[Radioisomorphisms of sclerosing cholangitis]

For differentiation of Primary Sclerosing Cholangitis (PSC) from AIDS-associated cholangitis (AAC), 95 CT or Cholangiography studies of 37 patients were reviewed and signs of biliary disease analysed. Only two each of PSC and AIDS-subjects were free from biliary lesions compatible with some kind of sclerosing cholangitis. Subgroup analysis revealed wide overlapping of morphological findings in PSC and AAC. We conclude that radioisomorphism of etiologically different forms of sclerosing cholangitis may indicate pathophysiologically similar courses.

[Comparative imaging of HIV associated diseases of the hepatobiliary system in computerized tomography and cholangiography]

With the incidence of AIDS being on the rise, diagnostic work-up of hepatobiliary disease in these patients is of increasing interest. 57 x-ray cholangiograms and computed tomographic studies of 13 AIDS-patients with clinical signs of cholangitis were reviewed. Nine patients had abnormal cholangiographic findings. Computed tomography of 8 patients revealed hepatobiliary disease in six cases. Of three patients with cholangiograms reflecting bile duct dilatation of neoplastic aetiology, CT was required in two for definite diagnosis. Cholangiography is the method of choice for diagnosing AIDS-associated cholangitis, whereas computed tomography compares favourably in depicting neoplastic disease of the hepatobiliary system. Follow-up of AIDS-associated cholangitis usually delineates unchanged radiologic findings.

Intracytoplasmic sperm injection: a novel treatment for all forms of male factor infertility

OBJECTIVE

To demonstrate the effectiveness of intracytoplasmic sperm injection to treat male factor infertility and to report on the achievement of fertilization and pregnancy compared with standard in vitro insemination.

DESIGN

Controlled clinical study.

SETTING

Couples suffering from male factor infertility treated in an academic research environment.

PATIENTS

Two hundred twenty-seven couples in whom the male partners were presumed to be the cause of repeated failed attempts at IVF or whose semen parameters were unacceptable for conventional IVF.

INTERVENTIONS

Oocytes for this study were harvested after superovulation with GnRH agonist and gonadotropins. After removing the cumulus cells, a single spermatozoon was injected directly into the cytoplasm of metaphase II oocytes, and the outcome was analyzed in terms of semen parameters and origin of semen sample.

MAIN OUTCOME MEASURES

Fertilization and pregnancy rates (PRs) in relation to sperm parameters and origin of semen sample.

RESULTS

Two hundred twenty-seven couples were treated by intracytoplasmic sperm injection resulting in an ongoing pregnancy rate of 37.0% per retrieval (84/227). There were 47 singleton pregnancies (5 of which were vanishing twin pregnancies), 30 twin gestations, 6 triplet pregnancies, and 1 quadruplet pregnancy. The concentration of the total motile spermatozoa present in the ejaculate as well as the origin of the samples influenced the fertilization rate but not the pregnancy outcome.

CONCLUSIONS

Intracytoplasmic sperm injection can be used successfully to treat couples who have failed IVF or who have too few spermatozoa for conventional methods of in vitro insemination. Sperm parameters do not clearly affect the outcome of this technique.

Human platelet antigen gene frequencies in the Austrian population

Gene frequencies for the human platelet antigen systems HPA-1, -2, -3, and -5 were determined directly from DNA isolated from cord blood of more than 900 randomly selected Caucasoid newborns in Vienna, Austria. Genotyping was performed by specific amplification of the respective regions coding for platelet glycoproteins GP Ib, IIb, IIIa, and Ia by PCR. These PCR products were analyzed after restriction enzyme digestion and electrophoresis. The observed gene frequencies were: HPA-1a: 0.852, HPA-1b: 0.148; HPA-2a: 0.918, HPA-2b: 0.082; HPA-3a: 0.612, HPA-3b: 0.388; HPA-5a: 0.892, HPA-5b: 0.108. There was a good fit with the Hardy-Weinberg equilibrium. Results from serological determinations and genotyping showed no discrepancies.

