Karyotypic abnormalities and Y chromosome microdeletions: How do these impact in vitro fertilization outcomes, and how common are they in the modern in vitro fertilization practice?

OBJECTIVE: To examine the outcomes of in vitro fertilization with intracytoplasmic sperm injection (IVF-ICSI) in couples in whom the male partner has a karyotypic abnormality or Y chromosome microdeletion (YCM). DESIGN: Retrospective cohort. SETTING: Single infertility center. PATIENTS: Couples treated with IVF-ICSI from January 2014 to April 2019 with male factor infertility, sperm concentration of <5 × 106 sperm/mL, and results for karyotype and/or YCM panel. INTERVENTIONS: In vitro fertilization with intracytoplasmic sperm injection. MAIN OUTCOME MEASURES: In couples in whom the male partner had a karyotypic abnormality or YCM: live birth rate/ongoing pregnancy rate, lack of partner sperm for fertilization, complete fertilization failure, cycle cancellation, and no embryos for transfer. The prevalence of karyotypic abnormalities and YCMs in the IVF population was calculated. RESULTS: The live birth rate/ongoing pregnancy rate for those using partner sperm was 51.4% per transfer. However, 8.5% of cycles that intended to use partner sperm and 22.2% of cycles that intended to use surgically extracted partner sperm had no sperm available. Of cycles that created embryos with partner sperm, 12.5% had no embryo to transfer. The prevalence of karyotypic abnormalities was similar to previous reports (6.0%), while that of YCMs was lower (4.4%). Azoospermia factor a and b mutations were not represented in this population. CONCLUSIONS: It is reasonable to attempt IVF-ICSI with partner sperm in patients with genetic causes of male infertility. Patients should be counseled regarding the possibility of no sperm being available from the male partner, poor/failed fertilization, and genetic implications for potential offspring. Contingency plans, including IVF with donor sperm backup or oocyte cryopreservation, need to be made for these scenarios.

Postdeployment Fertility Challenges and Treatment in the Modern Era.

Current war-fighting environments have shifted dramatically over the past decade, and with this change, new types of injuries are afflicting American soldiers. Operative Enduring Freedom and Operation Iraqi Freedom have noted an increased use of sophisticated improvised explosive devices by adversaries. Injuries not frequently seen in previous conflict are dismounted complex blast injuries, which involve multiple proximal amputations, pelvic fractures, and extensive perineal wounds. Thus, an unforeseen consequence of the decreased mortality rate after these complex blast injuries is a new wave of U.S. service members facing the challenges of recovering from the catastrophic amputations and genitourinary injuries. New applications of sperm retrieval methods may be used in these specific populations, as they recover and wish to purse family-building goals. Spinal cord injuries, traumatic brain injuries, and considerations unique to the female soldier are explored in this review of urologic care in wounded veterans.

Does the Presence of Blood in the Catheter or the Degree of Difficulty of Embryo Transfer Affect Live Birth?

The technique used for embryo transfer (ET) can affect implantation. Prior research that evaluated the effect of postprocedural blood of the transfer catheter tip have yielded mixed results, and it is unclear whether this is actually a marker of difficulty of the transfer. Our objective was to estimate the effect of blood at the time of ET and the difficulty of ET on live birth rates (LBR). This retrospective cohort study utilized generalized estimating equations (GEEs) with nesting for repeated cycles for all analyses. Univariate modeling was performed and a final multivariate (adjusted) GEE model accounted for all significant confounders. Embryo transfers were subjectively graded (easy, medium, or hard) by a physician at the time of transfer. The presence of blood at ET was associated with more difficult ETs, retained embryos, and presence of mucous in the catheter. In the univariate analysis, ET with blood was not associated with live birth, while the degree of difficulty for ET had a negative impact on LBR. In the final multivariate GEE model, which accounts for repeated cycles from a patient, the only factors associated with an increased LBR were the degree of difficulty of the ET, female age, and blastocyst transfer. After controlling for confounding variables, the presence of blood in the transfer catheter was not associated with the likelihood of pregnancy and thus was not an independent predictor of cycle outcome. This indicates that the difficulty of the transfer itself was a strong negative predictor of pregnancy.

