The role of thoracoscopic biopsies in the diagnosis of pleural tuberculosis.

Tuberculosis (TB) is a significant public health problem in many developing countries. In many cases, tuberculosis may present a significant diagnostic challenge. A 32-year-old male Chinese immigrant presented to our institution with a fever and non-productive cough. He was found to have a right pleural effusion, for which a chest drain was inserted. His tuberculin skin test was unreactive (0mm) although he was not immunocompromised (HIV negative). All cultures were negative, and 3 sputum samples and his pleural fluid sample tested negative for acid-fast bacilli. A computed tomography (CT) scan of his chest revealed features suggestive of an early empyema. There was no evidence suggestive of a malignant effusion. In an effort to attain a diagnosis, he underwent a video-assisted thoracoscopy (VATS) procedure with pleural drainage and biopsies. Anti-tuberculosis therapy (ATT) was commenced due to a high level of suspicion after failure of empirical therapy. Although the Ziehl-Neelsen stain for acid fast bacilli was negative, pleural biopsies demonstrated active chronic granulomatous pleuritis with many Langerhans type giant cells highly suggestive of tuberculosis. He was responsive to treatment and completed 6 months of ATT with complete clinical resolution. In young, immunocompetent patients with an exudative, culture-negative effusion, the diagnosis of pleural tuberculosis must be considered. Pleural biopsy is the gold standard for diagnosing pleural TB but demonstration of acid-fast bacilli or necrotizing granulomas in the specimen are not absolutely necessary to make the diagnosis.

Very low-dose (femtomolar) 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) disrupts steroidogenic enzyme mRNAs and steroid secretion by human luteinizing granulosa cells.

2,3,7,8-Tetrachlorodibenzo-p-dioxin (TCDD) is the most toxic congener of the polyhalogenated aromatic hydrocarbons (PAH), which causes anatomical abnormalities and developmental defects, impairs ovulation and reduces fertility. TCDD's endocrine-disrupting effects are, in part, caused by a direct action at the ovary. Herein we investigated the in-vitro effects of environmentally relevant doses of TCDD on estradiol-17ß (E2) production by human luteinizing granulosa cells (hLGC) obtained from women stimulated for in-vitro fertilization (IVF). TCDD at all concentrations tested (3.1fM, 3.1pM and 3.1nM) significantly decreased E2 secretion when assayed for by radioimmunoassay (RIA). Herein we confirm that TCDD alters E2 secretion by hLGC in a time-, not dose-dependent fashion and are the first to show decreases in E2 secretion with fM concentrations of TCDD. Using real-time quantitative PCR (RT-qPCR), the decreased E2 secretion correlates with a decrease in the mRNA expression levels two enzymes in the estrogen biosynthesis pathway: CYP11A1 and CYP19A1.

Life threatening haemorrhage after anterior needle aspiration of pneumothoraces. A role for lateral needle aspiration in emergency decompression of spontaneous pneumothorax.

Needle aspiration is a recognised emergency treatment of spontaneous pneumothorax and in the case of suspected tension is usually performed before chest radiography. Three cases are described of apparent life threatening haemorrhage after anterior aspiration in the second intercostal space, mid-clavicular line (2ICS MCL) requiring resuscitation, and transfer to a cardiothoracic unit. In these patients there was no evidence of haemothorax on initial presentation. Lateral needle aspiration, in the site recommended for chest drain insertion, the 5th intercostal space, anterior axillary line (5ICS ALL) is technically easy and may be a potentially safer option for decompressing pneumothoraces.

Traumatic cardiogenic shock due to massive air embolism. A possible role for cardiopulmonary bypass.

Systemic arterial embolism is a potentially lethal complication of bronchopulmonary venous fistula in trauma patients with blunt chest trauma or isolated penetrating lung injury on positive pressure ventilation. A high index of suspicion, early diagnosis and management in specialized centres are keys to a successful outcome.

Intraluminal biopsy of a superior vena cava mass.

A number of methods have been devised for the biopsy of intracaval tumour masses but all risk damage to the cava and tumour dissemination. We report on a case in which the tumour mass was almost entirely within the superior vena cava and describe an 'endoscopic' technique for biopsy.

