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The maturation of genomic surveillance in the past decade has enabled tracking of the emergence and spread of epidemics at an unprecedented level. During the COVID-19 pandemic, for example, genomic data revealed that local epidemics varied considerably in the frequency of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) lineage importation and persistence, likely due to a combination of COVID-19 restrictions and changing connectivity. Here, we show that local COVID-19 epidemics are driven by regional transmission, including across international boundaries, but can become increasingly connected to distant locations following the relaxation of public health interventions. By integrating genomic, mobility, and epidemiological data, we find abundant transmission occurring between both adjacent and distant locations, supported by dynamic mobility patterns. We find that changing connectivity significantly influences local COVID-19 incidence. Our findings demonstrate a complex meaning of "local" when investigating connected epidemics and emphasize the importance of collaborative interventions for pandemic prevention and mitigation., Competing Interests: Declaration of interests K.G.A. has received consulting fees on SARS-CoV-2 and the COVID-19 pandemic., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Aim: This study investigated the humoral response against SARS-CoV-2 in patients needing intensive care unit (ICU) care compared with those on general medicine wards., Materials & Methods: The authors retrospectively reviewed 113 hospitalized patients with COVID-19. They assessed antibody response against five SARS-CoV-2 epitopes at 6-14 days post symptom onset in these patients., Results: Patients with ICU admissions had decreased anti-nucleocapsid immunoglobulin (Ig)M and increased anti-spike IgG compared with patients not requiring the ICU. IgG levels were positively correlated with length of stay., Conclusion: Higher levels of IgG against the spike protein correlate with COVID-19 disease severity and length of stay in hospitalized patients. This adds to the knowledge of biochemical response to clinical disease and may help predict ICU needs., Competing Interests: Financial & competing interests disclosure The authors are providing this manuscript to the National Institutes of Health (NIH) to make it publicly available in PubMed Central after its official date of publication in the journal. This work was supported by the National Center for Advancing Translational Sciences, National Institutes of Health, through UL1TR002550 as well as linked award KL2TR002552 to J Cham, LJ Nicholson and AC Pandey. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed. No writing assistance was utilized in the production of this manuscript., (© 2022 The Authors.)

Although interest in the role of donor-specific antibodies (DSAs) in kidney transplant rejection, graft survival, and histopathological outcomes is increasing, their impact on steroid avoidance or minimization in renal transplant populations is poorly understood. Primary outcomes of graft survival, rejection, and histopathological findings were assessed in 188 patients who received transplants between 2012 and 2015 at the Scripps Center for Organ Transplantation, which follows a steroid avoidance protocol. Analyses were performed using data from the United Network for Organ Sharing. Cohorts included kidney transplant recipients with de novo DSAs (dnDSAs; n = 27), preformed DSAs (pfDSAs; n = 15), and no DSAs (nDSAs; n = 146). Median time to dnDSA development (classes I and II) was shorter (102 days) than in previous studies. Rejection of any type was associated with DSAs to class I HLA (P < .05) and class II HLA (P < .01) but not with graft loss. Although mean fluorescence intensity (MFI) independently showed no association with rejection, an MFI >5000 showed a trend toward more antibody-mediated rejection (P < .06), though graft loss was not independently associated. Banff chronic allograft nephropathy scores and a modified chronic injury score were increased in the dnDSA cohort at 6 months, but not at 2 years (P < .001 and P < .08, respectively). Our data suggest that dnDSAs and pfDSAs impact short-term rejection rates but do not negatively impact graft survival or histopathological outcomes at 2 years. Periodic protocol post-transplant DSA monitoring may preemptively identify patients who develop dnDSAs who are at a higher risk for rejection., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Rapid diagnostics for bloodstream infections have been shown to improve outcomes. Most studies have focused on rapid diagnostics for a single pathogen and have been conducted in academic medical centers. The Verigene Gram-Positive Blood Culture Test (BC-GP) identifies 12 gram-positive organisms and 3 genetic markers of antibiotic resistance from positive blood culture media in 2.5 hours. This study evaluates implementation of the Verigene BC-GP panel in combination with real-time support from the Antibiotic Stewardship Team (AST) in a community hospital system., Methods: This multicenter, pre-post, quasi-experimental study was conducted at the five hospitals that compose Scripps Healthcare. Rapid diagnostic testing was performed at a central laboratory from 7 a.m.-7 p.m. Pharmacists notified physicians of results and assisted with antibiotic modifications. The primary outcomes were average time to targeted antibiotic therapy and difference in antibiotic duration for contaminants. Secondary end points included hospital length of stay, mortality, pharmacy costs, and overall hospitalization costs. Adult patients with a gram-positive bacteremia admitted in 2011 (pre-rapid testing) were compared with those admitted in 2014 (post-rapid testing)., Results: There were 103 patients in the preintervention group and 64 patients in the intervention group. The optimized identification process, combined with AST intervention, improved mean time to targeted antibiotic therapy (61.1 vs 35.4 hrs, p<0.001) and decreased mean duration of antibiotic therapy for blood culture contaminants (42.3 vs 24.5 hrs, p=0.03). Median length of stay (9.1 vs 7.2 days, p=0.04) and overall median hospitalization costs ($17,530 vs $10,290, p=0.04) were lower in the intervention group. Mortality was similar between groups (9.1% vs 9.2%, p=0.98)., Conclusion: Rapid identification of gram-positive blood cultures with AST intervention decreased time to targeted antibiotic therapy, length of unnecessary antibiotic therapy for blood culture contaminants, length of stay, and overall hospital costs., (© 2015 Pharmacotherapy Publications, Inc.)

