Induction of ovulation with gonadotrophin-releasing hormone--life-table analysis of 50 courses of treatment

Ovulation induction by means of the pulsatile subcutaneous administration of gonadotrophin-releasing hormone by way of an infusion pump is described. The clinical outcome in 50 courses of treatment, which totalled 116 treatment cycles, was analysed and was compared with the pregnancy rates that were obtained with the administration of human pituitary gonadotrophins. We found that the pregnancy rates for these two treatments were similar. We also have shown that for those women who ovulated as a result of such treatment the conception rates were similar to those in ovulatory women who had discontinued contraception. We conclude that gonadotrophin-releasing hormone has an important place among the ovulation-induction agents.     

Xp Microdeletion Syndrome Characterized by Pathognomonic Linear Skin Defects on the Head and Neck

Abstract: We describe a new case of a rare syndrome characterized by ocular abnormalities and pathognomonic linear skin defects. This syndrome is the result of an unbalanced translocation resulting in a deletion of the distal end of the short arm of the X chromosome. We report the thirteenth case and review the clinical and cytogenetic aspects of this disorder. In addition we discuss new findings pertaining to the histopathology of the skin lesions.     

117Care of the Thermally Injured Breast

Introduction : Thermal injury to the female breast is one of the most challenging aspects of aesthetic burn surgery today. As the ability to provide coverage for large body surface injuries has progressed greatly in recent years; attention can now be directed towards achieving aesthetically pleasing results. Breast reconstruction in the burn patient can be accomplished in several ways. In planning the reconstruction, one must account for gender, age, and stage of breast development at the time of injury. The following is the treatment protocol utilized at our institution. After determining the level of injury the injured area is cleansed and treated with topical anti‐microbial agents such as Silvadene. If the decision is made to excise and graft the injured area one of two algorithms is followed. The first choice involves excising the burn and placing a split thickness skin graft to the area involved. This is done by placing a sheet graft and using aerosolized fibrin sealant to affix it to the wound bed. If the burn involves deeper elements of tissue then a second approach is taken which includes excision of the burn down to the level of fascia with preservation of the breast mounds and the nipple areola complex (NAR). The (NAR) is spared excision and allowed to heal. Reconstruction of the (NAR) can be deferred for a secondary procedure depending upon the response to primary healing. A split thickness skin graft is then applied to the area of injury. Again a sheet graft is preferred and fibrin sealant is utilized to improve graft fixation and contour. We attribute our excellent results to the sheet grafts and fibrin sealant used. It should be noted that the increased vascularity of the breast fat when compared to fat located elsewhere in the body allows the grafts to adhere and survive on this generally difficult to graft surface. Methods : We identified five female patients at our institution over the last 18 months with thermal injuries to the breasts. Each patient was placed into one of the two treatment algorithms. Results : The five patients had excellent outcomes. Breast mounds and symmetry were preserved. Further development of the breast was allowed in each patient. One patient even underwent a breast augmentation after surviving a 50% TBSA injury. Proper use of fibrin sealant and sheet grafts account for the excellent results seen at this institution. Conclusion : Following careful evaluation of the burned female breast cosmetically and functionally acceptable results can be attained when following our institution’s protocol for breast reconstruction in the female burn victim.     

Cervical Cancer with Paraaortic Metastases: Significance of Residual Paraaortic Disease after Surgical Staging

Cervical carcinoma frequently metastasizes to the paraaortic region, necessitating extended field radiotherapy to effect a cure. As imaging modalities are unreliable in identifying all cases of paraaortic nodal metastases (PAN), surgical staging is often utilized prior to radiotherapy. This study was aimed at identifying factors predictive of survival in women with cervical carcinoma and paraaortic metastases. In particular, survival based on extent of paraaortic disease was examined. The study group consisted of 43 women (stages IB–IVB) identified between 1982 and 1993 who were treated with extended field radiation for cervical carcinoma with histologically confirmed paraaortic metastases. The estimated 5-year survival for the study population was 24% with a median survival of 18 months. Pelvic tumor size had a significant impact on survival with the median survival being 34 months if the primary lesion was <6 cm compared to 14 months if ≥6 cm (P= 0.01). Eight of the 26 (31%) women without residual PAN disease after surgical staging remain alive and disease free (mean follow-up, 74 months). In contrast, only 1 of the 17 (6%) women with gross residual PAN is alive 71 months after treatment (P= 0.05). However, a comparison of Kaplan–Meier survival curves did not show a statistically significant advantage to the surgical excision of grossly involved PAN (P= 0.98). Although long-term survival among women with grossly involved, unresected paraaortic metastases is uncommon, further study is necessary to elucidate the role of surgical excision of bulky aortic disease in women with cervical cancer.     

