Is there a future for ovulation induction in the current era of assisted reproduction?

The clinical use of medical induction of ovulation in normogonadotrophic anovulatory women (WHO II), including polycystic ovary syndrome, is increasingly questioned. However, we believe that this treatment modality still represents a highly effective means of fertility treatment in women with low pregnancy chances without intervention. A conventional treatment algorithm involving clomiphene citrate (CC) followed by FSH induction of ovulation may result in a 71% cumulative singleton live birth rate. In attempts to improve treatment outcome further and reduce complication rates, new compounds such as insulin-sensitizing agents or aromatase inhibitors are currently used increasingly. Approaches such as patient selection for different treatment modalities on the basis of initial screening characteristics and alternative protocols for FSH ovulation induction may also be proposed to render treatment algorithms more patient tailored and therefore improve overall outcomes. More research is needed in this area, rather than referring these patients to assisted reproduction prematurely. This may lead to a more individually tailored approach for ovulation induction in a given patient, resulting in a further improvement of the balance between chances for success versus complications.     

The couple's decision-making in IVF: one or two embryos at transfer?

BACKGROUND: The aim of this study was to evaluate the decision-making process and factors that contribute to the decision of IVF participants to choose one or two embryos at transfer. METHODS: Two hundred and seventy-four IVF patients equally distributed in males and females were personally interviewed using a semi-structured questionnaire which included 82 items. RESULTS: In the whole study population, previous childbirth [odds ratio (OR) 2.1; 95% confidence interval (CI) 1.9-3.6], and spare embryos to freeze (OR 23.6; 95% CI 11.2-54.5) emerged as the most important variables in patients who had one embryo transferred, while previous IVF treatments (OR 0.3; 95% CI 0.1-0.6) and the assumed increased pregnancy chance (OR 0.1; 95% CI 0.05-0.3) were the most important decision-making factors among those who had two embryos. The women were more satisfied with the information (83 versus 71%; P = 0.02), and more aware of the risks with twin pregnancies (77 versus 66%; P = 0.03) than the males. The women were also more concerned about their age. Knowledge about risks of multiple pregnancies was higher in females (77%) than in males (66%, P = 0.03). CONCLUSION: The results of this study indicate that despite good information about the risks for complications with multiple pregnancies, many patients wish to have two embryos transferred. Spare embryos to freeze, improvement of pregnancy rate in single embryo transfer and young age of the woman are predictive of choosing single embryo transfer. However, the final decision must always be made in agreement with the physician.     

Is a polysomnographic recording prior to MSLT worth the effort?

Objective

It was recently proposed that polysomnography (PSG) may be replaced by actigraphy in order to obtain long-term sleep time prior to the multiple sleep latency test (MSLT). Polysomnography is used to assess sleep time and to detect and classify underlying sleep pathology. In the following article, the contribution of PSG to the diagnostic outcome of the MSLT is discussed.

Methods

MSLT referrals (n?=?81) with in-home polysomnography from the neurology (n?=?39, 23 women, 37 (±13) years) and pulmonary medicine (n?=?42, 20 women, 41 (±14) years) departments were analyzed. The diagnostic outcomes of the PSG and MSLT were examined.

Results

Median total sleep time prior to MSLT was 362 (range, 156–530) min. Sleep apnea (respiratory disturbance index >?15/h and >?30/h) was diagnosed in 21 and 19 patients, respectively. Periodic limb movements (PLM) were identified in 5 patients; 3 of these had a PLM arousal index >?5/h. Sleep onset REM (SOREM) was detected during PSG in 5 patients; 4 of these also had SOREM in the MSLT.

Conclusion

PSG combined with MSLT was found to improve diagnostic outcome and is highly useful for recognition of sleep-related pathology. Various sleep disorders remain undetected if ACT alone is used prior to MSLT procedures.     

Growth and cellular differentiation: a physico-biochemical conundrum? The example of the hand

Currently, the predominant hypothesis explains cellular differentiation as an essentially genetic intracellular process. The goal of this paper is to suggest that cell growth and differentiation may be, simply, the result of physical and chemical constraints.Bone growth occurs at the level of cartilage conjunction (growth plate) in a zone of lesser constrain. It appears that this growth also induces muscle, tendon, nerve and skin elongation. This cartilage growth by itself seems to explain the elongation of the hand. Growth stops at puberty likely because of feed-back from an increasing muscle load. The ossification (that is differentiation of cartilage into bone) appears to result from the shear stress induced. The study of bone age, obtained by X-ray picture of the hand, shows that ossification of epiphyses is very precise both in time and space. Computer modelization suggests that this ossification occurs where shear stress is greatest. The cartilage which does not ossify (joint, nose, larynx, ear, bronchus, etc.) is not exposed to high shear.Shear stress induces the secretion of extracellular matrix and a change of the biochemical environment of the cell. Precipitation of calcium phosphate, as in ossification, seems related to the alkalosis induced by shear stress.To speak in more general terms, loss of cellular differentiation, as occurs with cancer, can result from a change in the physical-chemical environments.     

Is the Dodo bird endangered in the 21st century? A meta-analysis of treatment comparison studies

The Dodo bird hypothesis asserts that when bona fide treatments are compared they yield similar outcomes and this hypothesis is consistent with a common factors or contextual model of psychotherapy. Wampold et al. (1997), the most recent comprehensive meta-analysis to test the Dodo bird hypothesis, yielded consistent evidence of treatment equivalence. However, some of Wampold et al.'s analytic strategies, such as using multiple effect sizes from the same study and prioritizing long-term follow-up, may have obscured treatment differences. The current meta-analysis updated Wampold et al. by analyzing studies published in the subsequent 16 years (k = 51). Separate effect sizes were calculated for primary outcomes versus secondary outcomes, at termination and follow-up. Contrary to the Dodo bird hypothesis, there was evidence of treatment differences for primary outcomes at termination. Furthermore, cognitive-behavioral treatments may be incrementally more effective than alternative treatments for primary outcomes. Consistent with the Dodo bird hypothesis, there was little evidence of treatment differences for the secondary outcomes at termination and follow-up. There are small, statistically significant differences between bona-fide treatments when the specific targets of those treatments are assessed, but not when secondary outcomes are assessed, providing mixed support for both specific factors and contextual models of psychotherapy.     

Is perioperative home the future of surgical patient care?

Perioperative home(PH)or perioperative surgical home(PSH)is a patient centered medical service or primary care provider aimed at share decision-making and seamless continuity of care for the surgical patient.The goal is to improve operational efficiency,decrease resource utilization,reduce length of hospital/intensive care unit(ICU)stay and readmission,and to decrease complication and mortality rates.PH is an innovative model of delivering health care during the entire patient surgical/procedural experience.This model is centered around patient from the time of the decision for surgery till the patients have recovered and returned     

The alien hand syndrome: What makes the alien hand alien?

The alien hand syndrome is a deeply puzzling phenomenon in which brain-damaged patients experience their limb performing seemingly purposeful acts without their intention. Furthermore, the limb may interfere with the actions of their normal limb. We report a case of alien hand syndrome following a left medial frontal and corpus callosum ischemic lesion. From our clinical observations and the patient's performances on experimental tasks, we postulate that three factors contribute to the sense of alienness: First, the errant limb must be disinhibited and disproportionately reactive to external environmental stimuli. Second, the limb is under less volitional control and produces perseverative movements in which motor stereotypies are concatenated. Consequently, the disinhibited limb perseverates on external stimuli and appears purposeful, despite not being engaged in true goal-directed intentions. Finally, the patient needs to have a relatively intact action-monitoring system to be aware of the abnormal movements as they are occurring.