Are intracytoplasmic sperm injection and high serum estradiol compounding risk factors for adverse obstetric outcomes in assisted reproductive technology?

OBJECTIVE: To evaluate whether intracytoplasmic sperm injection (ICSI) use and E2 on the final day of assisted reproductive technology (ART) stimulation are associated with adverse obstetric complications related to placentation. DESIGN: Retrospective cohort study. SETTING: Large private ART practice. PATIENT(S): A total of 383 women who underwent ART resulting in a singleton live birth. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Adverse placental outcomes composed of placenta accreta, placental abruption, placenta previa, intrauterine growth restriction, preeclampsia, gestational hypertension, and small for gestational age infants. RESULT(S): Patients with adverse placental outcomes had higher peak serum E2 levels and were three times more likely to have used ICSI. Adverse placental outcomes were associated with increasing E2 (odds ratio 1.36, 95% confidence interval 1.13-1.65) and ICSI (odds ratio 3.86, 95% confidence interval 1.61-9.27). Adverse outcomes increased when E2 was >3,000 pg/mL and continued to increase in a linear fashion until E2 was >5,000 pg/mL. The association of ICSI with adverse outcomes was independent of male factor infertility. Interaction testing suggested the adverse effect of E2 was primarily seen in ICSI cycles, but not in conventional IVF cycles. Estradiol >5,000 pg/mL was associated with adverse placental events in 36% of all ART cycles and 52% of ICSI cycles. CONCLUSION(S): ICSI and elevated E2 on the day of hCG trigger were associated with adverse obstetric outcomes related to placentation. The finding of a potential interaction of E2 and ICSI with adverse placental events is novel and warrants further investigation.

Impact of a prior cesarean delivery on embryo transfer: a prospective study.

OBJECTIVE: To determine whether a history of prior cesarean delivery (CD) makes ET more difficult and impacts pregnancy outcomes. DESIGN: Prospective cohort study. SETTING: Tertiary care military facility. PATIENT(S): One hundred ninety-four patients with previous delivery undergoing IVF/intracytoplasmic sperm injection (ICSI)-ET. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Live birth (primary), positive hCG, clinical pregnancy, and time to perform ET. RESULT(S): There was no statistically significant difference between patients with a history of only vaginal deliveries versus those with a history of CD for live birth (39% vs. 32%), positive hCG (56% vs. 53%), or clinical pregnancy (49% vs. 41%). Embryo transfers took longer in the history of CD group (157 vs. 187 seconds) and were more likely to have mucus (27% vs. 45%) or blood (8% vs. 21%) on the catheter. CONCLUSION(S): Embryo transfers performed on patients with a prior CD took 30 seconds longer. They were also more likely to have blood or mucus on the catheter. Despite the apparently more difficult transfers, pregnancy outcomes were not different between the two groups.

GnRH agonist reduces estrogen receptor dimerization in GT1-7 cells: evidence for cross-talk between membrane-initiated estrogen and GnRH signaling.

17ß-estradiol (E2), a key participant on the initiation of the LH surge, exerts both positive and negative feedback on GnRH neurons. We sought to investigate potential interactions between estrogen receptors alpha (ERα) and beta (ERß) and gonadotropin releasing hormone receptor (GnRH-R) in GT1-7 cells. Radioligand binding studies demonstrated a significant decrease in saturation E2 binding in cells treated with GnRH agonist. Conversely, there was a significant reduction in GnRH binding in GT1-7 cells treated with E2. In BRET(1) experiments, ERα-ERα dimerization was suppressed in GT1-7 cells treated with GnRH agonist (p < 0.05). There was no evidence of direct interaction between ERs and GnRH-R. This study provides the first evidence of reduced ERα homodimerization by GnRH agonist. Collectively, these findings demonstrate significant cross-talk between membrane-initiated GnRH and E2 signaling in GT1-7 cells.

Upper gastrointestinal bleeding caused by severe esophagitis: a unique clinical syndrome.