Amiodarone alters thyroxine transfer and distribution in humans

Previous studies indicate that increased serum total and free T4 levels may be secondary to a proportionally greater decrease in serum T4 clearance rates than in production rates after short-term amiodarone administration, to increased T4 production rates as well as reduced serum clearance rates in selective hyperthyroxinemia without overt hyperthyroidism following chronic amiodarone administration, and to a relatively greater increase in T4 production rates than in clearance rates in classical hyperthyroidism. To further evaluate amiodarone-induced alterations of T4 metabolism, serum T4 transfer and distribution were evaluated by compartmental analysis of T4 kinetic studies from eight normal subjects receiving short-term amiodarone or an equivalent amount of iodide, five patients with selective hyperthyroxinemia induced by chronic amiodarone therapy (n = 4) or ioxithalamic acid (n = 1), and five with classical hyperthyroidism. The model consisted of rapidly and slowly equilibrating pools exchanging with serum, with all losses occurring from the tissue pools. Short-term amiodarone administration reduced the fractional T4 transfer rates between serum and the rapidly equilibrating pool to 82% of baseline. In selective hyperthyroxinemia the fractional rates of T4 transfer between serum and both extravascular pools were increased sixfold, whereas minimal alterations were present in the hyperthyroid group. The serum equivalent volume of T4 distribution in the slow pool was significantly reduced following short-term amiodarone, whereas serum and rapid pool volumes were reduced in selective hyperthyroxinemia and slow pool volume was increased in hyperthyroidism.(ABSTRACT TRUNCATED AT 250 WORDS)     

Epinephrine reduces the sedative side effects of epidural sufentanil for labour analgesia

PURPOSE: The use of opioids in labour analgesia has primarily been as an adjuvant to local anesthetics. For early labour, satisfactory analgesia with epidural sufentanil alone is possible. This study evaluates the impact of epinephrine on sedative side effects and analgesia related to the latter technique. METHODS: After Institutional Review Board approval and informed consent this prospective, randomized, double-blind study evaluated 43 nulliparous subjects requesting epidural analgesia. The study site, a tertiary care obstetric unit, accommodates 3500-4500 deliveries annually. Group selection was randomized and blinded by selection of a sealed envelope containing a number which corresponded to a premixed labelled syringe of saline or epinephrine (100 microg/mL). An epidural catheter was placed in a standardized fashion. All subjects received 40 microg of sufentanil and 0.5 mL from the premixed syringe, diluted to 10 mL with NaCl. A blinded observer collected data on maternal sedation, lightheadedness, hemodynamics, oxygenation, and fetal heart rate over a one-hour period following sufentanil injection. RESULTS: The addition of epinephrine significantly (P <0.05) reduced the incidence of sedation and lightheadedness after epidural sufentanil at all data collection points, except two. Analgesic duration was also significantly prolonged by this addition (120 +/- 56 vs 84 +/- 32 min). Maternal satisfaction was high regardless of solution. CONCLUSION: Forty micrograms of epidural sufentanil produces satisfactory analgesia in early labour. The addition of epinephrine improves the side effect profile of this technique while prolonging the duration of analgesia. Epidural sufentanil requires attention to maternal monitoring of oxygenation as maternal desaturation occurred in both groups.     

Characterization of a novel reaction by human O6-alkylguanine-DNA alkyltransferase with 1,3-bis(2-chloroethyl)-1-nitrosourea-treated DNA

The reaction of partially purified human O6-alkylguanine-DNA alkyltransferase with 1,3-bis(2-chloroethyl)-1-nitrosourea-treated DNA produces a covalent DNA-protein complex. Evidence that the complex-forming and the alkyltransferase activities are one and the same includes their copurification, identical heat inactivation kinetics, and similar responses to inhibitors. This novel reaction thus provides a sensitive alternative assay for detecting the alkyltransferase. It also provides support for a model in which N1,O6-ethanoguanine is an intermediate in formation of chloroethylnitrosourea-induced DNA interstrand cross-links.     

