from severely oligozoospermic men into the perivitelline space of mature oocytes, zona-drilling with acid phosphate-buffered saline (PBS) and direct zona-puncture in the presence of cytochalasin D were studied. Zona-drilling also was done for eggs from patients with previous failed in vitro fertilization (IVF). Forty-seven eggs from seven patients with oligozoospermia and three patients with failed IVF had a mean of between 2.6 and 3.6 sperm transferred into the perivitelline space. In the group whose eggs had zona-drilling with acid PBS, 1 of 13 eggs fertilized from the oligozoospermic category, while there was no fertilization from the failed IVF category. Karyotyping of the unfertilized eggs after zona-drilling revealed a high incidence (2/5 and 3/7, respectively) of possible arrest at anaphase II after reinitiation of meiosis. In the group whose eggs were directly punctured through the zona in the presence of cytochalasin D, there was no fertilization in 23 undamaged eggs. Two of the 15 interpretable karyotypes were aneuploid, but this incidence is within that observed for our unfertilized eggs after IVF. Hence, the use of acid PBS for zona-drilling is not advised. Moreover, transfer of sperm from men with previous failed fertilization resulted in poor fertilization rates.

Improved sperm concentration, motility, and fertilization rates following Ficoll treatment of sperm in a human in vitro fertilization program

Duplicate sperm samples from the spouses of 54 patients admitted to an in vitro fertilization program were prepared by the swim-up and a simplified procedure using Ficoll. Cellsoft (CRYO Resources, New York, NY) sperm curvilinear velocities (microns/sec) and mean amplitude of lateral head displacement values (microns) equivalent to grade 1 and 2 visual sperm motility were significantly higher for Ficoll as compared with swim-up samples (P less than 0.01). Fertilization rates were significantly higher in the Ficoll as compared with the swim-up group for poor semen samples (grade less than 2: 58% versus 24%; P less than 0.01) and normal semen samples (grade greater than or equal to 2: 85% versus 78%; P less than 0.05). Ficoll sperm separation appears to be an excellent method of yielding increased fertilization rates in in vitro fertilization programs.

GAP-43 gene expression during development: persistence in a distinctive set of neurons in the mature central nervous system

GAP-43 is a rapidly transported axonal protein most prominently expressed in regenerating and developing nerves. However, the low level persistence of GAP-43 in the adult CNS where growth and regenerative capacity are minimal may additionally indicate a role for this molecule in neuronal remodeling. Previous studies have revealed GAP-43 immunoreactivity in neurites throughout many regions of the CNS. To identify the CNS neurons that express GAP-43 at different stages of development, we utilized in situ hybridization and immunocytochemistry; the latter was performed with an antibody that recognizes GAP-43 immunoreactivity in both perikarya and neurites. In the perinatal period GAP-43 is expressed in all neurons. Subsequently its expression becomes progressively restricted such that by maturity most neurons no longer express detectable levels, although GAP-43 expression is still moderately high in the adult entorhinal cortex, and strikingly high in the adult hippocampus and olfactory bulb. In light of current notions about the function of GAP-43, it is tempting to speculate that this anatomy denotes neurons engaged in structural remodeling and functional plasticity.

Birth from replacement of frozen-thawed embryos after failure of gamete intra-fallopian transfer: a successful pregnancy case

The patient was 8 years subfertile and had failed other forms of treatment when she was enrolled in the GIFT program. Of the total of 16 oocytes recovered 4 were transferred and the remaining 12 inseminated with her husband's sperm. Four resulting embryos were frozen. When she did not conceive, the 4 embryos were thawed 3 months later and replaced into her. She conceived and recently delivered a pair of twins. The protocol will be discussed in detail. Cryopreservation of embryos therefore may increase the patient's chance of pregnancy in a GIFT program.

A Drosophila gene expressed in the embryonic CNS shares one conserved domain with the mammalian GAP-43

By cross hybridization with the mammalian growth-related protein, GAP-43, we have isolated several Drosophila cDNAs and genomic sequences. These sequences correspond to a single copy gene that encodes two developmentally regulated transcripts 2.4 and 2.0 kb in length. The predicted protein sequence from the cDNAs contains a stretch of 20 amino acids closely related to the mammalian GAP-43 protein. These residues are also highly conserved in a cDNA isolated from the nematode C. elegans. Prior to dorsal closure, expression of the Drosophila gene is observed in non-neuronal tissues, especially in the mesectoderm and presumptive epidermis, both in a metameric pattern. After dorsal closure, expression becomes restricted to sets of cells that are segmentally reiterated along the periphery of the nervous system. These cells appear to include at least one specific set of glia that may establish scaffolding for the development of the longitudinal neuropile.