Rodent models of absence seizures are used to investigate the network properties and regulatory mechanisms of the seizure's generalized spike and wave discharge (SWD). As rats age, SWDs occur more frequently, suggesting aging-related changes in the regulation of the corticothalamic mechanisms generating the SWD. We hypothesized that brain resetting mechanisms - how the brain "resets" itself to a more normal functional state following a transient period of abnormal function, e.g., a SWD - are impaired in aged animals and that brain infarction would further affect these resetting mechanisms. The main objective of this study was to determine the effects of aging, infarction, and their potential interaction on the resetting of EEG dynamics assessed by quantitative EEG (qEEG) measures of linear (signal energy measured by amplitude variation; signal frequency measured by mean zero-crossings) and nonlinear (signal complexity measured by the pattern match regularity statistic and the short-term maximum Lyapunov exponent) brain EEG dynamics in 4- and 20-month-old F344 rats with and without brain infarction. The main findings of the study were: 1) dynamic resetting of both linear and nonlinear EEG characteristics occurred following SWDs; 2) animal age significantly affected the degree of dynamic resetting in all four qEEG measures: SWDs in older rats exhibited a lower degree of dynamic resetting; 3) infarction significantly affected the degree of dynamic resetting only in terms of EEG signal complexity: SWDs in infarcted rats exhibited a lower degree of dynamic resetting; and 4) in all four qEEG measures, there was no significant interaction effect between age and infarction on dynamic resetting. We conclude that recovery of the brain to its interictal state following SWDs was better in young adult animals compared with aged animals, and to a lesser degree, in age-matched controls compared with infarction-injured animal groups, suggesting possible effects of brain resetting mechanisms and/or the disruption of the epileptogenic network that triggers SWDs., (Copyright © 2011 Elsevier Inc. All rights reserved.)

B cells and their immunoglobulin products participate in allograft rejection of transplanted human kidneys in which an interesting feature is the presence of a germinal center like B-cell clusters in the allograft. We report here that the immunoglobulin repertoires of these infiltrating B cells are highly restricted and the B cells within a cluster are clonal. Antibody libraries made from the infiltrating B cells of individual patients unexpectedly revealed that each patient utilizes a particular set of dominant germ line genes as well as dominant complementarity determining region 3. Comparison of kidney and peripheral blood from the same patient showed that the immunoglobulin genes from both compartments had dominant clones, but they differed. The lymphocytes that infiltrate the kidneys express the immunoglobulin gene somatic recombination machinery usually restricted to highly activated lymphocytes in germinal centers and lymphomas. An analogy can be made between the inescapable antigenic drive in chronic infection versus that in an allograft, both of which may lead to emergence of dominant B-cell clones and even lymphoid malignancy.

