The effectiveness of immediate versus delayed tubal flushing with oil-based contrast in women with unexplained infertility (H2Oil-timing study): study protocol of a randomized controlled trial.

BACKGROUND: In women with unexplained infertility, tubal flushing with oil-based contrast during hysterosalpingography leads to significantly more live births as compared to tubal flushing with water-based contrast during hysterosalpingography. However, it is unknown whether incorporating tubal flushing with oil-based contrast in the initial fertility work-up results to a reduced time to conception leading to live birth when compared to delayed tubal flushing that is performed six months after the initial fertility work-up. We also aim to evaluate the effectiveness of tubal flushing with oil-based contrast during hysterosalpingography versus no tubal flushing in the first six months of the study. METHODS: This study will be an investigator-initiated, open-label, international, multicenter, randomized controlled trial with a planned economic analysis alongside the study. Infertile women between 18 and 39 years of age, who have an ovulatory cycle, who are at low risk for tubal pathology and have been advised expectant management for at least six months (based on the Hunault prediction score) will be included in this study. Eligible women will be randomly allocated (1:1) to immediate tubal flushing (intervention) versus delayed tubal flushing (control group) by using web-based block randomization stratified per study center. The primary outcome is time to conception leading to live birth with conception within twelve months after randomization. We assess the cumulative conception rate at six and twelve months as two co-primary outcomes. Secondary outcomes include ongoing pregnancy rate, live birth rate, miscarriage rate, ectopic pregnancy rate, number of complications, procedural pain score and cost-effectiveness. To demonstrate or refute a shorter time to pregnancy of three months with a power of 90%, a sample size of 554 women is calculated. DISCUSSION: The H2Oil-timing study will provide insight into whether tubal flushing with oil-based contrast during hysterosalpingography should be incorporated in the initial fertility work-up in women with unexplained infertility as a therapeutic procedure. If this multicenter RCT shows that tubal flushing with oil-based contrast incorporated in the initial fertility work-up reduces time to conception and is a cost-effective strategy, the results may lead to adjustments of (inter)national guidelines and change clinical practice. TRIAL REGISTRATION NUMBER: The study was retrospectively registered in International Clinical Trials Registry Platform (Main ID: EUCTR2018-004153-24-NL).

Thermal requirements for growth, survival and aerobic performance of weatherfish larvae Misgurnus fossilis.

Thermal requirements of larval weatherfish Misgurnus fossilis were investigated in terms of growth, survival and aerobic performance. Growth and survival of M. fossilis larvae acclimated to five temperatures (11, 15, 19, 23 and 27° C) were measured over 25 days. In the upper temperature treatments (19, 23 and 27° C), survival of larvae was stable throughout the entire rearing period (>75%), whereas 11 and 15° C resulted in severe declines in survival (to <10%). Growth of larvae (expressed as dry mass and total length) was highest at 19 and 23° C, but significantly decreased at 27° C. Routine metabolic rate of 3 days post-hatch larvae was estimated as oxygen consumption rate (MO2 ) during acute exposure (30 min to 1 h) to seven temperatures (11, 15, 19, 23, 27, 31 and 35° C). Larval oxygen uptake increased with each consecutive temperature step from 11 to 27° C, until a plateau was reached at temperatures >27° C. All larvae of the 35° C regime, however, died within the MO2 measurement period. M. fossilis larvae show greater than expected tolerance of high temperatures. On the other hand, low temperatures that are within the range of likely habitat conditions are critical because they might lead to high mortality rates when larvae are exposed over periods >10 days. These findings help to improve rearing conditions and to identify suitable waters for stocking and thus support the management of re-introduction activities for endangered M. fossilis.

First report of a cystic malformation on the upper jaw of hatchery-reared allis shad Alosa alosa.

The anadromous allis shad Alosa alosa has suffered dramatic population declines throughout Europe and is currently considered as endangered throughout its entire distribution range. In order to reestablish allis shad in the River Rhine, which formerly housed one of the largest and most important populations, an EU-LIFE Project 'The re-introduction of allis shad in the Rhine system' was started in 2007. In course of the LIFE+ Projects, allis shad larvae bred from genitor fish of the Gironde-Garonne-Dordogne population in France were reared in a pilot ex situ stock plant pilot facility in Aßlar, Germany. At an age of 1-2 months, about 100% of these fish developed approximately 0.5- to 0.8-cm large, fluid-filled, transparent cysts in conjunction with the upper jaw. The performed microbiological, virological, parasitological and histological examinations did not detect any infectious agents. Possible causative agents are discussed with regard to environmental factors and the nutrition of larvae. In conclusion, the observed malformations are considered a sign for a severe health problem and therefore a risk for the successful breeding of allis shad in aquaculture.

