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The associate membership of the American Association for the Surgery of Trauma (AAST) was established in 2019 to create a defined but incorporated entity within the larger AAST for the next generation of acute care surgeons. The Associate Member Council (AMC) was subsequently established in 2020 to provide the new AM with an elected group of leaders who would represent them within the AAST. In its inaugural year, this cohort of junior faculty and surgical trainees had developed for the AM a set of bylaws, a mission statement, a strategic vision, and a succession plan. The experience of the AAST AMC is exemplary of what can be accomplished with collaboration, mentorship, innovation, and tenacity. It has the potential to serve as a template for the creation and vitalization of future professional groups. In this piece, the AMC proposes a blueprint for the successful conception of a new organization.

This review focuses on the recent evolution of the initial resuscitation of combat-injured personnel. It summarizes the recommendations of TCCC and makes recommendations based on literature review and author experience. Over nearly 20 years, the experience in caring for combat casualties in the global war on terror has led to significant changes within military trauma care. Evolution of pre-hospital care, utilization of tourniquets and TXA for hemorrhage control, and use of whole blood as the preferred resuscitative fluid have significantly reduced mortality. Additionally, the collective wisdom of experienced trauma surgeons serves as an invaluable guide for managing setup and flow within the various levels of the military trauma system. This review article highlights recommended practices for the initial resuscitation of personnel injured in combat along with providing proven methods for trauma team preparation and management that can and should be used by any surgeon preparing to deploy.

Complicated gallstone disease (CGD) is a common condition requiring intervention during pregnancy to avert adverse birth outcomes (ABO).Cohort study using the California OSHPD 2007-2014 database. Records of pregnant patients were analyzed for gallbladder calculus within four months of delivery. Biliary system interventions were evaluated as the primary exposure.Of 7,597 patients, those with CGD had a greater likelihood of biliary system procedures than those with uncomplicated gallstone disease (36.6% vs. 2.5%, p 0.001). Patients with CGD also had increased odds of ABO (OR 2.02, 95% CI, 1.48-2.76). Compared to patients without biliary system procedures, those with interventions for gallstones had an OR of 3.46 (95% CI, 2.48-4.82) for ABO. After adjustment, biliary system intervention for CGD had an even greater risk of ABO (OR 4.26, 95% CI, 2.86-6.35).The risk of ABO is significantly increased in women with CGD and intervention for gallstones.

Background The aim of this study was to evaluate quetiapine-associated pulmonary complications (PC) in critically injured trauma patients. Methods Injured adults admitted during 2016 to the ICU at a Level I trauma center were analyzed. Outcomes were evaluated by competing risks survival analysis. Results Of 254 admissions, 40 (15.7%) had PC and 214 (84.3%) were non-events. PC patients were more severely injured, had longer hospital stays and were more likely to die. Patients administered quetiapine were more likely to develop PC and acquire PC earlier than those without quetiapine. Quetiapine was a positive risk factor for PC (sHR 2.24, p = 0.013). Stratification by ventilator use revealed non-ventilated patients administered quetiapine had the highest risk for PC (sHR 4.66, p = 0.099). Conclusions Quetiapine exposure in critically injured trauma patients was associated with increased risk of PC. Guidelines for treatment of delirium with quetiapine in critically injured trauma patients should account for this risk.

BACKGROUND Although adhesive small-bowel obstruction (ASBO) is frequently managed nonoperatively, little is known regarding outcomes on readmission following this approach. Using a large population-based dataset, we evaluated risk factors for operative intervention and mortality at readmission in patients with ASBO who were initially managed nonoperatively. METHODS The ASBO patients were identified in the California Office of Statewide Health Planning and Development 2007 to 2014 patient discharge database. Patients who were managed operatively at index admission or had an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code for nonadhesive obstructive small bowel disease were excluded. Associations between risk factors and both operative intervention and death following readmission were evaluated using survival analysis. RESULTS Among 15,963 ASBO patients, 3,103 (19.4%) had at least one readmission. The 1,069 (34.5%) who received an operation during their first readmission presented sooner (175 days vs. 316 days, p < 0.001) and were more likely to die during that readmission (5.2% vs. 0.7%, p < 0.001). Operative management at first readmission was associated with younger age, fewer comorbidities, and shorter times to readmission. Patients operatively managed at first readmission had longer times to second readmission compared with nonoperative patients. Stratified analyses using nonoperative patients as the reference over the study period revealed that patients who underwent lysis of adhesions and bowel resection were 5.04 times (95% confidence interval [CI], 2.82-9.00) as likely to die while those who underwent lysis only were 2.09 times (95% CI, 1.14-3.85) as likely to die. Patients with bowel resection only were at an increased risk for subsequent interventions beyond the first readmission (hazard ratio, 1.79; 95% CI, 1.11-2.87). CONCLUSION In a large cohort readmitted for ASBO and initially managed nonoperatively, subsequent operative intervention conferred a greater risk of death and a longer time to readmission among survivors. Prospective research is needed to further delineate outcomes associated with initial nonoperative management of ASBO. LEVEL OF EVIDENCE Prognostic and epidemiological, level III.