Objective: To evaluate the accuracy, utility, and cost effectiveness of a new electromagnetic patient positioning and continuous, real-time monitoring system, which uses permanently implanted resonant transponders in the target (Calypso 4D Localization System and Beacon transponders, Seattle, WA) to continuously monitor tumor location and movement during external beam radiation therapy of the prostate., Materials and Methods: This clinical trial studied 43 patients at 5 sites. All patients were implanted with 3 transponders each. In 41 patients, the system was used for initial alignment at each therapy session. Thirty-five patients had continuous monitoring during their radiation treatment. Over 1,000 alignment comparisons were made to a commercially available kV X-ray positioning system (BrainLAB ExacTrac, Munich, Germany). Using decision analysis and Markov processes, the outcomes of patients were simulated over a 5-year period and measured in terms of costs from a payer's perspective and quality-adjusted life years (QALYs)., Results: All patients had satisfactory transponder implantations for monitoring purposes. In over 75% of the treatment sessions, the correction to conventional positioning (laser and tattoos) directed by an electromagnetic patient positioning and monitoring system was greater than 5 mm. Ninety-seven percent (34/35) of the patients who underwent continuous monitoring had target motion that exceeded preset limits at some point during the course of their radiation therapy. Exceeding preset thresholds resulted in user intervention at least once during the therapy in 80% of the patients (28/35). Compared with localization using ultrasound, electronic portal imaging devices (EPID), or computed tomography (CT), localization with the electromagnetic patient positioning and monitoring system yielded superior gains in QALYs at comparable costs., Conclusions: Most patients positioned with conventional tattoos and lasers for prostate radiation therapy were found by use of the electromagnetic patient positioning and monitoring system to have alignment errors exceeding 5 mm. Almost all patients undergoing external beam radiation of the prostate have been shown to have target organ movement exceeding 3 mm during radiation therapy delivery. The ability of the electromagnetic technology to monitor tumor target location during the same time as radiation therapy is being delivered allows clinicians to provide real time adaptive radiation therapy for prostate cancer. This permits clinicians to intervene when the prostate moves outside the radiation isocenter, which should decrease adverse events and improve patient outcomes. Additionally, a cost-utility analysis has demonstrated that the electromagnetic patient positioning and monitoring system offers patient outcome benefits at a cost that falls well within the payer's customary willingness to pay (WTP) threshold of $50,000 per QALY.

Medullary carcinoma of the thyroid requires aggressive treatment because of its potential to metastasize and because of the current limitations of preoperative localization and systemic therapy. If these tumors could be made to fluoresce in vivo with tagged fluorophore antibodies against tumor antigens, surgeons would be able to obtain additional information in the operating room to facilitate a more complete resection. Based on the success of our previous work in breast and colon cancer models, we conducted an animal study of in vivo tumor fluorescence of a human medullary thyroid cell line in which bright tumor fluorescence is visible during dissection. To accomplish this, we used an inexpensive and commercially available handheld, blue (470 nm), light-emitting diode flashlight and filtered goggles (520 nm). This procedure, which we call the fluorescent antibody-assisted surgical technique (FAAST), is easy to perform, requires no complex or expensive technical equipment, and has the potential to be applied to a wide variety of tumors. To the best of our knowledge, this is the first experiment of its kind to be reported in the literature.

Background: : Primitive peripheral neuroectodermal tumors (PNETs) of the uterus are rare. Recent data have demonstrated improved response rates with adjuvant chemotherapy., Case: : A 26-year-old, gravida 2, para 1, Filipina female underwent an emergent cesarean section for fetal indications. Intraoperative findings were remarkable for a soft tissue mass in the lower uterine segment. Histologic features, immunohistochemical findings, and chromosomal analysis were consistent with a PNET. The patient underwent radical surgery, adjuvant chemotherapy with vincristine, doxorubicin, cyclophosphamide, ifosfamide and etoposide (VAC/IE), and whole pelvic radiation therapy., Conclusion: : Only 14 case reports of primitive neuroectodermal tumors of the uterus have been published in the English literature to date. No definitive conclusions concerning the therapeutic management and prognosis have been ascertained.

Widespread cutaneous and lymph nodes recurrence in breast cancer is regarded as therapy-resistant disease. We describe a 50-year-old patient who presented with treatment-refractory disease following multiple lines of chemo- and hormonotherapy, photodynamic therapy and radiotherapy, including re-irradiation to extended volumes of her chest, upper abdomen, back and regional lymph nodes. Following treatment with mitomycin-C (MMC)/vinblastine (VLB) alone, she entered sustained complete remission of 1-year duration without any side effects. A brief review of the current literature is also presented. The MMC/VLB combination might achieve reasonable response and improvement of quality life even in patients with advanced breast cancer.

