Growth plate extracellular matrix-derived scaffolds for large bone defect healing.

Limitations associated with demineralised bone matrix and other grafting materials have motivated the development of alternative strategies to enhance the repair of large bone defects. The growth plate (GP) of developing limbs contain a plethora of growth factors and matrix cues which contribute to long bone growth, suggesting that biomaterials derived from its extracellular matrix (ECM) may be uniquely suited to promoting bone regeneration. The goal of this study was to generate porous scaffolds from decellularised GP ECM and to evaluate their ability to enhance host mediated bone regeneration following their implantation into critically-sized rat cranial defects. The scaffolds were first assessed by culturing with primary human macrophages, which demonstrated that decellularisation resulted in reduced IL-1ß and IL-8 production. In vitro, GP derived scaffolds were found capable of supporting osteogenesis of mesenchymal stem cells via either an intramembranous or an endochondral pathway, demonstrating the intrinsic osteoinductivity of the biomaterial. Furthermore, upon implantation into cranial defects, GP derived scaffolds were observed to accelerate vessel in-growth, mineralisation and de novo bone formation. These results support the use of decellularised GP ECM as a scaffold for large bone defect regeneration.

Traumatic Orthopaedic Injury Is Not an Independent Risk Factor for High Postdischarge Opioid Consumption.

INTRODUCTION: The purpose of this study was to quantify how opioid use in patients with traumatic injury compared with opioid use in patients undergoing elective arthroplasty. METHODS: In a retrospective review, 235 adult trauma patients treated surgically for fracture were compared with 98 patients undergoing elective total hip or knee arthroplasty. Inpatient, discharge, and postdischarge opioid use were recorded in oral morphine equivalents (OMEs). RESULTS: There were no differences between trauma and elective arthroplasty patients for inpatient opioid use (OME/day: 70.2 vs. 67.3; P = 0.53), discharge prescription (OME: 542 vs. 594; P = 0.13), or postdischarge opioid use (OME: 986 vs. 1,147; P = 0.29). Postdischarge opioid use was positively correlated with Caucasian race, intensive care unit admission, baseline alcohol or opioid use, and higher discharge prescriptions (P < 0.0001; adjusted R2 = 0.127). Discharge prescription amount was the most significant predictor. DISCUSSION: Traumatic injury is not a predictor of high post-discharge opioid use. Demographic, social, and physician prescribing behaviors contribute to higher postdischarge opioid consumption.

Rhinitis medicamentosa.

Rhinitis medicamentosa (RM) is a condition induced by overuse of nasal decongestants. The term RM, also called rebound or chemical rhinitis, is also used to describe the adverse nasal congestion that develops after using medications other than topical decongestants. Such medications include oral beta-adrenoceptor antagonists, antipsychotics, oral contraceptives, and antihypertensives. However, there are differences in the mechanism through which congestion is caused by topical nasal decongestants and oral medications. Very few prospective studies of RM have been performed and most of the knowledge about the condition comes from case reports and histologic studies. Histologic changes consistent with RM include nasociliary loss, squamous cell metaplasia, epithelial edema, epithelial cell denudation, goblet cell hyperplasia, increased expression of the epidermal growth factor receptor, and inflammatory cell infiltration. Since the cumulative dose of nasal decongestants or time period needed to initiate RM has not been conclusively determined, these medications should only be used for the shortest period necessary. Validated criteria need to be developed for better diagnosis of the condition. Stopping the nasal decongestant is the first-line treatment for RM. If necessary, intranasal glucocorticosteroids should be used to speed recovery.

Laparoscopic kidney donation from patients older than 60 years.

