Limitations in activities of people affected by leprosy after completing multidrug therapy: application of the SALSA scale

Objectives: To identify people affected by leprosy with impairments after completing multidrug therapy for leprosy, and to assess their limitations in conducting daily activities by applying the Screening of Activity Limitation and Safety Awareness (SALSA) scale. Methods: A cross-sectional study was performed of all residents of a medium-sized city who were treated for leprosy from 1998 to 2006. A specific questionnaire was applied to obtain general and clinical data and the SALSA scale was used to assess limitations in activities. Impairments were assessed using the 'World Health Organization leprosy disability grading system' (WHO-DG). Findings: Of the 335 people affected by leprosy treated in the period, 223 (62.1%) were located and interviewed. A total of 51.6% were female with a mean age of 54 years (SD +/- 15.72) and 67.9% had up to 6 years formal education. The borderline form predominated among interviewees (39.9%) and 54.3% suffer from associated diseases with hypertension (29.1%) and diabetes (10.3%) being the most common. Pain was reported by 54.7% of interviewees. By multiple logistic regression analysis, associations were found between limitations in activities and being female (P < 0.025), family income <= 3 minimum wages (P-value < 0.003), reports of major lesions (P-value < 0.004), pain (P-value < 0.001), associated diseases (P-value < 0.023) and the WHO-DG (P-value < 0.001). Disabilities, as identified using the WHO-DG, were less common (32%) than limitations in activities as evaluated by the SALSA scale (57.8%). Conclusion: Limitations in activities proved to be common in people affected by leprosy and were. associated with low income, being female, reported major lesions, disability, disease and pain.

Prevalence of overweight preschool children in public day care centers: a cross-sectional study

CONTEXT AND OBJECTIVE: Brazil is undergoing a period of epidemiological transition associated with demographic and nutritional changes. The prevalence of obesity is also increasing in children and is causing numerous health problems that are becoming public health issues. The aim here was to evaluate the prevalence of overweight among children of two and three years of age. DESIGN AND SETTING: Cross-sectional study in municipal day care centers in Taubate, state of Sao Paulo, Brazil. METHODS: Weight and height measurements were made on 447 preschool children forming a probabilistic randomized sample. Their body mass index (BMI) was calculated. Their nutritional status was classified using the World Health Organization reference cutoff points (2006). Their mean weight, height and BMI were compared according to their age and sex. RESULTS: The mean values for the final sample (n = 447) were as follows: mean age: 38.6 months (+/- 3.5) and Z scores for: weight/height (W/H): 0.50 (+/- 1.22); height/age: -0.03 (+/- 1.07); weight/age (W/A): 0.51 (+/- 1.23); and BMI: 0.51(+/- 1.23). The prevalence of overweight children (BMI > 1 z) was 28.86%, while the prevalence of underweight children (BMI < -2 z) was 0.89%. There were no differences in mean BMI among the two and three-year age groups (P = 0.66). CONCLUSION: A high prevalence of overweight was observed in the sample of two and three-year-old children, with practically no malnutrition, thus showing that a significant nutritional transition may already be occurring, even in medium-sized cities of developing countries.

Gauging food and nutritional care quality in hospitals

Background: Food and nutritional care quality must be assessed and scored, so as to improve health institution efficacy. This study aimed to detect and compare actions related to food and nutritional care quality in public and private hospitals. Methods: Investigation of the Hospital Food and Nutrition Service (HFNS) of 37 hospitals by means of structured interviews assessing two quality control corpora, namely nutritional care quality (NCQ) and hospital food service quality (FSQ). HFNS was also evaluated with respect to human resources per hospital bed and per produced meal. Results: Comparison between public and private institutions revealed that there was a statistically significant difference between the number of hospital beds per HFNS staff member (p = 0.02) and per dietitian (p < 0.01). The mean compliance with NCQ criteria in public and private institutions was 51.8% and 41.6%, respectively. The percentage of public and private health institutions in conformity with FSQ criteria was 42.4% and 49.1%, respectively. Most of the actions comprising each corpus, NCQ and FSQ, varied considerably between the two types of institution. NCQ was positively influenced by hospital type (general) and presence of a clinical dietitian. FSQ was affected by institution size: large and medium-sized hospitals were significantly better than small ones. Conclusions: Food and nutritional care in hospital is still incipient, and actions concerning both nutritional care and food service take place on an irregular basis. It is clear that the design of food and nutritional care in hospital indicators is mandatory, and that guidelines for the development of actions as well as qualification and assessment of nutritional care are urgent.

