Is the use of letrozole to induce ovulation teratogenic?

QUESTION A patient of mine has been prescribed letrozole to induce ovulation; however, a recent release from the Food and Drug Administration contraindicates the use of letrozole in premenopausal women owing to teratogenicity. Does the use of letrozole increase the risk of a child being born with a birth defect?ANSWER The use of letrozole to induce ovulation has not been associated with an increased risk of a child being born with a birth defect; in contrast, the use of clomiphene citrate in pregnancy is associated with intrauterine growth restriction.     

Sonographic and Doppler characteristics of the corpus luteum: can they predict pregnancy outcome?

OBJECTIVE: To determine whether there is a relationship between gray scale or Doppler characteristics of the corpus luteum and first-trimester pregnancy outcome. METHODS: We conducted a prospective study of patients with spontaneous singleton pregnancies between 5 and 8 weeks' gestation. The corpus luteum size, sonographic appearance, resistive index, and peak systolic velocity were measured on transvaginal sonography. Maternal use of exogeneous progesterone was recorded. Only patients with known first-trimester outcome were included. RESULTS: There were 201 study patients. The corpus luteum could be visualized in 197 (98%) and had a mean +/- SD size of 1.9 +/- 0.6 cm, a mean resistive index of 0.50 +/- 0.08, and a peak systolic velocity of 20.5 +/- 11.2 cm/s. There were 151 first-trimester survivors (75.1 %) and 50 spontaneous losses (24.9%). In a comparison of the survivors and losses, there was no significant difference in mean corpus luteum size (1.9 versus 1.7 cm; P = .10, t test), mean resistive index (0.50 versus 0.50; P = .71, t test), peak systolic velocity (21 versus 19 cm/s; P = .29, t test), or sonographic appearance (P = .78, chi2 test). The lack of association between corpus luteum characteristics and outcome persisted when cases were stratified by progesterone use and the presence or absence of a heartbeat on the study sonogram. CONCLUSION: There is no apparent relationship between the characteristics of the corpus luteum and first-trimester pregnancy outcome.     

Is normal pregnancy atherogenic?

Serum cholesterol, triacylglycerols and low-density lipoprotein (LDL) subfractions were determined in 120 primagravid women during normal gestation (40 in each trimester) and in 20 non-pregnant age-matched controls. LDL subfractions were determined by PAGE, and an LDL score was calculated. The higher the score, the smaller the subfractions. The objective of the study was to determine the effects of the hyperlipidaemia, high oestrogen concentrations and insulin resistance known to exist in normal pregnancy on LDL subfraction formation. Pregnant women had an increased mean serum cholesterol concentration [5.78 (S.D. 1.09) mmol/l] in the first trimester compared with the non-pregnant controls [5.11 (0.77) mmol/l; P<0.01]. The serum cholesterol concentration increased progressively throughout gestation to a mean of 8.14 (1.39) mmol/l in the third trimester (P<0.001 compared with the second trimester). Triacylglycerol concentrations in the first trimester were similar to those of controls, and there was a non-significant increase by the second trimester to 1.32 (0.44) mmol/l. However, by the third trimester the mean triacylglycerol concentration had doubled [2.58 (0.98) mmol/l; P<0.001 compared with the first and second trimester]. During gestation the LDL score increased dramatically, from 1.17 (0.39) during the first trimester to 2.01 (0.37) in the second trimester (P<0.001) to 2.73 (0.48) in the third trimester (P<0.001 compared with the second trimester). Thus an atherogenic lipid profile develops during normal gestation. The significance of these changes remains unclear, but thay may have important implications for mother and foetus.     

Is recreational drug use normal?

The purpose of this paper is to define drug use and differentiate this behaviour from drug abuse. We argue that one fundamental principle of the War on Drugs, namely that all use of illicit drugs is harmful and must be prohibited, is invalid. Statistically, clinically, and socio-culturally, drug use is normal behaviour. Current drug policy is based on the flawed premise that any use of illicit drugs is unhealthy. A public health model emphasizing demand reduction (as opposed to supply reduction), individual freedom, reason, and tolerance is recommended.     

Is fibrinogen the answer to coagulopathy after massive transfusions?

Coagulopathy is a major cause of morbidity and mortality in patients who have suffered severe hemorrhage and received massive transfusions. Administration of a fibrinogen concentrate along with red blood cells can quickly restore hemostasis in a clinically relevant animal model.     

Is fever after infection part of the illness or the cure?

An increase in temperature above the normal range of 35.6 degrees C-38.2 degrees C (Ryan and Levy 2003) can indicate the presence of infection or sepsis. When the body detects infection, a series of responses to control infection are initiated that result in a rise in systemic temperature. Research suggests that this rise in temperature can be regarded as a cure, in that it is part of the autonomic response to remove infection and create a favourable environment for antibiotics. Nevertheless, it remains common practice to try to reduce fever with medication and physical cooling methods. This article explores the physiological changes that occur during bacterial sepsis that result in increased temperature, and discusses the pros and cons of administering antipyretic medication. The aim is to enable nurses to understand and support patients who present with fever.     

Is it tonotopy after all?