Outcomes following damage control laparotomy for trauma have been studied in detail. However, outcomes following a single operation, or "single-look trauma laparotomy" (SLTL), have not. We evaluated the association between SLTL and both short-term and long-term outcomes in a large population-based data set.The California Office of Statewide Health Planning and Development patient discharge database was evaluated for calendar years 2007 through 2014. Injured patients with SLTL during their index admission were identified using International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes. Diagnosis and procedure codes were used to identify specific abdominal organ injuries, surgical interventions, and perioperative complications. Subsequent acute care admissions were examined for postoperative complications and related surgical interventions. Clinical characteristics, injuries, surgical interventions, and outcomes were analyzed by mechanism of injury.There were 2113 patients with SLTL during their index admission; 712 (33.7%) had at least one readmission to an acute care facility. Median time to first readmission was 110 days. Penetrating mechanism was more common than blunt (60.6% vs. 39.4%). Compared to patients with penetrating injury, blunt-injured patients had a significantly higher median Injury Severity Score (9 vs. 18, p0.0001) and a significantly higher mortality rate during the index admission (4.1% vs. 27.0%, p0.0001). More than 30% of SLTL patients requiring readmission had a surgery-related complication. The most common primary reasons for readmission were bowel obstruction (17.7%), incisional hernia (11.8%), and infection (9.1%). There was no significant association between mechanism of injury and development of surgery-related complications requiring readmission.Patients with SLTL had postinjury morbidity and mortality, and more than 30% required readmission. Complication rates for SLTL were comparable to those reported for emergency general surgery procedures. Patients should be educated on signs and symptoms of the most common complications before discharge following SLTL. Further investigation should focus on the factors associated with the development of these complications.Prognostic and epidemiologic study, level III.

Although short-term outcomes for popliteal artery injury after endovascular versus open repair appear similar, studies on outcomes after discharge are limited. We evaluated popliteal artery injury repair in a population-based data set. We hypothesized that postdischarge outcomes for open repair are superior to endovascular repair.Patients with popliteal artery injury were identified in the California Office of Statewide Health Planning and Development 2007-2014 discharge database. Popliteal artery injury and other lower-extremity injuries were identified using International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. Procedure codes were evaluated to identify open repair, endovascular repair, fasciotomy, and amputation. Primary outcomes were mortality or amputation. The association between repair method and each outcome was evaluated with logistic regression. Postdischarge amputation and all-cause mortality were evaluated using survival analysis.Among 769 patients with popliteal artery injury, open repair occurred in 456 (59.3%), endovascular repair in 37 (4.3%), combined endovascular and open in 18 (2.3%), and nonoperative management in 258 (33.6%). Fasciotomy was performed more frequently in open than endovascular repair (p = 0.001) during index admission. Amputation rate was also increased in open repair, but this was not significant (p = 0.196). Arterial thromboembolus during index admission was more likely after endovascular or combined endovascular and open compared with open (24.3%, 55.6%, 16.7%, respectively, p0.001). Patients requiring both endovascular and open were more likely to undergo amputation postdischarge (hazard ratio, 4.11; 95% confidence interval, 1.16-14.53). Patients undergoing endovascular repair were more likely to die postdischarge (hazard ratio, 4.43; 95% confidence interval, 1.06-18.56) compared with patients who had open repair (median, 98.5 days postdischarge).In a large cohort with popliteal artery injury, open repair was associated with lower rates of index admission arterial thromboembolus as well as postdischarge amputation and all-cause mortality. We recommend conducting a prospective multicenter study to examine the appropriate use of endovascular repair for this injury.Therapeutic, level IV.

Objective: Open repair of ruptured abdominal aortic aneurysm (rAAA) has shown improved outcomes at trauma centers. Whether the benefit of trauma center designation extends to endovascular repair of rAAA is unknown. Methods: Retrospective cohort study using the California Office of Statewide Health Planning and Development 2007 to 2014 discharge database to identify patients with rAAA. Data included demographic and admission factors, discharge disposition, International Classification of Diseases, Ninth Revision, Clinical Modification codes, and hospital characteristics. Hospitals were categorized by trauma center designation and teaching hospital status. The effect of repair type and trauma center designation (level I, level II, or other—other trauma centers and nondesignated hospitals) was evaluated to determine rates and risks of 9 postoperative complications, in-hospital mortality, and 30-day postdischarge mortality. Results: Of 1941 rAAA repair patients, 61.2% had open and 37.8% had endovascular; 1.0% had both. Endovascular repair increased over the study interval. Hospitals were 12.0% level I, 25.0% level II, and 63.0% other. A total of 48.7% of hospitals were teaching hospitals (level I, 100%; level II, 42.2%; and other, 41.8%). Endovascular repair was significantly more common at teaching hospitals (41.5% vs 34.3%, P < .001) and was the primary repair method at level I trauma centers ( P < .001). Compared with open repair, endovascular repair was protective for most complications and in-hospital mortality. The risk for in-hospital mortality was highest among endovascular patients at level II trauma centers (hazard ratio 1.67, 95% confidence interval [CI]: 0.95-2.92) and other hospitals (hazard ratio 1.66, 95% CI: 1.01-2.72). Conclusions: Endovascular repair overall was associated with a lower risk of adverse outcomes. Endovascular repair at level I trauma centers had a lower risk of in-hospital mortality which may be a result of their teaching hospital status, organizational structure, and other factors. The weight of the contributions of such factors warrants further study.