Mode of childbirth and neonatal outcome after external cephalic version: A prospective cohort study.

OBJECTIVE: to assess the mode of childbirth and adverse neonatal outcomes in women with a breech presentation with or without an external cephalic version attempt, and to compare the mode of childbirth among women with successful ECV to women with a spontaneous cephalic presentation. DESIGN: prospective matched cohort study. SETTING: 25 clusters (hospitals and its referring midwifery practices) in the Netherlands. Data of the Netherlands perinatal registry for the matched cohort. PARTICIPANTS: singleton pregnancies from January 2011 to August 2012 with a fetus in breech presentation and a childbirth from 36 weeks gestation onwards. Spontaneous cephalic presentations (selected from national registry 2009 and 2010) were matched in a 2:1 ratio to cephalic presentations after a successful version attempt. Matching criteria were maternal age, parity, gestational age at childbirth and fetal gender. Main outcomes were mode of childbirth and neonatal outcomes. MEASUREMENTS AND FINDINGS: of 1613 women eligible for external cephalic version, 1169 (72.5%) received an ECV attempt. The overall caesarean childbirth rate was significantly lower compared to women who did not receive a version attempt (57% versus 87%; RR 0.66 (0.62-0.70)). Women with a cephalic presentation after ECV compared to women with a spontaneous cephalic presentation had a decreased risk for instrumental vaginal childbirth (RR 0.52 (95% CI 0.29-0.94)) and an increased risk of overall caesarean childbirth (RR 1.7 (95%CI 1.2-2.5)). KEY CONCLUSIONS: women who had a successful ECV are at increased risk for a caesarean childbirth but overall, ECV is an important tool to reduce the caesarean rate. IMPLICATION FOR PRACTICE: ECV is an important tool to reduce the caesarean section rates.

First evidence of natural reproduction of the Allis shad Alosa alosa in the River Rhine following re-introduction measures.

After stocking with larvae from the Gironde-Garonne-Dordogne population, in 2013, three young-of-the-year Allis shad Alosa alosa, probably originating from natural reproduction, were documented for the first time in a period of nearly 100 years in the River Rhine. In 2014, a further increase was observed when 57 juveniles and eight adults were caught; seven of these eight adults were derived from stocking, indicating the success of stocking measures within the framework of the EU-LIFE project.

Risk of developmental dysplasia of the hip in breech presentation: the effect of successful external cephalic version.

OBJECTIVE: To evaluate the effect of successful external cephalic version on the incidence of developmental dysplasia of the hip (DDH) requiring treatment in singleton breech presentation at term. DESIGN: Observational cohort study. SETTING: Three large teaching hospitals in the Netherlands. POPULATION: Women with a singleton breech presentation of 34 weeks of gestation or more, who underwent an external cephalic version attempt. METHODS: We made a comparison of the incidence of DDH between children born in breech presentation and children born in cephalic presentation after a successful external cephalic version. MAIN OUTCOME MEASURE: The incidence of DDH requiring either conservative treatment, with a harness, or surgical treatment. RESULTS: A total of 498 newborns were included in the study, of which 40 (8%) were diagnosed with DDH and 35 required treatment. Multivariate analysis showed that female gender (OR 2.79, 95% CI 1.23-6.35) and successful external cephalic version (OR 0.29, 95% CI 0.09-0.95) were independently associated with DDH. CONCLUSIONS: A successful external cephalic version is associated with a lower incidence of DDH, although a high percentage of children born after a successful external cephalic version still appear to have DDH. A larger cohort study is needed to establish the definite nature of this relationship. Until then, we recommend the same screening policy for infants born in cephalic position after a successful external cephalic version as for infants born in breech position.

Risk factors for developmental dysplasia of the hip: a meta-analysis.

