[Diagnostic approach of an IgM monoclonal gammopathy and clinical importance of gene MYD88 L265P mutation]

INTRODUCTION

An IgM monoclonal gammopathy points to a diagnosis of Waldenstrom's Macroglobulinemia. Other B lymphoproliferatives disorders should be ruled out but the limits are sometimes difficult to define. The discovery of the L265P mutation of the MYD88 gene simplified potentially the situation.

POPULATION AND METHODS

383 patients of the Jules Bordet Institute with an IgM level above 2 g/L were reviewed. For the 49 who had a monoclonal peak, we analysed the underlying pathology in termes of general, clinical and biological characteristics. We checked if the MYD88 mutation had been detected. The overall survival rate was studied.

RESULTS

5 histological groups were identified: Waldenstrom's Macroglobulinemia (MW, N = 27), lymphoplasmacytic lymphoma (LLP, N = 10), marginal zone lymphoma (LMZ, N = 7), monoclonal gammopathy of unknown significance and multiple myeloma (MGUS/MM, N = 5). The MW group was compared to the other groups. Regarding biological characteristics, the IgM level upon diagnosis was statistically higher in the MW group with a median level at 19.5 g/L (2.3-101 g/L) (p-value = 0,0001). Concerning the clinical characteristics, a splenomegaly was more frequent in the LMZ group (p-value = 0,04). The L265P mutation of the MYD88 gene was found in 77 % of patients in the MW group, 60 % of patients in the LLP group and 67 % in the LMZ group (p-value = 0,38). For the 49 patients, the 10-yearoverall survival was 85 % (CI 95 %, 67 % to 94 %) and the 15-year-overall survival was 65 % (CI 95 %, 41 % to 81 %).

CONCLUSION

A monoclonal IgM peak suggests a MW but other B lymphoproliferatives disorders should be excluded. Even if the L265P mutation is frequent in the LLP/MW, it is not specific. A precise diagnosis requires collating clinical, histological, immunophenotypical and genetical data.

[Monoclonal gammopathy of undetermined significance : when and why to look for them ?]

Monoclonal gammopathy of undetermined significance (MGUS) is an asymptomatic premalignant plasma cell disorder. MGUS is a common disorder and the diagnosis is often made accidentally when a protein electrophoresis is performed in a routine blood test or during a biological assessment for other conditions. In the absence of biological abnormalities or clinical symptoms suggesting a plasma or lymphoplasma-cell disorder, there is no indication for routine screening of the monoclonal protein. When MGUS is diagnosed, the risk of transformation into myeloma or other lymphoproliferative disorders is estimated at 1 % per year. MGUS can also be associated with diseases that are not malignant disorders and in some cases, the monoclonal gammopathy is the witness of another rare but severe disorder wich will be critical not to be missdiagnosed.

Factors Influencing Drivers' Left Turn Decisions

An experiment is reported which examined drivers' responses in turning left across a line of traffic as presented in a closed-loop, interactive, fixed-base driving simulator. Drivers were located near an intersection and instructed to turn left across a stream of on-coming traffic when they felt that it was safe for them to do so. The on-coming stream of traffic was varied in terms of the physical parameters of approach velocity, inter-vehicle time interval, and vehicle type. Specifically, seven velocities (10–70 mph) were crossed with seven gap sizes (3–9 sec) to yield forty-nine within-subject conditions for each of four, between-subject, vehicle types; motorcycle, compact car, large car, and delivery truck. There were ten subjects per vehicle type, giving forty total participants in the experiment. Results indicated differential acceptance of gap and velocity combinations depending upon the type of approaching vehicle. Collisions tended to occur along the boundaries where driver's decisions to reject or accept turns were ambivalent. They also occurred with greater frequency at higher velocity approach rates. Turn decisions were not dependent upon a single physical parameter such as vehicle velocity or inter-vehicle distance, although gap-size generated an arguable influence. Rather, left turn decisions appeared to result from the complex interplay of rate-of-change perceptual variables such as “time-to-contact” and the perceived characteristics of the vehicles themselves. Implications of the results are discussed with respect to the perception of vehicles and turn safety at roadway intersections.

Accuracy of computer-aided implant placement

AIM

To assess the accuracy of static computer-guided implant placement.

MATERIAL AND METHODS

Electronic and manual literature searches were conducted to collect information on the accuracy of static computer-guided implant placement and meta-regression analyses were performed to summarize and analyse the overall accuracy. The latter included a search for correlations between factors such as: support (teeth/mucosa/bone), number of templates, use of fixation pins, jaw, template production, guiding system, guided implant placement.