BACKGROUND: We have recognized a unique clinical syndrome in patients with upper gastrointestinal bleeding who are found to have severe esophagitis. AIM: We aimed to more clearly describe the clinical entity of upper gastrointestinal bleeding in patients with severe esophagitis. METHODS: We conducted a retrospective matched case-control study designed to investigate clinical features in patients with carefully defined upper gastrointestinal bleeding and severe esophagitis. Patient data were captured prospectively via a Gastrointestinal Bleeding Healthcare Registry, which collects data on all patients admitted with gastrointestinal bleeding. Patients with endoscopically documented esophagitis (cases) were matched with randomly selected controls that had upper gastrointestinal bleeding caused by other lesions. RESULTS: Epidemiologic features in patients with esophagitis were similar to those with other causes of upper gastrointestinal bleeding. However, hematemesis was more common in patients with esophagitis 86% (102/119) than in controls 55% (196/357) (p < 0.0001), while melena was less common in patients with esophagitis 38% (45/119) than in controls 68% (244/357) (p < 0.0001). Additionally, the more severe the esophagitis, the more frequent was melena. Patients with esophagitis had less abnormal vital signs, lesser decreases in hematocrit, and lesser increases in BUN. Both pre- and postRockall scores were lower in patients with esophagitis compared with controls (p = 0.01, and p < 0.0001, respectively). Length of hospital stay (p = 0.002), rebleeding rate at 42 days (p = 0.0007), and mortality were less in patients with esophagitis than controls. Finally, analysis of patients with esophagitis and cirrhosis suggested that this group of patients had more severe bleeding than those without cirrhosis. CONCLUSIONS: We have described a unique clinical syndrome in patients with upper gastrointestinal bleeding who have erosive esophagitis. This syndrome is manifest by typical clinical features and is associated with favorable outcomes.

Impact of ethnicity in upper gastrointestinal hemorrhage.

GOALS: To examine ethnicity's role in the etiology and outcome of upper gastrointestinal hemorrhage (UGIH). BACKGROUND: UGIH is a serious condition with considerable associated morbidity and mortality. MATERIALS AND METHODS: We analyzed 2196 patients admitted with acute UGIH between January 2006 and February 2012. Complete clinical data were gathered prospectively and entered into our GI Bleed Registry, which captures demographic and clinical variables. Results were analyzed using the χ² analyses and the analysis of variance techniques with Tukey multiple comparisons. RESULTS: Among 2196 patients, 620 (28%) were black, 625 (29%) white, 881 (40%) Hispanic, and 70 (3%) were members of other ethnicities. Gastroduodenal ulcers (25%), esophageal varices (25%), and esophagitis (12%) were the most frequently identified causes of UGIH. Blacks experienced a high rate of gastroduodenal ulcers (199/620), whereas Hispanics most commonly had esophageal varices. In all ethnicities, the most common cause of bleeding in patients younger than 35 or older than 65 years was gastroduodenal ulcer disease. However, among patients aged 35 to 64 years, there were differences in the etiology of UGIH. Blacks aged 50 to 64 years frequently experienced gastroduodenal ulcers, whereas Hispanics aged 35 to 49 years typically had esophageal varices. Rebleeding rates were significantly lower in whites (5.8%) than in Hispanics (9.9%) or blacks (8.7%) (P=0.02). CONCLUSIONS: By examining a diverse population, we conclude that UGIH may follow trends. Hispanics were likely to have esophageal varices and higher rebleeding rates, whereas blacks were likely to have ulcers and the highest mortality. Whites were equally likely to have ulcers or varices, but a lower rate of rebleeding.

More favorable outcomes with peptic ulcer bleeding due to Helicobacter pylori.