Early detection and subsequent treatment of developmental dysplasia of the hip (DDH) is thought to improve its prognosis. Frequently reported risk factors for DDH are a positive family history of DDH, female sex and breech presentation, but there is not a lot of systematic knowledge about DDH risk factors. We performed a systematic review and meta-analysis of the available evidence on DDH risk factors. We searched Medline, EMBASE and The Cochrane Library from conception up until October 2011 for primary articles on the subject. All studies reporting on potential risk factors for DDH that allowed construction of a two-by-two table were selected. Language restrictions were not applied. Two reviewers independently selected studies, extracted data and assessed study quality. The association between risk factors and DDH was expressed as a common odds ratio (OR) with a 95% confidence interval (CI). We identified 30 relevant studies reporting on 1,494,387 children; 26 studies were cohort studies and four studies used a case-control design. The risk of DDH was strongly increased in case of breech delivery (OR 5.7, 95% CI 4.4-7.4), female sex (OR 3.8, 95% CI 3.0-4.6) a positive family history of DDH (OR 4.8, 95% CI 2.8-8.2) and clicking hips at clinical examination (OR 8.6, 95% CI 4.5-16.6). This meta-analysis shows that infants born in breech presentation, female infants, infants with a positive family history and clicking hips at clinical examination have an increased risk for DDH. This knowledge can be helpful in the development of screening programs for DDH.

[Immune reconstituted inflammatory syndrome. Pitfalls of antiretroviral therapy]. / Immunrekonstitutionelle inflammatorische Syndrome. Das Janusgesicht der antiretroviralen Therapie.

The pandemic HIV infection, the more frequent use of immunosuppressive treatment, and the improved long-term prognosis of immunocompromised patients due to better supporting therapies have resulted in an increase in the prevalence of immunodeficiencies. Highly active antiretroviral therapy (HAART) can improve immunocompetence in HIV patients, even when the immunodeficiency is far advanced. This has resulted in an impressive and lasting lowering of the morbidity and mortality associated with HIV infection. However, immune reconstitution may exacerbate subclinical opportunistic infections or autoimmune diseases, or result in an unexpected, paradoxical aggravation of intercurrent inflammatory diseases. The atypical inflammatory conditions have a number of synonymous names: immune restoration disease (IRD), immune reconstitution syndrome (IRS), or immune reconstitution inflammatory syndrome (IRIS). In the light of specific differential therapeutic consequences, it is important to distinguish the clinical presentation from that of corresponding opportunistic infections. However, diagnostic and therapeutic standards for IRIS have not yet been worked out. The present overview also points to possible diagnostic pitfalls, and makes suggestions for a possible classification of the condition and the therapeutic options.

Lack of specific receptors for C-reactive protein on white blood cells.

The classic acute-phase reactant C-reactive protein (CRP) plays an important role in innate immunity. Specific CRP receptors have been described on white blood cells and were further characterized as Fcgamma receptors I and II. Here, we used biotinylated, highly purified natural CRP and recombinant human CRP from E. coli to investigate binding to white blood cells. The structural integrity of recombinant CRP was demonstrated by proof of pentamer assembly using non-denaturing gel electrophoresis. Furthermore, the functional capability was confirmed by calcium-dependent ligand binding (phosphorylcholine-coupled BSA and nuclear constituents), and by complement activation (C3 deposition). The monocytic cell line U937 expresses FcgammaRI and FcgammaRII--the proposed CRP receptors--in high density. Binding of biotinylated CRP was only detected by flow cytometry using a partially purified CRP preparation, that contained additional proteins, e.g. IgG as demonstrated by immunoblotting. Highly purified and recombinant CRP, free of IgG, were not bound. To exclude blocking of binding epitopes by labeling on recombinant CRP, biotinylation was performed at various biotin to protein ratios. In addition, competition assays demonstrated that binding of biotinylated, partially purified CRP was only inhibited by partially purified CRP and IgG, but not by highly purified and recombinant CRP. Recombinant CRP bound to U937 cells only after contamination with 0.5 microg IgG per 100 microg CRP before biotinylation. Therefore, we conclude that CRP itself is not bound to white blood cells and strongly suggest a reassessment of previous data.

Signal transduction via both human low-affinity IgG Fc receptors, Fc gamma RIIa and Fc gamma RIIIb, depends on the activity of different families of intracellular kinases.

