Florina Haimovici

Alcohol Use Disorders After Bariatric Surgery

BackgroundThe increased incidence of alcohol use disorders (AUD) after bariatric surgery has been proposed despite limited empirical support. We sought to determine the prevalence of current and lifetime AUD and other Axis I diagnoses in patients who have undergone bariatric surgery, and to test the hypothesis that greater weight loss is associated with a higher incidence of AUD following surgery.MethodsIndividuals who underwent bariatric surgery between 2004 and 2007 were recruited for inclusion in the study. The diagnosis of current and lifetime AUD and other Axis I disorders was assessed using the Structured Clinical Interview for DSM-IV.ResultsA total of 51 individuals were included. The prevalence of lifetime and current AUD was 35.3% and 11.8%, respectively. No associations were found between weight loss following surgery and the development of an AUD or other Axis I diagnoses. Significantly more current AUD was reported in (1) individuals with a lifetime history of AUD compared to those without a lifetime AUD (p < 0.05), and (2) individuals undergoing Roux-en-Y gastric bypass (RYGB) compared to those undergoing the laparoscopic adjustable gastric banding (LAGB) surgery (p < 0.05).ConclusionsIndividuals undergoing bariatric surgery were found to have a lifetime prevalence of AUD comparable to the general population. Although weight loss was not associated with the development of an AUD following surgery, individuals with a lifetime history of AUD may be at increased risk for relapsing to alcohol use after surgery. All instances of current AUD were identified in individuals undergoing RYGB as opposed to LAGB.

Patient- and Practice-Related Determinants of Emergency Department Length of Stay for Patients With Psychiatric Illness

STUDY OBJECTIVE To identify patient and clinical management factors related to emergency department (ED) length of stay for psychiatric patients. METHODS This was a prospective study of 1,092 adults treated at one of 5 EDs between June 2008 and May 2009. Regression analyses were used to identify factors associated with ED length of stay and its 4 subcomponents. Secondary analyses considered patients discharged to home and those who were admitted or transferred separately. RESULTS The overall mean ED length of stay was 11.5 hours (median 8.2 hours). ED length of stay varied by discharge disposition, with patients discharged to home staying 8.6 hours (95% confidence interval 7.7 to 9.5 hours) and patients transferred to a hospital outside the system of care staying 15 hours (95% confidence interval 12.7 to 17.6 hours) on average. Older age and being uninsured were associated with increased ED length of stay, whereas race, sex, and homelessness had no association. Patients with a positive toxicology screen result for alcohol stayed an average of 6.2 hours longer than patients without toxicology screens, an effect observed primarily in the periods before disposition decision. Diagnostic imaging was associated with an average 3.2-hour greater length of stay, prolonging both early and late components of the ED stay. Restraint use had a similar effect, leading to a length of stay 4.2 hours longer than that of patients not requiring restraints. CONCLUSION Psychiatric patients spent more than 11 hours in the ED on average when seeking care. The need for hospitalization, restraint use, and the completion of diagnostic imaging had the greatest effect on postassessment boarding time, whereas the presence of alcohol on toxicology screening led to delays earlier in the ED stay. Identification and sharing of best practices associated with each of these factors would provide an opportunity for improvement in ED care for this population.

Quantitation of Hiv-1-specific Igg, Iga, and Igm Antibodies in Human Genital Tract Secretions

A quantitative enzyme-linked immunosorbent assay (ELISA) has been developed for the quantitation of HIV-1-specific immunoglobulins of the IgG, IgA, and IgM isotypes and was used to assess HIV-specific antibody concentrations in semen and cervicovaginal lavage (CVL) specimens. Immunoglobulin isotype concentrations were assessed by capture ELISA using immunoglobulin isotype-specific secondary antibodies and commercial IgG, IgA, and IgM standards. HIV-1 antibody detection kits (Abbott Laboratories, North Chicago, IL, U.S.A.) and immunoglobulin isotype-specific secondary antibodies were used to obtain optical density (OD) units for HIV-1-specific antibodies of each isotype. To determine the antibody concentrations from the OD values, ODs were compared with those from HIV-1-specific antibody isotype standards of known concentration obtained from CVL specimens of seropositive women by affinity binding to HIV antigen-coated beads and acid elution. The sensitivity of the HIV-1-specific immunoglobulin assay was 0.01 microg/ml for IgG, 0.04 microg/ml for IgA, and 0.08 microg/ml for IgM. The interassay coefficient of variation for the different immunoglobulin isotypes varied from 5% to 33%, being lowest for IgG and highest for IgM. HIV-1-specific antibodies were detected in all semen samples from seropositive men in concentrations ranging from 53 to 261 microg/ml. Thirteen of 14 samples contained high levels of HIV-1-specific IgG antibodies (22-72 microg/ml) whereas 10 of the 14 (71%) semen samples contained detectable but lower levels of HIV-1-specific IgA and IgM (maximum level: 3.7 microg/ml for IgA and 14.8 microg/ml for IgM). HIV-1-specific IgG antibodies were detected in all 196 CVL samples from seropositive women in concentrations ranging from 0.01 to 47 microg/ml, whereas only 16 women (8%) had IgA levels above the detectable limit (range, 1.4-3.9 microg/ml), and only eight women (4%) had IgM levels above the detectable limit (range, 1.8-8.6 microg/ml). None of 80 low-risk women or 20 low-risk men (negative controls) had detectable levels of HIV-1-specific antibodies in genital tract specimens. HIV-1-specific IgG levels in CVL specimens of seropositive women were significantly higher in individuals who had acquired HIV through heterosexual transmission, and a majority of women with elevated levels of HIV-specific IgA isotype antibodies in CVL samples had evidence of genital tract inflammation (>10[4] polymorphonuclear leukocytes [PMNs]/ml). Use of this quantitative method will facilitate direct comparison of data obtained within and among laboratories and enable further research on factors affecting antibody levels in genital tract secretions and their effects on HIV-1 transmission.