BACKGROUND: Acute upper gastrointestinal bleeding is a common complication of peptic ulcer disease, often caused by Helicobacter pylori and nonsteroidal anti-inflammatory drug (NSAID) use. The purpose of this study was to determine whether the cause and biologic behavior of ulcers associated with acute upper gastrointestinal bleeding might lead to divergent patient outcomes. METHODS: In this Institutional Review Board-approved study, we compared clinical features and outcomes of patients with acute upper gastrointestinal bleeding due to ulcers categorized into 4 groups: Helicobacter pylori positive or negative combined with NSAID usage positive or negative. Likelihood chi-squared analyses were utilized for group comparisons and stepwise multiple logistic regression models were utilized to determine which factors were related to bleeding outcomes. RESULTS: Of 2242 patients with upper gastrointestinal bleeding, 575 (26%) had gastroduodenal ulcer disease, and of those with appropriate diagnostic testing, approximately half (228, 10% overall) had evidence of Helicobacter pylori infection and half (216, 10% overall) had no evidence of Helicobacter pylori infection. Patients without Helicobacter pylori infection had significantly more comorbid conditions than those with Helicobacter pylori and higher Charlson Index comorbidity scores (2.6 ± 2.6 [mean and SD] vs 1.9 ± 2.3, P = .003). Hospital length of stay was significantly longer for Helicobacter pylori-negative patients (mean 11.4 ± 21.7 vs 6 ± 8.5 days and median 5.5 vs 3 days, P <.001 and <.001, respectively). Rebleeding events within 30 days were more frequent in Helicobacter pylori-negative patients than Helicobacter pylori-positive patients (11% vs 5%, P = .009). Rebleeding was most frequent in patients without Helicobacter pylori and with no reported use of NSAIDS (18%, P = .01). CONCLUSIONS: Helicobacter pylori-negative ulcers were associated with poorer outcomes regardless of use of NSAIDs. Patients with ulcers negative for Helicobacter pylori and no history of NSAID use had the worst outcomes and had more severe systemic disease.

Novel hormone treatment of benign metastasizing leiomyoma: an analysis of five cases and literature review.

OBJECTIVE: To evaluate novel hormonal therapies in patients with unresectable benign metastasizing leiomyoma (BML) disease. DESIGN: Case series. SETTING: National Institutes of Health (NIH). PATIENT(S): Five subjects with the diagnosis of BML based on imaging and/or histopathologic diagnosis. INTERVENTION(S): Four patients were treated with single or combination therapy of leuprolide acetate and/or an aromatase inhibitor. One patient was treated with an antiprogestin (CDB-2914). MAIN OUTCOME MEASURE(S): Response to therapy was measured by tumor burden on cross-sectional imaging employing RECIST (Response Evaluation Criteria in Solid Tumors) 1.1 guidelines. RESULT(S): Four patients treated with single or combination therapy of leuprolide acetate and/or an aromatase inhibitor demonstrated stable disease with reduction in tumor burden. The fifth patient treated with antiprogestin (CDB-2914) had degeneration of her tumor, progression of its size, and an improvement in symptoms. CONCLUSION(S): Hormone treatment with GnRH agonist and/or aromatase inhibition may be a therapeutic option to reduce tumor burden in unresectable BML disease or for those patients who wish to avoid surgical intervention. RECIST 1.1 guidelines, while traditionally used to evaluate tumor response to cancer therapeutics, may be useful in evaluating BML tumor burden response to hormone therapy.

Preconception stress and the secondary sex ratio: a prospective cohort study.

OBJECTIVE: To study the association between salivary stress biomarkers and the secondary sex ratio. DESIGN: Prospective, longitudinal cohort study. SETTING: Community setting in the United Kingdom. PATIENT(S): On discontinuation of contraception for purposes of becoming pregnant, 338 women aged 18-40 years with complete data (90%) were followed until pregnant or up to six menstrual cycles. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Secondary sex ratio. RESULT(S): Human chorionic gonadotropin pregnancies were detected in 207 (61%) women of whom 130 (63%) delivered singleton infants with available gender data. The adjusted odds ratio for a male birth was decreased for women in the highest quartile (AOR = 0.26; 95% confidence interval = 0.09, 0.74) of salivary cortisol relative to women in the lowest quartile during cycle 1. An inverse relation was observed between α-amylase and the 2° sex ratio, though not statistically significant. CONCLUSION(S): Our findings are consistent with a reversal in the 2° sex ratio with increasing preconception salivary cortisol concentrations. This relation suggests that activation of the hypothalamus-pituitary-adrenal axis may have implications in sex allocation and requires further study.

