Intravenous immunoglobulin prophylaxis causing liver damage in 16 of 77 patients with hypogammaglobulinemia or IgG subclass deficiency.

Sixteen of 77 patients (21 percent) with common variable immunodeficiency or IgG subclass deficiency contracted non-A, non-B hepatitis in association with intravenous infusions of immunoglobulin. The hepatitis seemed to run a more severe course in these patients than in non-immunodeficient patients. Twelve patients had clinical symptoms, and five died with hepatitis being the cause of death in two and a contributing factor in three. Liver biopsy specimens showed early chronic active hepatitis and cirrhosis. In addition to increases in liver enzymes, 13 patients had increases in alkaline phosphatase levels. All but two patients who contracted hepatitis had been given 50 mg/kg per week or more of intravenous immunoglobulin. Lymphocyte counts, T/B cell ratios, and T-lymphocyte function did not differ between those in whom hepatitis developed and those in whom it did not develop. The hepatitis was associated with more than one batch of a Swedish intravenous immunoglobulin, the immunoglobulin being derived from United States sources as well as from European plasma. Three previous brief reports in the literature have also associated non-A, non-B hepatitis with the intravenous infusion of various immunoglobulins. Biologic materials given to patients, including immunoglobulin, should, whenever possible, be prepared so as to ensure absence of viruses.

Immunoglobulin subclass deficiency.

IgG subclass deficiency was first noted in 1968. Subnormal levels of one or two, occasionally three IgG subclasses may be relatively common. It has not been determined, however, at what level below the normal range the IgG subclass deficiency is of clinical relevance. It remains important to clarify this point because certain subclass deficiencies may be without relevance of their own. Because patients with decreases of various IgG subclasses often present with a number of diseases, the low immunoglobulin levels may signify the presence of other abnormalities of more biologic significance. IgG subclass deficiency has been noted in about 25% of patients with well-defined food allergy and in patients with asthma, diabetes mellitus, Henoch-Schönlein's purpura, Bechterew's disease, intractable epilepsy of childhood, Friedreich's ataxia and autoimmune cytopenias. Most commonly they have increased frequency of infections especially in the respiratory tract, including sinusitis, otitis media and bronchopneumonia, but also osteomyelitis, meningitis, septicemia and various skin infections. Low levels of various subclasses have been noted in connection with other immunodeficiencies such as ataxia-telangiectasia. In common variable immunodeficiency there is an obvious imbalance in the IgG subclasses. Furthermore IgG subclass deficiency can be seen in relatives of patients with common variable immunodeficiency and in IgA deficiency. They also occur in relatives of patients with systemic lupus erythematosus, diabetes mellitus type 1 and C2 deficiency. In a few cases of subclass deficiency gene deletions have been shown. Subnormal levels of IgG subclasses make a remarkable change in sex distribution around puberty from 3/1 in boys and girls to the reverse sex ratio among adults.(ABSTRACT TRUNCATED AT 250 WORDS)

Bipolar systems--do they perform?

Recent reports of bipolar sterilization failures have questioned the compatibility of bipolar forceps used with different electrogenerators. Four different bipolar forceps were matched and mismatched with five generators and the electrocoagulation effect was studied by two physicians trained in the histologic evaluation of electrical injury. All bipolar systems, matched or mismatched, failed to coagulate the fallopian tube as completely as unipolar control--except for the matched Kleppinger system. Conversely, when mismatched with other generators the coagulation effect of the Kleppinger forceps fell far below that of other bipolar forceps--matched or mismatched. Each bipolar system should be compatible and its electrocoagulation effect studied before it is used for female sterilization.

Reducing bipolar sterilization failures.