Development and implementation of intracytoplasmic sperm injection (ICSI)

The purpose of this paper is to elucidate the experimental steps that led to the development of intracytoplasmic sperm injection (ICSI) and its application in the human. ICSI has become the most successful micromanipulation procedure for treating male infertility. A total of 355 in vitro fertilization (IVF) cycles utilizing ICSI are described; 180 couples were previously treated in 509 IVF cycles but achieved no fertilization and 175 couples could not be treated by IVF because of extremely poor semen parameters. Of the 3063 metaphase II (M II) oocytes retrieved, 2970 were injected with a survival rate of 93.6%, yielding 1917 bipronuclear zygotes (64.5%). In 148 patients, a foetal heart was evidenced by ultrasound; 11 of these patients miscarried between 7 and 13 weeks of gestation. The ongoing pregnancy rate was 38.6% (137/355) per retrieval and 40.5% (137/338) per embryo replacement. At the time of writing, there were 22 deliveries and one therapeutic abortion for a trisomy 21 chromosomal abnormality. In addition, 66 singleton, 37 twin, 10 triplet and 1 quadruplet pregnancies were ongoing. The concentration of motile spermatozoa in the ejaculate only slightly influenced the fertilization rate (P < 0.001) and the pregnancy outcome (P < 0.01). A preliminary injection procedure utilizing intracytoplasmic injection of isolated sperm heads was performed in 35 M II human oocytes with resultant fertilization and cleavage rates of 74% and 73% respectively. Skills in ICSI were acquired by injecting hamster and unfertilized human oocytes with human sperm. ICSI can be used to successfully treat couples who have failed IVF or who have too few spermatozoa for conventional in vitro insemination.(ABSTRACT TRUNCATED AT 250 WORDS)

[Digital image intensification radiography in endoscopic retrograde cholangiopancreatography]

The standard in ERCP is the use of the conventional radiography system. Digital radiography system are very seldom used in ERCP, and then mostly by digital luminescence radiography. In this study we report our experience with digital image amplification radiography (DIAR) in ERCP. We examined 53 patients of clinical routine aged from 21 to 90 years. During the ERCP we used the X-ray statues and the real-time exposures. At the end of an examination the image post-processing followed. Both conventional and digital image amplification radiography needed the same examination conditions. The special X-ray protection (special lead-shields) used at digital ERCP did not hinder the examination. The DIAR provided at least the same amount of information as conventional radiography. An advantage of DIAR is the possibility of image post-processing such as contrast change, zooming, etc., and the digital archiving and communication. The examination time was reduced by about 30% as compared conventional ERCP, resulting in a reduction of the X-ray exposure time for the patients. The disadvantages of DIAR can surely be compensated by a high ERCP-rate.

Allogeneic human liposomal melanoma vaccine with or without IL-2 in metastatic melanoma patients: clinical and immunobiological effects

The aim of this pilot study was to assess the clinical and immunological effects of human allogeneic liposomal melanoma vaccine alone or combined with Interleukin-2 (IL-2) in patients with metastatic melanoma. Four concurrent treatment arms were included: vaccine alone (A); vaccine combined with systemic IL-2 (B); vaccine combined with low-dose liposomal regional IL-2 (C); and low-dose regional IL-2 as in group C but without vaccine (D). Vaccine was prepared from semisynthetic phospholipids (dimyristol phosphatidylcholine and dimyristol phosphatidylglycerol) and membranes of six human melanoma cell lines. The latter were chosen as expressing MHC class I and II antigens and a "mosaic" of melanoma-associated antigens (MAAs) as detected by MoAbs R24, p97, CF21 and TA99. Nine of the 24 patients had objective clinical responses: of the ten patients treated with liposomal vaccine and low dose regional IL-2 (arm C), three had complete responses (CR) and three had partial responses (PR); of the five patients treated with liposomal, low-dose regional liposomal IL-2 only (arm D), three had PRs. No clinical responses were seen in patients treated by vaccine alone (A) nor in patients treated by vaccine and systemic IL-2 (B). Patients' in vivo and in vitro cellular immune responses were closely monitored. Conversion to positive cutaneous delayed type hypersensitivity (DTH) to membrane vaccine (without liposomes) was induced only in the six clinical responders of arm C. Positive DTH correlated with augmented in vitro proliferative lymphocyte responses stimulated by melanoma cell lines and membrane preparation and with the augmented cytolytic activity against melanoma cell lines.