Hairy cell leukemia (HCL) is a rare chronic B-cell lymphoproliferative disorder characterized by splenomegaly, pancytopenia, and circulating atypical lymphocytes with circumferential cytoplasmic projections. Although uncommon, HCL cases refractory to standard therapy occur, and effective alternatives are limited. There is evolving literature supporting monoclonal antibody therapy in the treatment of B-cell lymphoid malignancies, including anti-CD52 (Campath-1H, alemtuzumab). We have examined nine cases of HCL and one case of HCL variant by flow cytometry for CD52 expression. All cases expressed CD52 antigen in 92-100% of the malignant cells. The demonstration of CD52 antigen expression on HCL cells provides the rationale for the use of alemtuzumab in refractory HCL., (Copyright 2003 Wiley-Liss, Inc.)

An immunocompetent 29-year-old male presented with an embolic stroke from an unusual primary cardiac lymphoma. The cardiac lesion consisted of a polypoid, left atrial, mural fibrin thrombus with anaplastic tumor cells lining the surface of the clot. Histologic, immunophenotypic, and molecular characterizations were consistent with a diagnosis of CD30+ large B-cell lymphoma with anaplastic cytology. While tumor emboli from invasive primary cardiac lymphomas have been reported, this noninvasive fibrin thrombus-associated lymphoma appears to be unique and previously unreported.

Primary bone lymphoma (PBL) is a rare entity. Nevertheless, very high long-term complete remission and survival rates following adriamycin-based chemotherapy alone or combined with involved-field radiation therapy have been reported. While the etiology is unknown, factors comprising local or general immunocompromised states have been suggested. Sporadic cases of local trauma followed by the emergence of primary bone lymphoma have been described. We describe 4 patients who developed primary bone lymphoma following direct trauma to a specific bone area. All 4 are alive with no evidence of disease after being treated with a combined chemo-radiotherapy regimen.

Neutropenic enterocolitis is a necrotizing inflammatory process with intramural infection that occurs predominantly in neutropenic patients. This syndrome is most frequently observed after chemotherapy for hematologic and solid tissue malignancies, but it can also be observed in a number of other clinical settings as well. Neutropenic enterocolitis can be a rare presenting complication of acute leukemia. We report a case of acute lymphoblastic leukemia that presented with abdominal pain due to neutropenic enterocolitis. The diagnostic and treatment challenges associated with this manner of presentation are discussed.

Background: We report a case of a palisaded angioleiomyoma, a histopathologic variant of angioleiomyoma with prominent Verocay body formation., Results: A healthy 31-year-old male requested removal of a subcutaneous nodule on the back of his head. The striking Verocay-like body formation of this tumor led to an initial frozen section diagnosis of neurilemoma. On hematoxylin and eosin staining, areas consistent with an angioleiomyoma were found as well. Immunohistochemistry gave positive reactions for actin and desmin, but was negative for S-100., Conclusions: To our knowledge this morphologic pattern in an angioleiomyoma has not been previously described. Palisaded angioleiomyoma should be added to the ever-expanding list of tumors that demonstrate nuclear palisades.

Background: Gemcitabine has demonstrated clinical activity against several common cancers. Our studies examine the ability of gemcitabine, both alone and in combination with other chemotherapeutic agents, to inhibit the in vitro and in vivo growth of several prostate cancer cell lines., Materials and Methods: Cultures of LNCaP, PC-3 or MLL cells were exposed to either gemcitabine or other appropriate agents for specified amounts of time. Cells were lysed and nuclei counted utilizing a Coulter Counter. For in vivo experiments, animals were injected with 1 x 10(5) MLL cells subcutaneously into the right flank. Animals were treated as indicated for 14 days. Tumors were then excised, weighed and measured., Results: In both human (PC-3 and LNCaP) and rat prostate (MLL) cancer cell lines our studies demonstrated gemcitabine had a strong effect in vitro, with an IC50 of approximately 500 nM in the human lines and 10 nM in MLL cells. In vivo, studies using the Dunning prostate cancer model in Copenhagen rats resulted in a dose response inhibition of tumor growth, with an 80% decrease in tumor size in rats treated with gemcitabine at 10 mg/kg., Conclusions: Our results demonstrated the potent activity of gemcitabine against prostate cancer in the Dunning rat model and suggest the addition of paclitaxel may not aid in this activity.

