A primary care approach to the infertile couple.

BACKGROUND: Approximately 20% of reproductive age couples have difficulty conceiving or maintaining an established pregnancy. The family physician is in a unique position to provide patient education, begin initial evaluation, make appropriate referrals, and offer ongoing counseling and support to couples who experience problems with fertility. METHODS: And extensive clinical review was conducted based on a MEDLINE search, the Cochrane database of systematic reviews, and other supporting evidence. RESULTS: Major physiologic influences affecting live birth rates include age, coital frequency, and duration of infertility. Male factor is associated with approximately 40% of these cases and should be addressed early in the evaluation. CONCLUSION: Many conditions once considered untreatable can now be routinely corrected. As managed care programs expand coverage to include infertility services, primary care providers will be asked to participate in the initial phase of this care. This article offers a practical approach.

Galactorrhea may be clue to serious problems. Patients deserve a thorough workup.

Three cases of nonphysiologic hyperprolactinemia associated with pituitary disease evidenced by galactorrhea are presented. Two patients had significant pituitary disease associated with low-level prolactin elevations. The third patient had only a history of infertility and expressible galactorrhea on examination. This patient was found to have high prolactin levels and a locally invasive pituitary tumor. Physicians need to be aware of the serious conditions associated with galactorrhea so that appropriate diagnostic studies can be done and treatment instituted.

Recombinant follicle-stimulating hormone in a patient hypersensitive to urinary-derived gonadotropins.

Hypersensitivity reactions are a documented complication of urinary-derived gonadotropin therapy. In this report, a patient allergic to these older products is successfully treated with recombinant follicle-stimulating hormone.

Esophageal atresia in an in vitro fertilization pregnancy.

Major congenital anomalies occur in approximately 4% of the newborn population. Although this risk is apparently the same for in vitro fertilization (IVF) pregnancies, couples having assisted reproduction therapy should receive appropriate genetic counseling, because coincidental maloccurrences are often erroneously linked to the technology. We report a case of newborn esophageal atresia with tracheoesophageal fistula occurring in an IVF pregnancy. Physicians are encouraged to educate all prospective parents regarding the rate of congenital anomalies in the general population so that they have realistic expectations concerning newborn outcome.

Rhodococcus equi infection in HIV-positive patients: report of 5 cases and literature overview.

The importance of Rhodococcus equi infection, an uncommon human pathogen that almost exclusively affects immunocompromised hosts, has greatly increased following the advent of acquired immune deficiency syndrome (AIDS) epidemics. Until the present time, 38 cases of R. equi infection have been described in human immunodeficiency virus (HIV)-infected patients; we now report a further five personal cases. R. equi was acquired via respiratory exposure to animals in less than half of the patients, and caused invasive pulmonary infection (91%), bacteraemia and sometimes bloodstream dissemination. R. equi was easily cultured from sputum or blood, but its diagnosis was often difficult due to microbiological and clinical similarities with other pathogens. The persistence of the micro-organism inside macrophages and its high tissular load represent the major limitation to an effective treatment. Several antibiotics are active in vitro, but their efficacy in vivo depends on macrophage uptake and/or bactericidal activity. Treatment should start with at least two intravenous bactericidal antibiotics for 3-4 weeks, and then continue with oral therapy for a period of up to several months with at least two intracellularly active drugs. Surgical resection of the lesions may be beneficial in selected cases.

Comparative analysis of torasemide and furosemide in liver cirrhosis.

This review concerns studies of the comparative efficacy and safety of torasemide and furosemide in patients with cirrhosis of the liver complicated by ascites and oedema. The short-term trials reviewed indicated that in patients who had failed to respond with adequate diuresis and loss of body weight and ascites to bed rest, restricted salt and water intake and spironolactone, torasemide had a longer duration of action than furosemide and resulted in a greater urinary excretion of salt and water and greater loss of body weight. Torasemide also had less effect than furosemide on urinary potassium excretion and unlike furosemide did not increase the fractional excretion of magnesium or phosphate or the blood ammonia concentration. Two longer term trials in similar patients with decompensated hepatic cirrhosis confirm the results of the shorter term studies. These studies, albeit each in relatively small numbers of patients, confirm the ability of torasemide to enhance diuresis, free water clearance and fractional excretion of sodium and chloride, resulting in loss of body weight and mobilization of ascites in patients with decompensated hepatic cirrhosis. In these patients, the relatively small increase in urinary excretion of potassium, induced by torasemide without any marked effect on renal function or on the plasma neurohormonal profile, enhances its potential safety.

Rhodococcus equi cavitary pneumonia in HIV-infected patients: an unsuspected opportunistic pathogen.

Two patients seropositive for human immunodeficiency virus (HIV) and with no previous acquired immunodeficiency syndrome-defining conditions developed cavitary pneumonia and pleural disease caused by Rhodococcus equi. R. equi was isolated from these patients' sputum and lung biopsy specimens, respectively, but the microorganism was initially considered to be a contaminant (patient 1) or misidentified as a nontuberculous mycobacterium (patient 2). The R. equi infection was fatal in one patient, who died after 4 months without specific antimicrobial therapy; the second patient was unresponsive to combination therapy with various antimicrobial agents. R. equi may cause life-threatening infections in HIV-infected patients. Microbiology laboratories should be cognizant of the need to exclude R. equi as a cause of infection in highly immunosuppressed patients.

Incidence of anti-hepatitis C virus antibodies in non-A, non-B post-transfusion hepatitis in an area of northern Italy.

