Effects of in vitro fertilization on low birth weight, preterm delivery, and multiple birth.

PURPOSE: To quantify the contribution of in vitro fertilization (IVF) on changes in the rates of low birth weight (LBW), preterm delivery, very low birth weight, and multiple births during the past 3 years. METHODS: Data on IVF pregnancies from 1994 to 1996 within Alberta were reviewed. Population data were obtained from the Provincial notice of a live or stillbirth. RESULTS: The IVF component of increased LBW rate in the province was 17.8% for infants <2500 g and 43.5% for those born <1500 g. IVF accounted for 10.5% of the provincial rate increase in deliveries <37 weeks' gestation and 66.2% of those <30 weeks' gestation. IVF accounted for 21.4% of the twins and all of the sets of triplets in the province. CONCLUSION: During a 3-year period IVF has affected the incidence of LBW, preterm delivery, and multiple birth. IVF is a substantial contributor to changes in very low birth weight and delivery before 30 weeks, which is partly related to multiple births.

Abnormalities for chromosomes 13 and 21 detected in spermatozoa from infertile men.

Sperm samples from infertile men with oligozoospermia or teratozoospermia were studied by multicolour fluorescence in-situ hybridization (FISH) using DNA probes for chromosomes 13 and 21. A total of 90 809 sperm nuclei from nine infertile men and 182 799 sperm nuclei from 18 control donors were analysed. There was a highly significant increase in the frequency of spermatozoa disomic for chromosome 13 in infertile patients (0.28%) compared to control donors (0.13%) (two-tailed Z statistic P < 0.0001) and for chromosome 21 (0.48% in infertile men versus 0.37% in controls, P < 0.0001). Also there was a significantly increased frequency of diploid spermatozoa in infertile men (0.85%) compared to control donors (0.66%) (P < 0.0001). Our previous studies on these same infertile patients demonstrated increased frequencies of sperm disomy for chromosomes 1 and XY. This suggests that infertile men, who are prime candidates for intracytoplasmic sperm injection, may be at a very small increased risk of aneuploid offspring.

A double-blind randomised study comparing danazol and medroxyprogesterone acetate in the management of menorrhagia.

A randomised study was undertaken comparing danazol 200 mg daily and medroxyprogesterone acetate 10 mg daily from days 16 to 25 in the management of menorrhagia. Twenty-three women were recruited to the study over a 12-month period. Eighteen subjects were suitable for analysis. Three months' therapy was given and patients were observed for a 3-month period following discontinuation of therapy. Menstrual blood loss was estimated during initial patient assessment and then during each of the 6 months of the study. In the danazol group mean blood loss at all treatment phase months was significantly decreased from baseline. In contrast, blood loss was not reduced significantly in any study month when compared with baseline in the medroxyprogesterone acetate group. During the post-treatment phase the mean blood loss in the danazol group increased to above normal levels but remained significantly lower than baseline, and there was a significant reduction in menstrual blood loss in the medroxyprogesterone acetate group.

Falloposcopic cannulation, oviductal appearances and prediction of treatment independent intrauterine pregnancy.

The purpose of this study was to determine whether there is an association between the appearance of the oviductal lumen during falloposcopic examination, and the occurrence of intrauterine pregnancy or ectopic pregnancy independent of treatment. Sixty-two consecutive women were recruited who were examined falloposcopically in-office, and who did not require subsequent surgical intervention to restore tubal patency. There was a heterogeneous group of presentations including unilateral and bilateral proximal tubal occlusion, unexplained infertility and the presence of minor laparoscopic abnormalities which might suggest the possibility of occult endotubal pathology. A stepwise Cox's model of life table analysis selected the number of falloposcopically normal and patent Fallopian tubes as the only variable significantly associated with intrauterine pregnancy, when all clinical, demographic and investigative data were analysed. The presence of minor distal intra-tubal adhesions was selected on stepwise analysis as the only variable significantly associated with the occurrence of ectopic pregnancy. A number of falloposcopic abnormalities were significantly associated with outcome in the clinical sub-group who presented with bilateral proximal tubal occlusion. These data suggest that falloposcopy is a valuable clinical tool which provides useful prognostic data for the prediction of intrauterine pregnancy or ectopic pregnancy.

Human embryo implantation following in-vitro fertilization: is there a seasonal variation?

The purpose of this study was to determine whether there is a seasonal variation in implantation and pregnancy rates following natural cycle replacement of cryopreserved embryos. A total of 321 consecutive cycles were analysed. There were 59 pregnancies (18.4%) and 48 live births or ongoing pregnancies (15.0%). Indicator variables for each month and variables representing temporal cycles of 12, 6, 4, 3 and 2 months were related to outcome. In addition, an analysis of periodicity was performed. No temporal, clinical or demographic variable was significantly related to pregnancy. This study indicated that there was no clear seasonal variation in the pregnancy rate following natural cycle replacement. However, the power of this study was low, and it was estimated that 963 subjects would be required to detect a 10% seasonal difference in pregnancy rates.