Selección de sustrato de la Holothuria tubulosa en función del tamaño de las partículas

Holothuria tubulosa, cuando la concentración de materia orgánica es constante en el sedimento, muestra una clara preferencia por ambientes con arenas conformadas mayoritariamente por partículas gruesas. Esta tendencia a permanecer más tiempo en estos ambientes se corresponde igualmente con la composición granulométrica de sus excrementos, principalmente conformados por partículas propias de arenas gruesas o medias. Este patrón de selección positiva hacia un determinado grosor de sedimentos contrasta con la composición de las excreciones cuando estos animales se han alimentado en su medio natural. ABSTRACT: Holothuria tubulosa, when the rate of organic matter in the sediments is a constant, shows a clear preference to stay in sandy environments conformed by thick particles. This tendency to pass more time in these environments is also corresponded with the granulometric composition of its excrements, mainly constituted by particles of thick or medium sized sands. This positive selection pattern toward a specific size of the sediment grains contrast with the size composition of the excretions when this animals feed at their natural habitat.

Hochgenaue Berechnungen von Energien und molekularen Eigenschaften mit Hilfe der Coupled-Cluster-Theorie

Coupled-Cluster-Theorie (CC) ist in der heutigen Quantenchemie eine der erfolgreichsten Methoden zur genauen Beschreibung von Molekülen. Die in dieser Arbeit vorgestellten Ergebnisse zeigen, daß neben den Berechnungen von Energien eine Reihe von Eigenschaften wie Strukturparameter, Schwingungsfrequenzen und Rotations-Schwingungs-Parameter kleiner und mittelgrofler Moleküle zuverlässig und präzise vorhergesagt werden können. Im ersten Teil der Arbeit wird mit dem Spin-adaptierten Coupled-Cluster-Ansatz (SA-CC) ein neuer Weg zur Verbesserung der Beschreibung von offenschaligen Systemen vorgestellt. Dabei werden zur Bestimmung der unbekannten Wellenfunktionsparameter zusätzlich die CC-Spingleichungen gelöst. Durch dieses Vorgehen wird gewährleistet, daß die erhaltene Wellenfunktion eine Spineigenfunktion ist. Die durchgeführte Implementierung des Spin-adaptierten CC-Ansatzes unter Berücksichtigung von Einfach- und Zweifachanregungen (CCSD) für high-spin Triplett-Systeme wird ausführlich erläutert. Im zweiten Teil werden CC-Additionsschemata vorgestellt, die auf der Annahme der Additivität von Elektronenkorrelations- und Basissatzeffekten basieren. Die etablierte Vorgehensweise, verschiedene Beiträge zur Energie mit an den Rechenaufwand angepassten Basissätzen separat zu berechnen und aufzusummieren, wird hier auf Gradienten und Kraftkonstanten übertragen. Für eine Beschreibung von Bindungslängen und harmonischen Schwingungsfrequenzen mit experimenteller Genauigkeit ist die Berücksichtigung von Innerschalenkorrelationseffekten sowie Dreifach- und Vierfachanregungen im Clusteroperator der Wellenfunktion nötig. Die Basissatzkonvergenz wird dabei zusätzlich mit Extrapolationsmethoden beschleunigt. Die quantitative Vorhersage der Bindungslängen von 17 kleinen Molekülen, aufgebaut aus Atomen der ersten Langperiode, ist so mit einer Genauigkeit von wenigen Hundertstel Pikometern möglich. Für die Schwingungsfrequenzen dieser Moleküle weist das CC-Additionsschema basierend auf den berechneten Kraftkonstanten im Vergleich zu experimentellen Ergebnissen einen mittleren absoluten Fehler von 3.5 cm-1 und eine Standardabweichung von 2.2 cm-1 auf. Darüber hinaus werden zur Unterstützung von experimentellen Untersuchungen berechnete spektroskopische Daten einiger größerer Moleküle vorgelegt. Die in dieser Arbeit vorgestellten Untersuchungen zur Isomerisierung von Dihalogensulfanen XSSX (X= F, Cl) oder die Berechnung von Struktur- und Rotations-Schwingungs-Parametern für die Moleküle CHCl2F und CHClF2 zeigen, daß bereits störungstheoretische CCSD(T)-Näherungsmethoden qualitativ gute Vorhersagen experimenteller Resultate liefern. Desweiteren werden Diskrepanzen von experimentellen und berechneten Bindungsabständen bei den Molekülen Borhydrid- und Carbenylium durch die Berücksichtigung des elektronischen Beitrages zum Trägheitsmoment beseitigt.