RESULTS

Nineteen accuracy studies met the inclusion criteria. Meta analysis revealed a mean error of 0.99 mm (ranging from 0 to 6.5 mm) at the entry point and of 1.24 mm (ranging from 0 to 6.9 mm) at the apex. The mean angular deviation was 3.81° (ranging from 0 to 24.9°). Significant differences for all deviation parameters was found for implant-guided placement compared to placement without guidance. Number of templates used was significant, influencing the apical and angular deviation in favour for the single template. Study design and jaw location had no significant effect. Less deviation was found when more fixation pins were used (significant for entry).

CONCLUSION

Computer-guided implant placement can be accurate, but significant deviations have to be taken into account. Randomized studies are needed to analyse the impact of individual parameters in order to allow optimization of this technique. Moreover, a clear overview on indications and benefits would help the clinicians to find the right candidates.

Model-based guided implant insertion for solitary tooth replacement: a pilot study

OBJECTIVE

The impact of the implant position on the restorative outcome could justify guided surgery even for the single implants particularly in the aesthetic zone and especially when a simplified concept is available.

MATERIAL AND METHODS

Based on a plaster model, on which the soft tissues were mimicked (according to the thickness measured on a Cone-Beam CT), a tooth-supported, surgical template was prepared. The latter guided all drills so that even flapless implant insertion became possible. All implants were placed by students of the master-after-master training program in Periodontology.

RESULTS

The prospective cohort included a total of 34 implants, all of AstraTech (Osteospeed(®)) type, which were successfully inserted in 29 patients, 16 flapless, 32 onestage. The marginal bone along the integrated implants remained stable over time, with 0.13 mm loss during the first year. The aesthetic parameters were reassuring.

CONCLUSIONS

This simple model-based concept seems to be reliable for the guided placement of single implants and the pre-operative preparation of their restorations.

Management of rectal foreign bodies

The presence of foreign bodies inserted into the rectum is not an uncommon situation. Precise guidelines for the management and extraction of these foreign bodies are not frequently described in the literature. Anal access, whether endoscopic or surgical, varies depending on the type of foreign bodies, their size and morphology, and their location in the lower digestive tract In this report, we describe a case of three rectal foreign bodies that necessitated a mixed endoscopic and surgical approach, and provide a review of the literature.

The obstetrical and neonatal outcome of babies born after single-embryo transfer in IVF/ICSI compares favourably to spontaneously conceived babies

BACKGROUND

Recently, concern has risen about poor obstetrical and neonatal outcome of singletons after IVF/ICSI. Because the population of patients receiving single-embryo transfer (SET) resulting in singleton pregnancies is different from the one that would have become pregnant (with a singleton) before SET was introduced, we wanted to investigate whether the outcome of singleton pregnancies after SET differed from spontaneously conceived singletons.

METHODS

The obstetrical and early neonatal outcome of all pregnancies originating from SET after IVF/ICSI procedures between 1 January 1998 and 31 December 2003, was prospectively collected and analyzed.

RESULTS

Data from 251 singleton pregnancies and births after SET were analyzed and compared to data from 59,535 spontaneously conceived singletons retrieved from the Centre for Perinatal Epidemiology. The mean birthweight of the singletons after SET was 3322 g (+/-538 SD) versus 3330 g (+/-531 SD) for the spontaneously conceived singletons (P = 0.82). The mean gestational age was 38.7 weeks (+/-1.9 SD) for SET and 38.9 weeks (+/-1.8 SD) for spontaneously conceived singletons (P = 0.06). The proportion of very preterm birth (<32 weeks) was 0.8% in each group, and the proportion of preterm birth (<37 weeks) was 10.0% for SET singletons and 6.24% for spontaneous singletons (P = 0.03). However, mean birthweight of very preterm, preterm and term SET singleton babies was similar to the mean birthweight in every category of gestational age in the spontaneous conceived control group. Stillbirth was 0.4% for both populations (P = 0.99).

CONCLUSIONS

Good prognosis patients, in whom SET is applied, do not only have a higher chance of conception but do not have an unfavourable outcome of their singleton baby when compared to spontaneous singletons.

Single top quality embryo transfer as a model for prediction of early pregnancy outcome

BACKGROUND

Single embryo transfer (particularly of a top quality embryo) is an excellent model to correlate embryo quality in terms of morphological criteria to early pregnancy. We investigated whether this model could provide us with more information on what happens after implantation in the first trimester of pregnancy.