Many bipolar sterilization failures have occurred because of incomplete desiccation of the endosalpinx. This study compared the effect upon human fallopian tubes of different waveforms of electrical energy at advancing power settings. When the Valleylab SSE2-L generator was attached to the Kleppinger bipolar forceps, complete desiccation was confirmed with the power set at 25 W in a cutting waveform. Other waveforms (coagulation and blend) failed to complete the task at the same power setting. An inline current meter assures the operator that all the available energy is delivered. This information should help to reduce bipolar sterilization failures.

Changing practice habits of King County obstetricians.

In 1987, all practicing King County, Washington obstetricians (N = 181) were surveyed to determine the impact of rising malpractice premium rates and the threat of litigation on their obstetric practices. Six percent of respondents anticipated closing their practices over the next year, which means an additional 520 deliveries will have to be absorbed into existing obstetric practices. Of the 71% who increased their professional fees in 1986, 90% attributed the increase to higher malpractice premiums and increased risk of litigation.

Tubal pregnancy and the risk of subsequent infertility.

One hundred forty-one women with tubal infertility, all of whom had been pregnant at least once before, were interviewed concerning their reproductive, contraceptive, medical, and sexual histories. Their responses were compared with those of a control group of 467 fertile women. A higher percentage of cases (13%) than controls (1%) had had a tubal pregnancy. From these percentages, we estimate that 92% of tubal infertility in women who have had a tubal pregnancy results from tubal pregnancy itself or factors that predisposed to its occurrence. We also estimate that approximately one-fifth of women who suffer a tubal pregnancy will subsequently be infertile because of a tubal abnormality. After controlling for the joint effects of several known risk factors for tubal pregnancy that independently predispose to infertility (eg, a history of pelvic inflammatory disease), the relative risk of tubal infertility associated with tubal pregnancy was 15.0 (95% confidence interval 5.2-43.6). However, because we had no sensitive indicator of antecedent tubal disease, we were extremely limited in our attempt to determine the extent to which this association was actually due to the consequences of the tubal pregnancy itself.

Ureteral injuries at laparoscopy: insights into diagnosis, management, and prevention.

The increasing use of laparoscopy as a therapeutic method mandates a reappraisal of the risks involved. Complications frequently described include injuries to the large and small bowels, bladder, and blood vessels. The world literature reports only eight cases of ureteral injury at laparoscopy. In this report, we present five additional cases of ureteral injury occurring at laparoscopy, in addition to a summary of those previously reported. Patients tend to present in the early postoperative period (48-72 hours) with low back pain, abdominal pain, leukocytosis, and peritonitis. The diagnosis should be made by intravenous pyelography; if possible, the injury should be stented by either the retrograde or percutaneous route. The injuries, except for one apparent trocar injury, involved the use of electrocoagulation, both unipolar and bipolar. The injuries occurred most commonly near the uterosacral ligaments. In 38% (five of 13) of the cases, the laparoscopy was performed for treatment of endometriosis. Three of the 13 patients eventually lost renal function of the affected side; two of these underwent a nephrectomy. Because visualization of the ureter near the cervix at the time of laparoscopy is difficult, especially in the presence of disease, laparoscopic procedures in this area must be carried out with caution.

Gynecologic endoscopic gas embolism.

OBJECTIVE: To alert gynecologic surgeons to the risk of room air embolism during endoscopy. DESIGN: Case reports. SETTING: Medico-legal consultations. PATIENTS: Five women having endoscopic procedures. INTERVENTIONS: Endoscopy followed by emergency resuscitative measures. RESULTS: Morbidity and mortality. CONCLUSIONS: The risk of room air embolism may be lessened by attention to the operative technique and by monitoring the end tidal carbon dioxide levels.

Retreatment with nafarelin for recurrent endometriosis symptoms: efficacy, safety, and bone mineral density.