In this functional MRI study the frequency-dependent localization of acoustically evoked BOLD responses within the human auditory cortex was investigated. A blocked design was employed, consisting of periods of tonal stimulation (random frequency modulations with center frequencies 0.25, 0.5, 4.0, and 8.0 kHz) and resting periods during which only the ambient scanner noise was audible. Multiple frequency-dependent activation sites were reliably demonstrated on the surface of the auditory cortex. The individual gyral pattern of the superior temporal plane (STP), especially the anatomy of Heschl's gyrus (HG), was found to be the major source of interindividual variability. Considering this variability by tracking the frequency responsiveness to the four stimulus frequencies along individual Heschl's gyri yielded medio-lateral gradients of responsiveness to high frequencies medially and low frequencies laterally. It is, however, argued that with regard to the results of electrophysiological and cytoarchitectonical studies in humans and in nonhuman primates, the multiple frequency-dependent activation sites found in the present study as well as in other recent fMRI investigations are no direct indication of tonotopic organization of cytoarchitectonical areas. An alternative interpretation is that the activation sites correspond to different cortical fields, the topological organization of which cannot be resolved with the current spatial resolution of fMRI. In this notion, the detected frequency selectivity of different cortical areas arises from an excess of neurons engaged in the processing of different acoustic features, which are associated with different frequency bands. Differences in the response properties of medial compared to lateral and frontal compared to occipital portions of HG strongly support this notion.     

Is depression normal in human beings? A critique of the evolutionary perspective

To the evolutionary biologist human beings at every stage of their development represent 'compromises' in their continual adaptation to their changing environments. Using a neo-Darwinian perspective, evolutionary psychiatrists such as Randolph Nesse (Professor of Psychiatry at the University of Michigan) argue that while natural selection does not shape disease itself, it does shape human traits and therefore vulnerability to disease. Accordingly, for him, depression is a human emotion which may represent a surviving positive response and is therefore not always pathological. This critique examines Nesse's principal arguments and reveals a number of weaknesses in those arguments. The article concludes with a review of the therapeutic and preventive implications of his evolutionary perspective on depressive states as well as some implications for mental health nurses .     

Is there life after evidence-based medicine?

Recent years have witnessed the rising star of evidence-based medicine (EBM) as an approach towards rationalizing clinical practice in the face of an exponentially growing body of knowledge. Along with it, however, a sense of unease is rising among practising doctors, as they feel that well-intentioned principles may be increasingly applied to disease management, with its economic and cost-cutting implications, rather than disease cure or treatment. There is a fear that any procedure, however time-honoured, that was not or cannot be subjected to randomized controlled clinical trial, may some day be discouraged, more or less strongly, based on statistical rather than clinical considerations. Resistance to EBM ranges from a 'we-know-best' uncompromising non-acceptance to a 'you-may-be-right-sometimes-but-don't-ever-tell-me-what-to-do' sort of openness. The problem is one of measure, in more than one sense: measure of how effective individual practitioners are in treating their patients, measure of how useful EBM is, measure in promoting what may become a dogmatic application of probability laws to the very improbable practice of medicine, measure in siding with the supporters of health care on a budget. There is much that EBM can give to clinical medicine by its ability to organize complex data sets for the ultimate benefit of patients, but there is also much that can stifle practice by forcing a dogmatic implementation, rather than a flexible common sense approach, of its principles.     

Is nasal packing really required after septoplasty?

Objective: Septoplasty is one of the most common operations performed by otorhinolaryngologists. Nasal packing is not an innocuous procedure. The most common problem encountered by the patients after septoplasty is the pain and discomfort during removal of the nasal packs. The objective of this study was to evaluate the results of septoplasty without postoperative nasal packing. Methods: Septoplasty was performed by standard technique. No nasal packing was used in these cases. Results: Seventy‐eight patients were included in the study. The majority of the patients (64.1%; 50/78) on a morning list were operated. Sixty‐two patients were discharged home the same day, the remaining others were discharged the next day. Our postoperative haemorrhage rate was 7.7% (6/78) and only 3.8% (3/78) patients required nasal packing. Majority (84.6%) of the patients were satisfied with the operation at the postoperative follow up 3 months later. Conclusions: Septoplasty can be safely performed without postoperative nasal packing. Only 3.8% patients required nasal packing in this study.     

Is automaticity of walking regained after stroke?

PURPOSE: The aim of this study was to determine whether people who have completed rehabilitation after stroke have regained a level of automaticity of walking comparable to healthy people of similar age. METHOD: Twenty stroke subjects, 20 healthy elderly controls and 20 healthy young controls were tested. To quantify the automaticity of walking, subjects were required to walk simultaneously while performing an additional task(s). Subjects walked under four counterbalanced conditions: a single walking task, a dual-cognitive task, a dual-manual task and a triple-task. Walking velocity, cadence, stride length and step length were analysed. RESULTS: Stroke subjects walked slower (p = 0.001), took shorter strides (p = 0.002) and fewer steps/min (p = 0.04) than elderly controls. Velocity declined significantly across conditions from the single to the dual-cognitive to the dual-manual and finally to the triple-task (p < 0.001). Both stroke and elderly groups showed similar deterioration in walking velocity across conditions (p = 0.99), while the deterioration in the young subjects was significantly less than for healthy elderly subjects (p = 0.04) and the stroke subjects (p = 0.02). CONCLUSION: Community dwelling stroke subjects display the same level of automaticity of walking as elderly controls, but both elderly controls and stroke subjects are less automated than young controls.     

Is cortisol the key to the pathogenesis of delirium after coronary artery bypass graft surgery?

Postoperative delirium is a serious complication of cardiac surgery. However, the pathophysiology of this mental syndrome is largely unknown. Recent findings suggest an association between elevated level of cortisol and postoperative delirium. Further studies should investigate the mechanisms responsible for excessive perioperative cortisol secretion.