BACKGROUND: The current study seeks to determine if the efficacy and safety of laparoscopic donor nephrectomy holds true when performed in patients older than 60 years of age. STUDY DESIGN: Medical records of 42 renal donors older than 60 years were reviewed compared with younger controls carefully matched for gender, race, nephrectomy side, auxiliary recipient procedures, and date of surgery. RESULTS: Preoperative baseline serum creatinine was identical in both groups (0.9 +/- 0.2 mg/dL) although controls had a slightly higher (NS) creatinine clearance (106.9 +/- 19.1 versus 100.0 +/- 35.5 mL/m). Operatively, there was no substantial difference between groups in operative time, warm ischemia time, estimated blood loss, number or size of ports used, and length of incision needed for removal of kidney. Intraoperative and postoperative complication rates were also equivalent between old and young donors. Postnephrectomy serum creatinine was identical. There was no increased length of hospitalization for older donors and they tended to require less morphine sulfate patient-controlled anesthesia. Recipient renal function was slightly better in the younger kidneys early and the difference became statistically significant at 6 to 12 months, but the magnitude of the improvement is not clinically important. CONCLUSIONS: Laparoscopic donor nephrectomy may be performed safely in patients older than 60 years of age. There was no increase in complication rates or length of hospital stay. Older donors did not have a greater increase in serum creatinine after donation compared with donors younger than 40 years of age, nor did recipients of these older kidneys have clinically significantly higher serum creatinine than recipients of kidneys from donors less than 40 years old.

Intracranial surgery: to shave or not to shave?

OBJECTIVE: In an effort to improve patient confidentiality as well as cosmesis, the authors have stopped shaving for all intracranial procedures. The objective was to determine whether this lack of shaving increased the postoperative infection rate. DESIGN: A retrospective study was performed comparing all intracranial surgical procedures performed in the last 2(1/2) years, when hair was not shaved, with the infection rate in patients who did have their hair shaved in the preceding 3(1/2) years. SETTING: An academic tertiary care referral center. PATIENTS: Every patient (children and adults) who underwent an intracranial procedure by the skull base surgery team was included. Similar patient demographics were used for the hair-shaved group. INTERVENTION(S): Intracranial procedures consisted of acoustic tumor removal, vestibular nerve sections, skull base surgery procedures, vascular decompressions, and craniotomies for benign and malignant tumors. MAIN OUTCOME MEASURES: The most essential criterion was to determine whether postoperative wound infection developed in a patient. This was documented as either minor (stitch abscess or wound dehiscence), moderate (wound breakdown requiring inpatient or outpatient therapy, such as oral or intravenous antibiotics), or severe (significant wound breakdown that required hospitalization, with surgical debridement and antibiotics). RESULTS: In all, 150 patients were not shaved for their intracranial procedures; postoperative wound infections developed in 11 (7%). The infections were minor (6), moderate (5), and severe (0). By comparison, 100 patients undergoing intracranial procedures had their hair shaved. In this group, the number of infections noted was 6 (6%). Their categorization into mild, moderate, and severe was 4, 2, and 0, respectively. Statistical analysis did not reveal any significant difference between the two infection rates. CONCLUSIONS: The rate of postoperative wound infection was statistically no greater when the hair was shaved than when it was not. Thus, for patient confidentiality as well as patient esteem, we recommend not shaving hair for intracranial procedures.

Laparoscopic right donor nephrectomy: technique and comparison with left nephrectomy.

BACKGROUND: Laparoscopic donor nephrectomy (LDN) preferentially involves the left kidney to optimize vessel length, but occasionally, right nephrectomy is preferred. Right LDN differs markedly in anatomic relations and the need for a fourth port. This retrospective study compares donor outcomes and graft function of right and left LDN and describes the technique. METHODS: Consecutive patients undergoing right LDN from March 26, 1996 to December 31, 2000 were compared with those undergoing left LDN. Age, height, weight, body mass index, creatinine, creatinine clearance, operative time, warm ischemia time, analgesic requirements, serial postoperative creatinine, time to diet resumption, and hospital stay were compared. A second cohort matched for age, gender, race, and temporal left LDN also were compared with the group undergoing right LDN. RESULTS: No significant differences were found for any of the parameters measured. CONCLUSION: This study demonstrates that despite substantial differences in the procedures, donor outcome and graft survival are similar for right and left LDN.

Failure of elimination of paternal mitochondrial DNA in abnormal embryos.

Paternal mitochondrial DNA is normally eliminated from mammalian embryos. We have shown the presence of paternal mtDNA at the blastocyst stage in some abnormal human embryos.

A naturally occurring genetic variant in the human chorionic gonadotropin-beta gene 5 is assembly inefficient.