Human fertilization by micro-injection of immotile spermatozoa

Microfertilization of human oocytes with spermatozoa from a man with immotile cilia syndrome is reported, confirming a preliminary investigation where a zona-free donor oocyte was fertilized with spermatozoa from the same patient. Oocytes from his spouse were obtained by laparoscopy after routine stimulation with clomiphene citrate, human menopausal and chorionic gonadotrophins, and were cultured for 4-6 h in Whittingham's T6 medium, supplemented with 10% of her serum. The spermatozoa were washed and processed in the same medium and capacitated for 6-8 h before micromanipulation. Three of five mature oocytes were fertilized by micro-injection of a single immotile spermatozoon into the perivitelline space. One oocyte produced a two-pronuclear ovum assessed 19 h after injection, while the other two produced 2-cell embryos with blastomeres of equal size, 22 h after injection. These embryos cleaved to 3-8-cell stages in culture before embryo replacement. No pregnancy resulted from embryo transfer. The results conclusively demonstrate that human oocytes can be fertilized successfully with immotile spermatozoa by micro-injection and the work has profound implications in the treatment of severe male infertility.

Home central venous hyperalimentation in fifteen patients with severe scleroderma bowel disease

Fifteen patients with severe scleroderma bowel disease began receiving home central venous hyperalimentation (HCVH) between 1979 and 1987. The major reasons for instituting HCVH were intestinal pseudo-obstruction, malabsorption, and malnutrition. Eleven patients had an improved quality of life. Serious complications encountered over these 15,700 catheter-use days were 2 episodes of septicemia and 2 episodes of superior vena cava obstruction. Seven patients died, but none directly from their gastrointestinal disease or from the HCVH.

Methyl isobutyl amiloride: a new probe to assess the number of Na-H antiporters

We measured the binding of [3H]-5-(N-methyl-N-isobutyl) amiloride (MIA) to purified rabbit renal brush border membranes. MIA binding was protein, temperature and time dependent with optimal binding at pH 8.0 or above. At low pH MIA binding was inhibited, suggesting competition between H+ ions and MIA for the MIA binding site. There was 70-80% specific binding which reached a plateau at 30 min and remained stable thereafter for 150 min. Scatchard analysis revealed one family of binding sites with Bmax of 3.4 +/- 0.4 pmoles/mg protein and Kd of 30.5 +/- 2.3 nM. MIA inhibited the Vmax of the Na-H antiporter (assessed by acridine orange quenching) in a dose dependent fashion with 100% inhibition at MIA concentration of 10(-3) M and this inhibition was greater than that of amiloride. We conclude that MIA, a potent inhibitor of the Na-H antiporter, displays a high percentage of specific binding to renal brush border membranes and can be used to assess the number of the Na-H antiporters.

Effect of sperm motility on human in vitro fertilization

Several sperm motility parameters in semen prepared by the swim-up technique were compared with IVF rates in 84 patients. The patients were either on clomiphene + human menopausal gonadotrophin or follicle stimulating hormone + human menopausal gonadotrophin stimulation regimens. Motility ratings were assessed both manually according to World Health Organization guidelines as well as computer-automated semen analysis (Cellsoft, Cryoresources, USA). Motility ratings of greater than or equal to 2 yielded significantly higher fertilization rates (78-82%) than ratings below 2 (20-23%) (p less than 0.001) for patients on both regimens. Velocity (41, 55, 78 microns/sec) and mean amplitude of lateral head displacement (1.96, 3.29, 4.91 microns) correlated significantly with and between manual ratings of 1, 2, and 3, respectively (r = 0.83; p less than 0.01). No significant differences were observed in linearity and beat/cross frequency between the manual ratings, although beat/cross frequencies tended to reduce linearly with increases in intensity of motility. The velocity of sperm motility has a significant effect on fertilization rates, and cut-off points of greater than or equal to 2 or greater than or equal to 50 microns/sec predict the actual potential and likely success of in vitro fertilization. These criteria on the swim-up semen should be used in the selection of patients admitted to IVF programs, and they justify the necessity of research investigations to improve motility in those patients with sluggish motility.

The effects of ultrarapid freezing on meiotic and mitotic spindles of mouse oocytes and embryos

Preovulatory mouse oocytes and 2-cell embryos were frozen with dimethyl sulfoxide and propanediol by an ultrarapid method. The survival of frozen oocytes was low (33-34%) compared to that of 2-cell embryos (78-79%) with either cryoprotectant. Development to blastocysts after postthaw culture was about 7-15% for oocytes and 79-80% for the embryos. Ultrarapid freezing preserves cell structure quite well as revealed by electron microscopy, but meiotic oocytes and late 2-cell embryos undergoing mitosis showed evidence of spindle disorganization involving loss or clumping of microtubules resulting in some scattering of chromosomes. Embryos developed from frozen eggs showed clear evidence of micronuclear formation and incomplete incorporation of chromosomal material into main nuclei. These experiments confirm our observations on freezing of human oocytes and show that spindle microtubules are sensitive to freeze-thawing and that cryopreservation could cause chromosomal aberrations during early development. A cautious approach to the introduction of oocyte freezing in human in vitro fertilization (IVF) programs is advocated.