Luteal phase support and severe ovarian hyperstimulation syndrome.

The incidence and statistical associations of the ovarian hyperstimulation syndrome (OHSS) were studied in 304 egg retrievals with gonadotrophin-releasing hormone agonist suppression, gonadotrophin administration and follicular aspiration. In addition to preserving corpus luteum function, the luteal phase administration of human chorionic gonadotrophin (HCG) was associated with a higher incidence of severe OHSS than was supplementation with progesterone alone (12 versus 0%, P less than 0.001). Severe OHSS occurred in 3.7% and 12% of retrievals without and with pregnancy respectively (P less than 0.01). Stepwise logistic regression showed that the occurrence of moderate or severe OHSS was statistically predicted by the log of the serum oestradiol on the day the initial HCG was given (P less than 0.0001), treatment with luteal phase HCG (P less than 0.0003), and fetal number (P less than 0.0079). In the late luteal phase of cycles without luteal HCG, the serum oestradiol concentration was one-tenth and the serum progesterone concentration was one-fifth of the luteal phase value with HCG support (P less than 0.001). Without luteal phase HCG, oestradiol was two-fold higher (P less than 0.001) and progesterone was 1.4-fold higher (P less than 0.005) in pregnant than in non-pregnant women. With luteal phase HCG, oestradiol was 1.4-fold higher in pregnant than in non-pregnant women (P less than 0.05), and progesterone was 1.7-fold higher (P less than 0.001). Oestradiol upper limits of 4400 and 14,700 pmol/l (1200 and 4000 pg/ml) for cycles with and without luteal phase HCG respectively correspond to approximately 5% risk of moderate or severe OHSS with a singleton pregnancy under these conditions.     

Amyloid in prostatic corpora amylacea.

AIM: To determine the presence and nature of amyloid in prostatic corpora amylacea using immunohistological studies. METHODS: Prostatic tissue from 18 transurethral and two open resection specimens was studied. Paraffin wax embedded tissue sections were stained with haematoxylin and eosin and the alkaline Congo red method with and without previous treatment with potassium permanganate. Sections were also stained with antibodies to amyloid A, beta 2 microglobulin, lambda and kappa light chains, prealbumin IgA, G, M, S100 protein, prostatic specific antigen, amyloid P component and CAM 5.2 (control and blocking studies were performed). RESULTS: The prostatic corpora amylacea universally showed the presence of amyloid. In all instances this contained beta 2 microglobulin. CONCLUSION: Prostatic corpora amylacea represents a localised amyloidosis of beta 2 microglobulin origin that is unrelated to chronic renal failure and haemodialysis.     

Biological resurfacing of the knee: a review of surgical management

Lesions of the articular surfaces of the knee have been managed by various techniques over the last 50 years. Surgical management has involved: excising the damaged area, refashioning the underlying bone to produce a fibrous response, and introducing allograft, autograft and synthetic materials to encourage a repair matrix. The techniques and their pitfalls are reviewed and discussed, and suggestions made as to the direction of future studies for the repair of osteochondral lesions in the painful knee.     

New York University Medical Center's Cooperative Care Unit: patient education and family participation during hospitalization--the first ten years

The New York University Medical Center Cooperative Care (CC) program is a model of a delivery system of acute inpatient hospital care characterized by a live-in family member or friend acting as a "care partner". It has an emphasis on education in order to encourage full patient and family involvement in care during the acute hospitalization, thereby preparing both parties for management at home after discharge. The education-intensive experience of CC provides an alternative to traditional inpatient hospital care with the expected outcome of CC being to increase patient and family knowledge and satisfaction, adherence to the medical regimen, and appropriate self-management. The functioning ability of the patient-care partner team should be improved on discharge, which may result in decreased subsequent utilization of high cost healthcare resources such as rehospitalization. This paper describes the structure of the CC form of inpatient care, the types of patients appropriate for such care, and the experience of its first ten years of operation, with its implications as a replicable model for other institutions.     

Good and bad models of market reform for managed care

The author argues that free market competition has not been given a fair chance in the health care industry and that the basic characteristics of a sound market can be met in the United States if the problem of asymmetric information is efficiently addressed. He proposes the "Buy-Right" system as an effective model for market reform.     

