Association of ovarian response with picoAMH in women undergoing controlled ovarian hyperstimulation

OBJECTIVE

Our study aims to evaluate the diagnostic performance of a high-sensitivity picoAnti-Müllerian Hormone (picoAMH) for predicting ovarian response in women undergoing controlled ovarian hyperstimulation and occurrence of ovarian hyperstimulation syndrome.

METHODS

Retrospective cohort study at a single academic fertility center including all patients with picoAMH ELISA who underwent controlled ovarian hyperstimulation. The primary outcome was the number of oocytes retrieved, and secondary outcomes included cycle cancellation and ovarian hyperstimulation syndrome. Patients were grouped into poor, normal, and hyper-responders based on number of oocytes retrieved.

RESULTS

The mean AMH and antral follicle count (AFC) were significantly different between normal response vs. hyper response group (p < 0.0001). Only serum AMH and not AFC was significantly increased in patients diagnosed with ovarian hyperstimulation syndrome (OHSS). For prediction of OHSS, receiver operating characteristic (ROC) analysis revealed that AMH (area under the ROC curve [AUC] = 0.85) was significantly better than the AFC (AUC = 0.64). The serum AMH cut-off at sensitivity of 80% for predicting OHSS among hyper responders from ROC curve was 3.67 ng/ml. Serum AMH measured by picoAMH ELISA showed superior correlation to number of oocytes retrieved when compared to AFC in the age group over 40 years old (r² = 0.74 and r² = 0.4, respectively) CONCLUSION: This study shows great utility of picoAMH ELISA for predicting ovarian response to controlled ovarian hyperstimulation (COH). Diagnostic performance of picoAMH for prediction of OHSS is superior to the AFC in our cohort.

Congenital Uterine Malformation by Experts (CUME): better criteria for distinguishing between normal/arcuate and septate uterus?

OBJECTIVES

To assess the level of agreement between experts in distinguishing between septate and normal/arcuate uterus using their subjective judgment when reviewing the coronal view of the uterus from three-dimensional ultrasound. Another aim was to determine the interobserver reliability and diagnostic test accuracy of three measurements suggested by recent guidelines, using as reference standard the decision made most often by experts (Congenital Uterine Malformation by Experts (CUME)).

METHODS

Images of the coronal plane of the uterus from 100 women with suspected fundal internal indentation were anonymized and provided to 15 experts (five clinicians, five surgeons and five sonologists). They were instructed to indicate whether they believed the uterus to be normal/arcuate (defined as normal uterine morphology or not clinically relevant degree of distortion caused by internal indentation) or septate (clinically relevant degree of distortion caused by internal indentation). Two other observers independently measured indentation depth, indentation angle and indentation-to-wall-thickness (I:WT) ratio. The agreement between experts was assessed using kappa, the interobserver reliability was assessed using the concordance correlation coefficient (CCC), the diagnostic test accuracy was assessed using the area under the receiver-operating characteristics curve (AUC) and the best cut-off value was assessed using Youden's index, considering as the reference standard the choice made most often by the experts (CUME).

RESULTS

There was good agreement between all experts (kappa, 0.62). There were 18 septate and 82 normal/arcuate uteri according to CUME; European Society of Human Reproduction and Embryology (ESHRE)-European Society for Gynaecological Endoscopy (ESGE) criteria (I:WT ratio > 50%) defined 80 septate and 20 normal/arcuate uteri, while American Society for Reproductive Medicine (ASRM) criteria defined five septate (depth > 15 mm and angle < 90°), 82 normal/arcuate (depth < 10 mm and angle > 90°) and 13 uteri that could not be classified (referred to as the gray-zone). The agreement between ESHRE-ESGE and CUME was 38% (kappa, 0.1); the agreement between ASRM criteria and CUME for septate was 87% (kappa, 0.39), and considering both septate and gray-zone as septate, the agreement was 98% (kappa, 0.93). Among the three measurements, the interobserver reproducibility of indentation depth (CCC, 0.99; 95% CI, 0.98-0.99) was better than both indentation angle (CCC, 0.96; 95% CI, 0.94-0.97) and I:WT ratio (CCC, 0.92; 95% CI, 0.90-0.94). The diagnostic test accuracy of these three measurements using CUME as reference standard was very good, with AUC between 0.96 and 1.00. The best cut-off values for these measurements to define septate uterus were: indentation depth ≥ 10 mm, indentation angle < 140° and I:WT ratio > 110% .

