Human immunodeficiency virus-specific and CD3-redirected cytotoxic T lymphocyte activity in the human female reproductive tract: lack of correlation between mucosa and peripheral blood.

CD8(+) T cell phenotype and function were assessed in the female reproductive tracts (FRTs) of 3 human immunodeficiency virus (HIV)-positive patients who had undergone hysterectomy. FRT cytotoxic T lymphocyte (CTL) lytic activity from 1 patient (patient 872) was detected by using CD3-dependent redirected-lysis assay and HIV-specific assay, concomitant with the presence of CD8(+) cells. In contrast, samples from the 2 other HIV-positive patients (patients 1356 and 1364), who also were asymptomatic for HIV-associated illnesses, demonstrated no CTL activity in any solid tissue tested by either assay, despite activity by autologous peripheral blood mononuclear cells (PBMC). This absence of CTL activity was correlated with a relative absence of CD8(+) cells in the FRT, whereas CD8(+) cells were present in PBMC. Thus, CTL activity in PBMC may fail to correlate with mucosal activity. The finding of CTL activity in the FRT of patient 872 represents the first description of CTL in upper and lower FRT tissues of an HIV-positive woman.

Has the impact of hormone replacement therapy on health-related quality of life been undervalued?

Previous economic evaluations of hormone replacement therapy (HRT) have restricted positive effects to alleviation of postmenopausal symptoms and negative effects to drug side effects. We studied the association between HRT use and postmenopausal women's valuation of both health-related quality of life and potential treatment side effects. Postmenopausal women with either a documented first vertebral fracture within the past 5 years or no history of osteoporotic fractures were recruited from Olmsted County, Minnesota, and from Dartmouth-Hitchcock Medical Center in New Hampshire to participate in a study to assess quality of life and women's attitudes toward osteoporosis prevention. Women's valuations of their current health and potential HRT-related side effects were quantified as quality-adjusted life years (QALYs) assessed by an automated utility assessment instrument (U-Titer) and the time tradeoff technique, by a vertical rating scale, and by estimated quality of well-being (QWB) scores. Health status was measured using the Medical Outcomes Study SF-36. Regression methods were used to assess the impact of current HRT use on health-related quality of life and valuation of side effects. There were 106 women with vertebral fracture and 180 with no history of hip, wrist, or vertebral fractures. Altogether, 116 (40.6%) women were currently taking HRT, 64 (22.2%) had taken HRT in the past, and 106 (37.1%) women had never taken HRT. Current HRT users had higher time tradeoff QALYs than never and past HRT users, with gains ranging from 15.0 to 83.7 days per year for current users relative to the others. Benefits were largest for women with a vertebral fracture and limitations in activities. The secondary QALY measures also showed significantly higher values for current HRT users compared with other women, as did SF-36 subscales for general health, physical function, role-emotional function, and vitality. There was substantial variability in women's perceptions of HRT side effects. Overall, the proportion of women willing to trade time to avoid bleeding was largest, at 95.5%, followed by breast tenderness, weight gain, and endometrial biopsy at 90.4%, 87.4%, and 82.7%, respectively. Current HRT users had higher health-related quality of life than past or never users according to all measures studied. Women's perceptions of potential side effects were highly variable and should be considered by physicians when prescribing an HRT regimen. If, as our results suggest, postmenopausal therapy has positive effects beyond the immediate postmenopausal years, previous economic studies may have underestimated the value of HRT.

The relationship between trauma, PTSD, and medical utilization in three high risk medical populations.

