Circulating androgens are associated with mood disturbances in young postmenopausal women.

OBJECTIVES: We aimed to evaluate the association between circulating androgens and the presence of psychological symptoms in a sample of healthy middle-aged women. METHODS: Psychological and depressive symptoms were evaluated in a total of 207 postmenopausal women, using the Symptom Checklist-90-R (SCL-90R) and the Zung Depression Scale, respectively. We investigated the associations between the SCL-90R and Zung Scale scores, and anthropometric, lifestyle parameters, as well as serum levels of androgens. RESULTS: The free androgen index was positively associated with scores of depression (b-coefficient ± standard error (SE) = 0.2 ± 0.2, p = 0.040), anxiety (b-coefficient ± SE = 0.2 ± 0.2, p = 0.028), anger/aggressiveness (b-coefficient ± SE = 0.3 ± 0.2, p = 0.026), psychotism (b-coefficient ± SE = 0.3 ± 0.1, p = 0.013) as well as with the global index of the SCL-90R scale (b-coefficient ± SE = 0.2 ± 0.1, p = 0.036), while sex hormone binding globulin was negatively associated with depression (b-coefficient ± SE = -0.2 ± 0.0, p = 0.046) and psychotism (b-coefficient ± SE = -0.2 ± 0.0, p = 0.047). These associations were independent of vasomotor symptomatology, smoking and hormone therapy intake and were more pronounced in younger (≤ 5.5 years) compared to older postmenopausal women. Levels of dehydroepiandrosterone sulfate were positively associated with interpersonal sensitivity (b-coefficient ± SE = 0.3 ± 0.3, p = 0.042), psychotism (b-coefficient ± SE = 0.4 ± 0.2, p = 0.007) and the global index (b-coefficient ± SE = 0.3 ± 0.2, p = 0.040) in women < 5.5 years postmenopausal. No significant associations were observed between the Zung or Greene Scale scores and levels of androgens. CONCLUSION: Higher androgenicity was positively associated with symptoms of anxiety and depression in postmenopausal women. These associations were stronger in women closer to the menopausal transition, a finding which may suggest that menopause rather than aging may mediate the association of androgens with mood disorders.

Safety and effectiveness of tinzaparin sodium in the management of recurrent pregnancy loss.

PURPOSE: To assess the safety and efficacy of tinzaparin sodium for the management of recurrent pregnancy loss. METHODS: The study included 62 women with a history of recurrent pregnancy loss and at least one factor of thrombophilic disorder. Of these, 31 received 50 IU/kg of tinzaparin sodium daily (Group A), and 33 received 100 mg of aspirin daily (Group B). RESULTS: Group A subjects (receiving tinzaparin sodium) had six new abortions, whereas Group B subjects (receiving aspirin) had 11 (significant difference). Cases of intrauterine growth restriction (none in Group A and 2 in Group B), placental abruption (one in Group A and 4 in Group B), and preeclampsia (one in Group A and 3 in Group B) were comparable between the two groups. Finally coagulation disorders (none in Group A and 6 in Group B) were significantly fewer in Group A. CONCLUSION: A 50 IU/kg daily dose of tinzaparin sodium seems to be effective for the management of recurrent abortion and has high standards of safety.

Oocyte morphology correlates with embryo quality and pregnancy rate after intracytoplasmic sperm injection.

OBJECTIVE: To evaluate the relation of oocyte morphology with embryo quality and pregnancy rates (PRs) after intracytoplasmic sperm injection (ICSI). DESIGN: Retrospective study of patients undergoing ICSI. SETTING: University Hospital IVF Center. PATIENT(S): Sixty-eight patients who underwent ICSI and had transfer of good-quality embryos (grade 3), 60 patients with transfer of both good- and poor-quality embryos (grade 3 and grade 2), and 18 patients with transfer of poor-quality embryos (grade 2). INTERVENTION(S): Comparison of the outcome of ICSI in the three groups of patients and the relation of oocyte morphology to embryo quality. MAIN OUTCOME MEASURE(S): Oocyte morphology and embryo quality (grade). Fertilization, cleavage, and pregnancy rates. Serum E2 on the day of hCG administration. RESULT(S): Oocytes with poor morphology (dark cytoplasm; many vacuoles or fragments in cytoplasm) led to poor-quality embryos and consequently to lower PRs (5.5% versus 29.4%). Serum E2 on the day of hCG administration was significantly higher in the group with good-quality embryos compared with that with poor-quality embryos (2,047 +/- 135.7 versus 1,651 +/- 164.8 pg/mL, respectively). CONCLUSION(S): Serum E2 on the day of hCG administration is a marker of embryo quality. Oocyte morphology correlates well with embryo quality and PRs after ICSI.

