Synchronous rectovaginal, urinary bladder, and pulmonary endometriosis.

BACKGROUND: Extragenital endometriosis is an uncommon condition that can affect almost any organ system and tissue in the human body. Disease involving multiple distant sites is extremely uncommon. METHODS: We report a rare case of synchronous rectovaginal, urinary bladder, and pulmonary endometriosis. We performed a Medline literature search using keywords "endom etriosis," "recto vaginal," "pulmonary," "bladder," "ureteral," "bowel," "extrapelvic," and "extragenital" and were unable to find any prior case reports of such findings. A 31-year-old female presented with catamenial dysuria of 1-year duration, pleurisy associated with spontaneous pneumothoraces of 7 months' duration and a long-standing history of pelvic pain. A multispecialty team with experience in endoscopic techniques was assembled, consisting of a thoracic, a urologic, and a gynecologic surgeon. Video-assisted thoracoscopic surgery with fulguration of all visible pleural endometriosis and pleurodesis was performed, followed by laparoscopic segmental bladder wall endometrioma excision and resection of rectovaginal endometriosis. Twelve months after surgery and without additional hormonal treatment, the patient is symptom free. CONCLUSION: Extragenital endometriosis may coexist in multiple sites. A high index of suspicion aids in the diagnosis. A multidisciplinary approach in a tertiary center, followed by appropriate surgical eradication of visible disease, can successfully treat endometriosis even in such extreme cases.     

Pulmonary infections in children with cystic fibrosis

Bronchopulmonary infections continue to be the major determinant of morbidity and mortality in patients with cystic fibrosis (CF). The basic pathogenesis of disease includes abnormal secretions and impaired mucociliary clearance. Colonization of the tracheobronchial tract with bacteria is then associated with a cycle of infection, inflammation and airway obstruction eventually leading to respiratory insufficiency. Early clinical features include persistent cough and failure to thrive. Hyperinflation and bronchial thickening are early radiographic changes suggestive of CF. Staphylococcus aureus is commonly the initial respiratory pathogen. Subsequently, Hemophilus influenzae and Pseudomonas aeruginosa colonize the respiratory tract. In addition, respiratory viruses and other pathogens such as Legionella and mycoplasma are implicated in the etiology of pulmonary infections. The culture of respiratory secretions such as sputum are important guidelines to the etiology of pulmonary infection in CF. The laboratory must be aware of the pathogens that are typical of this disease and use appropriate techniques and media. In large part, advances in treatment in CF over the past two decades are due to the availability of increasingly potent antibiotic agents. However, effective treatment must be multifaceted and include a variety of nonantimicrobial therapies. Different approaches to the antibiotic therapy of pulmonary infection in CF, including prevention, suppression, and definitive treatment are discussed. In addition to traditional antibiotic therapy, a variety of newer methods of therapy in CF are discussed. These include oral antipseudomonal antibiotics, corticosteroid therapy, aerosolized antibiotics, and continuous antimicrobial prophylaxis.     

Cell interactions in the suppression of in vitro antibody responses

Normal T and immune B lymphocytes interact in a fashion that leads to suppression of the immune response. Normal spleen cells added to cultures of primed spleen cells specifically suppressed both the IgM and IgG secondary antibody response of the primed cells to less than 30% of the response of the immune cells cultured alone. Cell crowding as a possible in vitro artifact was ruled out. The suppression was specific for the priming antigen, even when the specific and nonspecific antigens were included in the same cultures. Suppression required both normal T and immune B cells to be present in culture. We suggest that the immune population produces a signal that can induce normal T cells to become specific suppressor cells. This form of interaction may represent an important regulatory (homeostatic) mechanism in the immune system.     

Ontogeny of culture-generated suppressor cells

Culture of murine lymphoid cells without added antigen results in the generation of cells which suppress a variety of in vitro immune responses, such as the mixed lymphocyte response (MLR) and the generation of alloreactive cytotoxic T cells (CTL). The ontogeny of this phenomenon was studied. Cells which suppressed the MLR after preculture were isolated from spleens and hematopoietic livers of fetal and young (less than 1 wk old) mice. On the other hand, the generation of alloreactive CTL could be suppressed only by precultured spleen cells taken from 1-w-old or older mice. The parallel between the development of the suppressor functions and the maturation of the responses they regulate, suggests a possible biological significance of the effect.     

In vitro activity of sparfloxacin (AT-4140), a new quinolone agent, against invasive isolates from pediatric patients.