OBJECTIVE: To assess the efficacy, safety, and effect on bone mineral density of a 3-month course of retreatment with intranasal nafarelin acetate for recurrent symptoms of endometriosis. DESIGN: Multicenter, open-label, nonrandomized clinical trial. SETTING: Eleven hospital-based and private practices. PATIENT(S): Thirty-six women with endometriosis symptoms recurring after 3 or 6 months of treatment with nafarelin. INTERVENTION(S): Nasal nafarelin 200 micrograms twice daily for 3 months. MAIN OUTCOME MEASURE(S): Assessments for dysmenorrhea, dyspareunia, pelvic pain, tenderness, and induration. Measurement of bone mineral density of the lumbar spine. RESULT(S): Improvements from admission to the end of retreatment were significant for dysmenorrhea, pelvic pain, tenderness, induration, and dyspareunia. Three months after retreatment ended, mean symptom scores for dysmenorrhea and pelvic tenderness, although worse than at the end of retreatment, were still significantly better than scores at admission. Mean bone mineral density 3 months after retreatment was 0.56% lower than before retreatment and 1.94% lower than before initial treatment. CONCLUSION(S): Three-month nafarelin retreatment for recurrent endometriosis symptoms was effective and safe.

Tubal infertility in relation to prior induced abortion.

One hundred twenty-seven women who had been given diagnoses of tubal infertility between 1979 and 1981 in King County, Washington, yet previously had been pregnant, were interviewed to determine their prior history of legally induced abortion. Their responses were compared with those of 395 women who conceived a child at the same time the infertile women began their unsuccessful attempt to become pregnant. In making the comparison, we adjusted for the effects of variables that in this population were related both to having an induced abortion and to the occurrence of infertility, i.e., age, number of prior pregnancies, number of sexual partners, cigarette smoking habits, Dalkon Shield (A. H. Robins Company, Richmond, VA) use, and whether the woman worked outside the home. The risk of tubal infertility in women who had had an induced abortion was not increased above that of other women (relative risk, 1.15; 95% confidence interval, 0.70 to 1.89). For women with two or more abortions, the relative risk was 1.29 (95% confidence interval, 0.39 to 4.20). When only the most recent pregnancy was considered, the relative risk was 1.19 (95% confidence interval, 0.72 to 1.97). Our results suggest that legal abortion, as performed during the past decade in the United States, does not carry an excess risk for future tubal infertility.

PIP: 127 women who had been given diagnoses of tubal infertility between 1979-81 in King County, Washington, yet previously had been pregnant, were interviewed to determine their prior history of legally induced abortion. Their responses were compared with those of 395 women who had conceived a child at the same time the infertile women began their unsuccessful attempt to become pregnant. In making the comparison, the authors adjusted for the effects of variables that in this population were related to both having an induced abortion and to the occurrence of infertility; i.e., age, number of prior pregnancies, number of sexual partners, cigarette smoking habits, Dalkon Shield (A.H. Robins Co., Richmond, Virginia) use, and whether the woman worked outside the home. The risk of tubal infertility in women who had had an induced abortion was not increased above that of other women (relative risk, 1.15; 95% confidence interval, 0.70-1.89). For women with 2 or more abortions, the relative risk was 1.29 (95% confidence interval, 0.39-4.20). When only the most recent pregnancy was considered, the relative risk was 1.19 (95% confidence interval, 0.72-1.97). Results suggest that that abortion, as performed during the past decade in the U.S., does not carry an excess risk for risk tubal infertility.

Glycine as an irrigant during microsurgical hemostasis. A microsurgeon's observations.

The "drip-stop-coagulate" technique used during microsurgery is tedious and, at times, frustrating when electrolyte-rich solutions are used as an irrigant. Glycine, a nonelectrolyte solution, allows the gynecologist to apply electrosurgical energy in a fluid medium; lactated Ringer's solution, the irrigant frequently used by microsurgeons, will not. When, during microsurgery, glycine is used in place of lactated Ringer's solution, the origin of the bleeding site can be easily isolated and coagulated during irrigation, assisting the surgeon in precise and complete hemostasis.

Will progesterone save the IUD?