OBJECTIVE: Increased use of medical and psychiatric services has been reported as a correlate of exposure to trauma. Recent studies suggest that: 1) physical and sexual abuse traumas are particularly associated with increased utilization and 2) posttraumatic stress disorder (PTSD), a common sequela of abuse, mediates the relationship between trauma exposure andelevated utilization. The goal of this study was to explore the relationships between trauma, abuse, PTSD, and medical utilization in three medical help seeking groups reported to be at high risk for trauma exposure. METHOD: One hundred and seven patients receiving care at a university-affiliated medical center were surveyed for trauma history and PTSD using the Trauma History Questionnaire (THQ) and the PTSD Checklist (PCL). The sample included: forty-eight gynecologic outpatients, thirty-five inpatients with seizure disorders, and twenty-four psychiatric inpatients with non-PTSD admitting diagnoses. Medical utilization data were obtained from a computerized medical center data base. RESULTS: Ninety-six patients reported a trauma history. Of these patients, sixty-six reported abuse and forty-five qualified for PTSD diagnoses. Total number of traumas and reported sexual and physical abuse correlated significantly with elevated medical utilization and PTSD prevalence. PTSD diagnosis was not significantly correlated with utilization, but the five highest utilizers received PTSD diagnoses. CONCLUSIONS: Study results supported hypotheses regarding the relation of trauma exposure to medical utilization, but were less clear about the mediating role of PTSD. These findings suggest that routine screening of high-risk patient groups might promote timely identification of trauma history and PTSD, and subsequently impact health care utilization.

Vabra aspirator and pipelle endometrial suction curette. A comparison.

OBJECTIVE: To compare the Pipelle suction curette with the Vabra aspirating catheter in terms of their ability to obtain a sufficient amount of tissue (> or = 1 mm2 of endometrium) in order to make a histologic diagnosis. STUDY DESIGN: A prospective, randomized, double-blind, crossover study at Dartmouth-Hitchcock Medical Center, which serves as the clinical staff of the Dartmouth Medical School. RESULTS: Agreement between the Pipelle and Vabra was high: 74 of 79 (93.7%) samples. The Pipelle obtained adequate samples in 78 of 79 (98.7%) cases as compared with 75 of 79 (94.9%) for the Vabra. The McNemar test comparing these two proportions, adjusting for the fact that the Pipelle and Vabra readings were taken on the same subjects at the same visits, yielded a nonsignificant result (P = .180). CONCLUSION: The Pipelle and Vabra have equal diagnostic accuracy.

A bipolar radiofrequency catheter fails to occlude a feline uterine horn: A model for fallopian tube occlusion.

We developed a retrograde transvaginal-transcervical-transuterine sterilization technique capable of causing occlusive fibrosis and stricture in the human fallopian tube. The procedure is required to induce a lesion at the intramural-isthmic portion of the tube at sufficient depth to damage epithelium underlying the submucosa and inner muscular layer, without acute damage to the outer muscular layer and serosal surface. Nineteen nulliparous purpose-bred cats were induced and maintained in an anestrus state with testosterone cypionate 5 mg/kg intramuscularly and a 6-18-hour light-dark cycle. After laparotomy, all animals had focal radiofrequency lesioning of uterine horns. Ten of 30 treated uterine horns appeared grossly occluded at the time of sacrifice; however, histologic assessment demonstrated only 6 complete occlusions, and 4 horns showed lack of complete lumen occlusion with or without evidence of recanalization. Although no complications were encountered, bipolar radiofrequency failed to provide a consistent obstructive lesion in a tubular structure similar in size and morphology to the human fallopian tube.

A comparison of clomiphene citrate and human menopausal gonadotropin for use in conjunction with intrauterine insemination.

OBJECTIVE: To compare the outcome of superovulation using clomiphene citrate (CC) versus hMG in conjunction with IUI. DESIGN: Sequentially assigned, observational study. Couples initially were assigned to receive either CC or hMG for three cycles. SETTING: The Clinical Outpatient Department of the Dartmouth-Hitchcock Medical Center. PATIENT(S): Eighty-three infertile couples. INTERVENTION(S): IUI with hMG use. MAIN OUTCOME MEASURE(S): Conception rate, term pregnancy rate (PR), and pregnancy complications, such as spontaneous miscarriage and multiple gestation. RESULT(S): Of 83 couples who underwent at least one treatment cycle, 29 (35%) conceived during the study period. The relative rate of conception for hMG versus CC was 2.08 (95% confidence interval [CI], 0.93 to 4.68). The relative term PR was 2.10 (95% CI, 0.77 to 5.73) for hMG versus CC. There was no difference in the miscarriage rate for hMG versus CC. CONCLUSION(S): Both the conception rate and the term PR were higher using hMG, compared with CC, in combination with IUI, and showed a trend toward statistical significance.