Sparfloxacin is a new oral fluoroquinolone agent with putative activity against common pediatric pathogens. Using the broth microdilution method, we evaluated sparfloxacin activity in comparison with those of other antimicrobial agents against 383 pediatric isolates derived from cultures of blood and other normally sterile body fluids. MICs were assessed in Mueller-Hinton broth, serum, and urine, as well as at inoculum sizes of 10(4) to 10(8) CFU/ml. The emergence and stability of resistance and cross-resistance of Pseudomonas aeruginosa (mucoid and nonmucoid) and Staphylococcus aureus to sparfloxacin and ciprofloxacin were evaluated. Inhibitory activity of sparfloxacin against most test organisms was within achievable serum levels. Sparfloxacin was greater than or equal to 2- to 4-fold more active than other quinolones against gram-positive pathogens and 2- to 4-fold less active than ciprofloxacin against P. aeruginosa. Sparfloxacin activity was unaffected by urine and was enhanced by two- to eightfold in human serum. Its potency was not affected by inocula of less than or equal to 10(7) CFU/ml. The frequency of development of spontaneous resistance was similar to that found for other new quinolone agents, and stable resistance emerged only in P. aeruginosa. Sparfloxacin merits additional study against invasive pediatric pathogens.     

Penetration of latamoxef, cefoperazone and piperacillin into the sputum of patients with cystic fibrosis

Concentrations of latamoxef, cefoperazone and piperacillin, administered intravenously, were measured in serum and sputum of cystic fibrosis patients with recurrent pulmonary infections, chronically colonized with Pseudomonas aeruginosa. Serum pharmacokinetic data were consistent with prior reports. Peak sputum to peak serum concentrations were approximately 3% for each antimicrobial. However, the more prolonged sputum concentrations of piperacillin were reflected in greater areas under the sputum concentration-time curve and a longer duration above the MIC50 of tested P. aeruginosa strains for that drug.     

In vitro activity of E-1040, a 3-substituted cephalosporin, against pathogens from cystic fibrosis sputum.

On the basis of preliminary in vitro data, we evaluated E-1040, a new cephalosporin, against 188 cystic fibrosis (CF) sputum isolates obtained from 26 CF centers in the United States. These isolates included mucoid and nonmucoid Pseudomonas aeruginosa, Pseudomonas cepacia, Staphylococcus aureus, Haemophilus influenzae, and Escherichia coli. In addition to MICs measured under standard conditions, selected isolates were tested at various pH values, inoculum sizes, and diluent (CF serum and sputum) conditions. E-1040 activities (MICs for 50 and 90% of the strains) against the isolates were as follows: P. aeruginosa (mucoid and nonmucoid), 1 and 4 micrograms/ml; P. cepacia, 4 and 16 micrograms/ml; S. aureus, 8 and 8 micrograms/ml; H. influenzae, 1 and 4 micrograms/ml; and E. coli, less than or equal to 0.12 and less than or equal to 0.12 microgram/ml. E-1040 activity against mucoid P. aeruginosa was 4-fold greater than that of aztreonam, 16-fold greater than that of ceftazidime, and 32-fold greater than that of piperacillin. E-1040 was similar to other broad-spectrum cephalosporins against S. aureus, H. influenzae, and E. coli. Bactericidal activity was less than or equal to 1 dilution of MIC for 88% of the strains, although kinetic studies with mucoid strains of P. aeruginosa demonstrated effective killing only at eight times the MIC. Variations in pH from 5 to 8, in inoculum size from 10(3) to 10(7) CFU/ml, and in diluent (CF serum or CF sputum) did not affect E-1040 activity.     

Talbot phase-contrast x-ray imaging for the small joints of the hand

A high-resolution radiographic method for soft tissues in the small joints of the hand would aid in the study and treatment of rheumatoid arthritis (RA) and osteoarthritis (OA), which often attacks these joints. Of particular interest would be imaging with <100 μm resolution the joint cartilage, whose integrity is a main indicator of disease. Differential phase-contrast (DPC) or refraction-based x-ray imaging with Talbot grating interferometers could provide such a method, since it enhances soft tissue contrast and can be implemented with conventional x-ray tubes. A numerical joint phantom was first developed to assess the angular sensitivity and spectrum needed for a hand DPC system. The model predicts that, due to quite similar refraction indexes for joint soft tissues, the refraction effects are very small, requiring high angular resolution. To compare our model to experiment we built a high-resolution bench-top interferometer using 10 μm period gratings, a W anode tube and a CCD-based detector. Imaging experiments on animal cartilage and on a human finger support the model predictions. For instance, the estimated difference between the index of refraction of cartilage and water is of only several percent at ～25 keV mean energy, comparable to that between the linear attenuation coefficients. The potential advantage of DPC imaging thus comes mainly from the edge enhancement at the soft tissue interfaces. Experiments using a cadaveric human finger are also qualitatively consistent with the joint model, showing that refraction contrast is dominated by tendon embedded in muscle, with the cartilage layer difficult to observe in our conditions. Nevertheless, the model predicts that a DPC radiographic system for the small hand joints of the hand could be feasible using a low energy quasi-monochromatic source, such as a K-edge filtered Rh or Mo tube, in conjunction with a ～2 m long 'symmetric' interferometer operated in a high Talbot order.