Influence of HyCoSy on spontaneous pregnancy: a randomized controlled trial.

BACKGROUND: The aim of the study was to test whether the use of sonography contrast could enhance the chance of spontaneous clinical pregnancy in women undergoing subfertility investigation. METHODS: Couples with at least 1 year of infertility who were scheduled for a consultation including a hysterosalpingo contrast sonography (HyCoSy) were invited to participate in the study. We compared flushing with water-soluble contrast medium (WSCM) versus no flushing. Randomization sequence was computer generated, stratified for age and group allocation was concealed. Primary outcome was clinical pregnancy defined as a sonographically visible fetal sac, detected within 6 months from randomization. Secondary outcomes were spontaneous miscarriage and birth. Exclusion criteria were female age >or=40 years, severe male infertility, previously known severe tubal infertility and suspected anovulation. RESULTS: The mean age of the study population (n = 334) was 31.9 years. Duration of infertility was 2.1 years. The clinical pregnancy rate was 29.2% in the HyCoSy group and 26.5% in the non-flushing group, the difference being 2.7% (95% confidence interval -6.9 to 12.3%, P = 0.63). CONCLUSION: The clinical impression of an enhanced pregnancy rate after performing HyCoSy could not be confirmed. Tubal investigation with sonography using water-soluble contrast has a function as a diagnostic procedure but not in terms of increasing pregnancy rates in subfertile patients. TRIAL REGISTRATION NUMBER: ISRCTN20715945.

Autophagy regulates selective HMGB1 release in tumor cells that are destined to die.

Macroautophagy (hereafter referred to as autophagy) can increase or decrease the amount of cell death in response to various stimuli. To test whether autophagy also controls the characteristics associated with dying cells, we studied tumor cell killing by epidermal growth factor receptor-targeted diphtheria toxin (DT-EGF). DT-EGF kills epithelial and glioblastoma tumor cells with similar efficiency but by different mechanisms that depend on whether the cells activate autophagy when treated with the drug. Dying cells in which autophagy is induced selectively release the immune modulator high-mobility group B1 (HMGB1) without causing lysis of the cell membrane and classical necrosis. Conversely, cells that are killed by DT-EGF where autophagy is blocked, activate caspases but retain HMGB1. These data suggest that it may be feasible to manipulate the immunogenicity of dying cells by increasing or decreasing autophagy.

Induction of apoptosis by tumor cell-targeted toxins.

Targeted toxins are fusion proteins that combine a targeting molecule that selectively binds to and enters tumor cells with a protein toxin that kills the target cells. These molecules represent an exciting approach to develop effective cancer-specific therapeutics that have few side effects on normal tissues and numerous such toxins are in various stages of pre-clinical and clinical development to treat a wide variety of tumors. In this review, we discuss this strategy, describe ways that the toxins activate the apoptosis machinery and discuss future developments in this field.

Economic evaluation of infertility treatment for tubal disease.

PURPOSE: The number of published studies comparing cost-effectiveness of tubal surgery and IVF treatment is limited, in part because of the difficulties of conducting randomized trials, given that IVF is now a clinically accepted treatment and the decision to offer surgery or IVF is often dictated by the severity of the tubal disease and by the availability of the methods. The aim of this study was to compare the costs of our policy of offering tubal surgery to patients with mild or moderate tubal disease with the cost of offering IVF to these and severe tubal disease. METHODS: In this retrospective cohort study patients with tubal pathology as the sole reason for their infertility were included: 61 patients in the tubal surgery group and 464 patients in the IVF group. The delivery rates and costs per delivery were compared. RESULTS: Delivery rates were 28% in the tubal surgery group within 2 years of follow-up and 52% in the IVF group that involved up to three cycles of treatment. This economic evaluation demonstrated only small differences in the average cost when considering the cost per delivery. CONCLUSIONS: With a policy involving strict selection of patients, tubal surgery will continue to have a role in the treatment of infertility.

Hydrosalpinx and IVF outcome: cumulative results after salpingectomy in a randomized controlled trial.

