Investigation of the infertile couple: should diagnostic laparoscopy be performed in the infertility work up programme in patients undergoing intrauterine insemination?

Diagnostic laparoscopy is normally the standard procedure performed as the final test in the infertility work up before progressing to infertility treatment. Recently, there has been a growing tendency to bypass diagnostic laparoscopy after a normal hysterosalpingogram and instead to start direct infertility treatment [intrauterine insemination (IUI) or IVF] for indications such as unexplained infertility, male subfertility and cervical hostility. In our clinic, laparoscopy revealed abnormalities that resulted in changed treatment decisions in 25% of the patients who would normally have been scheduled for IUI if laparoscopy had not been performed. The changed treatments mainly concerned surgery for minimal/mild endometriosis and periadnexal adhesions, both performed during the diagnostic laparoscopy. Because the effect of such interventions on the success rate of IUI has never been described, it still remains unclear whether laparoscopy is usefully performed in these cases. Therefore, further prospective studies should be performed to assess whether delaying, or bypassing entirely, diagnostic laparoscopy is more cost effective and if laparoscopic interventions for intra-abdominal abnormalities are effective in terms of higher pregnancy rates after treatment with IUI.     

The laboratory approach to the diagnosis of autoimmune diseases: is it time to change?

Array technology and proteomics are about to launch the era of multiplexed analysis, which allows simultaneous detection of numerous autoantibody specificities and the possibility of defining broad autoantibody profiles. This will probably improve disease staging, risk stratification, prognosis and treatment. However, although these technologies are very promising, they are still in their infancy, and therefore need to undergo strict analytical and clinical validation processes. The latter should involve clinicians and pathologists in prospective, multicentric studies conducted on large numbers of patients to define the specific significance of the various autoantibody profiles. Establishing common standards for the publication and sharing of microarray-generated data will be important for this purpose. Only when these studies have been completed will these new technologies find a place in clinical laboratories. Although we are entering a decade which will probably see a radical change in the diagnostic approach to autoimmune diseases, we do not yet have sufficient knowledge to apply proteomic technologies on a large scale. For the time being, therefore, it is advisable to continue using well-established approaches and diagnostic algorithms such as those reported in the international guidelines, which have been prepared in accordance with the principles of appropriateness and evidence-based medicine.     

First admissions for depression: is the 'no-treatment interval' a critical predictor of time to remission?

BACKGROUND: This study aimed to replicate findings that length of episode prior to adequate antidepressant treatment (the 'no-treatment interval') and premorbid neuroticism predict time to remission from the institution of adequate treatment for depression. METHODS: Eighty-three inpatients meeting ICD-10 criteria for a depressive illness were entered into an 18-month prospective follow-up study of illness course. Subjects were assessed using the Schedules for Clinical Assessment in Neuropsychiatry, Maudsley Personality Inventory (MPI) and the Hamilton Rating Scale for Depression (HRSD). Remission was defined as an HRSD score of < 8 for 2 consecutive weeks. RESULTS: Twenty-two patients (27%) remained depressed 12 months after the onset of adequate treatment. Significantly longer times to remission were predicted by a longer no-treatment interval and higher premorbid neuroticism scores. LIMITATIONS: Adequate antidepressant treatment was commenced prior to admission in half the cases, requiring a retrospective assessment of illness course prior to study entry. Twenty-four patients (29%) had not remitted at the time of completion of the MPI. CONCLUSIONS: These results replicate previous findings identifying a longer time to treatment and higher neuroticism scores as predictors of chronicity in depression.     

Osteomyelitis of the jaw: time to rethink the bone sampling strategy?