METHODS

The outcome of 370 consecutive single top quality embryo transfers in patients younger than 38 years was analysed for pregnancy and first-trimester pregnancy loss (FTPL) before 13 weeks of gestation. Analysis was done on each cohort of embryos from which the transferred top quality embryo was selected. Serum HCG levels were measured on day 8 and day 12 after day 3 embryo transfer. The HCG index was calculated as the level of HCG on day 12/HCG on day 8.

RESULTS

The pregnancy rate after single top quality embryo transfer was 51.9%. This was independent of the patients' age. FTPL, however, appeared to be age dependent: 15.4% for the whole group, 9% in patients younger than 30 years and 19% in patients above 30 years. The pregnancy rate was 50% in IVF cycles and 52% in ICSI cycles; FTPL was 19% in IVF cycles and 10% in ICSI cycles. Multiple regression analysis showed that these differences originated from age differences between both populations rather than from technique-related factors. An HCG level >or=45 IU/l on day 12 was predictive for ongoing pregnancy with 75.6% sensitivity and 100% specificity; an HCG index >or=3.5 similarly predicted ongoing pregnancy with 72.3% sensitivity and 100% specificity.

CONCLUSIONS

These data show that embryo selection for transfer on day 3 can be used as an excellent tool for prediction of pregnancy but not for prediction of FTPL. The pregnancy rate of a single top quality embryo is not related to age, whereas FTPL is age dependent.

A real-life prospective health economic study of elective single embryo transfer versus two-embryo transfer in first IVF/ICSI cycles

BACKGROUND

We analysed the difference in maternal, neonatal and total costs after single (SET) versus double day 3 embryo transfer (DET).

METHODS

We performed a two-centre prospective study of women in their first IVF/ICSI cycle choosing between SET or DET. Infertility treatment data were gathered from a database; maternal and neonatal outcome data from a case report form (CRF); health economic data from medical acts registered in the CRF for the outpatient part and from hospital bills. SET was performed in 206/367 (56.1%) and DET in 161/367 (43.9%) women.

RESULTS

In all, 367 transfers yielded 186 positive pregnancy tests, 148 ongoing pregnancies and 136 live deliveries (50.7, 40.3 and 37.1% per embryo transfer) of which 15 (11.0%) were twins. Live birth rate was 37.4% for SET, 36.6% for DET. Intention-to-treat analysis showed differences for: duration of pregnancy (SET: 39.0 +/- 1.4 versus DET: 38.3 +/- 2.2 weeks; P = 0.055), percentage prematurity (8.5 versus 23.8%; P = 0.033), percentage of neonates hospitalized (5.7 versus 17.9%; P = 0.121) and duration of neonatal hospitalization (6.3 +/- 2.2 versus 10.3 +/- 10.1 days; P = 0.01). Total cost after DET was higher (SET: 4700 +/- 3239 versus DET: 8613 +/- 10 105; P = 0.105), due to significantly higher neonatal costs (451 +/- 957 versus 3453 +/- 8154; P < 0.001) and not to differences in maternal costs (4250 +/- 2882 versus 5160 +/- 4106; P = 0.152).

CONCLUSIONS

This prospective health economic study shows that transfer of a single top quality embryo is equally effective as, but substantially cheaper than, double embryo transfer in women <38 years of age in their first IVF/ICSI cycle.

Cryopreservation as a tool to reduce multiple birth

The potential role of embryo cryopreservation from the point of view of prevention of multiple pregnancies is analysed. Cryopreservation is an unavoidable option in stimulated IVF/intracytoplasmic sperm injection (ICSI), but at the same time an underestimated tool in the prevention of twins. There is a need for an evaluation system not only of the cryotechnology process per se, but also of the true augmenting effect of cryopreservation on the total reproductive potential of a single oocyte harvest. Only cryopregnancies occurring after an unsuccessful fresh cycle (possibly followed by one or more unsuccessful freeze-thaw cycles with embryos from the same harvest) truly reflect the augmentation potential of cryopreservation. This potential is greater than generally thought. First, the efficacy of cryopreservation is suboptimal with survival rates between 30 and 70%. Second, if single-embryo transfer were applied in a much larger proportion of cycles than is presently the case, more embryos would be available for cryopreservation, resulting in more and more successful freeze-thaw cycles. In the future, the combination of elective single-embryo transfer with an optimized cryopreservation programme is likely to become the standard of care for routine IVF/ICSI treatment.

Impact of patients' choice for single embryo transfer of a top quality embryo versus double embryo transfer in the first IVF/ICSI cycle

BACKGROUND

The aim of this study was to evaluate the impact of transferring a single top quality embryo in the first IVF/ICSI cycle of patients <38 years old who chose to have one or two embryos transferred.

