Can Anti-Müllerian Hormone levels predict future pregnancy outcomes in recurrent pregnancy loss?

OBJECTIVE

Serum Anti-Müllerian Hormone (AMH) levels have been shown to be lower among women who have experienced recurrent pregnancy loss (RPL) compared with the general population. However, it is unclear whether it can predict livebirth. This study aims to determine whether AMH can predict the likelihood of a livebirth in women with RPL.

STUDY DESIGN

Prospective analysis of a consecutive cohort of women undergoing investigation for RPL in a tertiary referral centre over a seven year period (August 2014 -December 2021). Analysis was performed using descriptive statistics, chi-square models and logistic regression models adjusting for maternal age and previous livebirth. Exclusion criteria for the regression analysis included abnormal parental karyotype and abnormal pelvic ultrasound scan. Pregnancy outcome was defined as livebirth or further pregnancy loss.

RESULTS

There were 488 women who underwent investigation of RPL during the study period. Of these, 65.2% (n = 318) conceived following attendance at the clinic. The majority of these women (69.4%, n = 221) proceeded to have a livebirth. There were no differences in median AMH levels between the livebirth group and the further pregnancy loss group (11 pmol/L vs 9 pmol/L respectively (p = 0.083). AMH did not affect clinical pregnancy rates (p = 0.77, 95% CI = 0.99 [0.98, 1.01]) or pregnancy outcome (p = 0.30, 95% CI = 1.01 [0.99, 1.04]). Abnormal pelvic ultrasonography (p = 0.04) and an abnormal parental karyotype (p = 0.04) were associated with an increased likelihood of a subsequent pregnancy loss.

CONCLUSION

Although AMH levels may have some utility in counselling of some couples with RPL, these contemporaneous data indicate that low AMH does not negatively influence subsequent pregnancy outcome in women with recurrent pregnancy loss.

Opportunistic and interventional salpingectomy in women at risk: a strategy for preventing pelvic serous cancer (PSC)

OBJECTIVE

Salpingectomy is proposed as a prophylactic measure to reduce the incidence of tubo-ovarian/pelvic serous cancers. We surveyed the attitudes of obstetrician/gynecologists to incorporating salpingectomy opportunistically into surgery for benign conditions, and electively for young BRCA mutation carriers.

STUDY DESIGN

A questionnaire, designed to assess current standard clinical practice and willingness to perform salpingectomy for female sterilization at abdominal hysterectomy for benign disease (ABH), vaginal benign hysterectomy (VBH) and electively for women with BRCA mutations who wish to postpone oophorectomy was mailed to obstetrician/gynecologists working in Irish hospitals.

RESULTS

In their current practice of interval female sterilization 96% of gynecologists applied clips at laparoscopy and 4% performed salpingectomy, and 73% were willing to consider salpingectomy. Eighty-one percent were willing to consider salpingectomy for sterilization at cesarean section. Gynecologists performing hysterectomy (without oophorectomy) for benign conditions did salpingectomy in 26% at ABH and 5.4% at VBH, and now 90% would consider salpingectomy at ABH and 66% at VBH. Two-thirds of respondents would consider salpingectomy for women at genetic risk of ovarian cancer who want to postpone oophorectomy.

CONCLUSION

Changing general gynecological practice to include more opportunistic salpingectomy has the potential to reduce the incidence of serous cancers. The majority of gynecologists are willing to incorporate more salpingectomies into their surgical practices and consider elective salpingectomy as an interim measure for women with defined genetic risk of pelvic serous cancer.

Stenting of partial and total coronary occlusions in Trinidad and Tobago

In order to evaluate the efficacy and safety of coronary stenting, we reviewed the first 32 consecutive patients (34 vessels) who underwent elective coronary stenting during the period August 1999 to August 2000 inclusive at the Digital Lab installed at the Eric Williams Medical Sciences Complex, Trinidad and Tobago. Aspirin, heparin and ticlopidine were used routinely. Abciximab was used in selected cases (38%). The mean age of patients was 55 +/- 10 years. Eighty-one per cent were male, 52% were hypertensive and 21% were diabetic. Sixty-five per cent had severe angina. Prior Coronary Artery Bypass Grafting (CABG) was performed in 3% and previous Percutaneous Transluminal Coronary Angioplasty (PTCA) in 3%. Multivessel disease was present in 43%. The mean left ventricular ejection fraction was 53 +/- 12%. The culprit lesion was located in either the native left anterior descending (LAD) coronary artery (53%), right coronary artery (RCA) (31%), circumflex artery 13% and saphenous vein graft (3%). The mean baseline diameter stenosis was 91 +/- 9% and this was reduced to 13 +/- 33% after stenting. Procedural success was 100% for 26 partially occluded vs 50% for 8 totally occluded vessels. For the total occlusions, procedural success was inversely related to the duration of the occlusion. There were no cases of death, acute vessel closure, Q-wave myocardial infarction, repeat PTCA or emergent Coronary Artery Bypass Graft (CABG) during and following the procedure. Distal embolization occurred in one patient. The mean duration of hospital stay was one day (for 30 outpatient cases). One patient had recurrence of symptoms with a negative stress test. No patient underwent repeat angiography during the first year of follow-up. Coronary stents were successfully implanted at a tertiary care facility in the Caribbean with low in-hospital morbidity and mortality. Stents markedly reduced the diameter stenosis of the coronary lesion during PTCA. The incidence of clinical restenosis was low. Coronary revascularisation can be successfully achieved by coronary stenting in the Caribbean.