Most deaths from cancer result from the metastatic spread of the disease. The antidiuretic amiloride has been shown to inhibit tumor growth and metastasis in several tumor systems. The object of these studies was to examine the effect on the in vitro and in vivo tumor growth and metastasis in the MatLyLu subline of the Dunning model of rat prostate cancer. In vitro, amiloride was found to have cytotoxic effects only at high concentrations, with an IC50 of 100 microg/ml. In vitro analysis of the ability of amiloride to inhibit invasion of MLL cells demonstrated that this drug was ineffective at all concentrations examined. In vivo, amiloride did not inhibit tumor growth or metastases development. Our studies demonstrate that amiloride does not have activity in this model of prostate cancer and suggest it may not be an appropriate therapy for the treatment of prostate cancer.

The nuclear matrix is the framework scaffolding of the nucleus and has been demonstrated to be an important component in a number of nuclear processes including transcription, replication, and RNA splicing and transport. In the interphase nucleus, DNA is specifically organized in a three-dimensional fashion. An example of this fact is that actively transcribed genes have been demonstrated to associate with the nuclear matrix. In this study, nuclear matrix proteins from various rat tissues, including two androgen-regulated tissues, the seminal vesicle and ventral prostate, were examined to determine if they contained proteins that associate with consensus binding sequences for several proteins involved in the regulation of transcription. Specific interactions were identified between proteins of the nuclear matrix and these transcriptional activator binding sequences. In addition, the sizes of the complexes binding to the DNA sequences appeared to vary in some of the tissues. These data support the concept that the nuclear matrix may serve as a support structure to bring together specific DNA sequences with factors involved in the regulation of gene expression.

The early diagnosis of bladder cancer is central to the effective treatment of the disease. Presently, there are no methods available to easily and specifically identify the presence of bladder cancer cells. The prevailing method for the detection of bladder cancer is the identification of bladder cancer cells by morphological examination of exfoliated cells or biopsy material by a pathologist. A hallmark of the malignant or transformed phenotype is an abnormal nuclear shape, the presence of multiple nucleoli, and altered patterns of chromatin organization. Nuclear structural alterations are so prevalent in cancer cells that they are commonly used as markers of transformation for many types of cancer. Nuclear shape is determined by the nuclear matrix, the dynamic skeleton of the nucleus. The nuclear matrix is the structural component of the nucleus that determines nuclear morphology, organizes the DNA in a three-dimensional fashion that is tissue specific, and has a central role in the regulation of a number of nuclear processes, including the regulation of DNA replication and gene expression. Previous investigations into prostate and breast cancer have revealed that nuclear matrix protein (NMP) composition undergoes alterations with transformation and that the nuclear matrix can serve as a marker for the malignant phenotype. In this study, we have identified NMPs with which it is possible to differentiate human bladder tumors from normal bladder epithelial cells. We examined the NMP composition of 17 matched tumor and normal samples from patients undergoing surgery for bladder cancer. We have identified six proteins present in all tumor samples that are not present in the corresponding normal samples and three proteins that are unique to the normal bladder tissues in comparison with the tumor samples. Five of the six bladder cancer-associated proteins were also identified in three human bladder cancer cells lines examined (253j, UMUC-2, and T24). Therefore, we have demonstrated that nuclear matrix composition is able to differentiate bladder cancer from normal bladder tissue and may provide useful tools for early detection and recurrence of the disease. Importantly, these markers may provide valuable tools for cytopathological screening for bladder carcinoma.

Forty-five women were evaluated as candidates to donate oocytes to an infertile couple. Twenty-four women completed a cycle as oocyte donors. Follow-up data on donor satisfaction were obtained for 23 women. Ninety-one per cent were moderately to extremely satisfied with the experience and 74% would donate for another cycle if given the chance. Transient adverse psychological symptoms were reported by two donors but were resolved with medical or psychological treatment. Two women became pregnant soon after donation, one unintentionally. Psychological risk factors predicted donor candidates' decisions to participate and their compliance but were not predictive (within the group that completed a cycle) of donor satisfaction as follow-up or recipient pregnancy.

IVF with donated oocytes, followed by embryo placement in the uterus of a recipient who has been primed with exogenous steroids, is a successful treatment for special cases of infertility. Preliminary results indicate that the success rate in this situation is even greater than that usually seen with normal IVF (with placement of the embryos back into the uteri of the women from whom the oocytes were recovered). Although different sources for donated oocytes have been identified, the use of "excess" oocytes from IVF cycles and the attempted collection of oocytes at the time of otherwise indicated pelvic surgery have ethical and practical problems associated with their use. We have herein described the establishment of a successful program relying on anonymous volunteers who go through ovarian stimulation, monitoring, and oocyte recovery procedures solely to donate oocytes. The potential donors go through an exhaustive screening and education process before they are accepted in the program. Psychological evaluation of our potential donors indicated a great degree of turmoil in their backgrounds and a wide variety of motivations for actually participating. Despite the extensive educational and screening process, a substantial percentage of the donors did not complete a donation cycle, having either voluntarily withdrawn or been dropped because of lack of compliance. Further investigation of the psychological aspects of participating in such a program is certainly warranted. The use of donated oocytes to alleviate specific types of infertility is quite successful, but the application of this treatment is likely to be limited by the relative unavailability of suitable oocyte donors.