BACKGROUND: A randomized controlled trial of salpingectomy prior to IVF in patients with hydrosalpinges has been conducted in Scandinavia. The results from the first transfer cycle have been published and clearly demonstrated an improved pregnancy outcome after salpingectomy had been performed in patients with hydrosalpinges large enough to be visible on ultrasound. The present article is aimed at analysing the effect of salpingectomy on cumulative birth rate, including all individual transfer cycles. METHODS AND RESULTS: A total of 186 women underwent 452 cycles. Among the 77 women randomized to no surgical intervention, 24 underwent salpingectomy after one or two failed cycles. Cumulative results were analysed by Cox regression, taking into account the number of cycles per patient and the presence of a salpingectomy after a previous transfer. Salpingectomy implied a significant increase in birth rate (hazard ratio 2.1, 95% CI 1.6-3.6, P = 0.014). Within the subgroup of patients with ultrasound-visible hydrosalpinges, the birth rate was even higher (hazard ratio 3.8, 95% CI 1.5-9.2, P = 0.004). Implantation rate was significantly higher in patients who had undergone salpingectomy (27.2% versus 20.2, P = 0.03) and, in the subgroup of patients with ultrasound-visible hydrosalpinges, the difference was even larger (30.3% versus 17.1%, P = 0.003). CONCLUSIONS: The results of the cumulative cycles strengthen the recommendation for a laparoscopic salpingectomy prior to IVF in patients with ultrasound-visible hydrosalpinges.

An apoptosis signaling pathway induced by the death domain of FADD selectively kills normal but not cancerous prostate epithelial cells.

The adaptor protein FADD directly, or indirectly via another adaptor called TRADD, recruits caspase 8 to death receptors of the tumor necrosis factor receptor family. Consequentially, a dominant-negative mutant (FADD-DN, which consists only of the FADD death domain) that binds to receptors but cannot recruit caspase 8 has been widely used to inhibit apoptosis by various stimuli that work via death receptors. Here, we show that FADD-DN also has another cell type- and cancer-dependent activity because it induces apoptosis of normal human prostate epithelial cells but not normal prostate stromal cells or prostate cancer cells. This activity is independent of FADD-DN's ability to bind to three known interacting proteins, Fas, TRADD or RIP suggesting that it is distinct from FADD's functions at activated death receptors. FADD-DN induces caspase activation in normal epithelial cells as demonstrated using a Fluorescence Resonance Energy Transfer assay that measures caspase activity in individual living cells. However, caspase-independent pathways are also implicated in FADD-DN-induced apoptosis because caspase inhibitors were inefficient at preventing prostate cell death. Therefore, the death domain of FADD has a previously unrecognized role in cell survival that is epithelial-specific and defective in cancer cells. This FADD-dependent signaling pathway may be important in prostate carcinogenesis.

Prophylactic salpingectomy does not impair the ovarian response in IVF treatment.

To examine the effect of prophylactic salpingectomy in patients with hydrosalpinges on the ovarian response to stimulation prior to IVF, 26 patients were included in a study in which they acted as their own controls. They were all part of a randomized controlled study, in which they had been randomized to no surgical intervention prior to IVF. After one or two failed cycles, they underwent laparoscopic uni- or bilateral salpingectomy of their diseased tubes. The cycles before and after surgery were compared and the ovarian response was assessed as the dose and duration of gonadotrophins and the number of retrieved and fertilized oocytes. There were no significant differences in any of the measured outcomes. The increasing age between cycles did not influence the ovarian response, assessed by a comparison with two matched control groups from the same original study; 46 patients salpingectomized before IVF and 25 patients without surgery. It is concluded that removal of hydrosalpinx as a prophylactic laparoscopic procedure does not compromise ovarian function.

Student learning through video assessment.

This paper reports on the use of video and self-assessment as a tool to guide and support undergraduate students in the practice of nursing. This method of learning and assessment promoted self- and peer evaluation as well as critical thinking. It encouraged students to take more responsibility for their learning and assisted academic staff and students to identify learning issues associated with clinical practices. Evaluative comments by teachers, students and educational experts have established the credibility and continued use of this approach within the Bachelor of Nursing program at a major university in Sydney, Australia.

The association of atopic dermatitis in infancy with immunoglobulin E food sensitization.

OBJECTIVE: To prospectively investigate the association of high levels of immunoglobulin E (IgE) sensitization to foods and the presence of atopic dermatitis (judged by reported topical steroid use during the first 16 months of life) in a birth cohort of 620 Australian children "at risk" of allergic disease because of family history. RESULTS: A total of 559 of the children in the cohort were fully evaluated, and the cumulative prevalence of atopic dermatitis was 24%. More children in the cohort who had atopic dermatitis had strongly positive skin test results (> or = 4+, histamine equivalent units, > or = approximately 6-mm wheal), consistent with IgE food sensitization to either cow's milk, egg, or peanut at 6 months (22% vs 5%, chi(2) = 35; P < 10(-6)) and at 12 months (36% vs 11%, chi(2) = 41; P < 10(-6)) than those without atopic dermatitis. The calculated attributable risk percent for IgE food sensitization as a cause of atopic dermatitis was 65% and 64% at these times. In a separate group of infants with severe atopic dermatitis, the equivalent rates of IgE food sensitization at 6 months was 83% and at 12 months, 65%. CONCLUSION: IgE food sensitization is a major risk factor for the presence of atopic dermatitis in infancy.