Work-based antipoverty programs for parents can enhance the school performance and social behavior of children

We assess the impact of the New Hope Project, an antipoverty program tested in a random assignment experimental design, on family functioning and developmental outcomes for preschool- and school-aged children (N = 913). New Hope offered wage supplements sufficient to raise family income above the poverty threshold and subsidies for child care and health insurance to adults who worked full-time. New Hope had strong positive effects on boys' academic achievement, classroom behavior skills, positive social behavior, and problem behaviors, as reported by teachers, and on boys' own expectations for advanced education and occupational aspirations. There were not corresponding program effects for girls. The child outcomes may have resulted from a combination of the following: Children in New Hope families spent more time in formal child care programs and other structured activities away from home than did children in control families. New Hope parents were employed more, had more material resources, reported more social support, and expressed less stress and more optimism about achieving their goals than did parents in the control sample. The results suggest that an anti-poverty program that provides support for combining work and family responsibilities can have beneficial effects on the development of school-age children.

Administration of DAB389IL-2 to patients with recalcitrant psoriasis: a double-blind, phase II multicenter trial

BACKGROUND

Current therapies for recalcitrant psoriasis focus on immunoregulation and targeting of activated T-lymphocytes rather than keratinocytes. Previous studies with low doses of the lymphocyte-selective fusion protein DAB389IL-2 have shown benefit to patients with psoriasis.

OBJECTIVE

We examined the safety and efficacy of DAB389IL-2 in 41 volunteers receiving more frequent and higher doses than in a previous trial.

METHODS

Patients were randomized to receive either placebo or 5, 10, or 15 microg/kg daily of DAB389IL-2 intravenously for 3 consecutive days each week for 4 consecutive weeks with a subsequent 4-week observation period.

RESULTS

Of the placebo group, 17% (2 of 12) exhibited at least 50% improvement from baseline Psoriasis Area and Severity Index scores at the end of the study, whereas 24% of all treated patients (7 of 29) showed the same improvement. Overall, 3 of 12 (25%) patients given placebo as opposed to 12 of 29 (41%) patients treated with DAB389IL-2 improved to this same extent at some point during the study. The rate of improvement for treated patients was significantly greater than for placebo patients (p = 0.04; repeated measures ANOVA). Among treated patients, decreases in Psoriasis Area and Severity Index scores were paralleled by changes in the Physician's Global Assessment and the Dermatology Life Quality Index. Treatment in ten patients was discontinued because of adverse events. Flu-like symptoms were the most common with severity increasing at the two higher doses. Only one serious adverse event was reported. This occurred in a patient receiving 5 microg/kg daily who experienced vasospasm and a coagulopathy resulting in arterial thrombosis.

CONCLUSION

Our findings are consistent with the potential antipsoriatic activity of DAB389IL-2 demonstrated in an earlier study. However, DAB389IL-2 was less well tolerated at this dosing regimen, particularly at the highest dose, and it was too toxic at these doses and schedules to be considered in the routine treatment of psoriasis.

Purchasing. The wasted millions

In the wake of the Child B rationing controversy, the Anti-Rationing Group challenged purchasers to allow them to scrutinise their practice. Eight health authorities accepted and, say Colin Roberts and colleagues, the results show public money being needlessly wasted on a staggering scale.

Education in emergency nursing: a new beginning. Part 2

Continuing from the previous issue, this paper discusses the process of developing the content of new courses under the umbrella of the Graduate Diploma/Masters in Emergency Care Nursing offered at Griffith University Gold Coast, Australia. Part 2 of this paper includes information on course structure, implementation, content, assessing methods and competences and the logistics of the course.