In contrast to IgG Fc receptor II (Fc gamma RIIa), the function of Src-family kinases, Syk and phosphoinositide 3-kinase (PI3K) in signal transduction of glycosylphosphatidylinositol-anchored Fc gamma RIIIb has not been analyzed in detail. Therefore pharmacological inhibitors were used to define the role of specific kinases in signalling of Fc gamma RIIa and Fc gamma RIIIb in myeloid cells. We demonstrate that the broad tyrosine kinase inhibitor genistein, the Src-family kinase inhibitor PP2, and the Syk kinase inhibitor piceatannol inhibit [Ca2+]i rise induced by both low-affinity Fc gamma R in neutrophils. Genistein and PP2 additionally prevent Fc gamma R-triggered hydrogen peroxide generation. In contrast, wortmannin, a PI3K inhibitor, which blocks Fc gamma RIIIb activation completely, abolishes Fc gamma RIIa-mediated [Ca2+]i flux only in the beginning. In addition, herbimycin A, a further specific inhibitor of Src-family kinases leads to a delayed Fc gamma RIIa-induced [Ca2+]i rise in THP-1 cells. In summary, our data demonstrate differences between both low-affinity IgG Fc receptors, and provide evidence for an essential role of Src-family kinases, Syk and PI3K in Fc gamma RIIIb-mediated signalling.

Influence of extraction temperature on amounts and quality of rendered chicken fat recovered from ground or homogenized skin.

A study was undertaken to determine the influence of extraction process on recovery and quality of fat from chicken skin. In order to do so, 20-kg batches of skin were ground (9.5 mm plate) or homogenized in a colloidal mill (0.2-mm knife set), then heated to 50 or 80 C to rupture fat cells. The fat was recovered by centrifugation and was evaluated for composition, appearance, and stability. A maximum amount of fat (89.6% of the fat initially contained in skin) was recovered from homogenized skin heated to 80 C, whereas heating ground skin to 50 C yielded the lowest fat recovery (51.5% of skin fat content). In general, fat composition and appearance were little affected by extraction conditions, with the exception that the fat extracted from homogenized skin contained more (P < or = 0.001) unsaponifiable cell membrane constituents (0.17 to 0.20%), including antioxidant tocopherol fractions (10.3 microg/ml), than the fat extracted from ground skin (0.08% and 7.5 to 8.3 microg/ml, respectively). This difference likely contributed to the greater oxidative stability of the fat extracted from homogenized skin, which was observed in Schaal oven tests.

Effect of low extraction temperatures on microbiological quality of rendered chicken fat recovered from skin.

Ground or finely homogenized skin, inoculated with circa 7 log10 cfu/g of an Acinetobacter sp., Brochothrix thermosphacta, Candida tropicalis, Debaryomyces hansenii, Enterobacter agglomerans, Enterococcus faecalis, a Lactobacillus sp., or Pseudomonas fluorescens, or not inoculated, was heated to 50 or 80 C to release fat from adipocytes, and the released fat was separated by centrifugation. Extraction at 80 C resulted in nearly complete inactivation of indigenous and inoculated flora, resulting in microbiological counts generally below detection level in skin residue and rendered fat. In contrast, large numbers of organisms (3.69 to 7.28 log10 cfu/g) survived the 50 C extraction process. Even though the majority (91.5 to 99.9%) of these organisms remained in the residual skin at the time of fat separation, some organisms were also found occasionally in fat at concentrations of 2.85 to 3.74 log10 cfu/g. Therefore, an additional step such as flash pasteurization is recommended for safety, should extraction temperatures below 80 C be selected.

Uncommon metastasis of a glioblastoma multiforme in liver and spleen.

A case of a glioblastoma multiforme is presented. Craniotomy was performed with total resection of the right temporal tumor. Postoperatively, the patient received adjuvant radiotherapy, but 6 months after therapy he developed severe nausea and weight loss. Recurrence of an intracranial tumor in the right temporal region with nodules in the liver and spleen were detected by CT scan. Fine-needle biopsies of the liver confirmed the diagnosis of a glioblastoma metastasis with characteristic immunohistochemical staining for glial fibrillary acidic protein. This rare case of an intracerebral glioblastoma metastasizing to liver and spleen was managed by systemic chemotherapy.