Involuntary infertility is an increasing problem in this era of delayed childbearing. Fortunately, many advances have been made recently in the medical and surgical treatment of infertility. This article reviews the principal aetiologies of infertility and their treatments, and focuses on the current and future uses of ovulation-inducing drugs and other infertility treatments. Proper diagnosis of anovulation and luteal phase dysfunction is discussed together with a description of conventional treatments with clomiphene and human menopausal gonadotrophins (hMG). Recent advances including the use of synthetic gonadotrophin hormone-releasing hormone (GnRH), purified human follicle stimulating hormone and a combination of GnRH and hMG are described, along with the application of the same agents for enhanced follicular recruitment for in vitro fertilisation. In addition, several promising future developments for pharmacological induction of normal ovulation are also discussed.

The current clinical and laboratory protocols of the in vitro fertilization program at the University of Texas at Houston are described and detailed. Most patients treated have tubal disease, with a limited number of couples having male factors. Clomiphene citrate (50 mg/day, cycle days 5-9) with or without added menopausal gonadotropins is the principle agent for enhanced follicular recruitment. Follicular development is monitored primarily with daily ultrasonography, and human chorionic gonadotropin (hCG) is given when the largest follicle reaches or exceeds 20-mm mean diameter. The culture media used are modifications of Ham's F-10. Mature oocytes are preincubated for 5 hr before insemination with 50,000 motile sperm per oocyte. Using these protocols, the clinical pregnancy rate is 11.6% per laparoscopy (11/95) and 16.2% per embryo transfer (11/68).

A critical aspect of human in vitro fertilization (IVF) treatment programs is the timing of human chorionic gonadotropin (hCG) administration to induce final oocyte maturation. Patients were treated with clomiphene citrate (Serophene, Serono Laboratories, Inc., Randolph, MA), 100 mg, and human menopausal gonadotropin (Pergonal, Serono Laboratories, Inc.) 1 ampule daily from cycle days 4 through 8. The baseline estradiol (E2) level was determined by averaging the E2 values from cycle days 3 and 4. The first day of E2 rise was defined as the day that the E2 level exceeded 150% of the baseline. In general, 5000 IU of hCG (Profasi-HP, Serono Laboratories, Inc.) was administered on the evening of the sixth day of E2 rise. Significantly fewer oocytes were recovered per patient when the hCG was administered on the seventh day of E2 rise, compared with the fifth or sixth day. The recovered oocytes in the seventh-day E2 group had a significantly lower fertilization rate, compared with the other groups. The use of E2-rise days proved to be a simple, successful technique for the timing of hCG administration in an IVF treatment program.

Ovulatory dysfunction is a leading cause of female infertility in the United States. Fortunately, ovulatory dysfunction is often amenable to treatment. Thorough testing is necessary to identify the exact cause of anovulation before conventional ovulation-inducing therapy is started. Careful patient monitoring is essential to avoid risks such as the ovarian hyperstimulation syndrome. Several newer ovulation-inducing agents are available for use in special situations.

Patients beginning an in vitro fertilization (IVF) treatment cycle were prospectively randomized in double-blind fashion to receive either follicle-stimulating hormone (FSH) (Metrodin, Serono Laboratories, Inc., Randolph, MA) (n = 50) or human menopausal gonadotropin (hMG) (Pergonal, Serono) (n = 48) in combination with clomephene citrate (CC) (Serophene, Serono). There were no statistically significant differences in the percentage of dropped cycles, follicular response as measured by serum estradiol or ultrasound imaging, cycle day for hCG administration, number of oocytes recovered, fertilization and cleavage rates of the recovered oocytes, or the rate of clinical pregnancy establishment. In conclusion, there were no clinically important differences between FSH and hMG when combined with CC for enhanced follicular recruitment for IVF. Therefore, there is no apparent justification for the use of FSH in CC combination regimens, considering FSH's increased cost as compared with hMG.