Le aziende vitivinicole: da “machines à produire” a elementi di attrazione nel paesaggio. Proposte e criteri progettuali per l’efficienza funzionale e la qualità architettonica ed ambientale delle strutture ed infrastrutture della trasformazione enologica.

La ricerca ha per oggetto la messa a punto e applicazione di un approccio metaprogettuale finalizzato alla definizione di criteri di qualità architettonica e paesaggistica nella progettazione di aziende vitivinicole medio-piccole, che effettuano la trasformazione della materia prima, prevalentemente di propria produzione. L’analisi della filiera vitivinicola, della letteratura scientifica, della normativa di settore, di esempi di “architetture del vino eccellenti” hanno esplicitato come prevalentemente vengano indagate cantine industriali ed aspetti connessi con l'innovazione tecnologica delle attrezzature. Soluzioni costruttive e tecnologiche finalizzate alla qualità architettonica ed ambientale, attuali dinamiche riguardanti il turismo enogastronomico, nuove funzionalità aziendali, problematiche legate alla sostenibilità dell’intervento risultano ancora poco esplorate, specialmente con riferimento a piccole e medie aziende vitivinicole. Assunto a riferimento il territorio ed il sistema costruito del Nuovo Circondario Imolese (areale rappresentativo per vocazione ed espressione produttiva del comparto vitivinicolo emiliano-romagnolo) è stato identificato un campione di aziende con produzioni annue non superiori ai 5000 hl. Le analisi svolte sul campione hanno permesso di determinare: modalità di aggregazione funzionale degli spazi costruiti, relazioni esistenti con il paesaggio, aspetti distributivi e materico-costruttivi, dimensioni di massima dei locali funzionali alla produzione. Il caso studio relativo alla riqualificazione di un’azienda rappresentativa del comparto è stato utilizzato per la messa a punto e sperimentazione di criteri di progettazione guidati da valutazioni relative alle prestazioni energetiche, alla qualità architettonica e alla sostenibilità ambientale, economica e paesaggistica. L'analisi costi-benefici (pur non considerando le ricadute positive in termini di benessere degli occupanti ed il guadagno della collettività in termini di danni collegati all’inquinamento che vengono evitati in architetture progettate per garantire qualità ambientale interna ed efficienza energetica) ha esplicitato il ritorno in pochi anni dell’investimento proposto, nonostante gli ancora elevati costi di materiali di qualità e dei componenti per il corretto controllo climatico delle costruzioni.