A simplified ultrasound based infertility investigation protocol and its implications for patient management.

PURPOSE: To evaluate whether a simplified infertility investigation protocol, focusing on the use of hysterocontrast sonography (HyCoSy), one blood test, and a semen analysis, would be sufficient as an initial screening test to select couples for specific treatment. METHODS: The infertile couples underwent gynaecological examination, cervical sampling for cytology and Chlamydia trachomatis culture, B-mode transvaginal ultrasonography and basic hormonal analyses followed by a HyCoSy, and a semen analysis. A preliminary diagnosis was made for all patients. A management plan for treatment was suggested when possible; otherwise further examinations were recommended. The data were stored for later analysis and the routine investigation protocol was then adhered to and a final diagnosis and treatment were decided upon. RESULTS: Agreement between the diagnosis based on HyCoSy and our routine protocol was present in 74% of cases (N = 73). In 13% (N = 13) there was partial agreement. In 36% the HyCoSy based protocol was considered sufficient to suggest treatment. CONCLUSIONS: A simplified approach may lead to a significant reduction in both the time and cost of investigating an infertile couple.

The educational needs of part time clinical facilitators.

Clinical facilitators play an important role in the clinical practicum component of an undergraduate nursing programme. Part time teachers are often employed in this role, however very little has been written about the needs of these facilitators. An exploratory study design incorporating focus group interviews and questionnaires was used to identify the needs of clinical facilitators at a large Australian university. This study showed that they are committed nurses who often feel inadequate in a role they feel lacks support and identity. The findings of the study have implications for the preparation of clinical facilitators.

Hydrosalpinx and IVF outcome: a prospective, randomized multicentre trial in Scandinavia on salpingectomy prior to IVF.

Many retrospective studies have shown that hydrosalpinx is associated with poor in-vitro fertilization (IVF) outcome. The mechanism of the actual cause is not yet fully understood. A clinical practice of performing salpingectomy before IVF has developed, without any evidence from prospective trials. The aim of the present prospective randomized trial was to test if a salpingectomy prior to IVF was effective in terms of increased pregnancy rates. Patients with hydrosalpinx were randomized to either a laparoscopic salpingectomy or no intervention before IVF. A total of 204 patients was available for an intention-to-treat analysis and 192 actually started IVF. Clinical pregnancy rates per included patient were 36.6% in the salpingectomy group and 23.9% in the non-intervention group (not significant, P = 0.067) and the ensuing delivery rates were 28.6% and 16.3% (P = 0.045). The corresponding delivery rates per transfer cycle were 29.5% versus 17. 5% (not significant, P = 0.083). A subgroup analysis revealed significant differences in favour of salpingectomy, in implantation rates in patients with bilateral hydrosalpinges (25.6% versus 12.3%, P = 0.038) and in clinical pregnancy rates (45.7% versus 22.5%, P = 0.029) and delivery rates (40.0% versus 17.5%, P = 0.038) in patients with ultrasound visible hydrosalpinges. The delivery rate was increased 3.5-fold in patients with bilateral hydrosalpinges visible on ultrasound (P = 0.019).

The assessment of endometrial pathology and tubal patency: a comparison between the use of ultrasonography and X-ray hysterosalpingography for the investigation of infertility patients.