This work aims at describing the diversity of osteomyelitis of the jaw (OJ) and at assessing the relevance of a new method designed to avoid salivary contamination during bone sampling in order to improve microbiological analysis and clinical decision-making. We reviewed medical and microbiological data of patients with a suspected OJ based on clinical and/or CT-scan signs and at least one bone sample made for microbiological analysis. During the study period, a new procedure for intraoral bone sampling was elaborated by surgeons and infectious diseases specialists authoring this article (based on stratified samples, cleaning of the surgical site and change of instruments between each sample). A comparison of the microbiological analyses between the two procedures was performed. From 2012 to 2017, 56 patients were included. Median age was 58 years (11–90), sex ratio: 1.24. Main risk factors were having a dental disease (n =?24) or cancer (n =?21). Nineteen patients with the new sample procedure were compared to 37 patients with standard procedure, especially non-cancer patients (n =?16 and 19, respectively). With the new procedure, a median of 3 (1–7) microorganisms per sample was recovered, vs. 7 (1–14) with the former (p <?0.001), a significant decrease of the microbial density was observed for all types of microbes, especially in deeper samples and cultures were more frequently sterile. The way sampling is managed deeply influences microbiological analysis. This strategy facilitates the distinction between pathogens and contaminants and should constitute the first step toward an evidence-based antimicrobial strategy for OJ.     

Division of labour within the visual system: fact or fiction? Which kind of evidence is appropriate to clarify this debate?

The perception versus action hypothesis of Goodale and Milner (Trends Neurosci 15:20–25, 1992) and Milner and Goodale (The visual brain in action. Oxford University Press, Oxford, 1995) postulated two different pathways within the visual system—one for action and one for perception. With the help of pictorial illusions, evidence for this dissociation was found in various studies. There is an ongoing debate, however, as to whether or not this evidence is biased by methodological issues. Indeed, relevant and decisive data can come only from those studies that (1) match conditions appropriately with respect to task demands, (2) use illusions that do not provide any potential obstacles for the hand, (3) do not risk that grasping is either memory driven (when the target is not visible) or online corrected (due to a direct comparison of the grip aperture with the size of the target object), (4) do not confound differences between perception and action conditions with differences in visual feedback, and (5) correct for differences in response functions between grasping and perception. In following all these points outlined above we found support for the perception versus action hypothesis: grip aperture follows actual size independent of illusory effects, while perceived length as indicated by finger–thumb span clearly was subject to the illusion.     

Molecular classification of breast cancer: is it time to pack up our microscopes?

Breast cancer is a heterogeneous disease. The traditional classification uses morphology to divide tumours into distinct categories with differing prognosis and behavior. Despite providing high quality data cheaply, it has limitations and hence there has been a hope that the new molecular methods may help to refine the classification systems. Much has been learned in the last few years however, the molecular taxonomy is still in evolution and likely to change over the coming years. Whether the molecular classification is as useful for special subtypes of breast cancers as it has been for ductal carcinoma, no special type, remains to be determined.     

When is it appropriate to prescribe postmenopausal hormone therapy?

OBJECTIVE: To develop evidence and consensus-based recommendations for the use of hormone therapy (HT) in postmenopausal women. DESIGN: Using evidence from clinical trials and other publications, a multidisciplinary group of women's health experts developed consensus-based recommendations for HT use in more than 300 clinical scenarios. These panelists utilized the RAND Appropriateness Method and a quantitative scale to rate the appropriateness of treatment options for women with various risk factors and clinical scenarios. RESULTS: The panel judged it appropriate to prescribe all forms of HT to women with intolerable menopause symptoms and usual (age-expected) risks of cardiovascular disease (CVD), venous thromboembolism (VTE), or stroke. Use of HT was judged not appropriate for the clinical scenarios of bone preservation, cosmetic appearance, current memory loss, loss of libido, or CVD protection. For a woman still using HT after 5 or more years, it was considered appropriate to recommend the options of stopping or lowering the dose even if stopping was previously attempted. In treating intolerable symptoms in the presence of some elevated risk for diseases related to HT, route of administration may affect appropriateness but prior stroke or TIA# is a contraindication. CONCLUSIONS: Standard HT is appropriate for women with intolerable menopause symptoms in the absence of HT-related risk factors (eg, CVD, stroke, VTE, breast cancer). Panelists judged it appropriate to repeatedly present the option of stopping or reducing the dose. In most cases, presence of risk factors makes standard-dose oral HT not appropriate; however, some women may be candidates for a different dose or route of administration.     

Hysterosalpingography: a potential alternative to laparoscopy in the evaluation of tubal obstruction in infertile patients?