The hCGbeta gene family is composed of six homologous genes linked in tandem repeat on chromosome 19; the order of the genes is 7, 8, 5, 1, 2, and 3. Previous studies have shown that hCGbeta gene 5 is highly expressed during the first trimester of pregnancy. The purpose of our study was to identify naturally occurring polymorphisms in hCGbeta gene 5 and determine whether these alterations affected hCG function. The data presented here show that hCGbeta gene 5 was highly conserved in the 334 asymptomatic individuals and 41 infertile patients examined for polymorphisms using PCR followed by single stranded conformational polymorphism analysis. Most of the polymorphisms detected were either silent or located in intron regions. However, one genetic variant identified in beta gene 5 exon 3 was a G to A transition that changed the naturally occurring valine residue to methionine in codon 79 (V79M) in 4.2% of the random population studied. The V79M polymorphism was always linked to a silent C to T transition in codon 82 (tyrosine). To determine whether betaV79M hCG had biological properties that differed from those of wild-type hCG, a beta-subunit containing the V79M substitution was created by site-directed mutagenesis and was coexpressed with the glycoprotein hormone alpha-subunit in Chinese hamster ovary cells and 293T cells. When we examined betaV79M hCG biosynthesis, we detected atypical betaV79M hCG folding intermediates, including a betaV79M conformational variant that resulted in a beta-subunit with impaired ability to assemble with the alpha-subunit. The inefficient assembly of betaV79M hCG appeared to be independent of beta-subunit glycosylation or of the cell type studied, but, rather, was due to the inability of the betaV79M subunit to fold correctly. The majority of the V79M beta-subunit synthesized was secreted as unassembled free beta. Although the amount of alphabeta hCG heterodimer formed and secreted by betaV79M-producing cells was less than that by wild-type beta-producing cells, the hCG that was secreted as alphabeta V79M heterodimer exhibited biological activity indistinguishable from that of wild-type hCG.

Transforming growth factor beta receptor expression in hyperstimulated human granulosa cells and cleavage potential of the zygotes.

A possible relationship between transforming growth factor beta receptor type I (TbetaRI) and type II (TbetaRII) protein expression in human granulosa cells and the quality of preimplantation embryo development in vitro was studied using immunoblot analysis of TbetaRI and TbetaRII in hyperstimulated granulosa cells and morphological assessment of the cleavage potential of the zygotes in vitro. Washed granulosa cells were collected from

Human chorionic gonadotropin-beta gene expression in first trimester placenta.

The hCGbeta gene family contains six genes linked in tandem on chromosome 19 and labeled beta genes 7, 8, 5, 1, 2, and 3. Previous studies on a small number of placentas have indicated that beta gene 5 was the most highly expressed gene during the first trimester of pregnancy, followed by genes 3 and 8. Beta genes 7, 1, and 2 were expressed at very low levels. The purpose of this study was to determine 1) whether this pattern of expression was typical during normal pregnancy by sampling a large number of first trimester placentas, and 2) whether there was a correlation between gestational age and the pattern of hCGbeta gene expression. Total RNA from 27 first trimester placentas varying in age from 6-16 weeks was reverse transcribed into complementary DNA. The complementary DNA was amplified by PCR, and the amount of DNA representative of each hCGbeta gene was quantified by Genescan analysis. In 14 of the 27 placentas, hCGbeta gene 5 accounted for 50% or more of the total beta messenger RNA expressed. Beta gene 3 was expressed at levels ranging from 1-42% of the total, and beta gene 8 expression ranged from 12-32% of the total. Gene 7 expression was less than 3% of the total beta expression in all 27 placentas. Although there appeared to be a trend toward lower expression of beta gene 3 in placentas beyond 10 weeks gestational age, there was no correlation of the pattern of beta expression with placental age. Beta gene expression was also examined in two blighted ova, a spontaneous abortion sample, and a hydatidiform mole as well as in cultured JAR choriocarcinoma cells. With the exception of JAR cells, these abnormal tissues had low levels of gene 3 expression, but these levels were within the range of the patterns observed in normal placentas. These data suggest that it is the total amount of hCGbeta gene expression rather than the expression of individual beta genes that is important for the maintenance of normal pregnancy.

Transfer of cryopreserved-thawed pre-embryos in a cycle using exogenous steroids without prior gonadotrophin-releasing hormone agonist suppression yields favourable pregnancy results.

