Mycobacterium haemophilum infection in an SLE patient on mycophenolate mofetil.

We describe a case of Mycobacterium haemophilum in an immunocompromised patient with systemic lupus erythematosus (SLE). Mycobacterium haemophilum is a recently described pathogen which has not been previously described either in SLE patients or patients on Mycophenolate Mofetil. Mycobacterium haemophilum can be difficult to diagnose, as it may not have the granulomas characteristic of atypical mycobacterial infections. Combination therapy with at least two drugs for several months is required and the outcome depends on the patient's underlying immunocompromised state. Our report highlights the need for early diagnosis and treatment of Mycobacterium haemophilum in immunocompromised patients with SLE.

Nonfatal and fatal infections caused by Chromobacterium violaceum.

Human infection caused by Chromobacterium violaceum is rare, but when it occurs it is associated with a high mortality rate. We report the cases of two patients with infection due to Chromobacterium violaceum. One patient presented early in the course of disease and survived after receiving appropriate antibiotic therapy. The other patient presented late in the course of disease and died of fulminant sepsis with abscesses in multiple organs. We discuss the similarity between C. violaceum infection and the septicemic form of melioidosis.

Langerhans cell histiocytosis presenting as a goitre: a case report.

We report a case of Langerhans cell histiocytosis (histiocytosis X) in a 36-year-old female with an euthyroid nodular goitre as the rare initial presentation. She subsequently developed a pathological fracture of the lumbar spine which was initially thought to be due to malignant infiltration, possibly from metastatic thyroid carcinoma. Open vertebral biopsy and total thyroidectomy were performed. Histological features of histiocytic proliferation with erythrophagocytosis were found in both the thyroid gland and in the involved vertebral body. The diagnosis of histiocytosis X was made on the basis of the positive immunoperoxidase staining of the histiocytic cells with S-100 and peanut agglutinin (PNA) as well as the clinical picture. Despite systemic chemotherapy with low dose corticosteroids and vinblastine, diabetes insipidus with a suprasellar mass occurred three years post thyroidectomy. Successful management of this uncommon disease is difficult to conduct and evaluate at the present time.

In vitro fertilization culture medium surveys. A College of American Pathologists pilot proficiency testing survey.

Two pilot surveys for in vitro fertilization culture medium were conducted by the Reproductive Biology Resource Committee of the College of American Pathologists. The first phase (February 1991) involved seven laboratories, all of them being members of the committee, while the second phase (April 1991) also included other laboratories that voluntarily participated in the survey. Questionnaires accompanied the media and included variables such as conditions of shipment and measurements of pH and osmolarity, along with quality control results obtained from mouse embryo culture studies. Of the two medium samples per shipment, one was adulterated with an embryotoxic substance. The results of these surveys revealed consistency in most laboratories, while some laboratories could be easily identified due to their out-of-range results. These surveys have described the first attempts to develop an intralaboratory testing system for clinical in vitro fertilization laboratories. Further studies will be required to achieve greater consistency among laboratories with respect to implementation of the survey and reporting of results. Additionally, other systems should be evaluated, particularly for those laboratories that use systems other than mouse embryo culture.

Pregnancy outcome in neosalpingostomy by the cuff vs Bruhat technique using the carbon dioxide laser.

Distal tubal occlusion is one of the most challenging conditions that the reproductive surgeon faces in the management of tubal disease. This study was designed to compare the pregnancy rates between two well-known techniques for tuboplasty using the carbon dioxide laser from March 1982 to October 1988. Alternate infertility patients with distal tubal occlusion were assigned to either a cuff or Bruhat technique. Only patients with bilateral hydrosalpinges and no other infertility factors qualified for this study. Nineteen patients had a cuff neosalpingostomy, and 15 patients had a Bruhat neosalpingostomy. Two patients who were assigned to the Bruhat technique had to be changed to the cuff technique because of technical problems. The mean age and length of infertility were similar in both groups. Six patients in the cuff group (31.6%) and 5 (33.3%) in the Bruhat group conceived. One ectopic pregnancy occurred in each group. This study shows that both techniques produce similar pregnancy rates. The Bruhat technique is considerably faster but cannot be applied adequately when the fallopian tubes have thick walls.

Comparison of three modes of treatment for infertility patients with minimal pelvic endometriosis.

Minimal pelvic endometriosis can be the only pathology found in infertility patients undergoing an infertility work-up. Although the mechanism by which endometriosis causes infertility is not known, it is well established that pregnancy can be attained in many patients when this disease is treated. Three different modes of treatment were used in 167 infertility patients who had minimal pelvic endometriosis without other pelvic pathology. Group I (danazol) achieved 48.9% pregnancy rates (23/47), group II (CO2 laser) had 44.6% pregnancy rates (37/83), and group III (CO2 laser and danazol) achieved 51.4% pregnancy rates (19/37). Although the pregnancy rates in groups I and III were higher, they were not statistically significant when compared with group II.