GnRH antagonist rescue in high responders at risk for OHSS results in excellent assisted reproduction outcomes.

Gonadotrophin-releasing hormone (GnRH) antagonist rescue is performed by replacing a GnRH agonist with a GnRH antagonist in patients with rapidly rising serum oestradiol who are at risk of ovarian hyperstimulation syndrome (OHSS) during stimulation. It results in a rapid reduction in serum oestradiol, allowing for the avoidance of cycle cancellation and the continuation of exogenous gonadotrophin administration. A total of 387 patients who underwent GnRH antagonist rescue for ovarian hyperresponse were compared with 271 patients who did not receive GnRH antagonist rescue and had oestradiol concentrations >4000 pg/ml on the day of human chorionic gonadotrophin (HCG) administration. GnRH antagonist rescue decreased the mean oestradiol concentration by 35% on the first day of use. There was no difference in oocyte maturity (82% versus 83%) or fertilization rate (69% versus 67%) between the antagonist rescue and comparison groups, respectively. The percentage of high-grade embryos on day 3 and the blastocyst development rate were also similar between groups. The live-birth rate was 41.9% in the antagonist rescue group and 36.9% in the comparison group. GnRH antagonist rescue enabled cycle completion with high live-birth rates in patients at risk for OHSS. GnRH antagonist was associated with high oocyte quality, blastocyst development and pregnancy. Gonadotrophin-releasing hormone (GnRH) antagonist rescue is a protocol to reduce the risk of ovarian hyperstimulation syndrome (OHSS) in assisted reproduction treatment. Patients who have a hyperresponse to medication during their treatment cycle have their GnRH agonist discontinued and a GnRH antagonist started in its place. This causes a rapid reduction in oestrogen concentrations and allows for the continuation of stimulation medication. We evaluated the effectiveness of this protocol by comparing patients who had GnRH antagonist rescue against high-responding patients who did not receive GnRH antagonist rescue. GnRH antagonist rescue resulted in a 35% reduction in oestrogen concentration and only a 1.5% cycle cancellation rate. There were no differences in oocyte maturity or fertilization between the two groups. There were no differences in the quality of day-3 and day-5 embryos between the two groups. The live birth rate was 41.9% in the antagonist rescue group and 36.9% in the comparison group. GnRH antagonist rescue reduced serum oestradiol concentrations and enabled cycle completion with high live-birth rates in patients at risk for OHSS. GnRH antagonist was associated with high oocyte quality, blastocyst development and pregnancy.

Raynaud's phenomenon of the nipple.

BACKGROUND: Raynaud's phenomenon is a well-described pathologic state in which there is episodic vasospasm followed by vasodilation. It is described most commonly in the digits but also has been shown to affect the nipple vasculature. Raynaud's phenomenon of the nipple may result in discontinuation of breastfeeding secondary to pain and disruption of the maternal-infant bonding process. CASES: We present the cases of two patients with painful breastfeeding associated with color changes of the nipple. Owing to a clinical presentation similar to fungal infections, the patients were treated repeatedly with antifungals before the correct diagnosis was made. Symptoms resolved with a course of nifedipine. CONCLUSION: Increased awareness in the obstetric field will lead to appropriate diagnoses, earlier treatment and relief, and more successful breastfeeding experiences.

Environmental and epigenetic effects upon preimplantation embryo metabolism and development.

In vitro fertilization has provided a unique window into the metabolic processes that drive embryonic growth and development from a fertilized ovum to a competent blastocyst. Post-fertilization development is dependent upon a dramatic reshuffling of the parental genomes during meiosis, as well as epigenetic changes that provide a new and autonomous set of instructions to guide cellular differentiation both in the embryo and beyond. Although early literature focused simply on the substrates and culture conditions required for progress through embryonic development, more recent insights lead us to suggest that the surrounding environment can alter the epigenome, which can, in turn, impact upon embryonic metabolism and developmental competence.

Experience with a patient-friendly, mandatory, single-blastocyst transfer policy: the power of one.