In vitro cell-mediated immune responses induced by a polyvalent allogeneic melanoma vaccine

Peripheral mononuclear cells (PMNC) from 18 melanoma were monitored for vaccine-related changes in their immune responses by measuring functional activity and phenotypic expression of PMNC prior to- and following 4-6 vaccinations. Assays included: cytolytic responses directed against melanoma cell lines included in the vaccine (M20, M14, HM54 and SKMel28), control melanoma (SKMel23) and non-melanoma (SKCo1, K562 and Daudi) cell lines. Direct lytic responses were significantly enhanced following vaccine treatment, mainly against M20 cell line and was further augmented following In Vitro Stimulation (IVS) by Mit-C-treated M20 or M14 cells. No evidence was found of augmentation of NK or LAK activity by vaccine treatment. Significantly enhanced proliferative responses to of vaccine-treated patients' PMNC to melanoma cell lines were also observed. The human melanoma cell lines used for vaccine preparation (M14, M20 and SKMel28) are high expressors of HLA class I, while high expression of HLA-DR only on M20 cells. Cell surface markers' study indicate a shift in CD4/CD8 ratio from 1.1 to 2.1 and increase in CD25 and HLA-DR positive cells. In M20-stimulated cultures of post-vaccine patients' PMNC the predominant phenotype was CD3+/CD4+. In conclusion, we have demonstrated that treatment with polyvalent allogeneic melanoma vaccine significantly augments T-cell mediated CD3+/CD4+), anti-melanoma lytic and proliferative responses, non-MHC-restricted.

Improved endoscopic management of severe upper gastrointestinal hemorrhage using a new wide-channel endoscope

Problems in emergency endoscopy for upper gastrointestinal bleeding may arise due to blood and food debris preventing proper endoscopic vision and orientation. We present here a new big channel endoscope with a 6 mm suction and drainage channel that achieved complete evacuation of stomach contents in 122 of 123 patients with upper gastrointestinal bleeding, in whom complete gastric cleaning and identification of the bleeding source had proved impossible using standard endoscopes. Gastric emptying using the big-channel endoscope was possible within five minutes in all successful cases. Optimal conditions for therapeutic procedures were therefore provided. The size of the instrumentation channel may open up new indications also for non-emergency endoscopic diagnosis and treatment.

[Tendon interposition arthroplasty vs Kessler silicone prosthesis for basal joint arthritis of the thumb]

Of 86 patients with osteoarthrosis of the trapeziometacarpal or pantrapezial joint operated on during 1978-1988, 52 cases (14 males, 38 females) were reviewed. 32 had undergone interposition of the flexor carpi radialis tendon and 18 Kessler's silicone prosthesis technique. 2 had silicone prosthesis replacement in 1 hand and tendon interposition in the other. The average age of all patients was 65.5 years (range 56-74). Average follow-up was 7.0 years for the 32 after the interposition procedure (range 8-14), and 10.5 years (range 8-14) after prosthesis implantation. A greater proportion of those after tendon interposition reported alleviation of pain. There was no statistically significant difference between the groups with regard to patient satisfaction, need for job change, range of abduction and opposition, grip and pinch power, thumb length and ability in activities of daily living. Tendon interposition arthroplasty is simple and relatively inexpensive compared to silicone prosthesis insertion, which has inherent complications, such as breakage of the prosthesis and synovitis. Tendon interposition has therefore been our standard procedure since 1988.

Pulmonary fat embolism: a distinct cause of severe acute chest syndrome in sickle cell anemia

The etiology of most cases of acute chest syndrome (ACS) in sickle cell disease (SCD) is unknown. Although pulmonary fat embolism (PFE) is frequently found on autopsy, it is rarely considered in the differential diagnosis in pediatric patients. We conducted a study to determine if we could identify PFE in SCD patients with ACS, define the clinical and laboratory course of PFE, and determine if bronchoalveolar lavage is safe and useful in diagnosis of PFE. Twenty-seven SCD patients with ACS were evaluated and compared with 43 control patients. Serial tests (complete blood count, platelet count, nucleated red blood cells [NRBCs], chest x-ray, and oxygen saturations) were compared with steady-state results. Diagnosis of PFE was made by quantitative evaluation of pulmonary macrophages for intracellular fat. No serious complications from bronchoscopy were observed. In the SCD patients with ACS, 12 were PFE+ and 15 were PFE-. The clinical course of the two groups was quite different. All PFE+ patients experienced bone pain and 11 of 12 had chest pain. In contrast, only 6 of 15 of PFE- patients had bone or chest pain. Neurologic symptoms developed in 6 of 12 of the PFE+ group and in none of the PFE- group. Mean hospital days for PFE+ was 13 compared with 7 for PFE-. Laboratory studies in PFE+ showed a significant decrease in hemoglobin (-2 g, P < .05), platelet count (-293,000, P < .001), and an increase in NRBCs/100 white blood cells (+8.3, P < .001) compared with PFE-. These results indicate that when PFE is associated with ACS, it is characterized by a distinct clinical course, and that bronchial lavage is a safe and useful test in diagnosing PFE in patients with ACS.