Complications of congenital posterolateral diaphragmatic hernia in the adult. Report of two cases and literature review.

The literature on incarceration in Bochdalek hernias in adults is rather limited. Our purpose is to present two cases of this lesion that were treated surgically in the past ten years. The first patient, a 32 year old female was admitted in shock with an 8h history of left chest pain and dyspnoea. Chest X-ray showed a pleural effusion in the left hemithorax. Chest tube drainage revealed gastric fluid. We operated on her immediately, through a left thoracotomy, and found rupture of the stomach into the left pleural cavity. Strangulation of the fundus of the stomach due to congenital diaphragmatic hernia, Bochdalek's type, was found to be the cause of the rupture. We performed resection of the gangrenous segment of the stomach with primary closure. The second patient a 48 year old man was admitted with symptoms of large bowel obstruction. Per os gastrographin study showed the splenic flexure herniated into the left hemithorax. At the operation, through a paramedian left incision, the herniated large bowel was reduced back into the abdomen. In both cases the defect of the left hemidiaphragm was sutured with interrupted silk sutures. Both patients had an uneventful postoperative course. The diagnosis of Bochdalek hernia in the adult is usually made in case of complications, and that demands an immediate surgical repair.

Doppler-ultrasound as a predictor of uterine fibroid response to GnRH therapy.

OBJECTIVES: GnRH agonists (GnRHa) are able to reduce the bleeding and size of fibroids. We monitored the response of fibroids to GnRHa with power-Doppler ultrasound. METHODS: Thirty-five women with fibroids, aged 32-48, received a 6-month course with the GnRHa triptorelin (Decapeptyl, Ipsen, France). The resistance index (RI) of the uterine artery was measured with power-Doppler ultrasound. RESULTS: The uterine volume reduced from 470+/-347 to 297+/-295 cm3 (P<0.01) at the 6th month of treatment. The fibroid volume reduced after 3 months of treatment from 62+/-81 to 44+/-78 cm3 (P<0.05) and after 6 months of treatment to 30+/-70 cm3 (P<0.001 from baseline). Uterine artery RI increased from 0.73+/-0.16 to 1.05+/-0.27 at the 3rd month of treatment (P<0.001). The percent reduction of fibroid volume at the 6th month correlated with the percent increase of uterine RI at the 3rd month of treatment (r=0.45, P=0.01). CONCLUSIONS: The administration of triptorelin reduced fibroid dimensions. The increase of the uterine artery resistance index (RI) at the 3rd month correlated with fibroid shrinkage at the 6th month of treatment and may be used to predict the response to this therapeutic maneuver.

Fetal tachycardia and meconium staining: a sign of fetal infection.

A retrospective study was carried out on 72 liveborn babies in whom perinatal infection was suspected. Twenty-nine of the 72 neonates were effectively infected. Analysis of intrapartum FHR recordings showed that tachycardia (base line FHR above 160 beats/min) during labor, occurred more often among infected babies (P less than 0.001). When fetal tachycardia is associated with meconium stained amniotic fluid (MSAF), the relative risk of fetal infection is 51 times as great as in babies without MSAF. Fetal tachycardia is not related to maternal fever nor to prematurity. It is not a sign of limited placental or amniotic fluid infection, but implies infection of the fetus itself. Since most infected babies displayed infectious diarrhea immediately at birth, it is suggested that MSAF may eventually be due to antenatal intestinal infection and intrauterine emission of infected stools. Although great caution is advocated for the management of labor in the presence of fetal tachycardia, MSAF should not be always regarded as a sign of acute fetal distress when antenatal infection of the fetus is suspected.