International Agricultural Trade under Regulatory Asymmetry: An Economic Analysis of SME Export Behavior

Over the last three decades, international agricultural trade has grown significantly. Technological advances in transportation logistics and storage have created opportunities to ship anything almost anywhere. Bilateral and multilateral trade agreements have also opened new pathways to an increasingly global market place. Yet, international agricultural trade is often constrained by differences in regulatory regimes. The impact of “regulatory asymmetry” is particularly acute for small and medium sized enterprises (SMEs) that lack resources and expertise to successfully operate in markets that have substantially different regulatory structures. As governments seek to encourage the development of SMEs, policy makers often confront the critical question of what ultimately motivates SME export behavior. Specifically, there is considerable interest in understanding how SMEs confront the challenges of regulatory asymmetry. Neoclassical models of the firm generally emphasize expected profit maximization under uncertainty, however these approaches do not adequately explain the entrepreneurial decision under regulatory asymmetry. Behavioral theories of the firm offer a far richer understanding of decision making by taking into account aspirations and adaptive performance in risky environments. This paper develops an analytical framework for decision making of a single agent. Considering risk, uncertainty and opportunity cost, the analysis focuses on the export behavior response of an SME in a situation of regulatory asymmetry. Drawing on the experience of fruit processor in Muzaffarpur, India, who must consider different regulatory environments when shipping fruit treated with sulfur dioxide, the study dissects the firm-level decision using @Risk, a Monte Carlo computational tool.

Application of innovative methods of source apportionment in air contamination assessment

In this work, new tools in atmospheric pollutant sampling and analysis were applied in order to go deeper in source apportionment study. The project was developed mainly by the study of atmospheric emission sources in a suburban area influenced by a municipal solid waste incinerator (MSWI), a medium-sized coastal tourist town and a motorway. Two main research lines were followed. For what concerns the first line, the potentiality of the use of PM samplers coupled with a wind select sensor was assessed. Results showed that they may be a valid support in source apportionment studies. However, meteorological and territorial conditions could strongly affect the results. Moreover, new markers were investigated, particularly focusing on the processes of biomass burning. OC revealed a good biomass combustion process indicator, as well as all determined organic compounds. Among metals, lead and aluminium are well related to the biomass combustion. Surprisingly PM was not enriched of potassium during bonfire event. The second research line consists on the application of Positive Matrix factorization (PMF), a new statistical tool in data analysis. This new technique was applied to datasets which refer to different time resolution data. PMF application to atmospheric deposition fluxes identified six main sources affecting the area. The incinerator’s relative contribution seemed to be negligible. PMF analysis was then applied to PM2.5 collected with samplers coupled with a wind select sensor. The higher number of determined environmental indicators allowed to obtain more detailed results on the sources affecting the area. Vehicular traffic revealed the source of greatest concern for the study area. Also in this case, incinerator’s relative contribution seemed to be negligible. Finally, the application of PMF analysis to hourly aerosol data demonstrated that the higher the temporal resolution of the data was, the more the source profiles were close to the real one.

Übergangsmomente zwischen angeregten Zuständen mit der RI-CC2-Methode: Implementierung und Anwendung auf Triplett-Excimere