Epididymal micropuncture with in vitro fertilization and oocyte micromanipulation for the treatment of unreconstructable obstructive azoospermia

OBJECTIVE

To provide fertility to couples in whom the man has surgically unreconstructable obstructive azoospermia.

DESIGN

Prospective.

SETTING

Hospital-based IVF unit, including associated division of urologic microsurgery.

PATIENTS

Couples referred to our fertility unit for treatment of men with surgically unreconstructable reproductive tract obstruction, including congenital absence of the vas deferens.

MAIN OUTCOME MEASURES

Fertilization, pregnancies, and live births.

RESULTS

Of 51 cycles in which sperm and eggs were retrieved, 67% (34/51) resulted in fertilization and 27.5% (14/51) developed clinical pregnancy. Clinical pregnancy rate per couple was 33% (14/43). A total of 15 live births have been obtained in 11 couples with one ongoing pregnancy. Epididymal length was the best predictor of sperm quality and pregnancy results. For couples with at least the corpus epididymis present, 41% (9/22) of cycles resulted in clinical pregnancies.

CONCLUSIONS

Pregnancy rates are optimized using sperm retrieved from the epididymis by micropuncture and when micromanipulation is available for use during IVF.

Prognostic significance of cell DNA content in early-stage ovarian cancer (FIGO stages I and II/A) by means of automatic image cytometry

Paraffin-embedded material from 69 patients with epithelial ovarian cancer FIGO stages I and II/A (including 21 patients with borderline carcinoma) was studied with automatic DNA image cytometry. Univariate analysis indicated a significant difference in survival based on the presence of nuclei with high DNA content (higher than 5 C). A group of patients with less than 0.2% cells with high DNA content had a 6-year survival of 87%, whereas in a group of patients with more than 0.2% of such cells, 6-year survival was 49%. This parameter remained significant when used in a group of stage I/a and I/b patients. Statistical analysis of diploid vs. non-diploid tumors also showed significant difference in survival. Separate analysis of 48 invasive ovarian cancers indicated that ploidy, the percentage of cells with high DNA content and tumor stage (stage I/a + b vs. stages I/c + II/a) reached significance for survival, whereas grading did not. In addition, comparison of clinical stage, grading, ploidy and the percentage of cells exceeding 5 C with a threshold at 0.2% by means of a multivariate analysis (Cox regression model) showed that only the percentage of cells exceeding 5 C remained statistically significant.

[Vaginal sonography of the cervix in twin pregnancies]

In a prospective study of 97 uncomplicated twin pregnancies, vaginosonographic cervix measurements of length, thickness and width of the internal os were performed. Furthermore, a group of 113 uncomplicated primipara was measured by vaginosonography. The twin pregnancies were examined sonographically at 4-5 week intervals between the 14th and 34th week of gestation. The results of the measurements were correlated between these two groups in accordance with duration of pregnancy and the number of deliveries. The results showed in general, that the cervical length of multipara-multiple pregnancy is longer than in the primipara-multiple pregnancy. Between the 13th and 17th week of gestation the cervix of primipara showed a length of 48.1 +/- 2.1 mm, the multipara twins showed a length of 52.3 +/- 3.4 mm. Between the 18th and 22nd gestational week, the primipara showed a cervical length of 49.4 +/- 3.6 mm and the multipara a length of 49.6 +/- 2.6 mm. In the 23rd to 27th week, the primipara had a cervical length of 39.4 +/- 2.4 mm, the multipara of 49.3 +/- 3.7 mm. From the 28th to 33rd week, cervical length was reduced in primipara to 31.2 +/- 2.9 mm, and in multipara to 42.7 +/- 5.1 mm. In the normal group of multipara, the cervical length was slightly longer. The assessment of cervical thickness showed the widest cervices in multipara gemini followed by the primipara gemini, the smallest cervices were found in primipara-single pregnancies.(ABSTRACT TRUNCATED AT 250 WORDS)

A neural network image reconstruction technique for electrical impedance tomography

Reconstruction of images in electrical impedance tomography requires the solution of a nonlinear inverse problem on noisy data. This problem is typically ill-conditioned and requires either simplifying assumptions or regularization based on a priori knowledge. The authors present a reconstruction algorithm using neural network techniques which calculates a linear approximation of the inverse problem directly from finite element simulations of the forward problem. This inverse is adapted to the geometry of the medium and the signal-to-noise ratio (SNR) used during network training. Results show good conductivity reconstruction where measurement SNR is similar to the training conditions. The advantages of this method are its conceptual simplicity and ease of implementation, and the ability to control the compromise between the noise performance and resolution of the image reconstruction.