OBJECTIVES: The aim of the present study was to examine the role of hysterosalpingocontrast sonography (HyCoSy) as a screening test for endometrial and tubal pathology at the start of the infertility investigation protocol. METHODS: HyCoSy was compared with X-ray hysterosalpingography (HSG) for the assessment of the endometrial cavity and Fallopian tube patency. A total of 103 women with a history of at least 1 year's infertility were included. Each woman underwent both HyCoSy and HSG on the same day. Laparoscopy was performed in 43 cases. For HyCoSy examinations, saline was used for evaluation of the endometrial cavity and Echovist contrast medium to assess Fallopian tube patency. RESULTS: The concordance between HyCoSy and HSG for the presence of endometrial cavity pathology was 90%, but for tubal patency the concordance was lower (72%). HyCoSy classed more examinations of tubal patency as uncertain. HSG more frequently classified tubes as occluded. In the subset of patients in whom all three techniques were used, HSG and HyCoSy demonstrated a high concordance with laparoscopy (83% and 80%, respectively). The prevalence of occluded tubes according to laparoscopy as the reference standard was 13%. The two methods had a high negative predictive value for tubal disease (HSG, 94%; HyCoSy, 88%), and the positive predictive values were 47% and 75%, respectively. The detection rate for occluded tubes was 73% and 27%, and specificity 87% and 90%, respectively. CONCLUSIONS: Our data demonstrate that HyCoSy obtains similar information about the status of the endometrial cavity and Fallopian tube patency to that of HSG. It is possible that in some cases HyCoSy may replace HSG in order to select women with patent tubes who may be suitable for further infertility treatment without more invasive investigation.

Cell density and contraction regulate p38 MAP kinase-dependent responses in neonatal rat cardiac myocytes.

In vitro cardiac myocyte hypertrophy is characterized by increased cell size, sarcomere organization, and induction of several genes including atrial natriuretic factor (ANF). The hypertrophic growth program has been associated with activation of various mitogen-activated protein kinase (MAP) kinase family members, one of which is a stress kinase, p38. In this study, we found that the p38-specific inhibitor SB-203580 failed to inhibit phenylephrine-induced ANF-driven gene expression in low-density myocyte cultures but did inhibit gene expression in higher density cultures. Dense myocyte cultures also had a higher metabolic activity and contraction rate than cells plated at low density. We found that mimicking this effect by rapid electrical pacing activated ANF-driven gene expression and that this expression was inhibited by inactivation of p38. However, addition of SB-203580 at time points ranging between 1 and 72 h suggests that the effect of p38 on the ANF promoter may be both direct and indirect. Electrical pacing induced a small, but consistent, increase in p38 phosphorylation (phospho-p38) at time points ranging from 30 min to 4 h, but at later times phospho-p38 levels were reduced. When myocytes were treated with phenylephrine or electrically paced in the presence of the p38 inhibitor, there was little discernible change in morphology or rates of protein synthesis from DMSO-treated cells at 48 or 72 h. These data indicate that cell density and myocyte contraction may modulate p38-dependent pathways for ANF gene expression, but these pathways may not be direct and have limited effects on hypertrophic morphology.

Risk factors for ectopic pregnancy in assisted reproduction.

OBJECTIVE: To identify risk factors for ectopic pregnancy (EP) after IVF-ET. DESIGN: Retrospective cohort study. SETTING: In vitro fertilization clinic at a university hospital. PATIENT(S): A total of 725 women who conceived after IVF were studied with regard to background factors, indications for IVF, and factors related to the IVF procedure through review of their medical charts. The rate of EP was 4%, corresponding with 29 EPs, of which 2 were heterotopic. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Pregnancy outcome, defined as intrauterine pregnancy or EP. Background factors, indications for IVF, and factors related to the IVF procedure were analyzed for possible correlation with the outcome of EP. Risk factors for EP were identified by logistic regression analysis. RESULT(S): Tubal factor infertility, various previous abdominal surgeries, previous EP or pelvic infection, presence of a hydrosalpinx or fibroid, and type of transfer catheter used showed a positive correlation with EP as outcome. Logistic regression analysis identified two factors with predictive power: tubal factor infertility and previous myomectomy. CONCLUSION(S): Tubal factor infertility was the most prominent risk factor for EP after IVF. Previous myomectomy appeared to be another important risk factor, but this is a new finding that needs to be confirmed by further study.

A low-affinity serum response element allows other transcription factors to activate inducible gene expression in cardiac myocytes.

Hypertrophic growth of cardiac muscle cells is induced by a variety of physiological and pathological stimuli and is associated with a number of changes, including activation of genes such as atrial natriuretic factor. We found that two serum response element (SRE)-like DNA elements, one of which does not meet the consensus sequence and binds serum response factor (SRF) with low affinity, regulate the activity of this promoter. Surprisingly, the ability to induce the promoter by two different physiologic stimuli, as well as various activated transcription factors, including SRF-VP16, was primarily dependent upon the nonconsensus rather than the consensus SRE. This SRE controls the induction of gene expression via an unusual mechanism in that it is required to allow some, but not all, active transcription factors at unrelated sites on the promoter to stimulate gene expression. Thus, in addition to regulation of SRF activity by growth stimuli, regulation of a low-affinity SRE element controls inducible gene expression by modulating the ability of other transcription factors to stimulate the transcription machinery.