Hospital Variability in Emergency Department Length of Stay for Adult Patients Receiving Psychiatric Consultation: A Prospective Study

STUDY OBJECTIVE We ascertain the components of emergency department (ED) length of stay for adult patients receiving psychiatric evaluation and to examine their variability across 5 hospitals within a health care system. METHODS This was a prospective study of 1,092 adults treated between June 2008 and May 2009. Research staff abstracted length of stay and clinical information from the medical records. Clinicians completed a time log for each patient contact. Main outcomes were median times for the overall ED length of stay and its 4 components, or time from triage to request for psychiatric evaluation, request to start of psychiatric evaluation, start to completion of psychiatric evaluation with a disposition decision, and disposition decision to discharge from the ED. RESULTS The overall median length of stay was more than 8 hours. Median times for the components were 1.8 hours from triage to request, 15 minutes from request to start of psychiatric evaluation, 75 minutes from start of psychiatric evaluation to disposition decision, and nearly 3 hours from disposition decision to ED discharge. The median disposition decision to discharge time was substantially shorter for patients who went home (40 minutes) than for patients who were admitted (2.5 hours) or transferred for psychiatric admission at other facilities (6.3 hours). When adjustments for patient and clinical factors were made, differences in ED length of stay persisted between hospitals. CONCLUSION ED length of stay for psychiatric patients varied greatly between hospitals, highlighting differences in the organization of psychiatric services and inpatient bed availability. Findings may not generalize to other settings or populations.

Detection of Semen in Cervicovaginal Secretions

Sperm were detectable by microscopic examination in human cervicovaginal lavage (CVL) specimens < or = 8 h after intercourse, whereas an enzyme-linked immunosorbent assay using the monoclonal antibody MHS-5, specific for a seminal vesicle antigen present in semen detected semen at a concentration of 1:2,500,000 (0.00004%) in CVL specimens and was positive < or = 24 h following unprotected intercourse. We recommend the routine use of semen detection assays to reduce false-positive results attributable to semen contamination in assays of pathogens, antibodies, or other factors in cervicovaginal secretions.

Variables affecting toxicity of human sera in mouse embryo cultures

It has been reported that sera from women with reproductive disorders can inhibit mouse embryo development. While performing tests on this subject in our laboratory, two unexpected variables were identified that can influence the effect of human serum on mouse embryo cultures. In a standard embryo culture system in which heatinactivated sera (10% final concentration) were added to two-cell mouse embryos and percentage blastocyst development was scored after 4 days, sera that had been collected into standard clinical Monoject blood collection red-stopper tubes were significantly more embryotoxic than sera collected from the same subjects into 15-ml Falcon centrifuge tubes (P<0.005). Furthermore, we observed that sera from laboratory personnel that worked with mice often inhibited mouse embryo development. To study this effect further, sera were collected from five fertile individuals who were routinely exposed to mice and from fertile women with no previous exposure to rodents. Sera from the mouse-exposed group were significantly more inhibitory than sera from the nonexposed control group (P<0.005). The effect was observed in the ammonium sulfate-precipitated immunoglobulin fraction of the mouse-exposed groups sera, and high titers of antibodies reactive with mouse spleen cells were detected in sera and immunoglobulin fractions from this group by enzyme-linked immunosorbent assay (ELISA). Embryotoxic activity was neutralized by absorption with mouse lymphocytes, but not with rabbit or human lymphocytes, suggesting that a heterophilic antimouse antibody is the factor responsible for this effect. These data emphasize the importance of including extensive controls in experiments addressing toxic effects of human sera on mouse embryos.

