Microfracture combined with anterior cruciate ligament reconstruction compared to isolated microfractures for osteochondral lesions.

There is limited evidence whether increased growth-factor and stem-cell influx during bone tunnel drilling for ACL-reconstruction enhances clinical results of microfracture treatment of small cartilage defects. The goal of this study was to compare clinical and radiological results in patients treated with microfracture alone and patients treated with microfracture plus ACL-reconstruction. A total of 67 patients that were either treated with microfracture alone (primary stable knees, n= 40) or microfracture plus ACL-reconstruction (ACL deficient knees, n= 27) were included and prospectively evaluated. Subjects were preoperatively assessed radiologically using the MR-based AMADEUS-score (Area Measurement and Depth & Underlying Structures) and clinically using the Lysholm-score before the intervention. At minimum 24-month follow-up, the regenerate tissue was assessed by the MR-based MOCART-score (Magnetic resonance observation of cartilage repair tissue) and by use of the Lysholm-Tegner-score for clinical evaluation. Preoperatively both groups had similar AMADEUS-scores. The Lysholm-score was significantly higher in the microfracture group (p < 0.001). In the postoperative assessment there was a significant difference (p = 0.04) in the MOCART-score in favor of the microfracture plus ACL-reconstruction group. The Lysholm-score significantly improved (p <0.001) in the microfracture plus ACL-reconstruction group and was significantly higher than in the microfracture group (p = 0.004). Conclusion: A combination of microfracture and ACL-reconstruction leads to comparable functional results, yet superior MOCART-scores as compared to microfracture alone. ACL reconstruction enhances biological healing responses in microfracture treated cartilage and thus improves clinical outcomes by additional bone marrow influx from bone tunnels.

Advanced Rotator Cuff Tear Score (ARoCuS): a multi-scaled tool for the classification and description of rotator cuff tears.

BACKGROUND: To introduce a (semi-)quantitative surgical score for the classification of rotator cuff tears. MATERIAL AND METHODS: A total of 146 consecutive patients underwent rotator cuff repair and were assessed using the previously defined Advanced Rotator Cuff Tear Score (ARoCuS) criteria: muscle tendon, size, tissue quality, pattern as well as mobilization of the tear. The data set was split into a training (125 patients) and a testing set (21 patients). The training data set fitted a nonlinear predictive model of the tear score based on the ARoCuS criteria, while the testing data served as control. Based on the scoring results, rotator cuff tears were assigned to one of four categories (ΔV I-IV) and received a stage-adapted treatment. For statistical analysis, mean values ± standard deviation, interclass correlation coefficients (ICC) and kappa values were calculated. RESULTS: Overall, 32 patients were classified as ΔV I, 68 as ΔV II and 37 as ΔV III. Nine patients showed ΔV IV tears. Patients of all ΔV groups improved significantly their Constant scores (p < 0.001) and profited from significant pain reduction after surgery (p < 0.001). To date, ten patients have undergone revision surgery with five of them primarily classified as ΔV IV. Kappa values for the interobserver reliability ranged between 0.69 and 0.95. ICC scores for the ΔV category were 0.95 for interobserver reliability. CONCLUSIONS: The ARoCuS facilitates intra-operative decision-making and enables surgeons and researches to document rotator cuff tears in a standardized and reproducible manner.

Improving care with nurse case managers: practical aspects of designing lipid clinics.

Compliance with the National Cholesterol Education Program (NCEP II) Adult Treatment Panel II guidelines for lipid management in patients with coronary artery disease has not been widespread. Barriers to effective lipid management occur at numerous levels of interaction between the patient, provider, and healthcare organizations. Nurse care managers (NCMs), recognized in the inpatient and discharge planning settings, are emerging in new roles in the outpatient setting working in subspecialty areas including lipid/risk-reduction, heart failure, and anticoagulation clinics. To improve patient adherence to NCEP II goals, NCMs can help overcome treatment barriers by: (1) bridging inpatient/outpatient care; (2) securing long-term patient compliance and follow-up; (3) developing clinic policy and computerized patient databases; (4) implementing management algorithms; and (5) enhancing financial reimbursement from insurers. Additional graduate nursing programs and novel healthcare delivery models demonstrating the ability to overcome the barriers to improved patient care must be encouraged and supported.

Oocyte retention after follicle luteinization.