MABDOSE. II: Validation of a general purpose dose estimation code.

The MABDOSE software represents a general tool to assess internal radiation dose. A suite of tests are described that validate the dosimetry system's implementation. METHODS: The validation suite is divided among tests that verify target digitalization, tumor digitalization and organ replacement, cumulated activity calculation, random number generation, radiation transport, and dose calculation. RESULTS: A comparison between Reference Man organ volumes and MABDOSE organ volumes at (5 mm)3 resolution demonstrates volume correspondence within 10% save for ten organs having dimensions smaller than the target lattice resolution. An accounting of normal organ volume replaced by an arbitrary tumor volume indicates mass is conserved. A comparison between cumulated activities generated by MABDOSE and solutions obtained analytically demonstrates exact correspondence for curve-fitting algorithms. For mathematical modeling algorithms, cumulated activity solutions converge to their correct values provided sufficient data of high precision are input, accompanied by reasonable initial estimates of rate constants. A comparison of MABDOSE results with the MIRD 3 report demonstrates good agreement (<8% difference) in absorbed fractions for spheres at energies from 20 keV to 2.75 MeV. A comparison of MABDOSE results with the Cristy-Eckerman report demonstrates marginal agreement (specific absorbed fractions within a factor of 2 for all Reference Man organs) at simulation energies of 20, 50, and 100 keV. Lack of exact correspondence is attributed to volume digitalization errors, and to differences in cross-section libraries, interpolation schemes between cross-section data points, and random number generators. Finally, the doses reported by MABDOSE correspond to the correct algebraic combination of paired cumulated activities and "S" values. CONCLUSIONS: The MABDOSE program has been validated as a general purpose computation tool for use in internal radionuclide dosimetry.     

A comparison of non-invasive methods of blood pressure measurement in normotensive and hypertensive pregnant women

We compared two types of automatic non-invasive blood pressure measuring device with sphygmomanometey in 47 normotensive and 38 hypertensive women in the third trimester of pregnancy. An automatic oscillometric device (Accutor) and a volume-clamp device (Finapres) significantly underestimated the diastolic pressure as measured by the fourth Korotkoff sound using a Hawksley random zero sphygmomanometer. The mean difference between the sphygmomanometer and Accutor measurement of diastolic blood pressure was +3.1 mmHg in the normotensive women and +8.3 mmHg in the hypertensive women (P = 0.001). The mean difference between the sphygmomanometer and Finapres measurement of diastolic blood pressure was +6.1 mmHg in the normotensive women and +11.5 mmHg in hypertensive women (P = 0.003). The increased use of continuous non-invasive devices to monitor blood pressure in women with hypertension should be accompanied by sound knowledge of their limitations in this group of patients.     

Hypospadias trends in two US surveillance systems

OBJECTIVE: Hypospadias is a common congenital anomaly, the cause of which is unknown. Unexplained increases in the rates of hypospadias occurred in five European countries in the 1970s and 1980s. We examined data from two birth defects surveillance systems in the United States for evidence of similar trends. METHODOLOGY: The Metropolitan Atlanta Congenital Defects Program (MACDP) provided birth prevalence rates from 1968 to 1993. The nationwide Birth Defects Monitoring Program (BDMP) provided rates from 1970 to 1993. MACDP data are population-based and could be categorized by the severity of the hypospadias. BDMP data allowed analysis of rate trends for the four census regions of the United States. RESULTS: Data from both surveillance systems showed an approximate doubling of hypospadias rates in the 1970s and 1980s. MACDP data showed that the rate of severe cases increased while the ratio of mild to severe cases decreased. BDMP data showed that hypospadias rates increased markedly in all four regions of the United States. CONCLUSIONS: The observed increases are unlikely to be attributable to increased sensitivity of the surveillance systems or the identification of more mild cases by physicians over time, because either trend would have increased rather than decreased the ratio of mild to severe cases. If real, these trends represent the largest number of cases and the first report of an increase in hypospadias rates outside of Europe. Additional investigation of a possible increase in hypospadias rates is warranted.