Laser laparoscopy versus laparotomy in the treatment of infertility patients with severe endometriosis.

The best pregnancy rates reported in the literature for infertility patients with severe pelvic endometriosis (stage IV) have been attributed to surgical management. In the last few years, improved endoscopic instruments have allowed gynecologists to treat difficult conditions with the CO 2 laser via laparoscopy, with good results. To assess the usefulness of the CO 2 laser via laparoscopy in treating severe pelvic endometriosis, two groups of patients were studied. Thirteen patients were treated by laparotomy (group I) and 11 patients by laparoscopy (group II). Seven achieved pregnancy in group I (53.8%), and pregnancy occurred in 6 patients in group II (54.5%). This study suggests that the management of severe pelvic endometriosis in infertility patients via laparoscopy seems to yield similar pregnancy rates to those treated with laparotomy, with the advantages of faster recovery and fewer hospitalization days for those undergoing laparoscopic surgery.

Evaluation of the clinical performance of three triphasic oral contraceptives: a multicenter, randomized comparative trial.

Three hundred thirteen women participated in an open, multicenter comparison of the incidence of intermenstrual bleeding (breakthrough bleeding and or spotting) associated with the use of three triphasic oral contraceptives. Triphasil (n = 107), containing levonorgestrel and ethinyl estradiol, and Ortho-Novum 7/7/7 (n = 97) and Tri-Norinyl (n = 109), both of which contain norethindrone and ethinyl estradiol, were administered over four cycles for a total of 1141 cycles. The total incidence of intermenstrual bleeding was significantly lower with Triphasil (17.2%) than with Ortho-Novum 7/7/7 (39.5%) or Tri-Norinyl (49.0%). The pattern remained the same when findings were analyzed cycle by cycle and for breakthrough bleeding and spotting separately. The incidence of other side effects was comparable for all regimens. Results of this study demonstrate superior cycle control with Triphasil compared with Ortho-Novum 7/7/7 and Tri-Norinyl during the first four cycles of use.

PIP: 313 women participated in an open, multicenter comparison of the incidence of intermenstrual bleeding (breakthrough bleeding or spotting) associated with the use of 3 triphasic oral contraceptives. Triphasil (n=107), containing levonorgestrel and ethinyl estradiol, and Ortho-Novum 7/7/7 (n=97) and Tri-Norinyl (n=109), both of which contain norethindrone and ethinyl estradiol, were administered over 4 cycles for a total of 1141 cycles. The total incidence of intermenstrual bleeding was significantly lower with Triphasil (17.2%) than with Ortho-Novum 7/7/7 (39.5%) or Tri-Norinyl (49.0%). The pattern remained the same when findings were analyzed cycle by cycle and for breakthrough bleeding and spotting separately. The incidence of other side effects was comparable for all regimes. Results of this study demonstrate superior cycle control with Triphasil compared with Ortho-Novum 7/7/7 and Tri-Norinyl during the first 4 cycles of use.

Identification and management of clomiphene citrate responses.

Clomiphene citrate (CC) is widely used for induction of ovulation; however, adequate time is rarely used to monitor patients on this form of therapy. Two hundred thirty-one infertility patients qualified for this study in 1155 cycles, during which basal body temperature charts were kept and the quality of cervical mucus was evaluated. Nine types of responses were classified: three ovulatory (O1, O2, O3), three anovulatory (A1, A2, A3), and three miscellaneous (M1, M2, M3). The overall, uncorrected pregnancy rate was 54.9%, and 79.2% showed ovulatory responses. The most common response was O1 (normal responses, 38.5%) with the highest pregnancy rates (92.1%). Poor estrogenic response with poor cervical mucus (CM) (O2) was fairly common (13.4%) and had poor pregnancy rates, even with the addition of estrogens (12.9%). It is suggested that this new classification of CC responses will help to identify and more efficiently manage patients undergoing this form of therapy.

Usefulness of double-puncture laparoscopy in the infertility work-up.

This retrospective study confirms that laparoscopy should be performed early in the infertility investigation when pelvic pathology is suspected. If performed, the procedure should be via the double-puncture technique. Otherwise, it should be done when the rest of the tests have proven to be within normal limits and there is only the possibility of peritoneal involvement (i.e., pelvic adhesions or pelvic endometriosis). Our impression is that the single-puncture technique seriously compromises the physician's ability to assess pelvic pathology adequately.

Influence of weight in the induction of ovulation with human menopausal gonadotropin and human chorionic gonadotropin.