[Late complication of tubal pregnancy visualized with color Doppler ultrasound. A case report]

An invasive mole in an ectopic pregnancy was diagnosed in the 16th week post amenorrhoea by transvaginal colour flow mapping. Colour flow mapping was the only noninvasive method used to verify the diagnosis. In this case the serum level of human chorionic gonadotropin (HCG) was very low (0.196 IU/ml) and subjective symptoms and uterine bleeding were absent.

Rapid discrimination of early CD34+ myeloid progenitors using CD45-RA analysis

Mononuclear cells (MNC) isolated by density centrifugation of cord blood and healthy bone marrow, and of peripheral blood (PB) from patients treated with granulocyte-macrophage colony-stimulating factor (GM-CSF) or G-CSF after chemotherapy, were double-stained with anti CD34 monoclonal antibody (MoAb) (8G12) versus anti CD45, CD45-RB, CD45-RO, and CD45-RA, respectively, and analyzed by flow cytometry. In all specimens, CD34+ MNC co-expressed CD45 at a low level and the expression of CD45-RB was similar or slightly higher. Most CD34+ MNC were negative for CD45-RO, a weak coexpression was only seen in some bone marrow (BM) and blood samples. In contrast, CD45-RA could subdivide the CD34+ population into fractions negative, dim (+), and normal positive (++) for these subgroups, and typical staining patterns were observed for the different sources of hematopoietic cells: in BM, most CD34+ MNC were RA++. In PB, their majority was RA++ after G-CSF but RA+ or RA- after GM-CSF. In cord blood, the hematopoietic progenitors were mainly RA-/RO-. Semisolid culture of sorted CD34+ MNC showed that clusters and dispersed (late) colony-forming unit-GM (CFU-GM) originated from 34+/RA++ cells, while the 34+/RA- MNC formed compact and multicentric, both white and red colonies derived from early progenitors. Addition of 20 ng stem cell factor per milliliter of medium containing 34+/RA- cord blood MNC led to a change of many burst-forming unit-erythrocyte (BFU-E) to CFU-mix which was not, at least to this extent, seen in blood and BM. We conclude that early myeloid CD34+ cells are 45+/RA-. Because this population excludes 34+/19+ B cells and 33+ myeloid cells, both of which are RA++, two-color flow cytometric analysis using CD34 and CD45-RA facilitates the characterization and quantification of early myeloid progenitor cells.

[Delayed stenosis after endoscopic sphincterotomy (EST)?]

To answer the question of restenosis following endoscopic sphincterotomy (EST) different and sophisticated methods were performed. Using the Erlangen type papillotome we developed a practicable and standardised method for measurement of the size of the EST that is able to define a restenosis. Depending on the indication for EST we found different percentages of restenosis: common bile-duct stones 14%, papillary stenosis 23.1%, duodenal diverticula without bile duct stones as cholestatic entity 40%. On one hand reduction of EST size is not corresponding to clinical symptoms, on the other hand the symptoms of patients after EST with sufficient EST size have to explained in other ways such as gall bladder still existing. Due to these experiences in patients with symptoms following EST we propose a control ERC combined with mechanical measurement of the sphincterotomy size.

Plasmanate as a medium supplement for in vitro fertilization

PURPOSE

The purpose of this study was to evaluate the use of Plasmanate, a protein preparation containing human serum albumin and mixed globulins to autologous preovulatory maternal serum, as an in vitro fertilization (IVF) medium supplement. Plasmanate was used most often in cases involving unexplained infertility, sperm antibodies, and endometriosis or when serum was unavailable.

RESULTS

In a retrospective analysis of 1019 consecutive IVF cycles, Plasmanate was used as the protein supplement to the fertilization medium in 28.6% and maternal serum was used in 71.4% of the attempts. Attempting to eliminate the effects of different medium lots and laboratory conditions, 450 matched patient cycles were compared using the two protein supplements. Finally, the effects of Plasmanate versus maternal serum were compared in prospective randomized trial on patients diagnosed with tubal infertility who were attempting IVF for the first time. The clinical pregnancy rate was 34% for the Plasmanate group versus 24% for those using maternal serum in the retrospective investigation. However, this trend was reversed in the prospective trial.

CONCLUSION

Although further investigation is necessary, it appears that Plasmanate is an appropriate protein substitute in patient cases where serum is absent or unsuitable.