CONCLUSIONS

The suggested ESHRE-ESGE cut-off value overestimates the prevalence of septate uterus while that of ASRM underestimates this prevalence, leaving in the gray-zone most of the uteri that experts considered as septate. We recommend considering indentation depth ≥ 10 mm as septate, since the measurement is simple and reliable and this criterion is in agreement with expert opinion. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Optimization of oestradiol assays to improve utility in an in vitro fertilization setting

Background The measurement of oestradiol is an integral component for the management of ovarian stimulation for in vitro fertilization. Automated immunoassays offer fast assay times and high throughput, with less sensitivity and specificity. The aim of this study is to optimize the oestradiol assay in patients undergoing ovarian stimulation for in vitro fertilization via comparison of oestradiol values obtained using two immunoassays compared with mass spectrometry. Methods Patients undergoing ovarian stimulation were prospectively recruited. Serum samples were analysed with ADVIA Centaur® CP Immunoassay, Abbott Architect i1000® immunoassay and AB Sciex 5500 liquid chromatography-tandem mass spectrometry (LC-MS/MS) systems. Per cent bias was determined for each system to report the average tendency of the values to be larger or smaller than the LC-MS/MS value. Linear regression of total follicular volume and oestradiol was computed. Results The ADVIA Centaur® CP assay had a positive bias of 20% compared with LC-MS/MS, while the Architect i1000® had a non-significant, negative bias of 0.3%. With regression fit, a clear, positive relationship was seen between follicular volume and oestradiol. The Architect i1000® assay had a greater correlation (R²= 0.46) compared with Centaur® CP (R²= 0.36), when oestradiol values were >1000 pg/mL (3670 pmol/L). Conclusions The Abbott Architect i1000® oestradiol assay exhibits greater agreement with LC-MS/MS and exhibited better correlation to follicular volume when oestradiol values are >1000 pg/mL (3670 pmol/L), prompting a change in the clinic's oestradiol platform. Attention to assay quality assurance via LC-MS/MS can improve the oestradiol accuracy and permit more informed clinical decisions for improved patient outcomes.

Profiling transient daytime peaks in urban air pollutants: city centre traffic hotspot versus urban background concentrations

Averaged annual and daily limit values imposed for the protection of human health from urban air pollutants fail to address the potential influence of variations in personal exposure during the day, even though asthma attacks, myocardial ischaemia, and other effects have been linked to highly transient rises in atmospheric contamination. There is, therefore, a general need for the wider availability of information on hourly variations in urban pollutant levels, as well as on spatial differences between urban background and localised contamination hotspots. We compare data from urban background and traffic hotspot monitoring stations over a 12-month period to demonstrate the hourly flux of air pollutants, notably NO(x), SO(2) and PM(10), and illustrate the effects of controlling influences, such as traffic movements and exotic dust intrusions. Our methodology focuses on daytime transient peaks, which occur when much of the urban population is awake and active, and when striking increases in pollutant concentrations are especially common at traffic hotspots. Greater emphasis on the daily reality of transient peaks in urban atmospheric pollutants offers a higher degree of spatial and temporal data resolution for use in epidemiological studies.

Biomarkers in cancer: Survey of diagnostic needs

e22222

Background: Much ongoing work in the field of diagnostics is related to identifying novel and clinically useful tumor markers. However, it is not clear that this discovery is focused on the clinical uses that are most important to physicians. Methods: Consequently, we conducted a survey to assess these needs. Our survey of oncologists, specialists and primary care physicians received 236 responses. Of these, 214 doctors provided their view, ranking with an 8 point Likert scale, for which of eight aspects of cancer that they would like to better differentially diagnose. Of the respondents, 45% were oncologists, 17% primary care, 16% urology and 15% OB/Gyn. Of the physicians surveyed, 57% were in private practice and 32% were in academic medicine, with the remaining 11% in a variety of other settings. Results: As may be unexpected, respondents believed that they still could benefit most from diagnosis itself (indexed score 6.1), followed closely by improving earlier diagnosis or identifying latent disease (5.6), as opposed to simple screening (4.82). The aspects that they believed required the least improvement were prognosis for metastasis (3.6) and prognosis for progression (4.0). Surprisingly, desire for the ability for better treatment planning was unremarkable as well (4.3). We also gauged the respondents familiarity with tumor markers using a 5 point Likert scale. 29% considered themselves very familiar, and only 13% considered themselves with less than average familiarity. Conclusions: The results of the survey suggest it may be useful to consider evaluation of biomarkers which aid early diagnosis rather than disease prognosis.