Dioxin perturbs, in a dose- and time-dependent fashion, steroid secretion, and induces apoptosis of human luteinized granulosa cells.

Dioxin (2,3,7,8-tetrachlorodibenzo-p-dioxin; TCDD) is the most toxic congener of a large class of environmental pollutants. Several studies have shown that TCDD exposure reduced fecundity and ovulatory rate in rats and increased the incidence of endometriosis in monkeys. Recent work suggests that TCDD's endocrine-disrupting effects are, at least in part, caused by a direct action at the ovary. Although the factors involved in TCDD-induced toxicity are still under investigation, several studies have shown that TCDD induces programmed cell death, or apoptosis, in various tissues and may act in a similar fashion in the ovary. In the present study, we set out to evaluate the in vitro effects of TCDD on steroid secretion, specifically estradiol-17beta (E2) and progesterone, by human luteinized granulosa cells (LGC), and to further determine whether TCDD is capable of inducing apoptosis in this cell type. Human LGC were obtained from women participating in an in vitro fertilization program. Medium, with or without three different concentrations of TCDD and substrates [androstenedione (A4) or pregnenolone], was added to each culture. The media were collected at 4, 8, 12, 24, 36, and 48 h and were assayed by RIA. At 24 and 48 h, the LGC were fixed for assessment of DNA fragmentation via an in situ immunofluorescence technique. Transmission electron microscopy was also performed on LGC after 24 and 48 h with TCDD. TCDD, at all concentrations tested (3.1 pM, 3.1 nM, and 3.1 microM), significantly reduced E2 accumulation in the media at 8, 12, and 24 h, compared with controls. At 36 and 48 h, TCDD treatment (at 3.1 microM) caused a significant increase in E2, compared with controls. The effect of TCDD on E2 was abolished with the addition of A4. TCDD treatment did not alter progesterone accumulation. Apoptosis increased at 24 h with 3.1 microM TCDD, with no apparent effect at 3.1 nM. By 48 h, however, TCDD increased apoptosis in a dose-dependent manner. Transmission electron microscopy showed ultrastructural differences in LGC with 3.1 microM TCDD at 24 and 48 h. Collectively, the results of the present study suggest that TCDD perturbs E2 secretion by depletion of A4 precursor and increases apoptotic cell death of human LGC in a dose- and time-dependent fashion.

The relationship of human granulosa-lutein cell proliferative index to follicular diameter and serum estradiol.

OBJECTIVE: To examine the relationships of follicular diameter and serum estradiol (E2) to the percentage of granulosa cells undergoing mitosis as reflected by the proliferative index of granulosa cells. METHODS: In this prospective study, we enrolled 44 consecutive women undergoing controlled ovarian hyperstimulation for in vitro fertilization. Deoxyribonucleic acid histograms were generated by flow cytometry from granulosa cells isolated at the time of transvaginal aspiration. Proliferative index was defined as the sum of G2/M and S phases. We assessed the correlation between proliferative index and age, maximum serum E2, number of oocytes retrieved, percent mature oocytes, and follicular diameter. RESULTS: Follicles less than 16 mm had a significantly higher proliferative index (19.9 +/- 3.3%) than follicles 20 mm or greater (14.8 +/- 3.9%, P = .016). However, there was no significant difference between proliferative index of the latter group and proliferative index of follicles 16-19 mm (17.8 +/- 4.7%). An inverse correlation between patient age and proliferative index of granulosa cells was noted (r = -.39, P = .018). There was no significant relationship between serum E2 and proliferative index (P = .97). CONCLUSION: Mitotic activity tends to decrease as follicular diameter increases after a threshold diameter is achieved. Proliferative index of granulosa cells provides insight into the underlying cell biology of a follicle.

Modulation of ovarian follicle maturation and effects on apoptotic cell death in Holtzman rats exposed to 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) in utero and lactationally.