Introduction Non-compressible torso hemorrhage accounts for 70% of battlefield deaths. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an emerging technology used to mitigate massive truncal hemorrhage. Use of REBOA on the battlefield is limited by the need for radiographic guided balloon placement. Radiofrequency identification (RFID) is a simple, portable, real-time technology utilized to detect retained sponges during surgery. We investigated the feasibility of RFID to confirm the placement of ER-REBOA. Materials and methods This was a single-arm prospective proof-of-concept experimental study approved by the institutional review board at Naval Medical Center San Diego. The ER-REBOA (Prytime Medical Devices, Inc, Boerne, TX, USA) was modified by placement of a RFID tag. The tagged ER-REBOA was placed in zone I or zone III of the aorta in a previously perfused cadaver. Exact location was documented with X-ray. Five blinded individuals used the RF Assure Detection System (Medtronic, Minneapolis, MN, USA) handheld detection wand to predict catheter tip location from the xiphoid process (zone I) or pubic tubercle (zone III). Results In zone I, actual distance (Da) of the catheter tip was 11 cm from the xiphoid process. Mean predicted distance (Dp) from Da was 1.52 cm (95% CI 1.19-1.85). In zone III, Da was 14 cm from the pubic tubercle. Mean Dp from Da was 4.11 cm (95% CI 3.68-4.54). Sensitivity of detection was 100% in both zones. Specificity (Defined as Dp within 2 cm of Da) was 86% in zone I and 16% in zone III. Conclusions Using RFID to confirm the placement of ER-REBOA is feasible with specificity highest in zone I. Future work should focus on refining this technology for the forward-deployed setting.

Type 2 diabetes mellitus (T2DM) with the presence of metabolic syndrome (MetS) carries increased risk for cardiovascular disease. Adjunctive exenatide treatment in patients with T2DM is associated with improvements in glycemic control coupled with progressive weight reduction. We evaluated exenatide use on glycosylated hemoglobin A1c (HbA(1c)) and cardiometabolic risk factors in patients with T2DM and MetS in a single clinical practice setting.A retrospective analysis of clinical data extracted from the records of 176 adult patients with T2DM and MetS (106 women, 70 men) who received exenatide along with existing therapeutic regimes from 2005 to 2007 was performed. HbA(1c), lipid profiles, blood pressure, and anthropometric measures were evaluated at baseline and after 16 (+/-4) weeks of exenatide therapy.Mean HbA(1c) was significantly reduced from baseline in 16 weeks (P0.001), with 68% of patients achieving HbA(1c)7%. Total, high-density lipoprotein-, and low-density lipoprotein-cholesterol levels decreased significantly. This decline was not attributable to changes in lipid-lowering agents. Significant reductions were also noted in body mass index, mean body weight, and abdominal girth (AG) with the addition of exenatide. Additional analyses showed 76% of subjects lost weight. Lessening of AG was much more pronounced in female compared with male subjects with diabetes (P0.032). No consistent changes in blood pressure were observed.We found that addition of exenatide to an existing treatment regimen in patients with T2DM and MetS resulted in significant reductions in HbA(1c) along with decline in lipids, AG, and body weight. This indicates improvement in these patients' metabolic profiles.

� Objective: To evaluate the effect of exenatide therapy on cardiometabolic risk factors and anthropometric parameters in patients with metabolic syndrome. � Methods: From June 2005 to June 2007, we performed a retrospective analysis of data extracted from the records of adult patients with metabolic syndrome being treated with exenatide. Diagnosis of any type of diabetes mellitus was exclusionary. Patients were initiated on exenatide therapy, 5 mcg, 1 hour before their morning and evening meals for the first month and were instructed to titrate up to 10 mcg. Cardiometabolic risk factors (total cholesterol, high-density lipoprotein cholesterol, triglycerides, calculated lowdensity lipoprotein cholesterol, and blood pressure) and anthropometric parameters (absolute body weight, body mass index, and abdominal girth) were measured at baseline and at 16 ± 4 weeks after initiating exenatide therapy. Data collected also included age, sex, metabolic syndrome diagnosis, and other concomitant medication used in the management of endocrine disorders. � Results: The study population consisted of 299 patients (259 women, 40 men) with an age range of 18 to 74 years. Exenatide treatment was associated with significant reduc tions in mean body weight (P

Platelet-activating factor (1-O-alkyl-2-acetyl-sn-glycero-3-phosphocholine; PAF), a potent signaling phospholipid, has a significant role in preimplantation embryo development. CFW mouse embryos respond to PAF with improved development and implantation rates. PAF's signal transduction mechanism in other cell types is receptor mediated. However, embryonic mRNA for the PAF receptor has not been detected. The study objectives were to determine the presence of PAF receptor mRNA in CFW mouse two-cell embryos by reverse transcription (RT)-polymerase chain reaction and Northern blot analysis and to ascertain the effect of PAF on intracellular calcium levels (a receptor-mediated event). Total RNA was purified by acid-phenol extraction and ethanol precipitation. Complementary DNA was synthesized by RT. RNA was primed with oligo-dT plus PAF receptor-specific primer (3' to 5') at 42 degrees C for 60 min, 95 degrees C for 10 min, and 5 degrees C for 5 min. The RT product was amplified with Taq polymerase and PAF receptor-specific primer (5' to 3') at 94 degrees C for 5 min and 54 degrees C for 5 min for one cycle, and at 72 degrees C for 3 min, 93 degrees C for 90 sec, and 61 degrees C for 150 sec for 30 cycles followed by 72 degrees C for 10 min and then holding at 4 degrees C. The product was analyzed by agarose gel electrophoresis, producing a single band (610 base pairs [bp]), thus demonstrating the presence of PAF-receptor mRNA. Sequence analysis of the cloned 610-bp fragment confirmed that it is the PAF receptor. Northern blot analysis also confirmed the expression of the PAF receptor in the CFW mouse preimplantation two-cell-stage embryo. PAF treatment of the two-cell-stage CFW mouse embryo resulted in a fourfold increase in intracellular calcium over background levels.