None of the procedures utilized in human IVF are unique or technically very difficult to perform. However, when considering the nature of the material being handled, it is essential that all laboratory procedures, equipment, and supplies are optimal for IVF . The individuals handling the gametes and embryos must be suitably trained and experienced in handling mammalian gametes and embryos before working with human tissues. In addition, the technologists must be trained in proper tissue culture techniques. Above and beyond the training and experience of the technologist, it is necessary that all laboratory equipment and chemicals for medium preparation be of the highest quality and known consistency, and that periodic checks of the culture conditions be performed using the bioassay of mouse embryos. The functioning of the equipment must be constantly monitored and backup systems be in place wherever possible in order to minimize the chances that laboratory accidents will result in loss or damage of the embryos. Meticulous attention to all aspects of the laboratory procedures will result in the patient's having the best possible chance to obtain a pregnancy.

When clomiphene citrate is used for enhanced follicular recruitment in an in vitro fertilization and embryo transfer program, the usual dosage is 150 mg/day, although we recently reported comparable follicular development (size and number) with 50 mg/day. The present report compares circulating hormone levels between groups of patients receiving the two regimens. Gonadotropin levels were higher in the 150-mg group throughout the follicular phase. Serum estradiol (E2) levels, expressed either as total E2 or E2 per follicle greater than or equal to 15 mm, were also higher throughout the follicular phase in the 150-mg group. During the luteal phase, the progesterone levels were similar in both groups. However, there were higher E2 levels in the 150-mg group during the entire luteal phase. Even though there were no significant differences between groups with regard to the degree of enhanced follicular recruitment, there were significant differences in the observed hormone levels.

The number of infertile couples undergoing treatment by means of in vitro fertilization and embryo replacement is still increasing at a logarithmic rate from the first successful delivery in July 1978. At the present time, several hundred centers around the world are treating patients and had produced in excess of 2,200 live births by fall of 1985. Recent advances including better treatment regimens to increase the number of recoverable oocytes, refinements of laboratory procedures, less invasive oocyte recovery procedures, and the development of embryo freezing should lead to wider availability, lower cost, and most importantly, higher success rates of successful pregnancy establishment. Along with these advantages, the increased number of oocytes and embryo freezing have raised certain questions concerning the rights and obligations of doctors, parents, and even embryos.

Clomiphene citrate (CC) (150 mg/day) is used in most clinical in vitro fertilization and embryo transfer (IVF-ET) programs to induce maturation of several preovulatory follicles rather than the one characteristic of the unstimulated cycle. This study examines whether a reduced dosage of CC will induce the maturation of a similar number of follicles. The advantage of the reduced dosage should be a decrease in the dose-dependent antiestrogenic effects of CC. Normally ovulating women undergoing treatment in an IVF-ET program received CC on cycle days 5 to 9. Thirty-six patients received 150 mg/day, and 60 patients received 50 mg/day. There were no significant differences between the groups in the number or the size of follicles as measured by ultrasonography on the day of human chorionic gonadotropin administration. All seven clinical pregnancies were in the 50 mg group (P less than 0.05). These data suggest that there is no advantage to the 150 mg/day dosage of CC as compared with 50 mg/day with respect to enhanced follicular recruitment, and the higher dosage may have a detrimental effect on pregnancy establishment.

The degree and normality of nuclear maturation were assessed with the fluorochrome Hoechst 33342 in two groups of inseminated human oocytes that had failed to undergo fertilization. Group 1 consisted of 67 oocytes from 27 patients, each of whom had at least two other oocytes that had been fertilized and had cleaved. Group 2 consisted of 65 oocytes from 14 patients, none of whose oocytes had been fertilized. In group 1, 52.3% of the oocytes were found to be immature (germinal vesicle stage or metaphase-telophase I), whereas in group 2 only 26% were found to be immature. Thus oocyte nuclear immaturity was the major cause of fertilization failure when companion oocytes were fertilized. When no oocytes of a patient were fertilized, most oocytes were found to be mature, so other factors, such as sperm dysfunction or zona binding abnormalities, must account for most of the fertilization failure in this group of patients.