Recent reports have described the reproduction-modulating and endocrine-disrupting effects following exposure to toxic substances such as 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD). Herein, we set out (1) to determine whether TCDD exposure exerts detrimental effects on follicle maturation in the Holtzman rat ovary and (2) to determine whether the effects of TCDD are mediated in part via apoptotic cell death. In certain species, dioxin exposure is correlated with reduced fecundity, reduced ovulatory rate, an increased incidence of endometriosis, and various reproductive cancers. Although some of the effects of TCDD are mediated via the hypothalamic-pituitary axis, direct effects on the ovary have also been observed. In the present study, an oral dose of 1 microgram TCDD/kg maternal body weight was administered on Day 15 of gestation. Female pups were sacrificed on Postnatal Day 21/22, and the ovaries were excised, fixed for histologic analysis, and analyzed in a double-blind paradigm. The analysis included a count and measurement and classification of preantral and antral follicles throughout the entire ovary. The contralateral ovary from each animal was analyzed for DNA fragmentation indicative of apoptotic cell death. The results indicate that TCDD treatment significantly reduced the number of antral follicles in the size classes 50,000 to 74,999 microns2 and > 100,000 microns2. We also observed a reduction in the number of preantral follicles less than 50,000 microns2. No difference was observed in the degree of apoptotic cell death in antral (50,000 to > 100,000 microns2) and preantral follicles (50,000 microns2 to > 75,000 microns2) between TCDD-treated and control-treated tissues. These data support the hypothesis that TCDD results in a diminution in the number of antral and preantral follicles of certain size classes in animals exposed during critical periods of development, but that apoptosis does not appear to be the underlying mechanism in these particular follicles. This does not preclude apoptosis occurring in pools of smaller precursor follicles.

Comparison of mouse embryo development in open and microdrop co-culture systems.

Co-culture with numerous cell lines has been shown to improve in-vitro embryo development. It is usually performed in open culture without an oil overlay, or in relatively large volumes of medium (e.g. 0.5 ml) under oil. We compared the efficacy of open and microdrop co-culture systems using human endometrial and tubal cell lines and mouse zygotes. Although the mean pH values of the media from the tubal cell cultures (both open and oil-covered) decreased significantly over 5 days of culture, this did not appear to impair embryo development. Both co-culture and microdrop culture significantly improved blastocyst and hatching blastocyst formation rates. The combination of the two techniques (microdrop and co-culture) demonstrated the highest blastocyst formation and hatching blastocyst formation rates, as well as the highest mean cell numbers in hatching blastocysts. Co-culture in a microdrop is a superior system for mouse embryo culture.

Optimizing tubal epithelial cell growth promotes mouse embryo hatching in coculture.

PURPOSE: This study investigates the relationship between human tubal epithelial cell growth characteristics and mouse embryonic development to determine which cellular requirements should be preferentially provided in a coculture system. METHODS: Cell growth and viability were assessed for 5 days in alpha-minimal essential medium or human tubal fluid supplemented with 10% human serum or 10% synthetic serum. Two-cell mouse embryo development to blastocyst and hatching blastocyst stages was also assessed with or without coculture. RESULTS: Both epithelial cell growth and embryo development were dependent on serum supplementation with better cell viability and growth rates in human serum and better blastocyst development in synthetic serum. The highest proportion of hatching blastocysts was found in alpha-minimal essential medium and human serum with coculture. CONCLUSIONS: Culture conditions which improve tubal epithelial cell growth also improve the hatching rate of mouse embryos in coculture. This indicates that by meeting the metabolic and nutritional demands for epithelial cell growth, the beneficial effects of coculture on embryo development may be optimized.

Estrogen receptor and aromatic hydrocarbon receptor in the primate ovary.