Virilization during pregnancy with spontaneous resolution postpartum: a case report and review of the English literature.

The incidence of gestational hyperandrogenism secondary to ovarian pathology is low. However, when the condition does exist, diagnosis should be made with minimally invasive modalities. It is important to provide appropriate medical/surgical intervention without disturbing the pregnancy iatrogenically or causing unnecessary maternal morbidity. This case report adds to the existing radiographic data concerning this rare obstetrical condition. Presented is a review of the English literature on virilizing ovarian tumors during pregnancy, and a discussion of an approach to managing these tumors when they occur during pregnancy.

Antisperm antibodies in women: variability in antibody levels in serum, mucus, and peritoneal fluid.

OBJECTIVE: To look for patterns of antisperm antibody expression in women by exploring the levels of antisperm antibodies in different body fluids. This was achieved by studying sequential serum samples from individual patients and by comparing the levels of antisperm antibodies in serum from a number of patients with the levels of antisperm antibodies in cervical mucus or peritoneal fluid (PF). DESIGN: Prospective studies were performed on sequential serum samples within a menstrual cycle. Retrospective studies were done to compare antisperm antibodies in serum and mucus or PF. The immunobead assay was used to measure antisperm antibodies in these fluids. SETTING: Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire. PATIENTS: A random sample of patients undergoing evaluation for infertility. RESULTS: The levels of antisperm antibodies in sera drawn from patients at different points in a menstrual cycle stimulated by the presence of exogenous hormones did not change during the follicular phase of the menstrual cycle. Also, in many samples, the antisperm antibody level in serum did not correlate with the antisperm antibody levels in mucus or PF. CONCLUSIONS: The data suggest that measurement of antisperm antibodies at a single point in time or from a single fluid is not sufficient when evaluating a woman for immunological infertility. The data also suggest that numerous and complex factors contribute to the expression of antisperm antibodies in women.

A 10-year prospective study of women with a history of recurrent fetal losses fails to identify Listeria monocytogenes in the genital tract.

An attempt was made to isolate L. monocytogenes from the cervix and endometrium of patients who presented to the Dartmouth-Hitchcock Medical Center's Reproductive Counseling Unit with a history of two or more fetal losses. Endometrial tissue and endocervical swabs were cultured in a prospective fashion for the presence of L. monocytogenes. During the 10-year study period, none of the patients with recurrent fetal losses were found to harbor the organism in their genital tract. It would appear that L. monocytogenes contributes to fetal loss, but probably not on a recurrent basis. Routine culturing for L. monocytogenes in the asymptomatic patient in a clinical setting is not cost-effective and is therefore unwarranted. The portal of entry is possibly the GI tract, with bacteremia and transplacental spread to the fetus. Ascending infection through the introduction of L. monocytogenes into the vagina and cervix may occur. Because of the difficulty in identifying L. monocytogenes in the feces, as well as the self-limiting nature of listeriosis, it would appear unwarranted to give routine administration of antibiotics in patients who have had a history of a fetal loss because of L. monocytogenes.

Alveolar and peritoneal macrophages bear three distinct classes of Fc receptors for IgG.

