＂One sperm,one embryo,one baby＂？

Dear Editor,
The introduction of intracytoplasmic sperm injection （ICSI） technology has revolutionised the treatment of patients with severe oligozoospermia and azoospermia. A patient is usually considered oligozoospermic if his sperm concentration is less than 20 million mL^-1. A patient is labelled azoospermic according to the World Health Organisation guideline , if, on two different occasions, no spermatozoa can be detected by high-power microscopy after the seminal fluid has been centrifuged for 15 min at a centrifugation force of 3 000 × g or greater.     

Hand transplantation: is it an ethical decision, a bioethical one, or both?

Essays by Seigler and Emmanuel define some criteria and requirements when doing an innovative procedure such as hand transplantation to determine whether it is possible to conduct clinical research.These criteria and requirements take into account the patient, the medical team, and society. However, we think that there are still other considerations that have not been given sufficient emphasis to justify an innovative procedure and are mainly determined by the patient and his environment, along with other quality-of-life issues, including social acceptance (according to cultural norms), appearance (body image), and function. There should be a balance between the patient, the medical team, and societal considerations in the decision process. Progressive societies are responsible for the distribution of the necessary resources to perform innovative procedures while controlling the costs of integral treatment and ensuring related investigations, thus facilitating the evaluation and advancement of innovative surgery. If these factors are taken into account along with the criteria already outlined involving the patient's cultural dimensions and the involved costs a decision can be made whether to proceed with hand transplantation. Being a difficult complex decision, it is imperative that it be made not only by an individual or group, either the patient or the medical team (ethical decision), but in conjunction with public discussion (bioethical decision) that not only takes into account the risks, benefits, and costs, but by including all criteria must also be at least technical, human, and social.     

“发型师one by one示范”四大超囧发型自救术

大家一定都有过头发被剪坏的经历，遇到这种欲哭无泪的情况，真的会让人不知所措。现在，小编锁定了四种容易出现的发型问题，专业发型师将对此进行一对一指导，让你不用再去美发店补救也能变好看哦!     

Obstetrical epidural analgesia during labour: one dural puncture, repeated postural headaches, three blood patches…

We report the case of a patient in whom three blood patches had to be performed to treat a post-dural puncture headache following the insertion of an epidural catheter for labour analgesia. There are few data about repeated blood patches used to treat recurring symptoms after failure of a previous blood patch. The technical guidelines used to perform a first blood patch should be followed for the next procedure as well. The role of the cerebrospinal fluid leaking in the symptoms has to be verified, to avoid performing a useless blood patch and to miss another cause, which needs an urgent treatment.     

Hypoxaemic rescue therapies in acute respiratory distress syndrome: Why,when, what and which one?

Acute respiratory distress syndrome (ARDS) is an inflammatory condition of the lungs which can result in refractory and life-threatening hypoxaemic respiratory failure. The risk factors for the development of ARDS are many but include trauma, multiple blood transfusions, burns and major surgery, therefore this condition is not uncommon in the severely injured patient. When ARDS is severe, high-inspired oxygen concentrations are frequently required to minimise hypoxaemia. In these situations clinicians commonly utilise interventions termed ‘hypoxaemic rescue therapies’ in an attempt to improve oxygenation, as without these, conventional mechanical ventilation can be associated with high mortality. However, their lack of efficacy on mortality when used prophylactically in generalised ARDS cohorts has resulted in their use being confined to clinical trials and the subset of ARDS patients with refractory hypoxaemia.     

Splenic marginal-zone lymphoma: one or more entities? A histologic, immunohistochemical, and molecular study of 42 cases

We analyzed 42 splenic marginal-zone lymphoma (SMZL) cases diagnosed on splenectomy specimens after established World Health Organization criteria. A predominantly nodular growth pattern was observed in 24 cases; the remainder showed predominantly (11/42) or exclusively (7/42) diffuse infiltration. Twenty-one cases showed the "classic" biphasic appearance; 13 cases exhibited marginal-zone morphology; finally, 8 cases were composed predominantly of small cells. CD21 and CD35 were expressed by 12/42 and 17/38 cases, respectively. DBA.44 was detected in 24/42 cases. Seventeen of 37 cases were surface IgD (SIgD)-positive. Twenty-one of 22 analyzed cases were SIgM-positive (12/21 coexpressed SIgD). Five of 37 cases were SIgG-positive. CD27 staining was observed in 21/35 cases; 7/18 CD27-positive cases coexpressed SIgD; 7/14 CD27-negative cases were SIgD-positive. Forty IGHV-D-J rearrangements were amplified in 34/42 cases: the IGHV4-34 gene predominated, followed by IGHV1-2. Using the 98% homology cut-off, 25/40 (62.5%) IGHV sequences were considered as "mutated": 10/11 cases with monomorphous, marginal-zone morphology were IGHV-mutated; in contrast, 4/6 cases with monomorphous, small-cell morphology were IGHV-unmutated. Five of 7 cases expressing IGHV1 subgroup genes had biphasic morphology, whereas 6/9 IGHV3-expressing cases had monomorphous, marginal-zone morphology. Most IGHV-mutated cases (14/20; 70%) were SIgD-negative; in contrast, 8/11 IGHV-unmutated cases expressed SIgD. CD27 was detected in 10/17 IGHV-mutated and 6/10 IGHV-unmutated cases. Seven of 11 CD27-negative cases were IGHV-mutated; 5/7 CD27-negative/IGHV-mutated cases expressed DBA.44. These results confirm the considerable histologic, immunohistochemical, and molecular heterogeneity of SMZL and indicate an origin from the diverse resident B-cell populations of the normal SMZ.     

Renoprotection: one or many therapies?

BACKGROUND: Renal disease that progresses to end-stage renal disease (ESRD) imposes a great burden on the affected individual and on society, which mainly bears the cost of ESRD (currently more than $10 billion to treat about 333,000 patients annually in the U.S.). Thus, there is a great need to identify therapies that arrest the progression mechanisms common to all forms of renal disease. Progress is being made. Perhaps the most visible advance is the randomized controlled trials (RCT) demonstrating the renoprotective effects of angiotensin-converting enzyme (ACE) inhibitors. There are also numerous other promising renoprotective therapies. Unfortunately, testing each therapy in RCT is not feasible. Thus the nephrologist has two choices: restrict renoprotective therapy to those shown to be effective in RCT, or expand the use of renoprotective therapies to include those that, although unproven, are plausibly effective and prudent to use. The goal of this work is to provide the documentation needed for the nephrologist to choose between these strategies. METHODS: This work first describes the mechanisms believed to be involved in the progression of renal disease. Based largely on this information, 18 separate interventions that slow the progression are described. Each intervention is assigned a level of recommendation (Level 1 is the highest and Level 3 the lowest) according to the strength of evidence supporting its renoprotective efficacy. RESULTS: The number of interventions at each level of recommendation are: Level 1, N = 4; Level 2, N = 4; Level 3, N = 10. Our own experience with the multiple-risk-factor intervention is that most patients can achieve the majority of the Level 1 and 2 interventions, and many of the Level 3 interventions. We recommend the expanded renoprotection strategy. CONCLUSION: This work advances the hypothesis that, until better information becomes available, a broad-based, multiple-risk-factor intervention intended to slow the progression of renal disease can be justified in those with progressive nephropathies. This work is intended primarily for clinical nephrologists and thus each recommended intervention is described in substantial practical detail.