Indirect evidence supports the existence of the luteinized unruptured follicle syndrome in infertile women. To seek direct evidence of oocyte retention, infertile and normal women were studied in the early and midluteal phase by visual documentation of ovulation stigma, needle aspiration of ovarian follicles, and peritoneal fluid collection for estradiol and progesterone assay. Luteal phase was confirmed by endometrial biopsy (postovulation day 2 to 8). In normal control subjects (n = 16), 25% of test cycles were stigma-negative and no oocytes were recovered. In infertile group (n = 23), 43% of test cycles were stigma-negative. Five oocytes were recovered including one from a stigma-bearing follicle. Peritoneal fluid steroid levels failed to discriminate stigma-positive from stigma-negative cycles in either group. Oocyte retention after luteinization occurs in infertile women.

Treatment of esophageal Crohn's disease by enteral feeding via percutaneous endoscopic gastrostomy.

BACKGROUND: Crohn's disease of the esophagus is rare, and medical treatment often ineffective. Complications such as abscess and fistula may arise, and the morbidity of surgery is high. METHODS: Two cases of refractory esophageal Crohn's disease were confirmed by endoscopy and biopsy. Percutaneous endoscopic gastrostomies (PEGs) were inserted and used for enteral nutrition for 9 and 1 month, respectively. RESULTS: The PEGs were well tolerated. Symptoms subsided rapidly, and later gastroscopies confirmed healing of the esophageal ulcers. No complications occurred, and the gastrostomy sites closed quickly after removal of the tubes, with minimal scarring. CONCLUSIONS: Enteral feeding via PEG appears to be safe and well tolerated and may be of great value in the management not only of esophageal Crohn's disease but also of refractory disease at other sites.

Evaluation of the site of synthesis of rabbit sperm acrosome stabilizing factor using immunocytochemical and metabolic labeling techniques.

Antibodies to rabbit acrosome stabilizing factor (ASF) were raised in mice and proved monospecific on Western electroblots . Anti-ASF was utilized to immunolabel tissue sections of male reproductive tract organs. Staining of principal cell cytoplasm was observed primarily in the corpus epididymidis (Regions 6 and 7), and secondarily in the cytoplasm of principal cells of the distal cauda epididymidis (Region 8b ) and the columnar cells of the vas deferens epithelium. The microvilli of principal cells in the proximal cauda epididymidis (Region 8a ) were densely stained. Spermatozoa appeared uniformly stained within the lumen of the corpus epididymidis and staining intensity increased distally. The Golgi region of corpus principal cells was not stained, nor were other cell types in this region. Testis, caput epididymidis, and accessory sex organs were not stained. Synthesis of ASF by corpus epididymidis was shown by immunoprecipitation of radiolabeled ASF from organ cultures of specific epididymal segments. Scant amounts of synthesis were also detected in the cauda epididymidis and vas deferens. The large subunit of ASF, immunoprecipitated from the corpus epididymidis, is 2000-4000 daltons larger than the large subunit of ASF from more distal regions of the reproductive tract, suggesting modification of this component.

Sperm surface components involved in the control of the acrosome reaction.

Several lines of evidence suggest that decapacitation of sperm occurs normally in the male reproductive tract, and as a result the acrosome is stabilized and the acrosome reaction is controlled. Since the defining experiments in 1951, where decapacitation was reversed in the female reproductive tract by capacitation, investigations have pursued the molecular events of this process. This review attempts to examine critically the older literature and compare that perspective with the current theories. The theories for decapacitation of sperm include the possible role of a peptide decapacitation factor, a glycoprotein-mediated steroid transfer to the sperm, masking of a galactosyl transferase by some macromolecule-containing carbohydrate, preclusion of calcium influx by a binding protein, and sperm interaction with the acrosome stabilizing factor. Although these theories are diverse, there are some unifying aspects. However, there remain some major unanswered questions. For example, although we point to some circumstantial evidence that infers a single decapacitation factor, this needs to be further substantiated. It is concluded that with the purification of a macromolecule involved in capacitation, specific proposals on the mechanism of capacitation, and new tools to evaluate the capacitation process, it is likely that another decade will not pass without emergence of a unifying molecular theory of sperm capacitation.

Chemical and physical characterization of rabbit sperm acrosome stabilizing factor.

Rabbit Acrosome Stabilizing Factor (ASF) is an epididymal product that reversibly inhibits the process of sperm capacitation. The native molecular weights of the monomer and dimer ASF were determined from sedimentation and diffusion data at 129,000 and 259,000 Mr. The monomer is composed of 92,000 and 38,000 Mr subunits according to sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE), with size heterogeneity demonstrated for the latter. The stoichiometry of the subunits appears to be one-to-one by gel scanning. Amino acid and carbohydrate compositions are characteristic of a globular glycoprotein, which is high in cysteine content and is 8.3% carbohydrate by weight. The sugar composition suggests the presence of both high mannose and complex N-linked oligosaccharides with the unusual feature of appreciable amounts of glucose. The isoelectric character of ASF spans a range from 5.3 to 7.0.