We have analysed the use of a programmed cycle of administration of exogenous steroids without prior suppression with a gonadotrophin-releasing hormone agonist (GnRHa) for the transfer of cryopreserved-thawed pre-embryos. From July 1992 to June 1994, 199 cycles (162 patients) were studied. Pre-embryos had been previously cryopreserved at the pronuclear stage using 1.5 M 1,2-propanediol as a cryoprotectant. Preparation of the endometrium was achieved in a step-up regime with transdermal oestradiol patches (0.1 to 0.4 mg). Progesterone in oil (50 mg i.m.) was started on cycle day 13. Pre-embryos were thawed on day 14 and transferred on day 15 after evidence of survival and cleavage. The mean (+/- SD) age of patients undergoing transfer was 35.4 +/- 4.3 years. The mean number of pre-embryos thawed was 4.7 +/- 1.8 with a mean of 3.3 +/- 1.4 pre-embryos being transferred. Eight of the cycles demonstrated follicular development >16 mm prior to thaw and transfer; however, these patients did not demonstrate a luteinizing hormone surge. Mean endometrial thickness on day 13 was 10.8 +/- 2.1 mm. Overall pregnancy rate was 29.2% (57/195). The ongoing or delivery rate was 16.1% (32/195). The rate of preclinical losses per transfer was 6.2% (12/195). Overall, the implantation rate was 6.2% (47/757). Thus, the use of a programmed cycle for cryopreserved embryo transfer yields favourable pregnancy outcome and offers practical advantages to patients. Prior suppression with a GnRHa is not necessary for endometrial preparation.

Inability to establish ectopic endometrium in a natural killer cell-deficient murine model. Immunologic, histologic and histochemical assessment.

OBJECTIVE: To investigate what effect natural killer (NK) cells have on the implantation of heterologous endometrial scrapings. STUDY DESIGN: Anti-asialo GM1 (AA-GM1) anti-sera have been shown to eliminate NK cell activity in various strains of rats and mice. Either AA-GM1 antibodies (+) or rabbit antiglobulin (-) was administered to beige mice (NK cell deficient) or beige control mice (not NK cell deficient of the same strain). The heterologous endometrial scrapings were prepared by scraping seven pairs of uterine horns from normal mice of the same strain. Beige and normal mice were then injected intraperitoneally every 3 days with the heterologous endometrial scraping and antibodies for a period of 50 days. The four experimental groups (n = 10 per group) can be summarized as being beige (+), beige (-), normal (+) and normal (-). RESULTS: There was no evidence of ectopic endometrial tissue in any of the four test groups by histologic examination or by using immunohistochemical staining techniques. Histologic evidence of an impaired immune response was clearly demonstrated in the beige mice receiving AA-GM1 antibodies. CONCLUSION: Using this model, a deficiency of NK cell activity did not appear to enhance the implantation of endometrial tissue on the abdominal peritoneum of mice.

Serum estradiol in the differential diagnosis of ectopic pregnancy.

In a prospective study using a cutoff value of 140 pg/mL, serum estradiol 17-beta assay had a sensitivity of 83% and a specificity of 100% in differentiating ectopic pregnancy (6 patients) from normal pregnancy with threatened abortion proceeding to viability (7 patients). In differentiating threatened abortion from spontaneous abortion (9 patients), the estradiol assay had a sensitivity of 88.9% and a specificity of 100%. All but one of the patients with ectopic pregnancy had estradiol levels below the cutoff value of 140 pg/mL, as did all but one of the patients who had spontaneous abortion. All the patients who had threatened abortion that progressed to viability had values well above the cutoff level. The mean estradiol values for the viable pregnancy group were significantly different from those of the other two groups. These data suggest that, at the institution where this study was done, serum estradiol determinations may be of value in the differentiation of both ectopic pregnancy and spontaneous abortion from threatened abortion but appears to be of very limited usefulness in distinguishing ectopic pregnancy from spontaneous abortion. The validity of these conclusions is limited by the small number of subjects. Further studies comprising greater numbers of subjects are needed.

Superior analytic characteristics of an immunometric assay for gonadotropins also provides useful clinical prediction of in vitro fertilization outcomes.