Significant global economic challenges, a war weary nation and coalition, and rising competitors in the Asia Pacific region are causing significant changes in our national security strategy. Military wide force structure reductions, smaller budgets, and the realization that allies, partners, and coalitions enhance regional stability and security all impact the ways in which we attempt to achieve our strategic objectives. A new emphasis on regionally aligned forces to build partner capacity and provide security cooperation will allow the United States to collaborate with key partners and allies to address regional and global problems. This paper examines the existing security cooperation initiatives and proposes recommendations to enhance allied interoperability and effectiveness.

Platelet-activating factor (l-O-alkyl-2-acetyl-sn-glycero-3-phosphocholine ; PAF) is a potent signaling phospholipid that has been implicated in a variety of reproductive processes. Human, rabbit, and mouse preimplantation embryos produce and secrete PAF. Anti-PAF antibodies interfere with mouse preimplantation development. A controversy exists on whether exogenous PAF is beneficial to preimplantation embryo development. The study objective was to determine the effect of exogenous PAF on embryo formation. One-cell mouse B 6 D 2 F 1 /J embryos were collected from PMSG/hCG primed females mated with fertile males. Embryos were exposed to PAF (0-10 μM) in MEM (0.3% BSA) for 15 min, then cultured in MEM (0.3% BSA) in a 5% CO 2 in air, 95% relative humidity at 37°C atmosphere, for 120 hr to the hatched blastocyst stage. PAF (0.1 or 0.01 μM) significantly (P < 0.05) improved preimplantation embryo development and formation in vitro. PAF at higher doses had no significant effect. Supplementation of culture medium with exogenous PAF was beneficial to preimplantation embryo development in B 6 D 2 F 1 /J mice.

To obtain the molecular weights (MW) of endometrial antigens eliciting immunoglobulin (Ig) G auto-antibodies in all endometriosis patients irrespective of their place of origin or race, and to verify their specificity and immunogenicity.We tested the serum and peritoneal fluid (P.F.) of 76 endometriosis patients and 24 controls from 4 cities against endometrial and implant antigens by Western blot analysis. Endometrial and implant antigens with MW of 34, 46/48, 64, 84, 94 and 120 kDa bound with IgG in serum and PF of most patients, but not the controls. Antigen(s) with MW of 64 kDa was reactive against serum or P.F. IgG of patients from all cities. Specificity: Endometrial and implant extracts did not react with monoclonal antibodies to WBC subsets and 5 sera with nuclear antibodies. Also, the presence of nuclear and endometrial antibodies did not correlate in 20 other patients with endometriosis. Immunogenicity: We immunized rabbits with the native and eluted (MW 29 to 68 kDa andor = 68 kDa) endometrial and implant proteins. The antiserum had specific IgG binding to the same glandular epithelial antigens as those bound by the patient's serum.Endometrial antigens with MW of 34, 46/48, 64, 94 and 120 kDa, especially 64 kDa appear to be specific, immunogenic and relevant to endometrial autoimmunity in all patients with endometriosis.

Our purpose was to investigate the effect of anti-PAF antibodies on CFW mouse embryo development in vitro.We studied the in vitro development of CFW mouse one-cell-stage embryos cultured in MEM supplemented with anti-PAF, anti-IgG, or MEM alone to the hatched blastocyst stage.Mouse embryos cultured with anti-PAF (1:5 dilution; 61%) significantly decreased embryo development compared to controls (MEM alone; 93%), whereas embryos cultured in anti-mouse IgG-supplemented MEM (1:10 dilution; 93%) had no effect.The results provide additional evidence that PAF is produced and secreted by cleavage-stage embryos and is required during the preimplantation period.

The development of mouse embryos in vitro is affected primarily by mouse strain-genotype and culture conditions. Embryo culture studies evaluate the effectiveness of culture conditions in supporting one- or two-cell mouse embryo development to the blastocyst stage by reporting the percentage blastocyst formation rate.Determining the cell number per cultured blastocyst may also help in determining embryo culture medium quality. The objective of this study was to determine the effect of MEM and Ham's F-10 on overall CFW mouse embryo development and hatched blastocyst cell number in vitro. CFW embryos cultured in MEM had significantly higher (87%; P0.001) hatched blastocyst rates than embryos cultured in F-10 (56%).A significant difference in nuclei per hatched blastocyst was found between MEM and F-10 (P0.001). The results demonstrate that inbred mouse embryos have significantly higher blastocyst hatching rates and higher cell numbers per blastocyst when cultured in MEM.

This report is a further characterization of data from an ecological cancer mortality study of a population (about 10,000) exposed to groundwater contaminated by hexavalent chromium [Cr(VI)] up to 20 mg/L near JinZhou City in the LiaoNing Province of China between 1960 and 1978. Prior reports showed an elevation in all-cancer mortality from 1970 to 1978 averaged across five agricultural villages with Cr(VI) in groundwater relative to average cancer rates for the district and province. The current study compares the cancer rates during the same time period for the same five exposed villages to those of four nearby areas with no Cr(VI) in groundwater. The use of a local comparison group is considered superior to the use of district or province averages because of the expected improved similarity among unmeasured covariates in nearby areas. The average lung-, stomach-, and all-cancer mortality rates for the three agricultural villages without Cr(VI) in groundwater were not statistically different from those of the five agricultural villages with Cr(VI) in groundwater. Also, three surrogate measures of village drinking-water Cr(VI) dose did not significantly correlate with cancer mortality rates in the five exposed villages. Further, the industrial town in which the Cr(VI) source was located had different demographics and a different pattern of stomach and lung cancers compared to the adjacent agricultural villages, regardless of Cr(VI) groundwater exposure. The results of other local investigations on cancer mortality and genotoxicity in the exposed populations are reviewed. The overall findings in the studied population do not indicate a dose-response relationship or a coherent pattern of association of lung-, stomach-, or all-cancer mortality with exposure to Cr(VI)-contaminated groundwater.