[Table: see text]

Outcome of intracytoplasmic sperm injection in azoospermic patients: stressing the liaison between the urologist and reproductive medicine specialist

OBJECTIVES

To analyze the outcome of intracytoplasmic sperm injection (ICSI) cycles in infertile couples in whom the main diagnosis of infertility was azoospermia of obstructive and nonobstructive origin.

METHODS

Eighty-three consecutive ICSI cycles were carried out with retrieved testicular or epididymal spermatozoa, 60 cycles in 32 patients with obstructive azoospermia and 23 cycles in 12 patients with nonobstructive azoospermia. Fifty-four testicular biopsies (testicular sperm extraction) and 18 epididymal aspirations (microepididymal sperm aspiration) were performed.Results. Motile spermatozoa were recovered in 65 cycles (90.3%). In another 3 (4.2%), nonmotile spermatozoa were retrieved. In 4 patients (5.5%), sperm could not be recovered. In 11 cycles, frozen sperm from a previous procedure were used. A significantly lower fertilization rate (64% versus 73%, P = 0.02), clinical pregnancy rate (13% versus 47%, P <0.001), and good embryo quality rates (35% versus 56%, P = 0.009) were observed in patients with nonobstructive azoospermia. In patients with obstructive azoospermia, no significant differences were observed when the outcome was analyzed on the basis of the sperm origin (ie, from testicular sperm extraction or microepididymal sperm aspiration).

CONCLUSIONS

When combining testicular sperm extraction or microepididymal sperm aspiration with ICSI in patients with obstructive azoospermia, the results in terms of fertilization, implantation, and pregnancy rates were similar to those found in patients with nonazoospermic obstruction who underwent ICSI with ejaculated sperm. Patients with nonobstructive azoospermia had lower fertilization, embryo quality, and pregnancy rates than did those with obstructive azoospermia, probably because of severe defects in spermatogenesis, leading to poor gamete quality. The urologist and reproductive endocrinologist now have an excellent therapeutic option to offer men with previously intractable infertility.

Evaluation of outpatient hysteroscopy, saline infusion hysterosonography, and hysterosalpingography in infertile women: a prospective, randomized study

OBJECTIVE

To compare the diagnostic accuracy, pain scores, and procedure length of outpatient hysteroscopy (OHS), hysterosalpingography (HSG), and saline infusion hysterosonography (SIS) for evaluation of the uterine cavity of infertile women.

DESIGN

Prospective, randomized, investigator-blind study.

SETTING

Tertiary infertility clinic.

PATIENT(S)

Forty-six consecutive infertile women.

INTERVENTION(S)

Outpatient HSG, OHS, and SIS, followed by operative hysteroscopy (HS).

MAIN OUTCOME MEASURE(S)

Uterine abnormalities, procedure length, and subjective pain.

RESULT(S)

Fifty-nine percent of infertile subjects were found to have an abnormality on at least one of three outpatient uterine evaluations. When compared with the case of definitive operative HS, 60% of abnormalities were correctly classified by HSG, 72% by OHS, and 52% by SIS (P: NS). When comparing all combinations of 2 outpatient screening tests to operative hysteroscopy, 68% were correctly classified by HSG/OHS, 58% by HSG/SIS, and 64% by OHS/SIS (P: NS). The average time length for the OHS was 9.1 min., which was significantly greater than for both HSG (average, 5.3 min) and SIS (average, 6.1 min.) (P<.0001 for both). HSG and SIS were not statistically different regarding procedure time length. The average pain score (0-10) for SIS was 2.7, compared with 5.8 and 5.3 for HSG and OHS, respectively. Both HSG and OHS mean pain scores were significantly greater than the SIS mean.

CONCLUSION(S)

OHS, SIS, and HSG were statistically equivalent regarding evaluation of uterine cavity pathology in infertile women.

Human embryos derived from in vitro and in vivo matured oocytes: analysis for chromosomal abnormalities and nuclear morphology

PURPOSE

To determine whether embryos resulting from oocytes matured in vitro have a higher incidence of nuclear and/or genetic abnormalities compared to embryos resulting from oocytes matured in vivo.

METHODS

Fluorescence in situ hybridization analysis for chromosomes X, Y, and 18 was used to compare the rates of aneuploidy, mosaicism, and nuclear abnormalities in embryos derived from oocytes that were prophase I at aspiration (immature group) to that observed in embryos resulting from oocytes that were metaphase I or II at aspiration (mature group).