In 1971 we began studying pelvic inflammatory disease (PID) in IUD users by examining fallopian tube specimens obtained after elective female sterilization. We studied four groups: 175 nonhormonal-IUD users, 22 Progestasert users, 1,500 non-IUD users and 100 non-IUD users who had had IUDs in the past. We found histologically detectable salpingitis in 49% of the nonhormonal-IUD users, none of whom had symptoms of PID. Culture of 100 specimens from these nonhormonal-IUD specimens proved to be sterile. Viewing the inflammation as predisposing the tissues to bacterial infection would help explain the higher frequency of PID among IUD users than among nonusers. All the Progestasert users lacked histologically detectable salpingitis; the difference was statistically significant (p < 10(-6). This finding suggests that women using progesterone-releasing IUDs have a lower risk of developing PID than do users of other kinds of IUDs.

Unusual uses of laparoscopy.

The marked enthusiasum recently seen in gynecologic endoscopy has brought forth numerous anecdotes of ingenuity. Without ingenuity, medicine and surgical skills would advance slowly. This anecdotal report is presented not only as information but as a stimulus to the endoscopist to consider new approaches to today's surgical problems. The laparoscope has been used to: 1. remove ectopic pregnancies, excise paraovarian cysts and retrieve foreign objects from the abdomen. 2. explore the abdomen for suspected trauma, 3. evaluate the abdomen and pleural cavity for metastatic disease, and 4. perform lumbar sympathectomy. These and other unusual uses of the laparoscope are presented for the "spelunkers" of modern-day endoscopy.

Colposcopic documentation. An objective approach to assessing sexual abuse of girls.

Accurate measurements of the genital anatomy of victims of child sexual abuse can be documented with colposcopic photography. Most colposcopies available, however, do not have a built-in measuring grid for medicolegal documentation. Because of the unique optics designed for the colposcope, an accurate comparison can be provided if the measuring tool is photographed in the same focal plane and at the same magnification as the object of concern. Properly labeled slides may then be used as clear evidence in court.

Lumbar epidural block anesthesia for outpatient laparoscopy.

This study confirms that lumbar epidural block is a satisfactory anesthetic technique for outpatient laparoscopic tubal sterilization. Oxygenation during the period of pneumoperitoneum was adequate. The technique resulted in a shortened postanesthesia recovery period and fewer postanesthesia complications. Surgeon, anesthesiologist and patient acceptance was excellent.

Depth of endometrial coagulation with the urologic resectoscope.

There is growing interest in using the urologic resectoscope for endometrial ablation, but the actual depth of tissue destruction is unknown. A preliminary in vitro study measured the depth of visible coagulation produced when various waveforms of high-frequency current were applied to tissue using the "rollerball" electrode of the resectoscope. Tissue necrosis caused by high-frequency electrical energy is not immediately apparent: several days must elapse before the true extent of the damage can be seen. To study it, the uterus from a woman who was planning to undergo a hysterectomy was treated with the resectoscope four days prior to surgery. The depth of tissue destruction caused by 19 and 59 W of "cutting" current and by 28 and 57 W of "coagulating" current was 1.5, 2.7, 6.1 and 1.8 mm, respectively. A second patient underwent a hysterectomy 48 hours after resectoscopic endometrial ablation. There was no endometrium remaining, and coagulation extended 2-3 mm into the myometrium. Visual effects on the surface do not predict actual tissue destruction, so further in vivo studies will be necessary in order to obtain consistent clinical results.

Salpingitis: a frequent response to intrauterine contraception.

Nonbacterial, chronic salpingitis was found in less than 1% of non-IUD users undergoing elective tubal sterilization, Nonbacterial, chronic salpingitis was found in 47% of IUD users undergoing elective sterilization. Speculation about the influence of this finding on inflammatory morbidity is presented.