Functional characterization of receptor-type protein tyrosine phosphatase CD148 (HPTP eta/DEP-1) in Fc gamma receptor IIa signal transduction of human neutrophils.

Activation of the 40-kDa low-affinity receptor for IgG (Fc gammaRIIa, CD32) leads to tyrosine phosphorylation, increase of cytosolic free calcium concentration ([Ca2+]i), and production of superoxide anions (O2-) in neutrophils (PMN). It has been established that protein tyrosine kinases (PTK) and phosphatases (PTP) are essential for the regulation of intracellular signaling. CD45 is a type I receptor-type protein tyrosine phosphatase (RPTP) with two PTP domains. Recently it has been demonstrated that co-cross-linking of CD45 modulates the signal transduction pathway of Fc gammaRIIa in PMN. In contrast, the functional characteristics of CD148 (HPTP eta/DEP-1), a new RPTP with only one PTP domain, is unknown. CD148 is expressed on PMN in slightly lower density than CD45, and in higher density than on lymphocytes. [Ca2+]i measured with fluo-3-loaded PMN by flow cytometry and O2- production determined by lucigenin-dependent chemiluminescence were inhibited by co-cross-linking of CD45 with Fc gammaRIIa in comparison to isotype control monoclonal antibody (mAb). In contrast, pre-incubation with CD148 mAb 143-41 abolished O2- generation, but did not inhibit [Ca2+]i rise. In summary, both clustered human RPTP, CD45 and CD148, inhibit Fc gammaRIIa-induced O2- production in PMN, but they differ in regulation of [Ca2+]i. Therefore, it is suggested that co-cross-linking of Fc gammaRII with CD45 and CD148 leads to dephosphorylation of different substrates. These distinct functional capacities may be important for differential regulation of Fc gammaR signaling by currently unknown ligands.

Cholinesterase variants: rapid characterisation by PCR/SSCP and evidence for molecular homogeneity.

We have applied the technique of PCR-SSCP (polymerase chain reaction-single stranded conformation polymorphism) to characterise the molecular basis of cholinesterase deficiency and variants in a Jordanian family. PCR-SSCP proved to be a quick and sensitive method of screening cholinesterase variants in a clinical setting. An AG insertion at position 351 was found to cause a silent allele, for which the parents were heterozygous and three children homozygous. In addition, the father and two sons were heterozygous for an A to G transition at position 209, known to cause the dibucaine resistant variant. No linkage to the K variant was found, which has been reported previously in white populations. These findings suggest considerable homogeneity in the molecular basis of CHE variants between different ethnic groups.

The loss of Fc gamma RIIIb in paroxysmal nocturnal hemoglobinuria is functionally replaced by Fc gamma RII.

Neutrophils from patients with paroxysmal nocturnal hemoglobinuria (PNH) show a deficiency for the glycosylphosphatidylinositol- (GPI) linked Fc gamma receptor IIIb (Fc gamma RIIIb, CD16). The functional consequences of this defect are not clear. Here, we examined Fc gamma RIIIb-deficient neutrophils for their activation via Fc gamma receptors. Hydrogen peroxide (H2O2) production and change of intracellular free calcium [Ca2+]i were used as parameters for cell activation. Fc gamma RII and Fc gamma RIIIb stimulation was reached by cross-linking using fragments of monoclonal antibodies or incubation with monoclonal IgG cryoglobulin complexes. In parallel to the deficiency of Fc gamma RIIIb expression, H2O2 production and [Ca2+]i influx were decreased after cross-linking of Fc gamma RIIIb in PNH neutrophils compared with that for normal neutrophils. Stimulation via Fc gamma RII was not affected. Cryoglobulin complexes previously shown to activate normal neutrophils predominantly via Fc gamma RIIIb stimulated PNH neutrophils at a level not significantly weaker than controls. But this activation was mediated only via Fc gamma RII as shown by blocking studies. The results suggest that the loss of GPI-anchored Fc gamma RIIIb is functionally replaced by Fc gamma RII during the immune complex stimulation of PNH neutrophils. Therefore, the equipment of neutrophils with pleomorphic Fc gamma receptors prevents an immunodeficiency in PNH.