Prospective studies in Mayan Indian children living in their natural setting were carried out from 1964 through 1974; observations began at birth and extended at least throughout the first three years of life. Adequate growth and survival were characteristic of exclusively breast-fed infants in the first months of life. Despite the high rate of infection, children exhibited a considerable resistance to intestinal protozoa, enterobacteriaceae and enteric viruses. Resistance against colonic invaders is attributed to the bifidus flora, and that against agents acting in the small bowel, to specific antibodies present in colostrum and milk. Diarrhoeal disease was least in this period and increased with weaning to reach maximum peaks at the time of weaning. The protracted weaning consisted of progressive administration of foods of low biological value given under deficient sanitary conditions. The nutrient value of the diet as a function of the child's weight was adequate in protein but in most cases it was markedly deficient in calories. Infectious diseases, particularly diarrhoea, were found associated with pronounced reductions in the already deficient calorie intake. Infection and infectious disease were common particularly during the first 6 to 18 months of life. Weight loss was a frequent finding during and after episodes of disease. The consequence of the malnutrition-infection interaction is a marked stunting of growth, clearly evident from examination of the growth curves of village children. Nutrient intake did not correlate with growth velocity. By contrast, the duration of breast-feeding was strongly associated with growth in the linear segment of the curve, while in the period of faster growth the correlation was inverse. On the other hand, morbidity was inversely correlated with calorie and protein intake and this was more obvious in the second than in the first year of life. The data indicate that infection is one of the leading factors associated with reduced calorie (and protein) intakes during the critical period of onset of malnutrition and mortality in childhood. By preventing infection, particularly diarrhoea, the food intake, nutrition and growth of children could be significantly improved.

Pramlintide, a synthetic amylin analog, was approved for type 2 diabetes as an adjunct treatment in patients who have failed to achieve desired glycemic control, despite optimal insulin therapy, with or without concomitant administration of oral antidiabetes agents (1). In clinical trials, pramlintide added to insulin treatment in patients with type 2 diabetes was shown to reduce postprandial glucose levels, improve glycemic control, and promote weight loss (2–8). We reviewed the medical records of our patients with type 2 diabetes who were on pramlintide in addition to insulin treatment to assess the efficacy of mealtime pramlintide on glycemic control and cardiometabolic risk factors in a single endocrine clinical practice setting. We retrospectively studied laboratory and medical parameters of 92 insulin-treated adult patients with type 2 diabetes (54 female, 38 male, aged 24–80 years) recorded at baseline, 12 ± 4 weeks, and 24 ± 4 weeks after initiating pramlintide therapy. Medical and laboratory information were pulled from the main database of the Metabolic Center of Louisiana through a query that extracted information on all patients with type 2 diabetes treated with insulin who were unable to achieve glycemic control and who had completed at least 24 weeks of pramlintide treatment from June 2005 to November 2006. Patients with type 1 diabetes, patients with type …

Jiang H, Pillai S, Ruby E, Howard L, Butler WJ, Zhang H. The presence of a Cl-inhibitor-like molecule (CI-INH-L) on human sperm: Its involvement in sperm motility. AJRI 1997; 38:384-390 © Munksgaard, Cophenhagen PROBLEM: An 88-92-kDa C1-inhibitor-like molecule (C1-INH-L) was previously identified to elicit cytotoxic sperm antibody response in infertile men and women. Here, we document that it is present on the human sperm surface and could be detected by an enzyme-labeled immunoglobulin G (IgG) fraction of anti-human C1-INH antibody. METHOD OF STUDY: Western blot analysis, enzyme-lined immunoadsorbent assay (ELISA) and computerized sperm motion analysis. RESULTS: The existence of Cl-INH-L on the sperm surface is calcium independent. Phosphatidylinositol-specific phospholipase C (PIPLC), EDTA, and acid (pH 3.0) could not remove the Cl-INH-L from sperm, but trypsin did. Activated Cls was able to bind to the sperm surface. Immunofluorescence studies localized the protein to the head and midpiece of the sperm membrane. The Cl -INH-L exists on both uncapacitated and capacitated sperm surfaces, which suggests that this protein is a sperm-surface protein. The heat-treated (56°C, 30 min) IgG fraction of anti-C1-INH greatly reduced the percentage of motile spermatozoa and the progressive and path velocities in the absence of complement. CONCLUSION: Our data suggest that C1-INH is a sperm membrane-anchored protein that may have complement and sperm motility regulatory function.