Emergency operations in the elderly: management and outcome.

For the purpose of highlighting the problems that arise in emergency surgical procedures in elderly patients and of defining safe management, the records of 797 patients aged over 70, operated urgently during a 22-year period, were reviewed. The mortality was 18.4% in the emergency and 4.5% in the elective operations (p < 0.0001). There was no correlation between mortality rates in different age groups. The majority of the patients (67.3%) with coexisting cardio or pulmonary diseases expired. The mortality was significantly lower in the second 11-year period (1982-1992) (14%) than in the first one (1971-1981) (23.8%), (p < 0.0001). In conclusion, age is not a contraindication for an emergency operation and does not affect mortality which appears to be directly related to the severity and nature of the disease and to the coexisting cardio pulmonary diseases. We must advise the elderly to be operated on timely. In some severe surgical conditions it is wise to perform ad hoc the most conservative operation.

Surgical management of primary retroperitoneal liposarcomas.

During a 21-year period (1970-1991), 7 patients with primary retroperitoneal liposarcomas were treated surgically in our department. All the tumours were excised completely, and in 2 patients an additional nephrectomy was performed. Postoperatively 4 patients had adjuvant radiotherapy. Two other patients received adjuvant chemotherapy. Both of them had to be reoperated, because of a local recurrence 12 and 9 months after their first operation. There was one death on the first postoperative day, and 4 patients died 1 1/2-2 years after the initial operation. Two patients are still alive 34 and 22 months after their first operation with recurrent disease. Adjuvant therapy proved to be ineffective on the survival of our patients. The prognosis of retroperitoneal liposarcomas continues to be poor and the primary treatment has to be aggressive with complete resection of the tumor.

Long-term results of management of type I choledochal cysts in adults.

Choledochal cysts in adults is a rare condition. The present study describes our experience with this abnormality of the biliary tree. During a 16-year period (1978-1993) eight adults with type I choledochal cyst were treated surgically in our departments. They were 4 men and 4 women with a mean age of 38.9 years (range 20-84). Symptoms, clinical findings and abnormalities in laboratory investigations included pain in all patients, history of cholangitis (n = 3), cholangitis (n = 2), acute pancreatitis (n = 1), palpable mass (n = 2), abdominal tenderness (n = 4), leucocytocis (n = 2), and increased levels of serum total bilirubin (n = 4), SGOT (n = 2), and serum alkaline phosphatase (n = 4). Diagnosis was established by intravenous cholangiography in one case, by CT-scanning in one, by ultrasonography in 5 and by intraoperative cholangiography in one. All the patients were treated surgically. Three of them underwent a Roux-en-Y choledochocystojejunostomy and one a choledochocystoduodenostomy. The other 4 patients were treated with cyst excision and Roux-en-Y hepaticojejunostomy. There were no deaths among our patients. The mean follow-up period was 6.7 years (range 1-17). So far, five episodes of mild ascending cholangitis have occurred in the patient treated with choledochocystoduodenostomy. One patient in whom a Roux-en-Y choledochocystojejunostomy was performed had 2 episodes of right upper quadrant colic pain and one episode of cholangitis. Both these patients were treated conservatively. The other 6 patients had no episodes of pain cholangitis or jaundice. In conclusion, the primary treatment of choledochal cyst type I is the excision of the cyst with Roux-en-Y hepaticojejunostomy. The Roux-en-Y choledochocystojejunostomy is indicated in cases where, for various reasons, the cyst can not be safely removed.

[Microsurgical treatment of proximal lesions of the fallopian tubes. Apropos of 51 cases]. / Traitement microchirurgical des lésions proximales de la trope. A propos de 51 cas.

Microsurgical anastomosis was carried out on 51 patients who had proximal tubal lesions that were either purely isthmal, interstitial or isthmo-interstitial. 18-24 months later there were, using an actuarial method of calculation, 64% of intra-uterine pregnancies (+/- 2 X 8% skew) (line 8, Table IV). There has not been a single case of extra-uterine pregnancy so far. These results confirm the superiority of microsurgical anastomosis over implantation of the tube into the uterus.