BackgroundEvaluation of the fallopian tubes are important for infertile patients. The two most important diagnostic procedures used to evaluate tubal patency are hysterosalpingography and laparoscopy.ObjectivesTo asses the hysterosalpingography and laparoscopy results of patients diagnosed with infertility and investigate the diagnostic value of hysterosalpingography in patients with tubal factor infertility.MethodsThe hysterosalpingography and laparoscopy results of 208 patients who presented to the Obstetrics and Gynecology Clinic at Dicle University, Faculty of Medicine between January 2014- January 2018 were retrospectively evaluated. Hysterosalpingography and laparoscopy results were compared with regard to the investigation of the presence of tubal obstruction and of the pelvic structures that could cause tubal obstruction. The specificity, sensitivity, positive, and negative predictive values of hysterosalpingography were computed.ResultsThe number of patients evaluated was 208. The ratio of primary infertile patients was 57.2% and 42.8% was secondary infertile. Hysterosalpingography was found to have a specificity of 64.6%, the sensitivity of 81.3%, the positive predictive value of 56.4%, and a negative predictive value of 86% in the determination of tubal obstruction.ConclusionPatients with suspected tubal infertility can primarily be examined using hysterosalpingography in consideration of the invasive nature and the higher complication rate of laparoscopy.     

Training-related modulations of the autonomic nervous system in endurance athletes: is female gender cardioprotective?

The risk of sudden death is increased in athletes with a male predominance. Regular physical activity increases vagal tone, and may protect against exercise-induced ventricular arrhythmias. We investigated training-related modulations of the autonomic nervous system in female and male endurance athletes. Runners of a 10-mile race were invited. Of 873 applicants, 68 female and 70 male athletes were randomly selected and stratified according to their average weekly training hours in a low (≤4 h) and high (>4 h) volume training group. Analysis of heart rate variability was performed over 24 h. Spectral components (high frequency [HF] and low frequency [LF] power in normalized units) were analyzed for hourly 5 min segments and averaged for day- and nighttime. One hundred and fourteen athletes (50 % female, mean age 42 ± 7 years) were included. No significant gender difference was observed for training volume and 10-mile race time. Over the 24-h period, female athletes exhibited a higher HF and lower LF power for each hourly time-point. Female gender and endurance training hours were independent predictors of a higher HF and lower LF power. In female athletes, higher training hours were associated with a higher HF and lower LF power during nighttime. In male athletes, the same was true during daytime. In conclusion, female and male athletes showed a different circadian pattern of the training-related increase in markers of vagal tone. For a comparable amount of training volume, female athletes maintained their higher markers of vagal tone, possibly indicating a superior protection against exercise-induced ventricular arrhythmias.     

HIV-1 infection: is it time to reconsider our concepts?

The long asymptomatic phase of HIV infection is critical in the progression to AIDS. It probably reflects an ancestral relationship with lentiviruses stemming from the primate-simian immunodeficiency virus evolutionary pathway leading to an idiosyncratic immune tolerance, which needs to be understood if effective vaccines are to be rationally designed. The majority of CD4+ T cells that die due to HIV-1 in the asymptomatic phase are not infected with the virus. Transmission of the predominant HIV-1 R5 variants to T cells is mediated by infected monocyte-derived macrophages. The two cell populations come into intimate contact mainly in the lymph nodes during antigen presentation where there is also active viral replication. We propose that HIV exploits antigen presentation to access target T cells and evade immune surveillance. This is achieved at the assembly point of an immunological synapse between an antigen presenting, HIV-1-infected macrophage and a responding effector/memory CD4+ T cell. Viral envelope gp120 glycoproteins proximal to MHC II molecules cross-link with T cell CD4 molecules, thus establishing a supra molecular immuno-viral synapse. The interaction results in conformational changes of gp120 exposing its V3 domain. Ionic interaction of this domain with the synapse-recruited chemokine receptor CCR5 dimerizes the receptor triggering intracellular signals that contribute to T cell receptor transactivation pathways and subsequent enhancement of T cell activation. HIV-downregulated MHC II gives weak immune complexes. Disruption of the immuno-viral synapse before completion of cell entry is a frequent outcome condemning the responding T cell to a premature activation-induced T cell death. Information on the assembly, mechanistic and functional interactions at the immuno-viral synapses may well assist in elucidating new strategies to combat HIV infection.