RESULTS

Based on nuclear morphology, significantly more embryos in the mature group (23%) were classified as normal compared to embryos in the immature group (3%). No difference was found in the rate of aneuploidy or in the incidence of mosaicism involving these chromosomes.

CONCLUSIONS

These findings suggest that few embryos derived from prophase I oocytes collected following ovarian stimulation are morphologically normal.

Radioprotection of hematopoietic stem cells by interleukin-1

Radioprotective agents such as interleukin-1 (IL-1) and tumor necrosis factor (TNF-alpha), when given prior to irradiation, protect animals from radiation damage. However, in vivo administration of these cytokines does not allow one to determine whether the protective effects act directly on the hematopoietic system. In the present study, we subjected male bone marrow cells to in vitro treatment with IL-1 prior to irradiation and bone marrow transplantation. We found that male bone marrow cells pretreated with IL-1 prior to irradiation increased the survival of irradiated female recipient mice when compared with nontreated irradiated marrow cells. In addition, irradiated female recipients that received IL-1-pretreated male donor bone marrow cells displayed an increased presence of male donor cells in their bone marrow, spleen, and thymus for up to 3 months posttransplant. Furthermore, serial transplantation studies revealed that male cells could only be detected in tertiary female recipients who received bone marrow from mice transplanted with IL-1-treated cells. These results indicate that IL-1 pretreatment protects both short-term and long-term repopulating stem cells from an irradiation insult and that these cells are capable of reconstituting the myeloid and lymphoid organs of recipient mice.

Exertional dyspnea and ventilation in hyperthyroidism

Dyspnea is recognized to be an important feature in patients with hyperthyroidism at rest and during exercise. However, its etiology is not well-understood. Since dyspnea is thought to be related to the perception of excessive ventilatory effort, we explored the possibility that dyspnea in these patients might be related to an inappropriate ventilatory response to the increased metabolic rate. We studied 11 hyperthyroid patients and 11 age- and sex-matched controls, performing spirometry, lung volumes, mouth pressure measurements, and incremental exercise test. Central drive was estimated by measuring P0.1 and sensation of dyspnea by the Borg scale. We found that hyperthyroid patients (1) have higher ventilation than normal subjects during exercise even when corrected for VCO2 levels; (2) this increased ventilation is secondary to increased central drive which is correlated to the T3ria level (r = 0.85, p less than 0.01); (3) hyperthyroid patients are more dyspneic than controls; and (4) the increased drive can be normalized by beta-blockade. We conclude that the main ventilatory abnormality in hyperthyroid patients is an inappropriate increase in respiratory drive, possibly secondary to increased adrenergic stimulation.

Conformational analysis of two cyclic disulfide peptides

Complete nmr and CD studies of two cyclic tetrapeptides with disulfide bonds, Ac-L-Pen-L-Pro-D-Val-L-Cys-NH2 (1) and Ac-L-Cys-L-Pro-D-Val-L-Cys-NH2 (2) bonds have been carried out in different solvents to investigate the formation and stabilization of beta-turn structures and to determine the stereochemistry of the disulfide linkage. Both peptides have three-dimensional structures with a type II beta-turn, as derived from quantitative nuclear Overhauser effect data. The combined use of CD and nmr indicates that the dihedral angle of the disulfide bridge is different in the two peptides, although the chirality is maintained.

Interaction of Rhizobium fredii USDA257 and nodulation mutants derived from it with the agronomically improved soybean cultivar McCall

Rhizobium fredii USDA257 does not nodulate McCall soybean (Glycine max (L.) Merr.), but two transposon-mutants derived from it, 257DH4 and 257DH5, do. All three organisms cause curling of McCall root hairs and induce the formation of underlying cortical cell divisions. The mutants produce infection threads, and many of the meristematic foci develop into nodules. In contrast, root hairs that deform in response to USDA257 lack infection threads, and meristematic activity ceases prior to the appearance of nodule meristems. Root systems nodulated by mutant 257DH4 reduce acetylene at rates similar to those of roots nodulated by reference R. fredii strain USDA191. The presence of living cells of USDA257 in inocula leads to strong inhibition of nodulation by 257DH4 but not by 257DH5. This blocking effect depends on the ratio of USDA257 cells to 257DH4 cells in the inoculum; nodules that form contain cells of 257DH4, but not those of parental strain USDA257.