[Significance of the diamine-oxidase test in the diagnosis of spontaneous rupture of fetal membranes]. / Intérêt du test à la diamine-oxydase (DAO) dans le diagnostic de la rupture spontanée des membranes ovulaires.

The authors report on their experience collected over a year of the use of the diamine-oxydase activity test after having collected the vaginal secretions on strips of Whatman paper placed in the vagina when they were trying to recognise premature rupture of the membranes. They studied: a control series of 90 patients (30 where the rupture was certain, 60 where it was definite that there was no rupture). They point out how reliable the method is at all stages of pregnancy and how simple and easy it is to carry out; a series of 89 consecutive patients whose clinical picture suggested premature rupture of the membranes; the diagnosis was shown to be wrong 48 times and confirmed 41 times (either immediately in 38 tests using DAO, or 48 hours after carrying out the first test in 3 cases). If this test is used to confirm that the membranes have really ruptured and to say when they have ruptured diamine-oxydase can be a very valuable factor when it is associated with the clinical picture and the ultrasound picture in leading to a rational handling of the case.

Hysteroscopy in the evaluation of habitual abortions.

OBJECTIVES: To evaluate the incidence of structural uterine anomalies (SUAs) in women with habitual abortion (HA) as diagnosed by means of hysteroscopy and to study hysteroscopy's therapeutic potential with regard to that pathology. METHODS: Forty-eight women with more than three consecutive pregnancy losses which occurred prior to the 20th week were included and hysteroscopy was performed on all of them. RESULTS: Twenty-five women (52%) had a normal hysteroscopy. The remaining 23 women (48%) presented SUAs: nine patients (19%) had intrauterine adhesions, four (8%) had submucous myomas, two (4%) had polyps and eight (17%) had congenital structural uterine anomalies (five cases of septate uterus and three of bicornuate uterus). Patients with abnormal hysteroscopy underwent appropriate therapy, when applicable. In the SUA group, 18 patients (78%) achieved a successful pregnancy, and five patients (22%) had another miscarriage. In the normal hysteroscopy group, eight patients (32%) achieved a successful pregnancy without additional treatment, 15 patients (60%) had recurrent miscarriages, and two patients (8%) had persistent secondary infertility. CONCLUSIONS: SUAs were detected in nearly half of the patients with HA. After appropriate treatment when applicable, 78% of patients with SUAs achieved a successful ongoing pregnancy. Hysteroscopy has much to offer in the diagnosis and treatment of SUAs.

HLA-G in murine peripheral blood after interruption of pregnancy.

HLA-G antigens are highly expressed in maternal peripheral blood during early pregnancy in transgenic mice. In this study, we determined the levels of HLA-G in white blood cells during early pregnancy and after interruption of pregnancy in triple transgenic mice (H-2K(b)/HLA-G, hbeta2m, and hCD2/hCD8-TRI). The pregnancies were interrupted on day 7 using the anti-progesterone agent mifepristone (RU486). Blood samples of 20 pregnant TRI mice were taken and the HLA-G levels were determined on days 2, 4 and 6 of pregnancy and on days 9, 11 and 13 after fertilization. The monoclonal antibody W6/32, specific for monomorphic determinant HLA class I molecules, was used in combination with an immunolocalization method using a photonic microscope. The HLA-G levels increased gradually on days 2, 4 and 6 of pregnancy, and the interruption of pregnancy on day 7 was followed by a decrease of HLA-G levels. The data indicate that pregnancy is characterized by the early presence of HLA-G in maternal peripheral blood in TRI transgenic mice and suggest that HLA-G may serve as a useful indicator for pregnancy maintenance and well-being.

Use of Marlex mesh in the repair of recurrent incisional hernia.

Recurrent incisional hernia remains a major problem for the general surgeon. The rate of recurrence of hernia repaired by primary closure using nylon sutures or with knitted monofilament polypropylene (Marlex) mesh was studied. A total of 102 repairs were performed over a 19-year period. Marlex mesh was used in 49 cases and primary closure in 53. All except two patients were followed from 1 to 15 (mean 7.6) years or to death. The incidence of recurrence was 8 per cent when Marlex was used and 25 per cent after primary closure. In both groups the majority of the recurrences were in the first 16 months after repair. The use of Marlex mesh should be considered in the management of recurrent incisional hernia.