We have previously shown by immunocytochemistry and autoradiography the presence of estrogen receptors (ER) in rhesus monkey ovary. Intense chromogen staining showed specific binding for ER in nuclei of germinal epithelium and granulosa cells of antral follicles; and radiolabeled ligand bound specifically to functional corpora lutea (CL). Although it is accepted that the germinal epithelium of the primate ovary contains ER, some controversy still persists regarding the intraovarian localization of this molecule. In addition, no data exist that localize the aromatic hydrocarbon (dioxin) receptor (AHR), which is known to modulate ER, to the primate ovary. In the present study, we show the presence of ER using Western blot analysis, and ER capable of binding DNA within intraovarian compartments in two species of the genusMacaca (rhesus macaque,Macaca mulatta and stumptail macaque,Macaca arctoides); extend these findings to human ovarian granulosa cells (GC) using Western blot, reverse transcription-polymerase chain reaction (RT-PCR), and gel mobility-shift analysis; and localize the AHR to intraovarian compartments of the macaque ovary by Western blots and gel-shift assays. These experiments strongly suggest that estrogens can exert effects on follicle development directly at the ovary, and provide the first direct evidence that AHR-mediated toxicity may be manifested at the ovary to induce possible antifertility effects.

Luteal phase estradiol and pregnancy outcome in gonadotropin releasing hormone agonist/human menopausal gonadotropin-treated gamete intrafallopian transfer cycles.

To correlate luteal estradiol (E2) levels with pregnancy outcome, 36 consecutive conceptions resulting from gamete intrafallopian transfer in gonadotropin releasing hormone agonist/human menopausal gonadotropin (GnRH-a/hMG) cycles were analyzed. GnRH-a was initiated during the preceding luteal phase. HMG was adjusted individually. Human chorionic gonadotropin (hCG), 5,000 IU, was administered when E2 was > 500 pg/mL and the leading follicle > 17 mm (day 0). The luteal phase was supported by (1) hCG, 1,500 IU in three doses from day 5 and (2) progesterone (P) from day 7. E2 and P levels were analyzed in three groups of patients: normally progressing pregnancy (NPP), abortion (AB) and preclinical abortion (PAB). No significant differences in mean E2 levels were seen between the groups from day 0 through day 5 after hCG. Midluteal E2 levels were significantly different between the groups (P < .05). Late luteal E2 values were significantly higher for NPP than for either AB or PAB (P < .05). There were no significant differences in luteal P values between the NPP, AB and PAB groups. Decreased luteal E2 appears to be associated with early pregnancy wastage; this may be due to inadequate endometrial support.

Elevated follicular fluid angiotensin II and pregnancy outcome.

OBJECTIVE: To assess whether a relationship exists between follicular fluid (FF) angiotensin II (AII) concentration and pregnancy outcome or earlier fecundity parameters and whether correlations exist among FF AII concentrations and P, E2, T, androstenedione (A), or various ratios of these. DESIGN: Retrospective study in which hormone concentrations in FF samples were measured. SETTING: In vitro fertilization clinic-Assisted Reproductive Technology Program, Rush Medical Center. PATIENTS: Twenty-six female patients underwent ovarian stimulation for IVF. INTERVENTION: Leuprolide acetate was combined with hMG and FSH for ovarian stimulation. MAIN OUTCOME MEASURE: Follicular fluid aspirates were collected and oocytes were recovered 34 to 36 hours after hCG injection. The patients proceeded to undergo IVF and ET. Follicular fluid hormones were measured using standard RIA. Angiotensin II and steroid hormone concentrations in FF were compared for pregnant versus nonpregnant women using the Student's t-test and rank-sum test. Pearson multiple-correlation analysis was performed to calculate correlation coefficients among AII concentrations and steroid concentrations in FF aspirates. RESULTS: Mean FF concentration of AII was significantly lower in samples from women showing clinical pregnancies (112.2 +/- 13.9 pg/mL [107.3 +/- 13.3 pmol/L]) compared with samples from women who did not achieve pregnancy (217.1 +/- 23.8 pg/mL [207.5 +/- 22.7 pmol/L]) (mean +/- SE). A negative correlation was observed between FF concentrations of AII and P. Correlations of AII with E2, T, A, or with ratios of these did not show significance. CONCLUSION: These data suggest that high AII concentration at time of oocyte recovery may indicate poor pregnancy outcome in women undergoing ovarian stimulation for IVF. These data corroborate previous results in animal models showing that AII predisposes follicles to undergo atresia-like conditions.

Effects of induced hyperprolactinemia on in vitro fertilization cycles.