OBJECTIVE: To determine whether an analytically superior gonadotropin assay, the monoclonal, two-site immunometric assay, also provided superior prediction of clinical outcomes when compared with conventional RIA methodology. DESIGN: Methods comparison study. SETTING: Tertiary academic center. PATIENTS: One hundred fifty-seven consecutive IVF patients. INTERVENTION: Comparisons of FSH and LH levels on cycle day 3 were made using paired RIA and immunometric assay procedures. The ability of day 3 LH, FSH, and their ratio in predicting IVF performance was determined using regression analyses. RESULTS: The predictive ability of FSH as assayed by immunometric assay at least equaled that obtained by RIA for both peak E2 levels and the number of mature oocytes retrieved. CONCLUSION: Results from this study indicate that gonadotropin levels as measured by immunometric assay represent an effective clinical tool in predicting IVF outcomes that may prove superior to RIA.

Risk adjustment: the missing piece of market competition.

This DataWatch describes the process adopted by The Health Insurance Plan of California (The HIPC) for assessing and adjusting for health risk differences among participating health plans. We also report on the results of the 1996 risk assessment/adjustment calculations. A risk assessment value is calculated for each health plan based on the plan's enrollee mix as compared with the mix of enrollees in The HIPC as a whole. The results indicated that approximately 1 percent of total premium dollars needs to be transferred to bring all health plan scores within the acceptable level (+/- 5 percent) of risk distribution.

The influence of pentoxifylline (Trental) on the antifertility effect of intrauterine devices in rats.

OBJECTIVE: To test the hypothesis that the inflammatory response stimulated by intrauterine devices (IUDs) plays a role in the antifertility action of IUDs. We treated rats with pentoxifylline (Trental; Hoechst-Roussel Pharmaceuticals, Inc., Somerville, NJ) and evaluated its effect on the anti-implantation action of IUDs. The number of embryos in treated compared with untreated rats was determined. DESIGN: Breeder female Sprague-Dawley rats (Harlan Sprague Dawley, Indianapolis, IN) were randomized into one of five test groups (n = 20 per group). A monofilament nylon IUD was inserted transcervically into one horn of the bicornuate uterus in two groups. The IUD-bearing groups received either intraperitoneal (IP) injections of pentoxifylline (45 mg/kg per every 12 hours) or normal saline (NS). The two non-IUD-bearing groups received IP injections of pentoxifylline or NS. The non-IUD group was not injected. All injections were administered daily for 21 days and the animals then mated. Successful mating was determined by the presence of spermatozoa in vaginal washings. The injections of pentoxifylline or NS were continued until day 12 of pregnancy when the rats were killed. The total number of embryos in each uterine horn was determined. SETTING: University research laboratory. RESULTS: Embryo numbers (1.0 +/- 0.6 [mean +/- SEM]) were reduced in the IUD horn compared with the contralateral non-IUD horn (6.4 +/- 1.0) and with the uterine horns from each of the four other test groups. The number of embryos were increased in the IUD horn (3.5 +/- 0.9) of the pentoxifylline-treated rats. CONCLUSION: Pentoxifylline appeared to reduce the contraceptive effectiveness of the IUDs in this model.

The process of carcinogenesis for endometrial adenocarcinoma could be short: development of a malignancy after endometrial ablation.

Endometrial ablation has been proposed as an alternative to hysterectomy for the treatment of dysfunctional uterine bleeding. We describe what we believe to be the first reported case of an endometrial adenocarcinoma that may have developed shortly after endometrial ablation.

Therapeutic intrauterine insemination improves with gonadotropin ovarian stimulation.

Therapeutic intrauterine insemination (IUI) is frequently used as a first line of treatment of infertility. The reported results vary, depending on the indication and the use of ovulation simulation protocols. In the present study, we review the experience at the Jones Institute for Reproductive Medicine in Virginia from January 1989 to January 1991. The patients were preferentially treated with ovulation induction with gonadotropins. With the addition of gonadotropin stimulation, the total and term pregnancy rates per cycle were 14% and 11%, respectively, including all etiologic factors. These rates were improved over the 3% and 2.6% rates reported in our previous study in which ovarian stimulation was not generally used. In male factor patients, the term pregnancy rate was 9%, higher than the 4% term pregnancy rate reported in our previous study. In the present series, morphology was the only severely impaired parameter. The term pregnancy rate was 11% for patients with ovulatory dysfunction, 10% for those with cervical factor, and 10.5% for those with unexplained infertility.