OBJECTIVE: To determine whether a mandatory single-blastocyst transfer (mSBT) algorithm reduced multiple gestation rates without sacrificing clinical pregnancy rates. DESIGN: Retrospective review. SETTING: U.S. university-based assisted reproductive technology (ART) program. PATIENT(S): All women younger than 38 years undergoing their first ART cycle from 2009 to 2010 with ≥4 high-grade embryos on day 3 after oocyte retrieval (patients from 2009 were the "before" group, and patients completing ART under the mSBT policy in 2010 were the "after" group). INTERVENTION(S): mSBT algorithm. MAIN OUTCOME MEASURE(S): Multiple gestation and clinical pregnancy rates. RESULT(S): Of the qualified patients, 136 women met inclusion criteria (62 from 2009, 74 from 2010). The baseline demographics were similar between the groups. Statistically significantly fewer blastocysts were transferred per patient in 2010 compared with 2009 (1.5 vs. 1.9). The clinical pregnancy rates before (67.7%) or after (63.5%) the mSBT policy were not statistically significantly different. Multiple gestation rates were statistically significantly reduced, from 43.8% (2009) to 14.6% (2010) after the mSBT policy was instituted. More patients from 2010 had ≥1 blastocyst cryopreserved compared with 2009 (52.9% vs. 30.6%). CONCLUSION(S): A novel single-blastocyst transfer algorithm reduced multiple gestation rates and improved cryopreservation rates without compromising clinical pregnancy rates in good-prognosis patients.

Is coronary computed tomography angiography a resource sparing strategy in the risk stratification and evaluation of acute chest pain? Results of a randomized controlled trial.

OBJECTIVES: Annually, almost 6 million U.S. citizens are evaluated for acute chest pain syndromes (ACPSs), and billions of dollars in resources are utilized. A large part of the resource utilization results from precautionary hospitalizations that occur because care providers are unable to exclude the presence of coronary artery disease (CAD) as the underlying cause of ACPSs. The purpose of this study was to examine whether the addition of coronary computerized tomography angiography (CCTA) to the concurrent standard care (SC) during an index emergency department (ED) visit could lower resource utilization when evaluating for the presence of CAD. METHODS: Sixty participants were assigned randomly to SC or SC + CCTA groups. Participants were interviewed at the index ED visit and at 90 days. Data collected included demographics, perceptions of the value of accessing health care, and clinical outcomes. Resource utilization included services received from both the primary in-network and the primary out-of-network providers. The prospectively defined primary endpoint was the total amount of resources utilized over a 90-day follow-up period when adding CCTA to the SC risk stratification in ACPSs. RESULTS: The mean (± standard deviation [SD]) for total resources utilized at 90 days for in-network plus out-of-network services was less for the participants in the SC + CCTA group ($10,134; SD ±$14,239) versus the SC-only group ($16,579; SD ±$19,148; p = 0.144), as was the median for the SC + CCTA ($4,288) versus SC only ($12,148; p = 0.652; median difference = -$1,291; 95% confidence interval [CI] = -$12,219 to $1,100; p = 0.652). Among the 60 total study patients, only 19 had an established diagnosis of CAD at 90 days. However, 18 (95%) of these diagnosed participants were in the SC + CCTA group. In addition, there were fewer hospital readmissions in the SC + CCTA group (6 of 30 [20%] vs. 16 of 30 [53%]; difference in proportions = -33%; 95% CI = -56% to -10%; p = 0.007). CONCLUSIONS: Adding CCTA to the current ED risk stratification of ACPSs resulted in no difference in the quantity of resources utilized, but an increased diagnosis of CAD, and significantly less recidivism and rehospitalization over a 90-day follow-up period.

Risk factors in children hospitalized with RSV bronchiolitis versus non-RSV bronchiolitis.