Sulfated oviductal glycoproteins in the rabbit: quantitation by competitive enzyme-linked immunosorbent assay.

The rabbit oviductal epithelium synthesizes and secretes a family of antigenically related, sulfated oviductal glycoproteins (SOG). Anti-SOG monoclonal antibodies (Mabs) were produced and two (Mab 1 and Mab 2) were selected for further characterization. Periodate oxidation of Western blots of oviductal fluid did not affect the binding of Mab 1 or Mab 2, thus suggesting that these antibodies recognized protein rather than carbohydrate epitopes on SOG. The specificity of Mab 1 was determined by Western blot analysis of tissues obtained from estrous rabbits and from the male rabbit reproductive tract. SOG was identified in tissue extracts of both the oviductal ampulla and isthmus. Cervix was the only non-oviductal tissue with which Mab 1 cross-reacted. Mab 1 was used to isolated SOG from whole oviductal fluid by immuno-affinity chromatography. Affinity-purified SOG and Mab 1 were used to develop a quantitative, SOG-specific, competitive enzyme-linked immunosorbent assay. This assay was used to quantify SOG in rabbit oviductal fluid collected during estrus and pseudopregnancy. SOG secretion during pseudopregnancy was resolved into two transient episodes of increased secretion. Maximum SOG secretion (X = 1039 +/- 199 micrograms/day) occurred within 48 h of the induction of pseudopregnancy. A second period of enhanced SOG secretion (X = 308 +/- 46 micrograms/day) occurred during the fifth and sixth days of pseudopregnancy. Baseline SOG secretion occurred during estrus at approximately 60% of maximum postovulatory secretion.

Concentration of acrosome stabilizing factor (ASF) in rabbit epididymal fluid and species specificity of anti-ASF antibodies.

Rabbit Acrosome Stabilizing Factor (ASF) concentrations were measured by immunoradiometric assay (IRA) in lumenal fluids obtained by micropuncture from the caput epididymidis, corpus epididymidis, cauda epididymidis, and the vas deferens of the rabbit. ASF was below the limit of detection in caput epididymidal fluids. Average ASF concentrations (3 bucks) in the corpus epididymidis, cauda epididymidis, and vas deferens were 880, 3363, and 3236 micrograms/ml, respectively. The average level of ASF in the cauda epididymidal fluid (CEF) represents from 10 to 23% of the total protein and is at least tenfold more than the amount previously determined to effect complete decapacitation of rabbit sperm by an in vivo assay. The average ASF concentration in seminal plasma from two vasectomized males was 0.155 micrograms/ml, approximately 100,000-fold less than is present in CEF and 2000-fold less than is present in normal seminal plasma. CEFs or seminal plasma from 11 different species were screened by Western blotting using high titer anti-ASF polyclonal antibodies to detect ASF-like molecules in other species. Only rabbit ASF was recognized.

Effect of steroid hormones on sulfated oviductal glycoprotein secretion by oviductal explants in vitro.

Explants of rabbit ampullary and isthmic tissue were cultured 4 days with and without exogenous steroids, and the sulfated oviductal glycoprotein (SOG) concentration in the explant culture supernatants was determined. Tissues cultured with progesterone plus estrogen secreted significantly more SOG than control tissues, whereas tissues cultured with estrogen alone did not. Ampullary tissues cultured with progesterone plus estrogen secreted significantly more SOG than control tissues on Days 2 and 3, whereas SOG secretion by isthmic tissues was significantly above control secretion on Day 4. Ampullary and isthmic tissues differed significantly in their secretory capacity. Maximum ampullary SOG secretion was approximately 650 ng SOG/mg tissue/day. Maximum isthmic SOG secretion was approximately 30 ng SOG/mg tissue/day. These findings suggest that the oviduct is composed of discrete functional regions that provide support to gametes and developing embryos through the unique secretory characteristics of each region.

The scientific basis of surgical glove selection in an in vitro fertilization laboratory.

Mouse embryos and human sperm are used as quality control bioassays in human in vitro fertilization (IVF) laboratories. These two models can reveal the cytotoxicty of items commonly used in IVF, such as surgical gloves. The literature published in this area points to the cytotoxicity of both glove powders and glove products.

Impact forces and neck muscle activity in heading by collegiate female soccer players.

