Acute suppurative cholangitis associated with choledochal sludge.

Three patients with acute cholangitis who lacked cholangiographic evidence of common bile duct stones are reported. One presented 7 yr after cholecystectomy, and the other two had gallbladder sludge but no gallstones. The clinical features were mild, consisting of biliary pain, low grade fever without chills, and with modest leukocytosis. In each case, free cannulation of the bile duct was not possible, necessitating needle-knife papillotomy. After endoscopic sphincterotomy, balloon retrieval yielded purulent bile and sludge, but no stones. Prompt clinical improvement resulted in all three patients. Cultures of bile obtained at endoscopic retrograde cholangiopancreatography grew Escherichia coli in two patients and Enterobacter aeruginosa in the other. These observations suggest a link between intermittent obstruction due to biliary sludge in the common bile duct and bacterial cholangitis. We hypothesize that recurrent passage of biliary sludge may precipitate obstructive inflammation and fibrosis of the ampulla of Vater. Acute cholangitis should be added to the differential of potential complications of biliary sludge.

Variability of midcycle estradiol positive feedback: evidence for unique pituitary responses in individual women.

In women the preovulatory estradiol (E2) level must reach a peak concentration and dose (strength and duration) to initiate the LH surge. The variability of the surge-initiating serum E2 level in individual women from cycle to cycle, however, has not been studied. Accordingly, we studied 24 normally ovulating women longitudinally during a total of 221 menstrual cycles (range, 4-17 cycles/woman). In those women we measured periovulatory serum E2 and LH concentrations daily from 3 days before the LH peak to the day after the LH peak. The mean peak E2 concentration was 343 pg/mL, and the mean E2 dose (concentration X time) was 979 pg/mL. When the values in individual women were compared between women by components of variance analysis of variance, the differences were significant (concentration, P less than 0.01; dose, P less than 0.005), indicating that individual women have discrete and characteristic responses to E2 positive feedback. When E2 peaks and doses from initial cycles were compared with subsequent cycles by regression analysis, there were strong positive correlations (peak: r = 0.47; P less than 0.001; dose: r = 0.60; P less than 0.001). Of the total group variance in mean E2 peak and mean dose, 67% of the peak and 54% of the dose variance resulted from an individual woman's cycle to cycle variability, while 33% of the peak and 46% of the dose variance was attributable to differences among the women's responses to positive feedback. We conclude that individual women have characteristic and predictable periovulatory E2 production, leading to a LH surge which is maintained from cycle to cycle; and approximately two thirds of the total variance in mean peak E2 concentration (67%) and approximately half the variance in mean dose (54%) are the result of cycle to cycle biological variability around this characteristic periovulatory pattern of E2 production.

Polysiloxane vaginal rings and cylinders for physiologic endometrial priming in functionally agonadal women.

17 beta-estradiol (E2)-and/or crystalline progesterone (P)-impregnated polysiloxane vaginal rings and cylinders were tested as a system for endometrial priming in functionally agonadal women awaiting donor embryo transfer. Endometrial tissue was obtained by a transcervical biopsy procedure on simulated cycle day 26. The adequacy of the replacement regimen was judged by endometrial histologic dating, scanning electron micrographs, receptor content, and circulating E2 and P serum concentrations. Endometrial dating was consistent with cycle day 26. Electron micrographs showed normal surface characteristics. E2 and P receptor concentrations were within the normal range. Serum E2 levels were midfollicular, 105 +/- 12.8 pg/ml (mean +/- SEM), and midcycle, 254 +/- 28.6 pg/ml. P levels during the simulated follicular phase were undetectable (less than 0.2 ng/ml) but rose to a mean peak level of 17.3 +/- 1.8 ng/ml. The steroid-impregnated polysiloxane vaginal ring and cylinder system provided continuous and sustained hormone release, morphologically and endocrinologically normal endometrium, serum levels of E2 and P within the normal range for the entire menstrual cycle, and a convenient and physiologic therapeutic alternative to oral, vaginal, or intramuscular steroid replacement.

Biologic and morphologic development of donated human ova recovered by nonsurgical uterine lavage.