METHODS

A total of 262 patients participated in the study, and 243 transfers were performed: 156 (64%) patients chose the transfer of a single top quality embryo, if available, and two non-top quality embryos if not available; 87 (36%) patients chose to have a double embryo transfer regardless of embryo quality.

RESULTS

In the first group an ongoing pregnancy rate of 40% (63/156) with a twin pregnancy rate of 2% (1/63) was achieved. In the second group the ongoing pregnancy rate was 44% (38/87) with 26% (10/38) twin pregnancies. In the patient group with only one embryo transferred, irrespective of the patient's choice, the ongoing pregnancy rate was 43% (54/127) with no twin pregnancies. For the study population as a whole, the ongoing pregnancy rate was 42% (101/243) with 11% (11/101) twins.

CONCLUSION

We conclude that the introduction of single embryo transfer in the first IVF/ICSI cycle is highly acceptable in women <38 years old.

Intracytoplasmic sperm injection in the treatment of male subfertility

OBJECTIVE

To evaluate the results obtained after intracytoplasmic sperm injection (ICSI) in couples with male factor subfertility.

DESIGN

Retrospective analysis of results obtained after ICSI in the unit of in vitro fertilisation in a private centre for infertility.

RESULTS

Application of ICSI in treatment cycles for male subfertility resulted in a fertilisation rate of 62%. An embryo transfer was done in 98% of the cycles, resulting in a 24% pregnancy rate/ET or 22% per cycle.

CONCLUSION

ICSI is the first microfertilisation technique with reproducible high fertilisation rates in different centres and the method of choice in the treatment of severely impaired sperm quality. Although, up to now, no higher incidence of congenital malformations has been reported, except for sex chromosomal anomalies, careful genetic counselling is mandatory because of the risk of transmitting genetically defined male subfertility to the next generation.

Mitochondrial distribution after fast embryo freezing

Mitochondrial distribution pattern after ultrarapid freezing in dimethylsulphoxide was assessed in human multipronucleate zygotes, 2-cell and 4-cell stage embryos using rhodamine 123. The mitochondrial distribution pattern was evaluated at 37 degrees C after a 30 min incubation in rhodamine 123 solution, 4 h and 24 h after thawing. Non-frozen human unfertilized oocytes, 2-cell and 4-cell embryos used as a control showed a homogeneous distribution of mitochondria throughout the cytoplasm, while there was sequestration of mitochondria from the cortex to the region surrounding the pronuclei in multipronucleate zygotes. Morphologically intact multipronucleate zygotes, 2-cell and 4-cell stage embryos after quick freeze-thawing showed the same mitochondrial distribution pattern found in the unfrozen controls. Mitochondria exhibited a typical severe aggregation (clumping) throughout the cytoplasm when non-viable single blastomeres or embryos at thawing were exposed to rhodamine 123. Our study indicates that quick freezing does not affect subcellular structures. The well-organized and specific mitochondrial distribution appeared still to be present after frozen storage, and subcellular structures seemed to be rather resistant targets for cryo-injury.

Subzonal insemination: a prospective randomized study in patients with abnormal sperm morphology

OBJECTIVE

To evaluate in a prospective randomized study the outcome of subzonal insemination (SUZI) in patients with male subfertility.

DESIGN

In a period of 7 months, 48 patients underwent IVF treatment for male subfertility reasons. Normal insemination and SUZI were performed on sibling oocytes. Patients were divided into three groups depending on the sperm morphology (strict criteria): group 1, 10% to 14%; group 2, 5% to 10%; group 3, 0% to 5%.

SETTING

Private fertility center in Leuven, Belgium.

MAIN OUTCOME MEASURES

The fertilization rates, cleavage rates, implantation rates, and pregnancy rates between the normally inseminated and the SUZI-treated group were compared.

RESULTS

The fertilization rate with SUZI was significantly higher (32%) than after normal insemination (7%). The difference was striking in groups 2 and 3 (35% and 33% versus 11% and 4%).

CONCLUSION

This study indicates that SUZI increases the fertility outcome in patients with male subfertility and that there is a marked difference in fertilization rate when morphology, using strict criteria, is < 10%.

Analysis of whole-arm translocations in malignant blood cells by nonisotopic in situ hybridization

Whole-arm translocations in five leukemic patients were studied using nonisotopic in situ hybridization with alpha satellite DNA and simple satellite chromosome-specific DNA probes to detect the target sequences. The results show that this technique provides additional information on the involvement of these DNA sequences in whole-arm translocations.