In an attempt to improve the pregnancy rate following in vitro fertilization and embryo transfer by increasing the numbers of embryos available for transfer to each patient, a prospective, randomized comparison of clomiphene citrate alone (50 mg/day, cycle days 5 to 9) with the combination of clomiphene as above plus human menopausal gonadotropin (2 ampules/day, cycle days 6, 8, and 10) was undertaken from January through April 1983, with 17 patients in each group. The combination produced increased follicular development, compared with clomiphene alone, resulting in the retrieval of more fertilizable oocytes. Two clinical pregnancies resulted in each group. These results show that a fixed combination of clomiphene and human menopausal gonadotropin produces a greater degree of enhanced follicular recruitment, resulting in the recovery of an increased number of fertilizable oocytes. The lack of a statistically significant increase in the number of embryos transferred per patient in the combination group as well as the identical number of clinical pregnancies in both groups suggests that this particular combination of clomiphene and human menopausal gonadotropin offers no advantage over the use of clomiphene alone for enhanced follicular recruitment.

Isotopes of a number of crustacean myofibrillar proteins have been identified with sodium dodecyl sulfate-polyacrylamide electrophoresis, and their distribution in muscles of the snapping shrimp has been examined. Fast-slow differences in distribution have been observed for myosin light chains and tropomyosin. In contrast, three troponin T subunits have been resolved, each specific to one of the three muscles examined. This result suggests that expression of crustacean contractile proteins is not accomplished by a simple coexpression of a battery of slow or fast isotopes. In addition, the expression of these proteins was examined during the quasi-developmental fiber-type transition of the main claw closer muscle during the reversal of claw asymmetry in response to the loss of the large snapper appendage. The changes observed appear similar to the cross-innervation induced changes in gene expression of vertebrate muscle.

We compared fertility potential measurements by the zona-free hamster egg bioassay with the in vitro fertilization of human eggs. Sperm from 24 husbands participating in an in vitro fertilization-embryo transfer program were used in 27 inseminations of the wives' eggs and in simultaneous inseminations of hamster eggs. In seven cases, a positive fertility assessment was obtained in the absence of fertilization of the wives' eggs attributable to egg immaturity or in one case to equipment failure. In the remaining 20 cases, at least one egg was fertilized, for a level of 73%. In 90% of the husbands who fertilized their wives' eggs, a positive fertility assessment was obtained. Two husbands gave false-negative assessments. To account for these, alternative culture conditions were examined; sperm exposure to longer preincubations or at higher concentrations usually improved assessments. These results indicate that fertility assessment with this bioassay is highly correlated with the fertilization of human eggs in vitro.

Prolactin levels during a gonadotropin-induced pregnancy have not been previously reported. A patient with Forbes-Albright syndrome is described. She received radiation therapy, with cessation of her galactorrhea, but she remained amenorrheic. Three years after irradiation, a pregnancy was successful induced with human menopausal gonadotropins and human chorionic gonadotropin. Prolactin levels determined prior to gonadotropin therapy, during an insulin hypoglycemia stimulation test, serially during pregnancy, and postpartum during lactation are presented. These levels are compared with the previously reported levels for basal prolactin, response to insulin hypoglycemia, pregnancy, and lactation. Possible etiologies for the abnormal values and responses obtained from investigation of this patient are discussed.

Polyzoospermia is a rare cause of male infertility. In our clinical practice, patients with exceedingly high sperm counts (ranging from 650 million/ml to 1.75 billion/ml) have invariably been found to have associated poor sperm motility and poor sperm migration in postcoital tests, although the sperm appear morphologically normal. Cases of two infertile couples are presented in which each husband had sperm counts greater than 1 billion/ml. Two methods are reported for the successful management of their infertility problems: (1) precoital dilutional douching and (2) in vitro seminal fluid dilution with 5% dextrose-Ringer's lactate solution and artificial insemination homologous. Each method resulted in improved sperm motility, postcoital tests, and pregnancy.

Stromal cells derived from proliferative or secretory human endometria, cultured in the absence of steroid hormones, grew as monolayers that showed only occasional areas of immunoreactive fibronectin and did not produce detectable levels of prolactin (PRL) or laminin. Treatment with physiological doses of estradiol and progesterone induced PRL production and stimulated cell proliferation, resulting in multilayering with an increase of the saturation density. Electron microscopy showed the development of gap junctions, whereas immunofluorescence revealed a dense pericellular matrix containing fibronectin and laminin. These findings show that human endometrial stromal cells in culture respond to physiological doses of ovarian hormones with ultrastructural, proliferative, and biochemical changes that are characteristic of decidualization in vivo. This culture system thus provides an in vitro model for human decidualization.