Effects of estrogen-progestin and raloxifene therapy on nitric oxide, prostacyclin and endothelin-1 synthesis.

This randomized double-blind study was conducted to investigate the effects of 17 beta-estradiol plus norethisterone acetate, and raloxifene, on nitric oxide (NO), prostacyclin (PGI2) and endothelin-1 (ET-1) serum levels in postmenopausal women. Treatment was initiated after a 28-50 day placebo period. Fourteen women were treated daily with 17 beta-estradiol 2 mg plus norethisterone acetate 1 mg (E2 + NETA), and 14 with raloxifene HCl 60 mg for a period of 6 months. Serum NO, PGI2 and ET-1 levels were estimated at baseline, after placebo, and at months 3 and 6. E2 + NETA decreased NO levels significantly, while raloxifene did not cause any appreciable change. Both regimens decreased PGI2 levels and ET-1 levels significantly. Finally, E2 + NETA and raloxifene increased the NO/ET-1 ratio by 61.4% and 81.1%, respectively. In conclusion, both regimens may exert a cardio-protective effect by decreasing ET-1 levels and increasing the NO/ET-1 ratio. In contrast, both regimens had a negative influence on PGI2 levels.

Thyroid autoimmunity in patients with recurrent spontaneous miscarriages.

Recurrent spontaneous miscarriage (RSM) is a multifactorial problem. Auto- and alloimmune parameters have been implicated. Antithyroid antibodies (ATA) were tested in a group of women with RSM. The presence of antipaternal antibodies (APCA) was evaluated as an index of alloimmune contribution. Thirty euthyroid women with RSM (three or more consecutive miscarriages) aged 25-37 years were compared with 15 matched controls. Thyroid peroxidase (TPO) and thyroglobulin antibodies were tested with a chemiluminescence immunoassay and APCA were tested with a cross-match reaction. Results were compared using the chi-squared test. There was a higher frequency of ATA in women with RSM compared to controls (37% versus 13%, p < 0.05). Twenty of the women (67%) with RSM were tested negative for APCA, indicating an alloimmune contribution to their infertility. In this subgroup of women, the frequency of ATA continued to be higher than controls (40% versus 13%, p < 0.05). In conclusion, women with RSM, independent of APCA status, have a higher frequency of ATA. This may represent an additional marker for impaired regulation of the maternal immune system.

TCRgammadelta + T lymphocytes in unexplained recurrent spontaneous abortions.

PROBLEM: It is generally accepted that the immune system and cellular immunity in particular are involved in the mechanisms affecting the outcome of gestation. In order to evaluate a putative role of lymphocytes in the immunological mechanisms of unexplained recurrent spontaneous abortions (URSA), we studied peripheral blood lymphocyte subpopulations in 244 women with URSA and 44 controls. METHOD OF STUDY: Direct immunofluorescence in whole blood with the appropriate combinations of monoclonal antibodies and flow cytometry was used. RESULTS: The study showed: a) a statistically significant increase of the mean CD4/CD8 ratio (2.12+/-0.84 vs 1.85+/-0.63, P = 0,039); b) a statistically significant decrease of the mean value of the percentage of CD5+ CD19+ lymphocytes (0.4+/-0.6 vs 1.4+/-0.78, P < 0.0001); and c) a statistically significant increase of the percentage of T lymphocytes expressing TCRgammadelta (4.68+/-3.19 vs 2.61+/-1.14, P < 0.0001). It should be noted that a statistically significant high number of women with URSA (72/195, 36.9%) showed an increased percentage of TCRgammadelta T cells (> or = 5%, where 5 equals the mean value + 2 standard deviations (SD) of the mean value of controls), whereas such a high percentage was not found in any control subject. CONCLUSIONS: It seems that women who experienced URSA comprise a heterogeneous population, as far as immunological parameters are concerned. At least in a subgroup of them, TCRgammadelta + T cells could be considered to play a role in the immune pathogenesis of fetal loss.