BACKGROUND: The trends in hospitalization rates and risk factors for severe bronchiolitis have not been recently described, especially after the routine implementation of prophylaxis for respiratory syncytial virus (RSV) infections. OBJECTIVES: To define the burden of hospitalizations related to RSV and non-RSV bronchiolitis in a tertiary-care children's hospital from 2002 to 2007 and to identify the risk factors associated with severe disease. METHODS: Medical records of patients hospitalized for bronchiolitis were reviewed for demographic, clinical, microbiologic, and radiologic characteristics as well as the presence of underlying medical conditions. Differences were evaluated between children with RSV and non-RSV bronchiolitis, and multivariable logistic regression analyses were performed to identify independent risk factors for severe disease. RESULTS: Bronchiolitis hospitalizations in children younger than 2 years old (n = 4800) significantly increased from 536 (3.3%) in 2002 to 1241 (5.5%) in 2007, mainly because of RSV infections. Patients with RSV bronchiolitis (n = 2840 [66%]) were younger at hospitalization and had a lower percentage of underlying medical conditions than children hospitalized with non-RSV bronchiolitis (27 vs 37.5%; P < .001). However, disease severity defined by length of hospitalization and requirement of supplemental oxygen, intensive care, and mechanical ventilation was significantly worse in children with RSV bronchiolitis. RSV infection and prematurity, regardless of the etiology, were identified as independent risk factors for severe bronchiolitis. CONCLUSIONS: There was a significant increase in hospitalizations for RSV bronchiolitis from 2002 to 2007. A majority of the children with RSV bronchiolitis were previously healthy, but their disease severity was worse compared with those hospitalized with non-RSV bronchiolitis.

The effect of the night float rotation on annual in-training examination performance.

OBJECTIVE: To assess whether night-float rotation affected resident performance on the Council on Resident Education in Obstetrics and Gynecology (CREOG) in-service examination. STUDY DESIGN: Review of annual CREOG in-service examination scores standardized for postgraduate year level (2001-2009) compared scores for residents on night float rotation at time of examination to those on non-night float rotation. Data were analyzed by linear mixed effects model. RESULTS: Data were obtained for 72 residents, 20 of whom were on night float at time of at least one examination. One to four test scores were available for each resident (total 225 test scores). Average test score was 213 (SD = 20). The mean score for residents on night float was 214 (95% CI 207-221); the mean score for those on non-night float rotations was 212 (95% CI 208-216, p = 0.53). Sample size was sufficient to detect a difference of 12 points with 80% power. CONCLUSION: Although night float rotations necessitate a complete reversal in sleep schedules, we found that night float service did not significantly affect scores On the annual in-service examination. To our knowledge, no studies have evaluated the impact of this schedule on test-taking ability.

Activating transcription factor 3 gene expression suggests that tissue stress plays a role in leiomyoma development.

OBJECTIVE: To determine whether expression of the stress response gene ATF3 and related members of activator protein complex-1, cJun and cFos, were altered in leiomyoma compared with myometrium, and whether this difference might correlate with leiomyoma size or race. DESIGN: Laboratory study. SETTING: University hospital. PATIENT(S): Fifteen women undergoing hysterectomy for symptomatic leiomyoma. INTERVENTION(S): Tissue procurement, RNA isolation, reverse-transcriptase polymerase chain reaction, real-time reverse-transcriptase polymerase (RT-PCR) chain reaction, immunohistochemistry, Western blot. MAIN OUTCOME MEASURE(S): Expression of mRNA and protein in leiomyoma and patient-matched myometrium. RESULT(S): mRNA transcripts of ATF3 were decreased in leiomyoma compared with matched myometrium by both RT-PCR and real-time RT-PCR. The decrease was greater than fivefold in a majority of samples. The reduction seen in ATF3 mRNA expression did not show a correlation with race and leiomyoma size. Surprisingly, immunohistochemistry and Western blot analysis demonstrated an elevation of ATF3 protein expression by a mean of 2.9-fold. Transcripts of related AP-1 genes, cJun and cFos, were significantly decreased by a mean of -29.57 for cJun and -23.78 for cFos, but there was no significant change in protein expression of the two transcription factors. CONCLUSIONS: Alterations in ATF3 gene expression resemble the response to mechanical and ischemic stress reported in other tissues. Results suggested that ATF3 protein expression was increased in leiomyoma, and may reflect increased tissue stress.