Characterization of a de novo duplication of 11p14----p13, using fluorescent in situ hybridization and southern hybridization

A de novo 11p+ chromosome was found in a child with mild mental retardation but no other remarkable dysmorphic characteristics. Banding studies suggested a duplication of regions 11p13 and 11p14 or regions 11p14 and 11p15. Using fluorescent in situ hybridization and digital imaging microscopy, we mapped probe p32.1 (D11S16) to the proximal part of region 11p14 (11p14.1) and demonstrated duplication of this probe in our patient. Southern hybridization showed duplication of p32.1 and other probes located at 11p13 and 11p14, but the gene for alpha calcitonin (CALCA), located at 11p15, was not duplicated. The application of these techniques led to the identification of the duplication as dir dup(11)(pter----p13::p15.1----qter).

Identification and characterization of normal length nonfluorescent Y chromosomes: cytogenetic analysis, southern hybridization and non-isotopic in situ hybridization

In two female patients with a 45,X/46,X, +mar karyotype the marker chromosomes were identified as normal length nonfluorescent Y chromosomes (nlYnf) using non-isotopic in situ hybridization (NISH) complementary to routine cytogenetic analysis and Southern hybridization. The recognition of the nlYnf as isodicentric in both patients illustrates and confirms the usefulness and importance of NISH in the identification and characterization of this and many other types of complex chromosome rearrangements.

Time estimation performance before, during, and following physical activity

An experiment is reported which evaluated performance on a 10-sec unfilled time interval estimation task before, during, and after physical work on a cycle ergometer at relative intensities of 30 and 60% VO2max. Results from eleven healthy male subjects revealed a significant increase in time estimation variability and a decrease in the mean estimated time intervals during exercise compared to non-exercise phases. These findings are part of a growing body of evidence which indicates that exercise and its severity has a substantive impact on perceptual and cognitive performance, particularly the ability to synchronize and anticipate the timing of events.

Intraseason changes in the body composition of collegiate female gymnasts

Body composition measures were collected pre-, mid- and post-season on a team of eight national-calibre collegiate women gymnasts to examine intraseason changes. Also analysed were interseason changes using pre- and post-season data on five of the eight subjects during the current and previous year, according to a 2 x 2 (years x tests) analysis of variance repeated-measures design. Skinfold, circumference and diameter measures were collected with percentage body fat, lean body mass and body density determined by regression equations developed specifically for collegiate female gymnasts. Intraseason body weight decreased significantly from pre- to mid-season (means = 55.0 and 53.6 kg respectively); but the difference between mid- and post-season (53.9 kg) values was not significant (P greater than 0.05). The majority of the 1.4 kg weight loss occurred during intense pre-season conditioning and not during the actual season. Percentage body fat, on the other hand, decreased significantly from pre- to mid-season and mid- to post-season (means = 21.4%, 17.4% and 13.45% respectively; P less than 0.0005). Body density increased significantly from pre- to mid-season and mid- to post-season (means = 1.0476, 1.0584 and 1.0681 respectively; P greater than 0.0005). Of the circumference and skinfold values used in calculating percentage body fat and body density, only the skinfold values displayed significant decreases throughout the season. Interseason analyses revealed no significant changes in any of the dependent measures between seasons, despite consistent trends. There were no significant years x tests interactions and all intraseason changes for two seasons (n = 5) were the same as those found in more detailed analysis of a single season (n = 8) except in the case of weight loss, which was marginally significant (P less than 0.046) in the single-season and not in the dual-season analysis (P greater than 0.05). Body composition of these gymnasts changed in many ways within competitive seasons. The most pronounced changes observed were decreases in subcutaneous fat and increases in body density. This study reinforces the need for administrators, coaches and athletes to be concerned with percentage body fat and skinfold measures rather than weight alone when determining if a person is 'fat'.

Hot air breathing: effects of elevated wet bulb temperatures on tissue temperatures of the mouth

Six healthy young men breathed room air or one of nine hot humid air conditions on separate days for one hour while walking on a treadmill (40% VO2 max). Inspired wet bulb temperatures ranged from 18.9 (room air) to 49.3 degrees C. Tissue temperatures in the mouth were measured by means of thermocouples placed on the tongue and hard palate. Analysis of variance on repeated measures showed significant increases in both tongue and hard palate tissue temperatures (p less than 0.001) as a result of increasing wet bulb temperatures; however, core temperature and heart rate were not affected (p greater than 0.05). Ratings of subjective discomfort increased proportionally with increases in wet bulb temperature of the inspired air. It was concluded that wet bulb temperature of inspired air is a valuable measure to uses in studying temperature responses of mouth tissues when inhaling hot humid air, particularly when investigating human tolerance levels in order to recommend federal standards for the design of breathing apparatus.