Further experience utilizing the Gildenberg technique for computed tomography-guided stereotactic biopsies

Initial experience using the Gildenberg technique for computed tomography-guided stereotactic biopsies is reviewed. Of 50 patients, adequate tissue was obtained in 49. In one patient, the stereotactic frame was unable to reach the selected biopsy site. In 32 of 49 patients, the diagnosis was obtained with one biopsy; in the remainder, two to five samples were required. In 4 cases, a subsequent craniotomy was performed; these provided similar histopathological tissue and in no case was the diagnosis altered. The lesions were categorized by CT as ring-enhancing lesions (REL), enhancing lesions with surrounding low density (ELLD), and low density lesions with and without peripheral areas of enhancement. Of the REL, 21 of 23 were primary tumors. Of the ELLD, 5 of 13 were primary tumors; the remainder had a wide spectrum of disease. Of the low density lesions without enhancement, 6 were primary tumors and 1 was an inflammatory process. Three patients had low density lesions with peripheral areas of enhancement and proved to have malignant primary tumors. The remaining patients had multiple lesions with both primary and metastatic disease. Twelve RELs were biopsied in multiple sites. An accurate diagnosis was best obtained by performing the first biopsy in the enhancing rim with additional biopsies as needed in the low density center. Homogeneous lesions could be biospied with target selection based upon a primary regard for safety rather than imaging characteristics. Three patients had transiently increased hemiparesis and one had a transient decrease in level of consciousness after biopsy.(ABSTRACT TRUNCATED AT 250 WORDS)     

Post-infectious bronchiolitis obliterans: clinical, radiological and pulmonary function sequelae

Background. There are few data on clinical, chest radiograph (CXR) or pulmonary function sequelae in children with post-infectious bronchiolitis obliterans (BO) (pulmonary crepitations, abnormalities on CXR, CT, nuclear medicine scans, or bronchography, with a history of past pulmonary infection and in the absence of other underlying pathology). Objective. To analyse the methodology of diagnosis, long-term clinical imaging and pulmonary function sequelae of post-infectious BO in children. Materials and methods. Imaging (CXRs, CT and nuclear lung scans) and clinical histories of 19 children were analysed. Results. Clinical follow-up (mean 6.8 years), revealed a high incidence of continuing problems (asthma and bronchiectasis). Fixed airway obstruction was the most common pulmonary function sequela. The sequelae on follow-up (mean 5.8 years) CXR were classified into five patterns which are illustrated: unilateral hyperlucency of an enlarged lung/part of lung; complete collapse of the affected lobe; unilateral hyperlucency of a small or normal-sized lung; bilateral hyperlucent lungs and a mixed pattern of persistent collapse, hyperlucency and peribronchial thickening. Conclusion. Long-term observations in children with post-infectious BO should be undertaken to detect bronchiectasis and obstructive airway disease. Sequelae evident on CXR, other than those previously described, can be found. Bronchography and/or lung biopsy are not usually required for the diagnosis of post-infectious BO. Received: 15 January 1997 Accepted: 23 June 1997     

Cell kinetics of oligodendroglioma and oligo-astrocytoma--Ki-67 PaP study

In order to determine the principal histologic features in distinguishing the "anaplastic" from the "well differentiated" oligodendroglioma and mixed glioma (oligo-astrocytoma), correlations between the growth fraction, and histologic grade and 6 histologic variables (vascular proliferation, cytologic pleomorphism, calcification, necrosis, cellularity, mitotic index) were studied in 24 patients. The growth fraction was calculated as the percentage of Ki-67-immunostained nuclei in frozen sections using Ki-67 monoclonal antibody. 6 histologic variables were checked with HE stain of paraffin-embedded tissue sections. The growth fraction was in general agreement with the histologic grade, in order of decreasing mean percentage, ranging from 11.1% (anaplastic mixed glioma) to 5.3% (anaplastic oligodendroglioma), 2.8% (isomorphic oligo.) and 1.9% (mixed, grade II). There was a significant association between the growth fraction and 3 histologic variables (vascular proliferation, cytologic pleomorphism, mitotic index) out of 6. Thus, even though there exist some gaps between these parameters in paraffin-embedded tissues and those in frozen sections, the percentage of Ki-67-immunostained nuclei is likely to be very valuable as a supplement information of histological grading and a prognostic indicator.