OBJECTIVE: To investigate the effect of induced endogenous hyperprolactinemia on the luteinization process, as expressed by the shift in the P:E2 ratio after hCG injection in IVF cycles. PATIENTS AND INTERVENTIONS: Serum PRL, E2, and P levels were measured in 49 IVF patients (leuprolide acetate and hMG protocol) on the day of hCG injection. Estradiol and P also were measured on the day after hCG. Serum P:E2 ratios were calculated for two groups of patients; group I (control): PRL < or = 20 ng/mL (conversion factor to SI unit, 1.00); group II (hyperprolactinemia): PRL > 20 ng/mL. Estradiol and P also were measured in follicular fluid (FF) and the gamete performance was compared between groups. RESULTS: Data analysis showed no significant differences in the mean +/- SD serum peak E2 (pg/mL; conversion factor to SI unit, 3.671) between groups: group I, 1,769 +/- 843; group II, 2,333 +/- 1,194; the mean FF E2 (pg/mL) group I, 351 +/- 221; group II, 370 +/- 186; or the mean FF P (ng/mL; conversion factor to SI unit, 3.180) group I, 8,357 +/- 3,127; group II, 11,354 +/- 12,888. No significant differences were found between groups in the P:E2 ratios on days 1 or 2: group I, 78 +/- 48 and 209 +/- 137; group II, 70 +/- 47 and 224 +/- 197, respectively. The magnitude of the P shift also showed no significant difference between the two groups; the mean +/- SD shift in the P level was 2.9 +/- 2.2 for group I, and 4.3 +/- 5.1 for group II. The serum PRL level had no effect on the fertilization rate (60% for group I and 70% for group II) or on the pregnancy rate (17% for group I and 23% for group II). CONCLUSION: These findings suggest that mild endogenous hyperprolactinemia induced by ovarian stimulation does not affect granulosa cell luteinization and gamete performance in humans.

Hormonal profiles of early gestations with abnormal karyotype.

OBJECTIVE: To describe the hormonal profiles of chromosomally abnormal pregnancies during the first trimester. DESIGN: A prospective study from 1984 through 1990 in which infertility patients who conceived were monitored weekly with serum E2, P, and beta-hCG levels. SETTING: The infertility practice at Rush-Presbyterian-St. Luke's Medical Center in Chicago, Illinois. PATIENTS: Study included 15 women who had dilatation and curettage for first trimester fetal losses with confirmed abnormal karyotype, 6 women with chromosomally normal male abortuses, and 60 consecutive women whose pregnancies yielded normal term infants. RESULTS: After natural conception, E2 demonstrated a moderate rise in both normal and chromosomally abnormal pregnancies to approximately 300 pg/mL by day 29 (6 weeks of gestation). In normal gestations, E2 continued a steady increase to exceed the level of 1,000 pg/mL by day 64 (11 weeks of gestation). In chromosomally abnormal pregnancies, the mean E2 plateaued and remained at approximately 200 pg/mL until fetal demise was noted. In stimulated conceptions, the rise of E2 was sharp and early (1,200 pg/mL by day 29); in normal pregnancies, E2 steadily increased to an average of 1,400 pg/mL by the end of the first trimester, whereas in karyotypically abnormal gestations, E2 declined to approximately 200 pg/mL by day 64. In pregnancies yielding a male abortus, a sharp decline and plateau at 800 pg/mL by day 56 (10 weeks of gestation) was observed. In both natural and stimulated normal pregnancies, hCG levels first demonstrated a linear rise, followed by a curvilinear increase from day 29 until day 56, with a peak of approximately 110,000 mIU/mL. The beta-hCG in chromosomally abnormal pregnancies, as well as in pregnancies yielding a male abortus, was characterized by a slow and gradual rise to a maximum of 40,000 mIU/mL, which remained relatively linear until day 64 when fetal demise was detected in all cases. Progesterone level data were excluded from analysis because of frequent P supplementation. CONCLUSIONS: There were significant differences in the hormonal profiles of chromosomally normal and abnormal pregnancies. Serial measurements of serum E2 and beta-hCG from the 6th week of gestation may be useful in predicting an abnormal karyotype sooner than other current diagnostic tests.