PROBLEM : Identifying the endometrial antigens inciting autoimmunity is important in setting up an antibody assay for a non-invasive diagnosis and clinical monitoring of endometriosis. METHODS : Two-dimensional gel electrophoresis of endometrial extracts, Western blot analysis, passive hemagglutination and enzyme-linked immunosorbent assay (ELISA), amino acid sequencing and molecular studies were done on chosen antigens. Forty-six women with endometriosis, 4 women with uterine leiomyomata, 4 with pelvic adhesions, 3 with repeat Cesarean sections (conditions that coexist with or predispose to endometriosis) and 46 controls participated. RESULTS : Antigens with molecular weights (MW) of 64 kDa [isoelectric point (pI) of 3.5-4.0] and 72 kDa (pI of 4.5) bound to IgG in all patients with endometriosis, but not the controls. Amino acid sequencing of the proteins revealed that they had homology to alpha 2-Heremans Schmidt (HS) glycoprotein (MW : 64 kDa) and transferrin (MW : 72 kDa). Endometriosis patients had significant antibody levels to these two proteins (predictive value of 80-90%). The analysis of patients' endometrial RNA detected the message for alpha 2-HS glycoprotein and transferrin. Albumin (pI 5.5) and collagen (pI 3.5) failed to elicit antibody responses. CONCLUSIONS : Patients with endometriosis have significant antibodies to endometrial transferrin and alpha 2-HS-glycoprotein. We can effectively use an antibody assay using these antigens for diagnosing endometriosis.

The purpose of this study was to prospectively evaluate the continuation rate of subdermal contraceptive implants (Norplant) among adolescent (20 years) and adult (or = 20 years) women in the clinic population of a tertiary care medical center.Adolescents and adults desiring contraception for greater than a 6-month period were eligible for Norplant insertion. Prior to insertion, personal counseling and extensive education were provided. Following insertion, rapid access, personal counseling, and prompt treatment were provided for complications that occurred. Device removal was available to all individuals at any time upon patient request or if side effects could not be ameliorated. Patient demographic, historical, physical, and follow-up data were entered into a computer data base.Since February 1991, 1800 subdermal contraceptive implants were inserted. Of these 1688 patients were prospectively followed, providing 45,576 women-months of data for analysis. Adolescents comprised 40% of the study population. Over a 50-month period, the cumulative continuation rate for adolescents was 93.6%, and for adults it was 91.1%. The mean duration of use among adolescents was 26.5 months and for adults was 27.6 months.There was no significant difference between adolescent and adult subdermal contraceptive implant continuation rates for up to 50 months of use. In this patient population, high continuation rates may result from a combination of extensive patient education and intensive surveillance by a well-trained and dedicated multidisciplinary staff. When all patients are enrolled in a program that provides aggressive education and supportive follow-up, age is not a significant factor in continuation rates.

We have previously reported the presence in human follicular fluid (hFF) of a high (greater than 5000) mol wt FSH receptor binding inhibitor (FSH-BI). This hFF FSH-BI was further purified by removal of material insoluble in acidified acetone (pH 4.1) but soluble in diethyl ether (pH 10.5), followed by molecular sieving through Sephacryl S-100. FSH-BI activity eluted from S-100 with an elution volume similar to that of hFSH, but could be distinguished from hFSH on the basis of a differential sensitivity to acid inactivation. Human FSH was inactivated in acetone at pH 4.1 (1 h, 25 C), whereas hFF FSH-BI retained activity under these conditions. Human FF FSH-BI also demonstrated FSH-like agonist activity, defined as the ability to stimulate basal levels of estradiol synthesis in cultured rat Sertoli cells. Human FSH-BI strongly cross-reacted to a commercially available monoclonal antibody used to measure serum hFSH. Indeed, recovery of FSH immunologic activity was significantly greater (134-fold on a mass basis) after partial purification, indicating that antibody recognition sites were apparently masked in unfractionated hFF. In summary, large mol wt hFSH-BI has been partially purified from hFF and found to be similar in size to pituitary hFSH and to have FSH-like agonist activity in vitro. Although distinguishable from pituitary hFSH on the basis of stability to acid, hFSH-BI appears immunologically related to pituitary hFSH so that measurements of hFSH levels in hFF using immunologic techniques should be interpreted with caution.

A low maternal serum alpha-fetoprotein screening result can be expected to cause measurable anxiety for couples, particularly when the woman is younger than 35 years of age. This study was designed to investigate the levels of anxiety present in these patients and show the effectiveness of genetic counseling on this anxiety. The women and their partners were given the State Trait Anxiety Inventory before and after counseling. A control group of low-risk pregnant patients was also given the state anxiety inventory for comparison. The mean level of anxiety for the control group was 36, significantly lower than either the precounseling or postcounseling level of the group with low maternal serum alpha-fetoprotein screening results (p less than .05). The study shows that genetic counseling, in addition to appraising couples of the risks and options involved, does significantly reduce their anxiety level regardless of whether an amniocentesis was performed.

Two patients who were administered topical vaginal 5-fluorouracil for human papilloma virus lesions became pregnant during treatment. The outcomes in both cases were healthy with normal developmental landmarks at 6 months of age. This experience highlights the potential for a positive outcome.