Problem Drinking in Women Evaluated for Infertility

Clinicians may wish to use the T-ACE, a screening instrument for prenatal risk drinking, for their infertile patients. Twenty-eight T-ACE negative and 23 T-ACE positive women presenting to an academic infertility clinic completed two interviews about their drinking. The 23 T-ACE positive participants were also randomized to receive a brief intervention. The T-ACE distinguished between heavier and lighter patterns of alcohol use in this sample. Moreover, it appeared that although the average quantity of alcohol consumed per drinking day was unchanged, the overall mean percentage of days drinking declined significantly from the time of enrollment to follow-up in all groups.

Influence of various dioxins on in vitro motility of human sperm

Abstract Human ejaculate was subjected to a 2 step Percoll® gradient fractionation to obtain highly motile spermatozoa. RPMI 1640 medium supplemented with 10% pooled human serum was contaminated with various defined congeners of dioxins to their respective solubility levels. Dioxin concentrations in the stock solutions ranged from 0.72 ng/ml (2,3,7,8-TCDD) to 6.09 ng/ml (1,2,3,4,6,7,8,9-OCDD). Sperm suspension in Hams F-10 medium was added to equal volumes of dioxin contaminated RPMI 1640 medium stock in glass tubes and incubated at 37°C under 5% CO2. Over a period of 60 hours the experimental and control tubes were sampled for motility measurements using a Hamilton Thorn HTM2030 automated motility analyzer at regular intervals. Results were plotted as means of triplicate readings +/− standard deviation. Control spermatozoa and treated cells did not noticeably differ in their respective loss of motility with time. Achievable dioxin concentrations in contaminated media, although clearly above levels found in body fluids of the average population, did not seem to impair motility in mature sperm after ejaculation.

Does emotional support during the luteal phase decrease the stress of in vitro fertilization

OBJECTIVE To determine if phone calls between ET and pregnancy test, decrease stress levels as determined by the Perceived Stress Scale (PSS). DESIGN Randomized controlled trial. SETTING Academic medical center. PATIENT(S) Women undergoing a first fresh cycle of assisted reproductive technology using autologous oocytes with a day 2 or 3 ET. INTERVENTION(S) Phone calls from specialized social workers or standard of care. MAIN OUTCOME MEASURE(S) Primary outcome was the change in PSS score from day of ET compared with 10 days after ET; secondary outcome was perceived patient benefit. RESULT(S) A total of 131 patients were randomized to the intervention (n = 66) or control (n = 65) group. No differences were seen in the final PSS score or the change in PSS score between groups. At the completion of the study, the intervention group was more likely to report that participating in this study was helpful (65.9% vs. 21.4%), as well as to recommend emotional support during an IVF cycle (95.4% vs. 78.6%). CONCLUSION(S) Although we observed no significant change in PSS score, first-cycle IVF patients felt that increased emotional support was needed during the waiting period between ET and pregnancy test. Additional research should be conducted to determine the best interventions for this time period.

Antifertility effects of antisperm cell-mediated immunity in mice

C57BL/6 female mice were immunized with allogeneic (DBA/2) sperm in Freunds adjuvant either subcutaneously (s.c.), transcervically into the uterine lumen (i.u.), or with a combination of s.c. and i.u. immunization approaches. Control mice received DBA/2 lymphocytes, human erythrocytes or saline in adjuvant using the same immunization protocols. Immunization with sperm or control cells in adjuvant exclusively by s.c. or i.u. approaches did not affect subsequent fertility, although sperm-injected mice from both protocols had high titers of circulating antisperm antibodies. In contrast, mice that were immunized with sperm in adjuvant by a combination of s.c. and i.u. injections demonstrated significant reductions in fertilization rate and number of viable fetuses and an increased rate of fetal resorption when compared with non-immunized and control-immunized mice. Mice receiving sperm by the s.c./i.u. protocol had high titers of antisperm antibodies and a marked infiltration of T lymphocytes and macrophages into the uterine endometrium. To determine whether cellular immune mechanisms contributed to the infertility effect, T lymphocytes from spleens and pelvic lymph nodes of s.c./i.u. sperm-immunized mice and non-immunized mice were passively transferred to naive syngeneic female recipients which were subsequently mated. The total number of fetuses on day 15 of pregnancy was significantly reduced in mice receiving T-lymphocytes from sperm-immunized mice and a significant increase in fetal resorption sites was also observed. These mice did not have detectable titers of circulating antisperm antibodies, but had a significant infiltration of CD4+ T lymphocytes and macrophages in the uterine epithelium and endometrium. These data indicate that intrauterine antisperm cell-mediated immunity can be induced in mice by a combination of systemic and intrauterine immunizations and provide evidence for the existence of reproductive tract mucosal antisperm cellular immune responses that adversely affect fertility and pregnancy.