Die Themengebiete dieser Arbeit umfassen sowohl methodische Weiterentwicklungen im Rahmen der ab initio zweiter Ordnungsmethoden CC2 und ADC(2) als auch Anwendungen dieser Weiterentwick-lungen auf aktuelle Fragestellungen. Die methodischen Erweiterungen stehen dabei hauptsächlich im Zusammenhang mit Übergangsmomenten zwischen angeregten Zuständen. Durch die Implementie-rung der selbigen ist nun die Berechnung transienter Absorptionsspektren möglich. Die Anwendungen behandeln vorwiegend das Feld der organischen Halbleiter und deren photo-elektronische Eigen-schaften. Dabei spielen die bislang wenig erforschten Triplett-Excimere eine zentrale Rolle.rnDie Übergangsmomente zwischen angeregten Zuständen wurden in das Programmpaket TUR-BOMOLE implementiert. Dadurch wurde die Berechnung der Übergangsmomente zwischen Zustän-den gleicher Multiplizität (d.h. sowohl Singulett-Singulett- als auch Triplett-Triplett-Übergänge) und unterschiedlicher Multiplizität (also Singulett-Triplett-Übergänge) möglich. Als Erweiterung wurde durch ein Interface zum ORCA Programm die Berechnung von Spin-Orbit-Matrixelementen (SOMEs) implementiert. Des Weiteren kann man mit dieser Implementierung auch Übergänge in offenschaligen Systemen berechnen. Um den Speicherbedarf und die Rechenzeit möglichst gering zu halten wurde die resolution-of-the-identity (RI-) Näherung benutzt. Damit lässt sich der Speicherbedarf von O(N4) auf O(N3) reduzieren, da die mit O(N4) skalierenden Größen (z. B. die T2-Amplituden) sehr effizient aus RI-Intermediaten berechnet werden können und daher nicht abgespeichert werden müssen. Dadurch wird eine Berechnung für mittelgroße Moleküle (ca. 20-50 Atome) mit einer angemessenen Basis möglich.rnDie Genauigkeit der Übergangsmomente zwischen angeregten Zuständen wurde für einen Testsatz kleiner Moleküle sowie für ausgewählte größere organische Moleküle getestet. Dabei stellte sich her-aus, dass der Fehler der RI-Näherung sehr klein ist. Die Vorhersage der transienten Spektren mit CC2 bzw. ADC(2) birgt allerdings ein Problem, da diese Methoden solche Zustände nur sehr unzureichend beschreiben, welche hauptsächlich durch zweifach-Anregungen bezüglich der Referenzdeterminante erzeugt werden. Dies ist für die Spektren aus dem angeregten Zustand relevant, da Übergänge zu diesen Zuständen energetisch zugänglich und erlaubt sein können. Ein Beispiel dafür wird anhand eines Singulett-Singulett-Spektrums in der vorliegenden Arbeit diskutiert. Für die Übergänge zwischen Triplettzuständen ist dies allerdings weniger problematisch, da die energetisch niedrigsten Doppelan-regungen geschlossenschalig sind und daher für Tripletts nicht auftreten.rnVon besonderem Interesse für diese Arbeit ist die Bildung von Excimeren im angeregten Triplettzu-stand. Diese können aufgrund starker Wechselwirkungen zwischen den π-Elektronensystemen großer organischer Moleküle auftreten, wie sie zum Beispiel als organische Halbleiter in organischen Leucht-dioden eingesetzt werden. Dabei können die Excimere die photo-elktronischen Eigenschaften dieser Substanzen signifikant beeinflussen. Im Rahmen dieser Dissertation wurden daher zwei solcher Sys-teme untersucht, [3.3](4,4’)Biphenylophan und das Naphthalin-Dimer. Hierzu wurden die transienten Anregungsspektren aus dem ersten angeregten Triplettzustand berechnet und diese Ergebnisse für die Interpretation der experimentellen Spektren herangezogen. Aufgrund der guten Übereinstimmung zwischen den berechneten und den experimentellen Spektren konnte gezeigt werden, dass es für eine koplanare Anordnung der beiden Monomere zu einer starken Kopplung zwischen lokal angereg-ten und charge-transfer Zuständen kommt. Diese Kopplung resultiert in einer signifikanten energeti-schen Absenkung des ersten angeregten Zustandes und zu einem sehr geringen Abstand zwischen den Monomereinheiten. Dabei ist der angeregte Zustand über beide Monomere delokalisiert. Die star-ke Kopplung tritt bei einem intermolekularen Abstand ≤4 Å auf, was einem typischen Abstand in orga-nischen Halbleitern entspricht. In diesem Bereich kann man zur Berechnung dieser Systeme nicht auf die Förster-Dexter-Theorie zurückgreifen, da diese nur für den Grenzfall der schwachen Kopplung gültig ist.

Aufbau von 2-alkinyl-substituierten Azepanen und Piperidinen und deren Aza-Claisen-Umlagerungen zu Allenyllactamen