Background Norplant is a user-independent subdennal contraceptive composed of six silastic, levonorgestrel containing capsules. Previously reported data demonstrated that the majority of women in our population chose Norplant within one year of a pregnancy (89% of adolescents and 69% of adults); 65% of these women initially became pregnant while using oral contraceptives. The purpose of this study is to prospectively compare the length of time between Norplant removal and unplanned pregnancy in adolescent ( Methods Women using Norplant are prospectively followed from device insertion through removal and subsequent annual examinations as part of an ongoing study. Patient data is collected by personal interview and chart review and entered into a computer database. Data is evaluated for significance by chi-square analysis where p Results Post-removal follow-up data for between 11 and 62 months is currently available for 367 Norplant removals (125 adolescents, 212 adults, and 30 individuals with incomplete data). The average length of follow-up is 24.8 months with a standard deviation of 9.9 months. There have been 41 pregnaneies to date following Norplant removal (18 adolescents and 23 adults). Thirty six (88%) of these pregnancies were unplanned (15 adolescents and 21 adults). The average length of time from device removal to unplanned pregnancy was 4.7 months in adolescents and 5.3 months in adults. Eighty seven percent of adolescent and 57% of adult unplanned pregnancies occurred following device removal despite placement on oral contraceptives. Conclusions Adolescent women discontinuing Norplant use are no more likely to experience unplanned pregnancy than adults. Women experiencing oral contraceptive failure are likely to experience repeat oral contraceptive failure. In this population, user dependent contraceptive methods are less reliable than user independent contraceptive methods.

In this paper, a generalized logistic regression model for correlated observations is used to analyze epidemiologic data on the frequency of spontaneous abortion among a group of women office workers. The results are compared to those obtained from the use of the standard logistic regression model that assumes statistical independence among all the pregnancies contributed by one woman. In this example, the correlation among pregnancies from the same woman is fairly small and did not have a substantial impact on the magnitude of estimates of parameters of the model. This is due at least partly to the small average number of pregnancies contributed by each woman.

Molecular analysis of deoxyribonucleic acid extracted from trophoblast has become an important component of modern prenatal diagnosis. Discrepancies between trophoblast and fetal tissue in both chromosomal and metabolic analysis have been reported. We studied 50 paired fetal and trophoblast deoxyribonucleic acid specimens with a highly polymorphic probe for repetitive “minisatellite” regions of deoxyribonucleic acid that may be areas of high recombination. Four pairs showed persistent variations in bands consistent with differences in fetal and trophoblast deoxyribonucleic acid. Discordance in trophoblast deoxyribonucleic acid as a reflection of fetal genotype may be secondary to mitotic recombination or sister chromatid exchange in the trophoblast, and the possiility of discordance must be considered in interpreting the results of prenatal diagnostic testing on trophoblast specimens.

A high proportion of the population of Tecumseh, Michigan, participated in comprehensive assessments of health, personal habits, and socioeconomic status during the periods 1959-1960 and 1962-1965. A total of 5735 persons older than 20 years of age, comprising 2749 men and 2986 women, form the subject of this report. Diabetics were identified at entry and contrasted to nondiabetics with respect to personal characteristics. During the period 1977-1979, health status of 69% of the eligible cohort was ascertained. Age, adiposity, and blood glucose level were the principal predictor of new cases of diabetes. Family history was a significant predictor only among middle-aged, overweight men. Diabetes tended to be related to central fat distribution as indicated by subscapular skinfold thickness. Predictors of new cases of diabetes were not necessarily related to prevalence of the disease in this population.

Three discriminant functions proposed by Bahadur (1961 a, b), Martin and Bradley (1972), and Ott and Kronmal (1976) are generalized to accommodate polychotomous predictor variables. The discrete Fourier orthogonal functions used in the generalization provide computational advantages with the use of the fast Fourier transform. Data-dependent inclusion rules for each expansion's coefficients are developed to “smooth” observed frequencies and improve discrimination. The performances of these methods are compared in a simulation study, and populations in which these rules are expected to perform well are identified.

Radiographs of the fingers and wrists of adult participants in the Tecumseh Community Health Study in 1962-65 were examined for signs of osteoarthritis (OA). The severity of OA for each of 32 joints of the fingers and wrists was recorded for each individual. Attention was restricted to the 3035 participants who were 32 years of age or older and for whom a diagnosis of OA was available for each of 32 joints. Joint-specific prevalence rates of OA increased sharply with age for both sexes, and at the older ages, the prevalence rates for most joints were higher for females. Older individuals with OA also had a greater number of affected joints, with females having a greater number of affected joints than males. Of those individuals aged 44 years or younger, only 6.2% had one or more joints affected with OA. The percentages were 21.6 and 42.0% for those aged 45-59 years and 60 or more years, respectively. The distal interphalangeal (DIP) joints were the most frequently affected joints in all age categories for both sexes and OA in the proximal interphalangeal (PIP) joints was positively associated with OA in the DIP joints. However, controlling for the number of affected DIP joints, the PIP joints of older subjects were more likely to exhibit OA than the PIP joints of younger subjects. Though there is an association between OA in the DIP and PIP joints, there was only a small, nonsignificant association (OR = 1.24, 95% CI = 0.83, 1.84) between disease in the DIP and PIP joints of the same finger.

The coronary heart disease mortality of participants in the Tecumseh study was examined with particular emphasis on the roles of diabetes and glucose tolerance as risk factors. The cohort consisted of 921 men and 937 women aged 40 years and older who did not have evident coronary heart disease at entry to the study during the period 1959-1965 and whose outcome was determined in the period 1977-1979. Previously diagnosed diabetes was a statistically significant risk factor for coronary heart disease mortality in both sexes even after controlling for systolic blood pressure, serum cholesterol, relative weight, and cigarette smoking. High blood glucose score in nondiabetics was associated with excess coronary heart disease mortality after controlling for other risk factors, but the magnitude of this effect was substantially below that of diabetes. The predictive power of most risk factors except age itself decreased among progressively older segments of the population.

