Immunology: High fecundity rates following in- vitro fertilization and embryo transfer in antiphospholipid antibody seropositive women treated with heparin and aspirin

This study was undertaken to explore whether intervention withheparin and aspirin (H/A) in selected patients undergoing in-vitrofertilization (TVF) and embryo transfer could improve fecundityrates. Specifically, it explored the possibility that womendiagnosed with organic pelvic disease who demonstrated antiphospholipidantibodies (APA) could benefit from H/A administration in asimilar manner to that used in patients with recurrent pregnancyloss. We used an enzyme–linked immunosorbent assay forsix different phospholipids to identify patients who expressedAPA before they underwent IVF/embryo transfer. This study wasconfined to the first IVF/embryo transfer cycle that followedassessment of APA status and accordingly, the number of IVF/embryotransfer cycles corresponds with the number of patients treated.APA seropositive patients were treated with aspirin, 81 mg orallyq.d., and heparin 5000 IU s.c. b.i.d., beginning on day 1 ofcontrolled ovarian stimulation. The endpoint for success wasa live birth or an ultrasound confirming fetal cardiac activity(a viable pregnancy). The prevalence of APA in patients diagnosedwith organic pelvic disease (53%) was much higher than in thosewithout female pathology (14%). The administration of H/A toAPA seropositive patients significantly (P < 0.05) improvedthe viable pregnancy rate (49%) compared to the untreated APAseropositive group (16%). The viable pregnancy rate for APAseropositive women treated with H/A was also significantly (P< 0.001) higher than for untreated APA seronegative patients(27%). We conclude that all women undergoing IVF/embryo transfershould be tested for APA prior to initiating ovarian stimulation,and those with APA seropositivity should be treated with H/A.     

Mirizzi Syndrome with a Double Biliary Fistula

Mirizzi syndrome is a partial obstruction of the biliary tree caused by a stone impacted in the cystic duct, with or without development of a cholecystobiliary fistula. Clinical signs are non-specific and suggest at first an obstructive jaundice. We describe a patient with a type I Mirizzi syndrome with a cholecystocolic and a cholecysto-internal biliary fistula. The diagnosis was suggested by ultrasonography and tomodensitometry, and confirmed by endoscopic retrograde cholangiopancreatography. A partial cholecystectomy with a Roux-en-Y hepaticojejunostomy reconstruction was performed. A review of the literature covering its clinical presentation, diagnosis and surgical treatment is presented.     

Rituximab and three dexamethasone cycles provide responses similar to splenectomy in women and those with immune thrombocytopenia of less than two years duration

Adults with newly diagnosed or persistent immunothrombocytopenia frequently relapse upon tapering steroids; adults and children with chronic disease have an even lower likelihood of lasting response. In adults with newly-diagnosed immunothrombocytopenia, two studies showed that dexamethasone 40 mg/day × four days and 4 rituximab infusions were superior to dexamethasone alone. Studies have also shown three cycles of dexamethasone are better than one and patients with persistent/chronic immunothrombocytopenia respond less well to either dexamethasone or rituximab. Therefore, 375 mg/m² × 4 rituximab was combined with three 4-day cycles of 28 mg/m² (max. 40 mg) dexamethasone at 2-week intervals and explored in 67 ITP patients. Best long-term response was assessed as complete (platelet count ≥100×10⁹/L) or partial (50–99×10⁹/L). Only 5 patients had not been previously treated. Fifty achieved complete (n=43, 64%) or partial (n=7, 10%) responses. Thirty-five of 50 responders maintained treatment-free platelet counts over 50×10⁹/L at a median 17 months (range 4–67) projecting 44% event-free survival. Duration of immunothrombocytopenia less than 24 months, achieving complete responses, and being female were associated with better long-term response (P<0.01). Adverse events were generally mild-moderate, but 3 patients developed serum sickness and 2 colitis; there were no sequelae. Dexamethasone could be difficult to tolerate. Fourteen patients became hypogammaglobulinemic and half had increased frequency of minor infections; 9 of 12 evaluable patients recovered their IgG levels. Rituximab combined with three cycles of dexamethasone provides apparently better results to reported findings with rituximab alone, dexamethasone alone, or the combination with one cycle of dexamethasone. The results suggest medical cure may be achievable in immunothrombocytopenia, especially in women and in patients within two years of diagnosis. (clinicaltrials.gov identifier:02050581)     

c-Fos expression as endogenous marker of lumbosacral spinal neuron activity in response to vaginocervical-stimulation

The focus of this paper is to describe a method for the simultaneous stimulation of the vagina and uterine cervix and recording of vaginal contractions in the female rat. The influence of the estrous cycle on vaginocervical sensitivity was also investigated. The use of a latex balloon, inflated with water via a syringe and connected to a pressure transducer allowed us to record vaginal contractions, the intensity of which is an index of vaginal sensitivity, and to stimulate those spinal neurons involved in the reflex arc; at the end of the stimulation the deflated balloon was used as a probe to perform a vaginal smear in order to determine the stage of the estrous cycle at the moment of the experiment. Activated neurons were identified by Fos-immunocytochemistry. Light microscope counting of Fos-immunoreactive neurons at different stages of the estrous cycle permitted us to quantify the response to vaginocervical stimulation and to demonstrate that vaginocervical sensitivity changes significantly throughout the estrous cycle. This finding confirms the important role of sex hormones in the modulation and control of the sensitivity of the vagina and cervix, a part of the female genital tract which is implicated in a variety of neuroendocrine, behavioral and neural changes.