Steroidogenesis of cultured granulosa cells in women at risk for ovarian hyperstimulation syndrome.

OBJECTIVE: To determine if cultured human granulosa cells (GCs) obtained from women at risk for ovarian hyperstimulation syndrome (OHSS) possess altered steroidogenic capacity. DESIGN: Prospective analysis of 28 consecutive in vitro fertilization-gamete intrafallopian transfer (IVF-GIFT) cycles. SETTING: In Vitro Fertilization Program at Rush Presbyterian St. Luke's Medical Center in Chicago, Illinois. PATIENTS: Eighteen patients (group I) with serum estradiol (E2) levels > 7,342 pmol/L on the day of exogenous human chorionic gonadotropin (hCG) administration (day 0) with > 10 ovarian follicles present (high risk for OHSS); 10 patients (group II) with E2 < or = 7,342 pmol/L on day 0 and < or = 10 follicles. INTERVENTIONS: Human GCs obtained during gonadotropin-releasing hormone agonist-pretreated IVF-GIFT cycles were cultured in the absence (control) or presence (hCG) of hCG, 1 IU/mL, and/or androstenedione (A) 10(-7) M. Granulosa cells obtained from follicles < or = 15 mm diameter were cultured separately from those obtained from follicles > 15 mm diameter. MAIN OUTCOME MEASURES: Estradiol (E2) and progesterone were measured in tissue-culture medium by a solid-phase direct radioimmunoassay. RESULTS: In vitro E2 production by cultured GCs was significantly increased in follicles < or = 15 mm diameter from women considered at risk of developing OHSS (group I). Estradiol response to hCG and/or A appeared enhanced in all follicles in group I. Progesterone production in the basal and hCG challenged state was greater in cells obtained from large follicles in group I than in group II. CONCLUSION: Ovarian hyperstimulation syndrome appears to be a function of an increased number of follicles that express an enhanced steroidogenic capacity.

Luteal phase support and severe ovarian hyperstimulation syndrome.

The incidence and statistical associations of the ovarian hyperstimulation syndrome (OHSS) were studied in 304 egg retrievals with gonadotrophin-releasing hormone agonist suppression, gonadotrophin administration and follicular aspiration. In addition to preserving corpus luteum function, the luteal phase administration of human chorionic gonadotrophin (HCG) was associated with a higher incidence of severe OHSS than was supplementation with progesterone alone (12 versus 0%, P less than 0.001). Severe OHSS occurred in 3.7% and 12% of retrievals without and with pregnancy respectively (P less than 0.01). Stepwise logistic regression showed that the occurrence of moderate or severe OHSS was statistically predicted by the log of the serum oestradiol on the day the initial HCG was given (P less than 0.0001), treatment with luteal phase HCG (P less than 0.0003), and fetal number (P less than 0.0079). In the late luteal phase of cycles without luteal HCG, the serum oestradiol concentration was one-tenth and the serum progesterone concentration was one-fifth of the luteal phase value with HCG support (P less than 0.001). Without luteal phase HCG, oestradiol was two-fold higher (P less than 0.001) and progesterone was 1.4-fold higher (P less than 0.005) in pregnant than in non-pregnant women. With luteal phase HCG, oestradiol was 1.4-fold higher in pregnant than in non-pregnant women (P less than 0.05), and progesterone was 1.7-fold higher (P less than 0.001). Oestradiol upper limits of 4400 and 14,700 pmol/l (1200 and 4000 pg/ml) for cycles with and without luteal phase HCG respectively correspond to approximately 5% risk of moderate or severe OHSS with a singleton pregnancy under these conditions.

Delayed ovarian response in oligomenorrheic women using gonadotropin-releasing hormone agonist.

Ovarian response to human menopausal gonadotropins (hMG) was studied in the presence or absence of prior ovarian suppression using gonadotropin-releasing hormone agonist in the same oligomenorrheic women. Delayed response, with higher hMG requirements, was observed in cycles with prior ovarian suppression.