Relationship between the results of sperm analysis and GIFT

In vitro fertilization (IVF) and GIFT have been proposed as therapeutic approaches in infertile couples where a significant male factor is present. To date, few published data are available relating the success rate of GIFT to the severity of the male factor. In this report the results of the first 172 GIFT cases were analyzed. The overall pregnancy rate was 18.0%. The relationship between the occurrence of pregnancy and sperm count (millions/ml), total sperm count (millions/ejaculate), % motility, motile sperm count (millions/ml) and total motile sperm count (millions/ejaculate) were examined. Significant direct correlations were observed between the clinical pregnancy rate and sperm count, total sperm count, motile sperm count and total motile sperm count. Motile sperm count and total motile sperm count had the best correlations with clinical pregnancy rates, which were over 24.0% in groups with motile sperm counts exceeding 40 X 10(6) cells/ml or total motile sperm counts greater than 100 X 10(6)/ejaculate. The clinical pregnancy rates were 12.5% and 7.7%, respectively, for groups with motile sperm counts under 10 X 10(6)/ml and total motile sperm counts below 25 X 10(6)/ejaculate. No correlation was found between percent motile cells and pregnancy rate. Results of the sperm penetration assay using zona-free hamster eggs were available in a subpopulation of 27 patients. No significant correlation between this sperm penetration assay and pregnancy rate could be demonstrated. The incidence of chemical pregnancy showed a significant negative correlation with the total motile sperm count, indicating a higher incidence of early pregnancy wastage in cases of oligozoospermia.(ABSTRACT TRUNCATED AT 250 WORDS)

Determinants of weaning and survival among patients with COPD who require mechanical ventilation for acute respiratory failure

The decision to institute MV in patients with COPD and ARF is difficult because the risk of complications is high and the long-term prognosis is poor. We reviewed our experience with 95 COPD patients with ARF requiring MV. Fifty-five patients required MV for more than two weeks, 72 were weaned successfully, and 59 died within one year of follow-up. Survival was associated with premorbid level of activity (p less than .001), FEV1 (p less than .01), serum albumin level (p less than .05), and severity of dyspnea (p less than .01). Cor pulmonale on ECG, premorbid hypercarbia, and history of left ventricular failure were also more common among those who died. Weaning from MV was associated with premorbid level of activity (p less than .001), FEV1 (p less than .001), albumin level (p less than .05), and negative inspiratory pressure (p less than .001) and respiratory rate during T-piece trial (p less than .01). The duration of intubation was associated only with premorbid level of activity (p less than .01). Predictive models for the weaning success and the one-year survival were developed.

A genetic analysis of suppressors of the PF10 mutation in Chlamydomonas reinhardtii

A mutation at the PF10 locus of the unicellular green alga Chlamydomonas reinhardtii leads to abnormal cell motility. The asymmetric form of the ciliary beat stroke characteristic of wild-type flagella is modified by this mutation to a nearly symmetric beat. We report here that this abnormal motility is a conditional phenotype that depends on light intensity. In the absence of light or under low light intensities, the motility is more severely impaired than at higher light intensities. By UV mutagenesis we obtained 11 intragenic and 70 extragenic strains that show reversion of the pf10 motility phenotype observed in low light. The intragenic events reverted the motility phenotype of the pf10 mutation completely. The extragenic events define at least seven suppressor loci; these map to linkage groups IV, VII, IX, XI, XII and XVII. Suppressor mutations at two of the seven loci (LIS1 and LIS2) require light for their suppressor activity. Forty-eight of the 70 extragenic suppressors were examined in heterozygous diploid cells; 47 of these mutants were recessive to the wild-type allele and one mutant (bop5-1) was dominant to the wild-type allele. Complementation analysis of the 47 recessive mutants showed unusual patterns. Most mutants within a recombinationally defined group failed to complement one another, although there were pairs that showed intra-allelic complementation. Additionally, some of the mutants at each recombinationally defined locus failed to complement mutants at other loci. They define dominant enhancers of one another.