Three soccer header types (shooting, clearing and passing) and two heading approaches (standing and jumping) were manipulated to quantify impact forces and neck muscle activity in elite female soccer players. The 15 participants were Division I intercollegiate soccer players. Impact forces were measured by a 15-sensor pressure array secured on the forehead. The electromyographic (EMG) activity of the left and right sternocleidomastoid and trapezius muscles was recorded using surface electrodes. Maximum impact forces and impulses as well as the EMG data were analysed with separate repeated-measures analyses of variance. Impact forces and impulses did not differ among the header types or approaches. Higher values were found for jumping versus standing headers in the mean normalized EMG for the right sternocleidomastoid. In addition, the integrated EMG was greater for the right sternocleidomastoid and right and left trapezius (P < 0.05). The sternocleidomastoid became active earlier than the trapezius and showed greater activity before ball contact. The trapezius became active just before ball contact and showed greater activity after ball contact. The increased muscle activity observed in the neck during the jumping approach appears to stabilize the connection between the head and body, thereby increasing the stability of the head-neck complex.

Gamete retrieval in terminal conditions.

There has been a growing interest and requests by patients facing intensive chemotherapy or surgically ablative procedures for gamete retrieval and preservation for future procreative efforts. There are technical difficulties in this area but little ethical discomfort. More troubling are the issues that arise with a terminally ill, incapable patient-one who is in a persistent vegetative state or who is declared brain dead or who is neurologically devastated with no hope for recovery, but not yet in either of the above states-or with a person who has suddenly died. In these cases, the surviving spouse, partner, or family members may request gamete retrieval for future reproductive efforts. Discussion of this topic within the Ethics Consultation Service at the University of Virginia demonstrated a need for development of insight derived from facts and ethical deliberation to help formulate a policy that would apply to such cases. A group was assembled with the expertise to explore the issue and to help formulate a policy that could be suggested for adoption by the hospital administration. The group consisted of a urologist with experience in sperm retrieval from terminally ill patients; the director of the laboratory supporting the assisted reproductive facility in the Department of Obstetrics and Gynecology; the chairperson of the Ethics Consultation Service (who is also a neonatologist); and 2 members of the Ethics Consultation Service, one a genetic counselor and the other an obstetrician-gynecologist with a master's degree in biomedical ethics. Current literature was reviewed, the expertise of the urological member and the reproductive laboratory director was explored, and the insight of the members of the Ethics Consultation Service was added. We explored the technical aspects of both male and female gamete retrieval and preservation and the reproductive potential of these stored gametes. We present a review of the current literature on both the technical and ethical aspects of the topic. Finally, we present a policy that we deem acceptable for adoption and that should be of value to other practitioners and facilities as they contemplate facing requests for gamete retrieval.

Human SP-10: acrosomal distribution, processing, and fate after the acrosome reaction.

SP-10 is a testis-specific acrosomal protein that has been detected in several species including humans. Extracts from whole human testis and epididymal, ejaculated, and capacitated sperm were analyzed by Western blot for SP-10 polypeptides. The testis extracts contained a full-length SP-10 protein at approximately 45 kDa as well as other immunoreactive SP-10 peptides at 32, 30, 28, and 26 kDa. Extracts from epididymal, ejaculated, and capacitated sperm contained several immunoreactive SP-10 peptides that co-migrated with the 32-26-kDa SP-10 peptides in the testis extracts. Epididymal, ejaculated, and capacitated sperm extracts did not contain the 45-kDa SP-10 peptide observed in testis extracts, but did contain immunoreactive SP-10 peptides from 25 to 18 kDa that were not detected in testis extracts. These results indicate that a full-length 45-kDa SP-10 precursor protein is present in the testis and that SP-10 peptides of 32, 30, 28, and 26 kDa result from proteolytic processing of the SP-10 precursor protein in the testis and/or alternative splicing. In addition, SP-10 peptides of 25-18 kDa were first detected in extracts of caput epididymal sperm and probably resulted from the proteolytic processing of the 45- and 32-26-kDa SP-10 peptides in the initial segment or caput epididymidis. Also, no additional SP-10 bands were detected in extracts of cauda epididymal, ejaculated, or capacitated sperm, suggesting that no further processing of the 32-18-kDa SP-10 peptides occurred during epididymal transit, ejaculation, and capacitation. Electron microscopic immunocytochemical observations of epididymal, ejaculated, and capacitated sperm revealed that colloidal gold labeling of SP-10 was most abundant within the principal segment and posterior bulb of the equatorial segment of the acrosome, while the colloidal gold labeling of SP-10 was sparse in the anterior equatorial segment of the acrosome. After a follicular fluid-induced acrosome reaction, SP-10 was detected on the inner acrosomal membrane in the equatorial segment and was associated with hybrid vesicles. This localization after the acrosome reaction is consistent with the hypothesis that SP-10 may be involved in sperm-zona binding or penetration.