The bidirectional relationship between achievement and externalizing behavior problems of students with learning disabilities.

The current study examined the bidirectional relationship between academic achievement and externalizing behavior problems of adolescents with learning disabilities. Forty-three students attending a residential school were assessed for externalizing behavior problems via parent and teacher reports on the Child Behavior Checklist and the Children's Attention and Adjustment Survey. The Wide Range Achievement Test-Revised was used to estimate academic achievement in reading, spelling, and arithmetic. Achievement measures did not predict externalizing behavior problems 1 to 2 years later, although verbal IQ predicted parent reports. Teacher reports of externalizing behavior problems predicted reading and spelling achievement scores 1 year later, and parent reports of externalizing behavior problems predicted changes in reading achievement. There was evidence that attentional problems were the component of externalizing behavior accounting for these relations, consistent with the explanation that inattentive students have difficulty achieving in an intensive learning environment.

"Superimposition" digital subtraction angiography: evaluation of total anomalous pulmonary venous connection.

Total anomalous pulmonary venous connection (TAPVC) has a relatively high surgical mortality, especially the infracardiac variety. A small left atrium may limit postoperative cardiac output. Superimposition of digitally subtracted angiographic (DSA) images may be used to define pulmonary venous anatomy, left atrial size, and its spatial relationship to the common pulmonary vein. The technique for acquiring superimposed digitally subtracted images and the results of two cases with infracardiac TAPVC are presented. We have found that this superimposition technique is easily performed and may provide important preoperative information in infants with TAPVC.

Exogenous control of the cycle simplifies thawed embryo transfer and results in a pregnancy rate similar to that for natural cycles.

To determine if a satisfactory PR could be achieved in thawed ET using a simplified protocol, standard monitoring in the natural cycle was compared with a controlled preparation of the endometrium with exogenous E2 and P without hormonal or ultrasonographic monitoring. All patients had normal ovarian function, and no GnRH-a were administered. Pregnancy rates, ongoing PRs, and embryo implantation rates were similar in the two groups. The use of exogenous E2 and P without GnRH-a suppression to control the cycle for thaw ET is safe, convenient, and results in PRs at least as good as in the natural cycle. It may be of particular value in patients with an irregular cycle or in those for whom prolonged monitoring is undesirable.

The utility of transesophageal echocardiography during and after Fontan operations in small children.

Transesophageal echocardiography with Doppler examination was performed intraoperatively in 19 children undergoing modified Fontan operations and in 10 patients postoperatively. Comparisons were made with results of intraoperative epicardial imaging (9 patients) and with postoperative transthoracic imaging (10 patients). Transesophageal echocardiography optimally visualized atriopulmonary and cavopulmonary anastomoses. Epicardial echocardiography was successful in only three of nine patients. Intraoperative transesophageal echocardiography showed residua in 8 of 19 studies and led directly to surgical revision or medical therapy. These residua included stenosis of the cavopulmonary anastomosis (1 patient), unsatisfactory atrial fenestration (2 patients), patent ductus arteriosus (1 patient), residual cavoatrial shunting (1 patient), atrial thrombi (1 patient), and poor ventricular function (2 patients). Results of examination in the postoperative intensive care unit showed significant abnormalities in 4 of 10 patients. This study demonstrates that transesophageal echocardiography provides unique anatomic and physiologic information during and after modified Fontan operations in small children and therefore may have significant impact on patient management.

Comparison of intraoperative transesophageal echocardiography to epicardial imaging in children undergoing ventricular septal defect repair.

Intraoperative transesophageal echocardiography was compared with epicardial echocardiography after ventricular septal defect repair. This comparison was made in 18 children aged 7 to 137 months (median, 32 months), weighing 6.3 to 49.1 kg (median, 10.8 kg) from November 1989 to January 1991. Ventricular septal defect types were perimembranous (six), malalignment (seven), supracristal (three), midmuscular (one), and inlet (one). Eight children had isolated ventricular septal defects, four had tetralogy of Fallot, three had double outlet right ventricle, two had double chambered right ventricle, and one had pulmonary stenosis. Patch interrogation was complete in 17 of 18 transesophageal echocardiography and 16 of 18 epicardial echocardiography studies. Inability to fully interrogate the ventricular septal defect patch by epicardial echocardiography occurred in two children as a result of anterior ventricular septal defect location, limited epicardial exposure, and surgical hardware interference. Incomplete transesophageal echocardiography patch interrogation occurred in the child with the midmuscular ventricular septal defect. Seven residual ventricular septal defects were documented by color flow Doppler in six patients. Five of seven residual defects were demonstrated by both real-time transesophageal echocardiography and epicardial echocardiography imaging. Transesophageal echocardiography and epicardial echocardiography missed 1 and 7 defects, respectively. The missed defects were different with each technique and were confirmed by postoperative surface echocardiography. No residual defects of sufficient size to require reoperation were found as determined by combination color flow jet analysis and intraoperative oximetry (no pulmonary to systemic flow ratio was greater than 1.50). Patches caused two-dimensional and Doppler signal masking, but this was not limiting because all residual defects were found at the margins of the ventricular septal defect patch.(ABSTRACT TRUNCATED AT 250 WORDS)