Education in emergency nursing: a new beginning. Part I

The movement of nurse education to the tertiary sector is all but complete in Australia. Trends are changing as new partnerships are being forged and the focus of education is now responsive to economic and political factors. These factors have resulted in the regionalisation of health care facilities and the de-institutionalisation of health services in Queensland, Australia. Moreover, de-institutionalisation of services coupled with economic rationalism has pre-empted the offering of post-graduate clinical courses by university nursing facilities. This paper addresses the process of developing the content of new courses under the umbrella of the Graduate Diploma/Masters in Emergency Care Nursing offered at Griffith University Gold Coast, Australia. This initiative is the first in Queensland and has revisioned the education of emergency care nursing. This course includes a tapestry of knowledge enhancing, clinical and factual subjects presented by experienced clinicians teaching with academics, recognising the collaborative nature of nursing practice with academics and clinicians working jointly in course development, teaching and clinical placement. Strategies developed collaboratively addressed course content including logistics, time management, the critical selective selection of appropriate content, assessment criteria, registerability within Queensland and other states and clinical competence. Moreover, this process of developing the course utilised the Australian National Registering Authorities' Competencies and Benner's use of the Dreyfus model to guide the knowledge level of the clinician at course completion. In particular this paper will not only address the blending of theory and practice to consolidate the relationship inherent between the clinician and education, but will establish the fact that no gap exists.

Systemic disease in subacute cutaneous lupus erythematosus: a controlled comparison with systemic lupus erythematosus

OBJECTIVE

We sought to compare the prevalence of systemic disease in subacute cutaneous lupus erythematosus (SCLE) with systemic lupus erythematosus (SLE).

METHODS

Clinical and laboratory features of 14 patients with SCLE were compared with 22 age and sex matched controls with SLE.

RESULTS

Manifestations other than arthritis and skin disease were present in 11/14 (79%) SCLE cases compared with 19/22 (82%) SLE cases. Severe systemic disease occurred in one-half of patients with SCLE (5/7 men, 1/7 women), and most had the papulosquamous pattern.

CONCLUSION

Systemic manifestations may be as varied in SCLE as in SLE, and severe disease is not unusual. In particular, men with papulosquamous SCLE may be at higher risk for severe extracutaneous disease.

Correlation between class I antigen expression and the ability to generate tumour infiltrating lymphocytes from bladder tumour biopsies

Analysis of tissue sections from transurethrally resected bladder tumours using anti-CD3 antibody showed the presence of T lymphocytes in intra-epithelial layers in eight of 12 cases investigated. In a larger group of patients, Tumour Infiltrating Lymphocyte (TIL) growth was established from six of 19 cases using Interleukin-2 (IL-2) and conditioned medium (CM) and resulted in the expansion of TILs up to 100-fold. TILs from these individuals were phenotyped with W6/32 (anti-HLA-A,B,C), HB55 (anti-DR) and anti-CD3 antibodies using FAC sorter. The mean +/- s.d. frequency of positive staining with these antibodies were 96.7 +/- 4.0%, 87.5 +/- 10.0% and 82.5 +/- 7.8% respectively, indicating the activated nature of these T cells. The cytotoxic activity of these TILs against Daudi (ie, LAK activity) cell line at 25/1 E/T ratios varied from 26.3 +/- 3.2 to 62.8 +/- 5.2%. In one case where TILs and autologous tumour cell line were established, cytotoxicity studies showed low level of cytotoxicity against the autologous tumour cells (15.8 +/- 1.6%) compared with 62.8 +/- 5.2% against Daudi. Staining of tumour sections from these 19 individuals with W6/32 and BBM.1 revealed positive staining in six of six that developed TILs but only six of 13 (46%) cases, whose tumour failed to grow TILs (P less than 0.02, Fisher exact test). These results are indicative of the presence of IL-2 passageable T cells in bladder cancer biopsy and demonstrate that the successful expansion of these cells correlates with the normal expression of class I antigens on the tumour cells.

Paired tumour infiltrating lymphocyte (TIL) and tumour cell line from bladder cancer: a new approach to study tumour immunology in vitro

This paper reports the first example of tumour infiltrating lymphocytes (TILs) and a tumour cell line from the same individual and analyses their characteristics. The tumour cell line (CAT), derived from a patient with well-differentiated (G3pTa) TCC, has been in culture for 24 months and subcultured more than 100 times. Epithelial origin was established by electronmicroscopy and use of a range of monoclonal antibodies (Mabs) against cytokeratins. The TILs isolated from the same tumour expressed all the phenotypic characteristics of normal activated T cells and demonstrated low levels of cytotoxicity against the autologous tumour line (CAT). Comparison of cell surface molecules of these cells revealed the loss of HLA-B7, B44 and Bw6 from the CAT cells whilst maintaining HLA-A2, A3 and Bw4. Karyotypic analysis demonstrated three rearranged chromosomes (between chromosomes 4 and 11, 10 and 13, 11 and 17) on CAT cells. The potential that study of paired autologous tumour cells and TILs in culture offers for studying the role of MHC antigens in tumour rejection and the impact of different approaches to correcting the defect are reviewed.