We have described an in vitro fertilization and embryo transfer accomplished by ultrasonically guided transurethral transvesical oocyte aspiration. Follicular aspiration using ultrasonography is a suitable alternative to traditional laparoscopic methods, and may have several advantages, including avoidance of surgical and general anesthesia complications. Further experience with this technique will clarify the benefits and/or risks, and this work is continuing.

1. 1. Torsion of ovarian tumors is an uncommon occurrence in childhood, as shown by the fact that only 26 cases, including our own, have been reported in the literature since 1900. 2. 2. About 50 per cent occurred between the ages of eight and ten. 3. 3. Sixty per cent of them were dermoids. 4. 4. The tumors varied in size from that of an adult ovary to one reaching above the umbilicus. 5. 5. The symptoms are those of an abdominal crisis similar to that of the same accident in adult life, sudden abdominal pain, vomiting, a variable degree of prostration, tenderness, rigidity, distention, temperature, increased pulse rate, and the presence of an abdominal tumor. 6. 6. The diagnosis is usually difficult, probably due to rarity. Appendicitis is often the preoperative diagnosis. 7. 7. The causes are much the same as in adult life. 8. 8. Fourteen claimed cases of torsion of normal adnexa have been reported to date. 9. 9. Eight of fourteen cases, more than half, occurred before the age of 20; four under 12, and presumably before puberty. 10. 10. The tube alone may be involved, the tube and ovary together, or the ovary may be essentially the offending organ. 11. 11. A large percentage occur in close relation to the menstrual period. 12. 12. Three are reported during pregnancy. 13. 13. Some question still exists as to whether a normal tube can undergo torsion, but it seems to be proved that a normal ovary may do so. 14. 14. Factors such as the length of the mesentery, the size of the ovary, and the length of the tube, must be considered as well as the histologic structure of the organ. 15. 15. Torsion of adnexa in hernial sacs (apart from strangulation) is relatively rare. It occurs only in congenital inguinal hernias and usually in the first year of life.

Fetus in Fetu (FIF) is a rare congenital anomaly in which a malformed parasitic twin is found within the body of a living child or adult. In this case report, an 18 month-old male child presented with a large abdominal mass and failure to thrive. Imaging studies confirmed the presence of a large retroperitoneal fetus in fetu with significant mass effect of the adjacent structures. A surgical resection was performed and pathology confirmed the diagnosis. These rare cases have become more frequently reported and a review of the literature for the past 15 years will describe the demographics, updated genetic findings, pathology and outcomes of this unusual tumor. Recent findings will also discuss an infrequent association with teratomas that may warrant a longer follow-up for surveillance of malignancy.

Needle electromyography demonstrated bizarre repetitive high frequency discharges of the periurethral muscles in 3 women with urinary incontinence. One patient recovered spontaneously and 2 had associated stress incontinence that was greatly accentuated. Surgical correction of the stress incontinence had been done in 1 woman before the sphincter neuropathy was recognized and she continued to experience severe incontinence unrelated to activity for 30 months while the neuropathy subsided and stabilized. The second patient with stress incontinence and sphincter pseudomyotonia was diagnosed preoperatively. The operation was delayed for a year until the peripheral neuropathy appeared to be stabilized. This case had a more predictable and satisfactory postoperative result. The experience with these patients suggests that other specific neurogenic disorders of the striated sphincters may cause significant urologic symptoms.

Revue des nouveaux developpements apportes par les progres de la biologie moleculaire concernant l'etiologie et le traitement des troubles de la reproduction, des avortements recidivant et des syndromes intersexe

Thirty-nine follicular aspirations for in vitro fertilization were performed in 30 patients. Oocyte retrieval was performed by laparoscopy in 21 cases and ultrasound-guided transurethral aspiration in 18 cases. All procedures were performed by the same ovarian stimulation protocol and the same aspirating needle. In the laparoscopy group 150 oocytes were recovered from 177 follicles aspirated (85%). The fertilization rate was 69% (104/150) and cleavage rate, excluding triploidy, was 82% (85/104) for oocytes obtained by laparoscopy. Five clinical pregnancies occurred in the laparoscopy group for a pregnancy rate of 24% per cycle and 25% per transfer. In the transurethral ultrasound-guided group 77 oocytes were recovered from 103 follicles aspirated (75%). The fertilization rate was 79% (61/77) and cleavage rate, excluding triploidy, was 90% (55/61). Three pregnancies occurred for a pregnancy rate of 17% per cycle and 18% per transfer. None of these differences were statistically significant. Transurethral ultrasound-guided oocyte retrieval is a feasible alternative to laparoscopy for in vitro fertilization.

The value of oocyte reinsemination in human in vitro fertilization (IVF) was evaluated in this study. Two groups of 25 cycles each were studied. In group 1 cycles, insemination of mature/questionably mature oocytes (judged by cumulus and corona cell appearance) at 6.5 hours postcollection yielded a fertilization rate of 42.3%. This value was significantly lower than that obtained with reinsemination (70.8%). In group 2, questionably mature oocytes were treated as immature and inseminated 24 to 30 hours postcollection. The fertilization rate of mature eggs in group 2 was 68.2%, with a reinsemination success rate of 40%. Triploidy rates and cleavage rates of mature eggs, fertilized either at initial insemination or reinsemination and of fertilized immature eggs, were similar within group 1 and group 2 cycles. In group 1, two pregnancies resulted from transfer of embryos arising solely from successful reinsemination, with one infant delivered. These results indicate that reinsemination offers a useful adjunct for IVF in cases where fertilization failure occurs.