A total of 210 patients consecutively submitted to heart surgery at the Parma University Hospital and transfused with 1,898 units of blood were followed after transfusion in order to evaluate both the incidence of anti-hepatitis C virus (HCV) seroconversion in non-A, non-B post-transfusion hepatitis (PTH-NANB) cases and the usefulness of the screening for anti-HCV in comparison with that for serum glutamic pyruvic transaminase (SGPT) values in preventing PTH-NANB transmission. Fifteen recipients developed PTH-NANB (group A); ten of them (66.6%) showed anti-HCV seroconversion within 3-12 months. Eight of the ten anti-HCV positive patients developed chronic hepatitis, but none of the five PTH-NANB anti-HCV negative did. None of the 15 controls (group B) randomly chosen among the patient population showed anti-HCV seroconversion. A close correlation with the transmission of PTH was showed by anti-HCV positivity but not by SGPT elevation in blood donors. Eleven of 172 blood products transfused to group A but none of 139 products transfused to group B were anti-HCV positive. The incidence of elevated SGPT values was similar between the two groups of the transfused blood products. Nevertheless, the correlation observed between anti-HCV positivity and SGPT levels in the blood products involved in PTH confirms the need to exclude blood donors with abnormal SGPT values. On the whole, anti-HCV screening of donors showed a predictive value higher than that of SGPT (100% vs. 53.3%), allowing a minor blood donation exclusion.(ABSTRACT TRUNCATED AT 250 WORDS)

Epidemiological study of urinary tract stones in a northern Italian city.

An epidemiological study of stone disease in a Northern Italian city was carried out by means of a postal questionnaire mailed to 6000 individuals (2.5% of the entire population). It was found that the incidence of stone disease was comparable to that of industrialised Western Europe. There was a relationship between stone disease and gout and stone disease and a positive family history. The frequency of uric acid stones was high (26.5%). Stone-formers showed no alimentary differences from non-stone formers apart from the use of spices and herbs. Stone-formers used less water from public aqueducts and more uncarbonated mineral water, but only 19% of these drank at least 2 litres a day.

[Renal colic: behavior of urinary parameters in the assessment of lithogenic risk]. / Colica renale: comportamento dei parametri urinari di valutazione del rischio litogeno.

In patients with renal colic we studied lithogenic urinary risk factors before and after the stone passage. We showed abnormalities in water, electrolytes and other substances excretion due to retention and metabolic disorders. The effects more pronounced is on urinary sodium, calcium, magnesium and ammonium. Citrate behaviour suggests a transient intracellular acidosis.

Determination of oxalate in urine by flow injection analysis.

A method is described for the determination of oxalate in urine using flow injection analysis and fluorimetry. Oxalate is precipitated with calcium chloride at pH 4.5, redissolved in H2SO4 and measured by flow injection analysis. The minimum detection limit is 6 mumol/l. The coefficient of variation is 7%. Results are in good accordance with normal values found with traditional oxalate analysis.

Plasma and skeletal muscle free amino acids in type I, insulin-treated diabetic subjects.

Insulin-dependent diabetes mellitus (IDDM) induces plasma amino acid (AA) abnormalities, including low alanine and high branched-chain (BCAA). While insulin treatment restores plasma AA pattern, proline, methionine, valine, isoleucine, and total BCAA remain elevated in skeletal muscle intracellular water. This suggests that the restoration of plasma AA concentrations is not a satisfactory index of recovered AA metabolism in IDDM.

Metabolic, water and electrolyte changes after moderate surgical trauma. Observations after different schedules of parenteral nutrition.

The effects of a moderate surgical trauma on body composition, in conditions comparable to fasting were assessed in a balance study. Two groups of patients under normal nutritional conditions were compared after cholecystectomy. The patients underwent for three days the following schedules of parenteral therapy: incomplete nutrition with balanced intake of water, sodium and potassium but carbohydrate deficient and lacking in amino acids (group 1, 10 cases); or complete nutrition with respect to calories, amino acids and other electrolytes (group 2, 9 cases). An evident loss in body weight was observed in patients undergoing incomplete nutrition, not justified by a moderately negative water balance. Statistical comparison of the two groups showed equal or positive balances for group 1 while group 2 gave negative results for all the parameters, particularly for nitrogen and potassium, suggestive of a loss in lean body mass greater than that usually occurring after simple fasting. Results confirmed the poor significance of serum values in expressing even significant degrees of electrolyte depletion. Substantial modifications in body composition may appear as clinical manifestations in cases with pre-existing malnutrition or when drugs that affect or are affected by the water and electrolyte balance are administered.

Skeletal muscle water and electrolytes in treated and untreated essential hypertension.

The question whether body electrolyte composition in patients with primary hypertension differs from that of normotensive subjects is still controversial. The aim of the present work was to investigate on water, electrolyte, and nitrogen muscle cell composition in essential human hypertension. Also the effects of antihypertensive drugs on muscle electrolyte contents were analyzed. The results indicate that muscle Na was higher and muscle K was lower in essential hypertensives in comparison with controls. Muscle water, Mg, and nitrogen were not different in treated patients (with or without diuretics) in comparison with untreated hypertensive patients. But in hypertensive patients treated with diuretics, Nam was higher and Km was lower than in untreated patients. Several mechanisms may explain the changes on muscle electrolyte composition in primary hypertension, but the cellular mechanism involving abnormalities in ion pump and electrolyte transmembrane fluxes are the most probable. The therapy with antihypertensive drugs especially diuretics, seems to enhance different muscle electrolyte patterns in essential hypertension.