Definiert konfigurierte mittelgroße ungesättigte Heterocyclen sind wertvolle Zwischenstufen in der Naturstoff- und Wirkstoffsynthese. Es konnte gezeigt werden, dass 2-alkinyl-substituierte Piperidine und Azepane in einer Aza-Keten-Claisen-Reaktion zu 10- und 11-gliedrigen Allenyllactamen umgelagert werden können. Ein 9-gliedriges Allenyllactam konnte nicht dargestellt werden (Ringspannung). Über eine sechs- bis sieben-stufige Reaktionssequenz konnten optisch aktive, geschützte Piperidinole aufgebaut werden. Es wurden Auxiliar kontrollierte Hetero-Diels-Alder-Reaktionen, diastereoselektive Reduktionen, Bestmann-Ohira Umlagerungen zu Alkinen und verschiedene Alkin-Funktionalisierungen erarbeitet. Eine Aza-Claisen-Umlagerung liefert schließlich optisch aktive Lactame deren absolute Konfiguration des Allensystems mittels NOE-NMR-Spektroskopie untersucht werden kann. Limitierungen und Möglichkeiten der Synthese werden eingehend diskutiert. Sowohl der stereochemische Verlauf der Reaktion als auch die Konformation der Produkte ermöglichen eine Fokussierung auf nachfolgende Naturstoffsynthesen vorzunehmen.

Advanced nail surgery

Six techniques not yet widely known or used in the dermatologic surgery of the nails are briefly described. Small-to-medium-sized tumours of the proximal nail fold (PNF) can be excised and the defect repaired with advancement or rotation flaps. A superficial biopsy technique of the matrix for the diagnosis of longitudinal brown streaks in the nail, which allows rapid histological diagnosis of the melanocyte focus to be performed, is described here. Because the excision is very shallow and leaves the morphogenetic connective tissue of the matrix intact, the defect heals without scarring. Laterally positioned nail tumours can be excised in the manner of a wide lateral longitudinal nail biopsy. The defect repair is performed with a bipedicled flap from the lateral aspect of the distal phalanx. Malignant tumours of the nail organ often require its complete ablation. These defects can be covered by a full-thickness skin graft, reversed dermal graft, or cross-finger flap. The surgical correction of a split nail is often difficult. The cicatricial tissue of the matrix and PNF have to be excised and the re-attachment of these wounds prevented. The matrix defect has to be excised and sutured or covered with a free matrix graft taken either from the neighbouring area or from the big toe nail.

Imaging appearances of Buerger's disease complications in the upper and lower limbs

Thromboangiitis obliterans (Buerger's disease) is a rare, non-atherosclerotic, segmental, inflammatory vasculitis that most commonly involves small and medium-sized arteries, veins and nerves of the extremities and affects tobacco smokers between the ages of 25 and 45 years. The manifestations of Buerger's disease can be extremely variable and, therefore, awareness of the condition is important for both general and musculoskeletal radiologists. This paper presents the radiological appearance of the sequelae of Buerger's disease involving the upper and lower limbs.

Neuronal expression of the ubiquitin ligase Nedd4-2 in rat dorsal root ganglia: modulation in the spared nerve injury model of neuropathic pain

Neuronal hyperexcitability following peripheral nerve lesions may stem from altered activity of voltage-gated sodium channels (VGSCs), which gives rise to allodynia or hyperalgesia. In vitro, the ubiquitin ligase Nedd4-2 is a negative regulator of VGSC α-subunits (Na(v)), in particular Na(v)1.7, a key actor in nociceptor excitability. We therefore studied Nedd4-2 in rat nociceptors, its co-expression with Na(v)1.7 and Na(v)1.8, and its regulation in pathology. Adult rats were submitted to the spared nerve injury (SNI) model of neuropathic pain or injected with complete Freund's adjuvant (CFA), a model of inflammatory pain. L4 dorsal root ganglia (DRG) were analyzed in sham-operated animals, seven days after SNI and 48 h after CFA with immunofluorescence and Western blot. We observed Nedd4-2 expression in almost 50% of DRG neurons, mostly small and medium-sized. A preponderant localization is found in the non-peptidergic sub-population. Additionally, 55.7 ± 2.7% and 55.0 ± 3.6% of Nedd4-2-positive cells are co-labeled with Na(v)1.7 and Na(v)1.8 respectively. SNI significantly decreases the proportion of Nedd4-2-positive neurons from 45.9 ± 1.9% to 33.5 ± 0.7% (p<0.01) and the total Nedd4-2 protein to 44% ± 0.13% of its basal level (p<0.01, n=4 animals in each group, mean ± SEM). In contrast, no change in Nedd4-2 was found after peripheral inflammation induced by CFA. These results indicate that Nedd4-2 is present in nociceptive neurons, is downregulated after peripheral nerve injury, and might therefore contribute to the dysregulation of Na(v)s involved in the hyperexcitability associated with peripheral nerve injuries.

