Prognostic significance of diagnostic laparoscopy for spontaneous fertility

OBJECTIVE: To determine the prognostic significance of laparoscopy results for fertility outcome. STUDY DESIGN: Consecutive patients undergoing hysterosalpingography and laparoscopy for subfertility in our department between May 1985 and November 1987 were identified from medical records. The impact of tubal occlusion, hydrosalpinx and adhesions as detected at laparoscopy was studied. Kaplan-Meier curves for the occurrence of spontaneous intrauterine pregnancy were constructed for patients without tubal pathology, with mild tubal pathology (unilateral pathology or adhesions) and with severe tubal pathology (bilateral pathology). Fecundity rate ratios (FRR) were calculated to express the association between findings at laparoscopy and the occurrence of spontaneous intrauterine pregnancy. RESULTS: Of the 200 cases that could be analyzed, 129 (65%) showed no tubal occlusion on laparoscopy, 40 (20%) had unilateral tubal occlusion, and 31 (15%) had bilateral tubal occlusion. Unilateral hydrosalpinx was present in 13 (7%) patients, whereas 19 (10%) patients had bilateral hydrosalpinx. Adjusted FRRs were 0.65 and 0.20 for unilateral and bilateral tubal occlusion, and 0.46 and 0.32 for unilateral and bilateral hydrosalpinx. Peritubal adhesions were detected in 43% of patients and seemed to have no prognostic significance. CONCLUSION: Severe tubal pathology detected at laparoscopy affects fertility prospects strongly. However, since spontaneous intrauterine pregnancies occurred even in patients with bilateral tubal occlusion at laparoscopy, this technique should not be considered the gold standard in the diagnosis of tubal infertility.     

Management of necrotizing fasciitis in the neck

Necrotizing fasciitis is a soft tissue infection, usually polymicrobial, characterized by necrosis of fascia and subcutaneous tissue. Although it more commonly involves the groin, abdomen and extremities, it may also occur in the head and neck. We report a case of cervical necrotizing fasciitis arising from a dental infection and review the cause, pathophsiology, diagnosis and treatment of this potentially lethal entity. Early detection and accurate intervention are emphasized. Extensive surgical debridement completed with hyperbaric oxygen therapy and antibiotics are the mainstay of treatment.     

Relation of age to isoenzyme pattern and total activity of amylase in serum

Pancreatic and salivary isoenzymes of amylase were determined in serum from 70 subjects. Thin-layer gel/isoelectric focusing was used to separate the isoenzymes. Because other studies (J. Lab. Clin. Med. 90: 141-151, 1977) show that the major isoamylases have isoelectric points between 5.8 and 7.2, we focused the sera on polyacrylamide gel plates with a pH gradient from 5.5 to 8.5. The separated amylase fractions were made visible by direct incubation with a commercially available dye-starch polymer. Isoelectric focusing proved to be convenient, precise, and reproducible, and it can be used as a routine analysis to detect even slight changes in serum amylase distributions. We found that the isoamylase distribution is age dependent, whereas total amylase activity shows no correlation with age.     

NEMO mutations in 2 unrelated boys with severe infections and conical teeth

X-linked recessive anhidrotic ectodermal dysplasia with immunodeficiency is a developmental and immunologic disorder caused by mutations in nuclear factor-kappaB essential modulator (NEMO), which is essential for nuclear factor-kappaB activation. Early in life, affected boys present a typical appearance, with hypotrichosis or atrichosis, hypohidrosis or anhidrosis, and hypodontia or anodontia with conical incisors. They are also susceptible to various microorganisms, mostly pyogenic bacteria and mycobacteria. Here we report 2 unrelated boys, aged 6 and 11 years, who have novel mutations in NEMO and present conical incisors and hypodontia as their sole and long-unrecognized developmental anomaly. One child had isolated recurrent pneumococcal disease, whereas the other had multiple infections. Our observations indicate that conical incisors should prompt the search for NEMO mutations in boys with unusual infectious diseases.     

Costs of treatment in patients with moderate to severe plaque psoriasis: economic analysis in a randomized controlled comparison of methotrexate and cyclosporine

OBJECTIVES: To document and compare the costs of treatment of psoriasis with 2 established systemic agents that differ substantially in their unit costs: methotrexate vs cyclosporine. DESIGN: Cost-minimization analysis within a randomized controlled trial. SETTING: Outpatient dermatology department at an academic hospital. PATIENTS: Adults with moderate to severe plaque psoriasis, with no previous methotrexate or cyclosporine treatment. INTERVENTION: Sixteen weeks of treatment with methotrexate or cyclosporine and an additional 36 weeks of follow-up. MAIN OUTCOME MEASURES: Direct and indirect medical and nonmedical costs associated with resource utilization during treatment and follow-up. RESULTS: Average cumulative total costs associated with 16 weeks of treatment were 1593 US dollars for methotrexate and 2114 US dollars for cyclosporine (521 US dollars less for methotrexate); during 36 weeks of follow-up, these costs were 2418 US dollars and 2306 US dollars, respectively. The overall difference in cumulative 1-year costs was 409 US dollars, or approximately 10% of the total costs. CONCLUSIONS: After 1 year, the overall difference in total costs between methotrexate and cyclosporine for 16 weeks of treatment and follow-up is relatively small. Systemic medication costs are only a fraction of the costs directly and indirectly generated by utilization of health care resources and associated with individual patients rather than with methotrexate or cyclosporine. Economic arguments can be supportive of but not decisive for individual patient decisions and guidelines for systemic therapy. Rational decision making for the treatment of psoriasis may include costs only within a long-term horizon and may consider the societal and patient benefits of different alternatives.