Using uterine lavage performed 5 days after the luteinizing hormone peak, we collected 25 uterine ova from five fertile donors who had had a single, periovular artificial insemination. After examination, all recovered ova were transferred to recipient uteri and resulted in three intrauterine and one tubal pregnancy. Morphologic development ranged from degenerating single-cell ova to mature blastocysts. Ages of the ova at recovery ranged from 93.5 to 130.0 hours postovulation. Mean age of the five blastocysts, 109.1 hours, was not significantly different from the mean age of the 20 less mature ova, 108.1 hours. Neither the mean interval from insemination to recovery for blastocysts nor the mean interval from insemination to ovulation for blastocysts was significantly different from the mean intervals of the other ova. The five blastocysts resulted in intrauterine pregnancies in three recipients. There were no intrauterine pregnancies from the other 20 transfers (p less than 0.004). A transferred 12-cell ovum with degenerating blastomeres was associated with tubal pregnancy in the recipient. The large variability in the state of intrauterine ova observed in the relatively fixed postovulatory interval of this study appears to be due to differences in viability and maturation, not differences in ovum age. Maturational state of the ova at the time of transfer appears to be a significant determinant of the likelihood of ensuring pregnancy.

Spontaneous bilateral pneumothorax in drug addicts.

Two cases of bilateral pneumothorax are reported in drug addicts; only one such case has been previously reported. They presented ostensibly as spontaneous pneumothoraces; however, meticulous history and physical examination proved them to be traumatic. Causes of spontaneous pneumothoraces are presented. Self-injection must be considered in the clinical differential diagnosis of spontaneous pneumothorax.

Nonsurgical ovum transfer as a treatment in infertile women. Preliminary experience.

This report summarizes our experience with nonsurgical ovum transfer at Harbor-UCLA Medical Center. In 29 attempts, 12 ova have been recovered and transferred. Two ongoing intrauterine recipient pregnancies have resulted from this preliminary research. There were two complications: one ectopic pregnancy in a recipient woman and one retained pregnancy in a donor woman who aborted spontaneously.

Magnetic enrichment of antibody-secreting cells.

AMino acid polymer antigens have been covalently coupled to sheep erythrocytes (SRBC) and these have been used in the high gradient magnetic separation (HGMS) technique to enrich murine lymph node cells which had specific receptors for antigen. The method was rapid and provided excellent cell recovery including the fraction retained on the HGMS column. The system could be operated to enrich preformed rosettes, or as an affinity column when preloaded with antigen-coupled SRBC. A 10-fold enrichment of plaque-forming cells was observed in either mode. The HGMS system employed a conventional electromagnet and the fractionation procedure required about 30 min for a sample of up to 10(8) cells.

A corneal scanner.

A pocket-sized self-illuminated diagnostic instrument is described which projects a circle or a line, continuous or interrupted, upon the cornea. It is moved in all directions, thus rapidly scanning the cornea for any distortion of the reflected image, indicating or localizing surface or structural pathology.

A pocket corneal astigmatism indicator.

A pocket-sized self-illuminated diagnostic instrument is described which projects a series of white dots upon the cornea from the center to the periphery radially disposed in a fashion similar to an astigmatic dial. The battery-operated instrument allows for a rapid qualitative estimate of corneal astigmatism and the meridians involved.

An illuminated Luedde Exophthalmometer.

A new type of Luedde exophthalmometer is available. It is constructed of a plastic rule attached to an ophthalmic penlight that serves as both illumination and a handle.

Lacrimal outflow patency demonstrated by chemiluminescence.

A chemiluminescent material (Cyalume) was injected into the lacrimal excretory passages of eight normal monkeys (16 eyes). Patency was established by almost instantaneous observation of a yellowish-green glow in the nose and pharynx. No toxic effects of the chemical were noted in any of the monkeys.

Dacryoscopy.

A miniature caliber endoscope is described for introduction into the lacrimal excretory passages. Direct observation and diagnostic inspection of the contents and lining of the lacrimal sac and naso-lacrimal duct are possible with the instrument, and complement standard examination procedures of the lacrimal outflow system.

A fiber-optics cyclodialysis spatula.

A cyclodialysis spatula for glaucoma surgery with a fiber-optics bundle incorporated within its thickness is described. The instrument is used as is commonly done at present with the standard cyclodialysis spatula. In addition, the fiber-optics bundle delivers cold light to the tip of the spatula which is useful in helping the surgeon locate the spatula within the sclera and the anterior chamber.