The use of a decremental dose regimen in patients treated with a chronic low-dose step-up protocol for WHO Group II anovulation: a prospective randomized multicentre study

BACKGROUND: In women with chronic anovulation, the choice of the FSH starting dose and the modality of subsequent dose adjustments are critical in controlling the risk of overstimulation. The aim of this prospective randomized study was to assess the efficacy and safety of a decremental FSH dose regimen applied once the leading follicle was 10-13 mm in diameter in women treated for WHO Group II anovulation according to a chronic low-dose (CLD; 75 IU FSH for 14 days with 37.5 IU increment) step-up protocol. METHODS: Two hundred and nine subfertile women were treated with recombinant human FSH (r-hFSH) (Gonal-f) for ovulation induction according to a CLD step-up regimen. When the leading follicle reached a diameter of 10-13 mm, 158 participants were randomized by means of a computer-generated list to receive either the same FSH dose required to achieve the threshold for follicular development (CLD regimen) or half of this FSH dose [sequential (SQ) regimen]. HCG was administered only if not more than three follicles >or=16 mm in diameter were present and/or serum estradiol (E(2)) values were <1200 pg/ml. The primary outcome measure was the number of follicles >or=16 mm in size at the time of hCG administration. RESULTS: Clinical characteristics and ovarian parameters at the time of randomization were similar in the two groups. Both CLD and SQ protocols achieved similar follicular growth as regards the total number of follicles and medium-sized or mature follicles (>/=16 mm: 1.5 +/- 0.9 versus 1.4 +/- 0.7, respectively). Furthermore, serum E(2) levels were equivalent in the two groups at the time of hCG administration (441 +/- 360 versus 425 +/- 480 pg/ml for CLD and SQ protocols, respectively). The rate of mono-follicular development was identical as well as the percentage of patients who ovulated and achieved pregnancy. CONCLUSIONS: The results show that the CLD step-up regimen for FSH administration is efficacious and safe for promoting mono-follicular ovulation in women with WHO Group II anovulation. This study confirms that maintaining the same FSH starting dose for 14 days before increasing the dose in step-up regimen is critical to adequately control the risk of over-response. Strict application of CLD regimen should be recommended in women with WHO Group II anovulation.

Excision of high and mid cervical spinal cord arteriovenous malformations by anterior operation

Symptomatic cervical spinal arteriovenous malformations (AVMs) located on the anterior aspect of the spinal cord are rare and surgical removal of these AVMs presents considerable challenges and risks. Surgical techniques to date have usually been by posterior approach and lateral dissection around the cord or via midline myelotomy, both approaches involving cord manipulation and retraction and in the latter, dissection through the spinal cord. We present two teenage patients with symptomatic anteriorly placed mid to high cervical spinal AVMs and associated aneurysm in which excision of the AVMs and aneurysm was performed by an anterior approach using vertebrectomy/corpectomy. The first case had a small perimedullary glomus-type AVM with an aneurysm on the anterior aspect of the cord at the C3/4 level; excision was performed using a single level vertebrectomy/corpectomy, the patient remaining neurologically intact. The second case had a medium-sized juvenile AVM with an aneurysm, both perimedullary and intramedullary, centred at the C5/6 level; excision was performed using a two-level vertebrectomy/corpectomy with no deterioration in the marked pre-operative tetraparesis, which at long-term follow up had improved and stabilised. Anterior approaches have been recently described for treatment of anteriorly placed cervical arteriovenous fistulas (AVFs) and an intramedullary haemangioblastoma, but not as yet for spinal AVMs. These are the first two reported cases of anteriorly situated cervical AVMs successfully removed surgically by an anterior approach and with good neurological outcomes.