PIP: Histologic specimens from both IUD-wearing and non-IUD-wearing women undergoing translaparoscopic tubal sterilization were examined for inflammatory changes. Among 1500 non-IUD wearers salpingitis was noted histologically in 10, less than 1%. At laparoscopy 3 of these had signs of old gonococcal infection, including peritubal adhesions. In 1 case perihepatic adhesions were observed. In 49 patients undergoing simultaneous IUD removal and sterilization, 23 (47%) had chronic salpingitis histologically similar to the inflammatory response previously reported in the endometrium among IUD wearers. The majority of IUDs were Dalkon shields, a reflection of IUD use in the Seattle community. Infectious morbidity did not complicate the poststerilization convalescence. Bacteriological investigation gave negative results. It seems likely that chronic nonbacterial tubal inflammation explains some of the symptoms commonly associated with the IUD. This study also lends histologic support to the theory that decrea sed host resistance to bacterial infection is an explanation for IUD-rel ated inflammatory morbidity.

The snare method of laparoscopic sterilization: an analysis of 1,000 cases with 4 failures.

The snare method has proven to be an effective method of tubal resection for sterilization. In the most experienced hands, significant complications are indeed rare. However, the failure rate appears to be higher than that of the coagulation-alone method, at least in the postabortal patient. The necessity for pathologic confirmation, a tradition of surgery, is critically questioned. Additional coagulation of the tubal ends after resection is now recommended, especially in the patient seeking abortion as well as sterilization. The authors await the comparative long-term results of bipolar forceps and the newer mechanical methods of laparoscopic tubal sterilization. It is conceivable that the snare and other unipolar electrosurgical instruments designed for female sterilization will become obsolete.

PIP: This paper reports the experience with 1000 patients who were sterilized with the snare method and followed up for at least 2 years. In most cases, the surgery was performed on an outpatient basis with general anesthesia and endotracheal intubation. The snare method was originally developed to produce a recognizable specimen to confirm that tubal integrity had been interrupted. The high complication rate (13/93 cases) when the method was 1st introduced was reduced dramatically by strict adherence to proper operator education and close supervision of equipment care. 4 pregnancies have been reported in 2 years of follow up. These pregnancies, all of which were intrauterine, occurred 11, 22, 28, and 32 months after sterilization. 2 of these patients had mesothelial fistulous tracts between the resection sites; the other 2 had complete, spontaneous reanastomoses. All 4 patients had had a concomitant pregnancy termination at the time of sterilization. The failure rate obtained in this study (1/250) is higher than that of the coagulation alone method, at least in postabortal patients. Because of the small surface area of the snare wire, the method cannot produce the degree of tubal tissue destruction required for successful sterilization. An additional coagulation of the proximal stump after snare resection would probably diminish or reduce the failure rate; however, newer mechanical methods of laparoscopic tubal sterilization may prove to be more efficacious than the snare and other unipolar electrosurgical instruments.

Bowel injuries during laparoscopy. Gross anatomy and histology.

Bowel injuries during laparoscopy can result from either electrical damage or direct trauma. When electrocoagulation is used with laparoscopy, it is frequently assumed that any bowel injury is from that source. That assumption might not be accurate. In animal studies we evaluated the histologic characteristics of both electrical and traumatic bowel injuries. A consistent difference in injury pattern, both gross and microscopic, was noted. With a high degree of accuracy, those histologic and gross characteristics can be used to distinguish traumatic from electrical injuries following operative laparoscopy.

Erythema nodosum. A review.

Erythema nodosum is not an uncommon dermatologic entity. Sarcoidosis and streptococcal infection have become the two most common causes, while tuberculosis was the predominant etiology prior to the use of isoniazid. Histoplasmosis and coccidioidomycosis are two important geographic considerations. Laboratory tests should include a PPD test, chest x-ray, throat culture for beta-streptococcus, and ASO titer determination as a minimum. Symptomatic treatment remains unsatisfactory in many cases, although recent success has been reported with oral potassium iodide.