Optimization of respiratory muscle relaxation during mechanical ventilation

The authors calculated the active work of inspiration (Wp) and the inspiratory muscle pressure-time product (integral of Pmus.dt) in seven patients undergoing mechanical ventilation (MV). This was done by comparing the areas under the inflation pressure-volume and inflation pressure-time curves generated when the patient was contributing to the work of ventilation with those following sedation, when inspiratory muscle activity was absent (defined as absence of diaphragmatic EMG activity and of palpable accessory muscle contraction). Inspiratory muscle inactivity could be predicted by the observation of a smooth rise in inflation pressure that was highly reproducible from breath to breath. Relaxation was present without sedation during MV in the control mode with inspiratory flow rates above 65 1/min. In the assist mode (AMV), both Wp and integral of Pmus.dt were significantly (P less than 0.05) greater than in the control (CMV) mode. Reducing trigger sensitivity during AMV further increased Wp and integral of Pmus.dt (P less than 0.05). During AMV and CMV Wp and integral of Pmus.dt decreased with increasing rate of inspiratory flow delivered by the ventilator. With AMV at low trigger sensitivity and low flow rates, Wp approached 65% of the total inspiratory work. The authors conclude that inspiratory muscle activity can be substantial during MV, particularly during AMV at low trigger sensitivity and flow. Monitoring of inflation pressure is a simple means of determining the degree of inspiratory muscle rest during MV.

Management of ovarian hyperstimulation syndrome with chlorpheniramine maleate, mannitol, and invasive hemodynamic monitoring

Ovarian hyperstimulation syndrome due to exogenous gonadotropin administration is life-threatening in its most severe form. Profound fluid shifts may occur, with concomitant cardiovascular changes. We present a case of severe ovarian hyperstimulation syndrome managed with chlorpheniramine maleate (previously shown to be effective in animal models) and invasive hemodynamic monitoring. Mannitol and albumin infusions were also used to maintain urine output and intravascular volume.

In-vitro fertilization as therapy for male-factor infertility

In conclusion, IVF is a viable option for the couple with infertility secondary to reduced semen quality unresponsive to routine treatment. The increase in sperm/egg interaction allowed by IVF is rewarded with a pregnancy rate that is not statistically different from that for the overall IVF population. In our last 100 consecutive cycles, after altering our ovulation induction method to produce more oocytes per retrieval attempt, our overall clinical pregnancy rate was 25 per cent. The pregnancy rate for the male-factor patients during this same time period was 20 per cent, a rate similar to the monthly fecundability rate of a normal population of fertile couples. Further, in our hands the sperm penetration assay is of great help in predicting the ability of a human sperm to fertilize a human oocyte.

Outbreak of diarrhea in a day care center with spread to household members: the role of Cryptosporidium

From August 1 to November 1, 1984, 80 (43%) of 186 children attending a day care center (DCC) in Tulsa, OK, had diarrhea. Seventy-one percent of children less than 3 years of age had diarrhea, compared with 17% of children 3 to 8 years old. The duration of illness was 1 to 42 days (median, 8 days). At least one stool specimen was obtained from 142 (76%) of the 186 children. Children who had had diarrhea were more likely to have a specimen positive for Cryptosporidium (27 of 77, 35%) than were children who had not had diarrhea (8 of 65, 12%) (P less than 0.01). The presence of Giardia, Campylobacter, enterovirus, or rotavirus was not statistically associated with diarrhea. These results suggest Cryptosporidium as a causative agent. The secondary attack rate for diarrhea among household contacts exposed to DCC children with diarrhea was 77 of 204 (38%) compared with 25 of 273 (9%) for household contacts of children in the DCC who did not have diarrhea (P less than 0.001). Stool specimens were obtained from 79 household contacts. Six (23%) of 26 household members exposed to a Cryptosporidium-positive child had a stool specimen positive for Cryptosporidium, compared with 1 (2%) of 53 household contacts exposed to a DCC child whose stool specimen was negative for Cryptosporidium (P less than 0.01). The outbreak resolved within 2 weeks after cohorting children with diarrhea and stressing the importance of handwashing among staff and older children. cryptosporidium can cause outbreaks of diarrhea in DCC settings, can be spread within households and may be more common than previously recognized among DCC attendees and their household members.

Patient cooperation: a determinant of perinatal outcome in the pregnant diabetic

From 1974 through 1978, 59 insulin-dependent diabetic patients were treated in a university-affiliated general hospital. They were managed primarily as outpatients with hospitalization for regaining glucose control and/or in the treatment of obstetric complications. In 1976 a special clinic for pregnant diabetic patients was established. The 26 patients treated during the clinic's first two years are compared to 33 treated in the preceding 2 1/2 years. The significant difference between the two groups was the improvement in the number of patients whose cooperation was good, 67% to 85% (p less than 0.05), and the reduction of perinatal morbidity and mortality. The perinatal mortality rate was 18% and 8% in the preclinic group (group I) and the clinic group (group II), respectively. The combined perinatal morbidity and mortality was reduced from 36% to 15%, respectively, in groups I and II (p less than 0.01). A constant rate of 3.2% perinatal mortality was observed in the obstetric population during the study period.