Successful catheter fulguration of the His bundle in a postoperative Mustard patient after unsuccessful fulguration of ectopic atrial foci.

Incessant supraventricular tachycardia (SVT) resistant to pharmacological agents may cause cardiac dysfunction requiring more aggressive therapy. We present the case of a 12-year-old postoperative Mustard patient who developed biventricular heart failure due to an atrial ectopic tachycardia resistant to amiodarone. Using endocavitary direct current fulguration techniques, catheter ablation of the His bundle was successfully performed after unsuccessful attempts at ablation of the ectopic atrial foci. After placement of a permanent transvenous rate responsive ventricular pacemaker, the patient's clinical status and cardiac function improved. Endocavitary fulguration of the His bundle is technically feasible after the Mustard procedure and should be considered for treatment of selective cases of pharmacologically resistant SVT.

Polyclonal carcinoembryonic antigen staining in the cytologic differential diagnosis of primary and metastatic hepatic malignancies.

In order to assess the utility of immunocytochemical staining of bile canaliculi with a polyclonal antiserum to carcinoembryonic antigen (pCEA) in the differentiation of primary hepatocellular carcinomas from metastatic malignancies, pCEA staining was performed on fine needle aspiration specimens from hepatic lesions in 60 patients. The original cytologic diagnoses were hepatocellular carcinoma in 22 patients, metastatic neoplasm or cholangiocarcinoma in 27 patients and benign hepatocytes in 11 cases. The cytologic diagnoses of malignancy were confirmed by surgical excision, autopsy or clinical investigations in 82% of the patients. Follow-up data, supported by pCEA staining, reversed the original cytologic diagnosis in three cases. Bile canalicular pCEA staining was identified in 18 of 22 cases of hepatocellular carcinoma and in all 11 benign hepatocellular aspirates. All 27 cases of metastatic malignancy or cholangiocarcinoma were negative for canalicular pCEA staining, although 11 cases exhibited cytoplasmic staining. Interpretation of pCEA staining was not affected by the intermingling of malignant cells and benign hepatocytes. Predictive values were 100% for a positive test and 87% for a negative test. These findings indicate that staining with pCEA antiserum is a useful adjunct in the differential cytologic diagnosis of malignant hepatic lesions.

Fine needle aspiration cytology of fibrolamellar hepatocellular carcinoma.

The major cytologic features seen in fine needle aspirates from two cases of fibrolamellar hepatocellular carcinoma were: liver-like tumor cells, characterized by plump, polygonal forms with eosinophilic, granular cytoplasm; large oval nuclei with extremely prominent solitary nucleoli; and parallel bands of fibrous tissue and fibrocytes seen within the tumor fragments. Other helpful features included intracytoplasmic hyaline globules and well-delineated pale bodies. Clinically, the tumors occurred in young patients with noncirrhotic livers and ran a more favorable course than do other types of hepatocellular carcinoma.

Some cytologic features of hepatocellular carcinoma as seen in fine needle aspirates.

Cytologic study of fine needle aspirates in 15 cases of hepatocellular carcinoma revealed the following cellular patterns in order of decreasing frequency: trabecular, acinar and anaplastic. The most useful cytologic criteria for the identification of hepatocellular carcinoma were the similarity of tumor cells to liver cells, the prominence of nucleoli and the frequent presence of a trabecular pattern. Our study showed that the cellular changes seen in aspirated material faithfully reflect the histologic alterations seen in tissue sections. Hence, familiarity with the histology of hepatocellular carcinoma is of tremendous value in the interpretation of cytologic material.

The management of the hyperactive child: an overview.

Hyperkinesis has been increasingly recognized as a medical problem of great significance in everyday practice. Not infrequently, a child has been labeled hyperkinetic at an early age, with a battery of tests, psychological evaluations and multiple medications, in addition to the family frustration and anxiety that follow the diagnosis of hyperkinesis of the offspring.