The FcR for IgG on the plasma membrane of cells of the mononuclear phagocyte system mediate a number of different biologic responses such as phagocytosis, pinocytosis, superoxide generation, and antibody-dependent cytotoxicity. In the interest of understanding the pathophysiology of these processes we have begun to characterize the FcR for IgG on two readily available sources of macrophages--the lung and the peritoneum--using antireceptor mAb. We find that all three of the distinct classes of FcR for IgG which have been described in man are present on both pulmonary and peritoneal macrophages. Most monocytes, we suggest, bear low numbers of Fc gamma RIII whereas a small subpopulation of monocytes expresses substantial numbers of Fc gamma RIII. Furthermore, we find that two different forms of Fc gamma RIII differ in their capacity to bind anti-Fc gamma RIII mab 3G8 in the presence of human IgG. Human IgG does not block the binding of mAb 3G8 to neutrophils, but it does block 3G8 binding to macrophages and large granular lymphocytes; this finding correlates with the expression of the two Fc gamma RIII genes, I and II, in man. Studies aimed at illuminating the molecular mechanisms of Fc gamma R-mediated processes in macrophages will require consideration of the receptors of all three classes.

Glucocorticoid effects on the production and actions of immune cytokines.

The immunosuppressive actions of glucocorticoids form the basis for their use in treatment of autoimmune diseases and prevention of allograft rejection. However, the mechanisms responsible for glucocorticoid-induced immunosuppression are still poorly understood. It is now clear that glucocorticoids do not inhibit all aspects of the immune response and, in some cases, may enhance certain functions of immune effector cells. One example is that of the dramatic increase induced by IFN-gamma in the number of IgG Fc receptors on human mononuclear phagocytes, which is enhanced rather than inhibited by glucocorticoids. An aspect of the immune response which appears to be consistently suppressed by glucocorticoids is the production of immune cytokines. Since these hormones appear to be essential mediators for a vigorous immune response, inhibition of their production may be an effective way for glucocorticoids to block the immune response.

Serum progesterone, 17 alpha-hydroxyprogesterone, human chorionic gonadotropin, and prolactin in early pregnancy and a case of spontaneous abortion.

Sequential serum samples were obtained from each of seven healthy volunteers whose dates of conception were carefully monitored, with the use of artificial insemination techniques. Progesterone, 17 alpha-hydroxyprogesterone, beta-hCG, and prolactin were measured by radioimmunoassay, utilizing specific antibodies. Of the seven initial volunteers, six women delivered viable, healthy infants. The seventh woman aborted spontaneously during the 10th week after conception. In the control patients, the levels for beta-hCG rose in a predictable fashion, rising to mean peak levels (10,000 mIU/ml) by the 8th week after conception. Progesterone concentrations gradually increased and plateaued from the 3rd to the 9th week. Mean progesterone values during that time period ranged from 20.6 to 24.6 ng/ml. The mean peak values of 4 ng/ml 17 alpha-hydroxyprogesterone was reached by the 3rd week after conception, gradually declining to luteal levels by the 8th week after conception. Prolactin remained below 30 ng/ml until the 7th week after conception, increasing gradually thereafter. This study failed to show that 17 alpha-hydroxyprogesterone was a reliable marker of corpus luteum function in pregnancy. Endocrine parameters reliably predicted fetal jeopardy in the abortion patient.

Probable parasellar meningioma in a pregnant woman.

An intracranial meningioma was diagnosed in a 28-year-old woman during the second trimester of her fifth pregnancy. Similar cases in the literature are reviewed and the experience at Thomas Jefferson University Hospital with intracranial neoplasms occurring in pregnant woman during the 10-year period from January 1965 to January 1976 is reported. The management of the reported patient and the pathophysiology of meningiomas are discussed.

Removing a sewing needle from the pelvic cul-de-sac with an operative laparoscope.

A case is reported of an unusual foreign body, a sewing needle, found in the pelvis beneath the peritoneum of the cul-de-sac and its successful removal via laparoscopy. The preoperative radiologic localization techniques are discussed. The use of the laparoscope for removing accessible foreign bodies can obviate the need for a more extensive surgical procedure.