Hydrosalpinx fluid does not adversely affect the normal development of human embryos and implantation in vitro.

Several retrospectively designed studies have shown an association between the presence of hydrosalpinx and impaired implantation and pregnancy rates among in-vitro fertilization (IVF) patients. In the present study we have evaluated the influence of hydrosalpinx fluid on normal human embryo development and implantation. Surplus, donated frozen embryos (n = 183) from IVF patients were used to study the effects on blastocyst development of hydrosalpinx fluid at concentrations of 50 and 100% compared with controls in S2 medium. The fluids were analysed for concentrations of electrolytes, osmolarity, protein content, endotoxin levels, bacterial or fungal contamination, pH and haemoglobin content. There was no difference in blastocyst development in cultures under mineral oil when control cultures (15/42 = 36%) were compared with cultures in 50% hydrosalpinx fluid (32/96 = 33%). The only biochemical parameter which correlated with capacity for blastocyst development was pH in hydrosalpinx fluid/medium (50/50%) after equilibration in 5% CO2 in air. When embryos were cultured in 100% hydrosalpinx fluid the blastocyst development was 14% (5/36) in comparison to control 33% (3/9). The original experiment was repeated in an open culture system without the protection of mineral oil but still in the presence of 50% hydrosalpinx fluid. The rate of blastocyst development was within the same range in the open system. In three separate experiments, the capability of expanded blastocyst to implant on multilayer artificial endometrium was tested. In these experiments, 1/3, 4/5 and 9/9 blastocysts implanted. The present study demonstrates that hydrosalpinx fluid does not generally exert any major negative effects on in-vitro development of human embryos or on the implantation process in vitro.

Membrane-targeting sequences on AKAP79 bind phosphatidylinositol-4, 5-bisphosphate.

Protein kinases and phosphatases are targeted through association with anchoring proteins that tether the enzymes to subcellular structures and organelles. Through in situ fluorescent techniques using a Green Fluorescent Protein tag, we have mapped membrane-targeting domains on AKAP79, a multivalent anchoring protein that binds the cAMP-dependent protein kinase (PKA), protein kinase C (PKC) and protein phosphatase 2B, calcineurin (CaN). Three linear sequences termed region A (residues 31-52), region B (residues 76-101) and region C (residues 116-145) mediate targeting of AKAP79 in HEK-293 cells and cortical neurons. Analysis of these targeting sequences suggests that they contain putative phosphorylation sites for PKA and PKC and are rich in basic and hydrophobic amino acids similar to a class of membrane-targeting domains which bind acidic phospholipids and calmodulin. Accordingly, the AKAP79 basic regions mediate binding to membrane vesicles containing acidic phospholipids including phosphatidylinositol-4, 5-bisphosphate [PtdIns(4,5)P2] and this binding is regulated by phosphorylation and calcium-calmodulin. Finally, AKAP79 was shown to be phosphorylated in HEK-293 cells following stimulation of PKA and PKC, and activation of PKC or calmodulin was shown to release AKAP79 from membrane particulate fractions. These findings suggest that AKAP79 might function in cells not only as an anchoring protein but also as a substrate and effector for the anchored kinases and phosphatases.

Treatment, failures and complications of ectopic pregnancy: changes over a 20 year period.

Data from all 225 women operated on for ectopic pregnancy in 1992-1994 at Sahlgrenska University Hospital were collected and compared with three previous cross-sectional investigations from our hospital (1975-1979, 1981-1982 and 1986-1987) in order to evaluate the extent to which surgical treatment and post-operative complications have changed over a 20 year period. Laparoscopic surgery, which was not possible in the 1970s, was used in almost 85% of the ectopic pregnancies in 1992-1994. Conservative treatment was still the most frequently used technique. The complication rate was 1.2% in 1975-1979 when only laparotomies were carried out. After the introduction of laparoscopic surgery (1986-1987), the complication rate rose significantly (7.3%) and continued to increase even when this procedure was established as routine (14.2% in 1992-1994). Post-operative complications were most frequent after conservative laparoscopic surgery (24.4%) while there were no complications after laparotomies. In spite of increasing complication rates the frequency of patients in pre-shock, as well as the proportion of patients with heavy intra-abdominal bleeding and tubal rupture, decreased over time.