Selective and non-selective loss of immunoregulatory molecules (HLA-A,B,C antigens and LFA-3) in transitional cell carcinoma

The expression of the major histocompatibility complex (MHC) class I and II antigens and lymphocyte function-associated antigen-3 (LFA-3) was investigated using immunohistochemical staining of bladder tissue sections from 18 patients with transitional cell carcinoma (TCC) and two normal bladder specimens. The expressions of HLA-A,B,C antigens varied greatly between different tumours. Complete loss was observed in one of 18 cases. Moderate to strong expression of HLA-A,B,C antigens was observed in 10 of 18 cases with the remaining seven cases showing either weak expression or expression on only a proportion of the tumour cells. Selective loss of HLA-Bw6 was seen in one of 18 cases. In many cases heterogenous and often focal expression of HLA-D products was seen. In one case tumour cells not expressing HLA-DR antigens were adjacent to strongly HLA-DR expressing non-neoplastic bladder epithelium, indicating a lack of inducible HLA-DR in the tumour cells. LFA-3 was undetectable in two of 18 cases with the remaining 16 cases showing moderate to strong expression of the molecule. These findings indicate that a substantial proportion of bladder tumours have one or more of a wide range of different alterations in the expressions of immunoregulatory molecules that could contribute to escape from immune surveillance.

Evaluation of the effect of continuous infusion recombinant interleukin-2 (bioleukin) on peripheral blood leucocytes of patients with terminal malignancy

Seventeen patients with terminal malignancy have been entered into a sequential investigation of two doses of continuous infusion recombinant interleukin-2 (bioleukin) given in the setting of a general ward. After an initial experience of a dose of 300 micrograms m-2 in eight patients the remainder received 400 micrograms m-2. Temporary interruption of treatment at the first sign of any serious toxicity led to rapid resolution of side-effects. No patient needed intensive care support, although nine of 17 required temporary interruption of infusion, lasting on average 4 h. Median lymphocyte rebound on day 14 was 3.6 times the pre-treatment level. It remained above pre-treatment levels in four of five patients who had no shown disease progression at day 56 after more than 28 days off treatment. Minor responses occurred in five patients, lasting on average 4 months.

Biological significance of beta hCG, HLA and other membrane antigen expression on bladder tumours and their relationship to tumour infiltrating lymphocytes (TIL)

Expression of beta human chorionic gonadotropin (beta hCG) by bladder tumours has been shown to be associated with increased metastases and resistance to treatment with radiotherapy and chemotherapy. Preliminary results from typing frozen tumours using monoclonal antibodies against HLA determinants show reduced or lost expression of one or more antigens in two thirds of patients studied with a trend for more malignant behaviour and inability to generate tumour infiltrating lymphocyte expression using Interleukin-2 in those patients whose tumours demonstrate loss. In this series beta hCG expression was only seen in a subgroup of those demonstrating loss of HLA antigen expression. Studies of beta hCG secreting bladder cancer cell lines showed that it was possible to induce class II HLA antigen expression with gamma Interferon, and that this treatment but not alpha Interferon reduced beta hCG production by the cell line.

First person account: growing up with a schizophrenic mother

In this essay, I have tried to present the way in which I grew up and matured in an environment where there was little or no nurturing due to the disease process of paranoid schizophrenia in my mother. I have attempted to describe my own particular method of dealing with my feelings in my attempt to survive my early home life and somehow emerge intact. As an adult, I had to halt in the path I had chosen and seek professional help in the form of psychotherapy to begin to unlearn my early survival tactics. Although they had been effective during my childhood, once I was no longer living with an active schizophrenic patient, these tactics no longer served me well. Indeed, they could have been my undoing.

Infrared spectrometer for Voyager

The Voyager IR investigation uses a Michelson interferometer with a 4.3-cm(-1) spectral resolution in the 80-2500-cm(-1) range and a single-channel radiometer for the visible and near-IR, 5000-30,000-cm(-1). Both devices share a Cassegrain telescope with a 50-cm diam primary mirror and a 0.25 degrees field of view. Design, calibration, and performance are discussed along with a sample spectrum of Jupiter.

A study of human cardiac allograft in a patient with four-year survival

A report is presented of a patient surviving four years with a human cardiac allograft. The allograft arteries showed marked graft arteriosclerosis with intimal fibrocellular proliferation. The arteriosclerotic lesions occurring in the larger epicardial vessels were strikingly similar to spontaneous atherosclerosis. The relationship of the long-term survival to the use of a permanent transvenous pacemaker and of the development of severe vascular lesions to acute rejection and hyperlipemia are discussed.