Patients failing to ovulate and conceive on clomiphene citrate (CC) or CC plus human chorionic gonadotropin (hCG) or patients with pituitary gonadotropin deficiency are candidates for human menopausal gonadotropin (hMG) plus hCG therapy. The duration and number of ampules needed to stimulate ovarian response leading to ovulation and/or pregnancy vary individually. Seventy-one patients who had complete follow-up evaluation and accurately documented body weights at the time of therapy were considered for the study. Of these 71 patients, 41 (57.3%) conceived in 293 cycles. The average number of ampules of hMG used by patients with 10% to 20% below ideal body weight (IBW) was 13.9 +/- 6.3 (mean +/- standard deviation [SD]). The average number of ampules used by patients with normal +/- 10% IBW was 14.2 +/- 3.5. Patients who were overweight by 10% to 25% used 15.3 +/- 5.4 ampules, and patients overweight by greater than or equal to 25% used 20.9 +/- 5.6 ampules of hMG. Eleven patients with severe hypothalamic chronic anovulation needed an average of 20.6 +/- 6.2 ampules. The data reveal a direct relationship between IBW and the amount of hMG needed to induce ovulation and/or pregnancy; however, in the presence of chronic hypoestrogenic conditions, it is expected that these patients will need higher amounts of hMG, regardless of body weight.

Postmortem endocrine levels in the vitreous humor.

The vitreous humor and sera from 51 autopsy cases were assayed for progesterone, estradiol, thyroxine, triiodothyronine, TSH, FSH, LH and prolactin. The results indicate that the blood retinal barrier has unique properties of its own. All hormones were measurable in the sera. Progesterone, estradiol, T3 and T4 were not detected despite their lipid solubility and their small molecular size while the larger glycoprotein hormones were easily measureable.

Pulmonary edema as a cause for fulminant death following microinjection of kainic acid into the rat medulla oblongata.

The present study confirmed histopathologically the suggestion that pulmonary edema may underlie the fulminant death following microinjection of kainic acid into many medullary sites in rats anesthetized with pentobarbital sodium. We also observed a sustained elevation in systemic arterial pressure, cardiac contractility and heart rate before the animal succumbed to kainate neurotoxicity. It is suggested that the increased systemic hydrostatic pressure may retrogradely promote pulmonary hypertension that precipitates pulmonary edema.

Danazol versus carbon dioxide laser plus postoperative danazol: treatment of infertility due to mild pelvic endometriosis.

The mechanism of action by which mild pelvic endometriosis causes infertility is still unknown. Danazol has been proposed as the sole agent to treat this condition; however, the results for pregnancy rates do not give as much cause for enthusiasm at the present time as they did when this drug was introduced. To ascertain the role of laser via the laparoscopic approach, this retrospective study looks at the pregnancy success rate in two groups of patients. Group I was treated with danazol alone; group II was treated with danazol after laser surgery. Although the success rate is better in group II, the population sample in both groups is modest and does not allow one to draw meaningful statistical conclusions at the present time, but the use of carbon dioxide laser with the laparoscope plus postoperative danazol seems to be a better approach to this condition that affects the infertile female.

Management of pelvic endometriosis by means of intraabdominal carbon dioxide laser.

A significant number of patients with severe pelvic endometriosis are at risk of developing pelvic adhesions and/or loss of ovarian function. Although numerous surgical techniques have been advocated, none has any clear advantage over the others. This article presents a new surgical method for conservative management of pelvic endometriosis. The CO2 laser, directed via the microscope or the freehand piece of the articulated arm, was utilized to vaporize focal endometrial implants, to excise endometrial cysts, and to lyse pelvic adhesions in 54 patients. Fourteen of 23 patients (60.8%) attempting pregnancy have conceived at the time of this report. The observed advantages of laser surgery for endometriosis are a bloodless field, precision destruction (vaporization), precision cutting, and the ability to treat poorly accessible areas.

The neglected laboratory test. The semen analysis.

Sixty-four laboratories from Connecticut, Massachusetts, and California were involved in a comparison of the types of semen analyses offered. The collected data indicate that there is a wide range of normal values for each parameter considered in a semen analysis. Very few laboratories gave simple and precise instructions for collection of the specimen. In many instances there was no record of the collection time or of the arrival time of the specimen at the laboratory. Most laboratories did not report motility or forward progression at time intervals, and abnormal morphology was not broken down according to the types of abnormalities involved. These data indicate the absolute need for adequate standardization of this important test, which is the basis upon which the clinician makes the important decision of implicating the male partner in the couple's infertility problem.

Intraabdominal surgery with the CO2 laser.

The CO2 laser produces a highly directional and collimated light beam that may be precisely focused to a fine point. Because the laser beam physically removes tissue by vaporization, causes little damage to neighboring cells and seals small vessels, a minimum amount of suture material is required and scar formation is reduced. Although the laser has been utilized commonly in recent years to treat lower genital tract pathology, its application to intraabdominal surgery is in the early developmental phase. Special adaptations of the operative microscope and special accessory instruments are necessary before the laser can be used within the abdominal cavity. One hundred twenty-one cases are described to illustrate the technique and use of the laser for infertility surgery and for the treatment of pelvic endometriosis.