Laparoscopic removal of endometriosis in the pouch of Douglas

Twenty-six patients with endometriosis in the pouch of Douglas were treated by laparoscopic excisional surgery; previous medical and surgical therapy had failed in 24 of them. Endometriosis in the pouch of Douglas occurred infrequently in association with bladder or ovarian endometriosis. Coital and rectal pain were markedly reduced or cured 6 months after surgery in all except 2 patients. Laparoscopic surgical excision of endometriosis is indicated when drug or other surgical treatments fail and may avoid the need for hysterectomy in some patients.

Exercise and glucocorticoid-induced diaphragmatic myopathy

We tested the hypothesis that a chronically active muscle, such as the rat diaphragm, would be more resistant to glucocorticoid-induced myopathy than a less active locomotor skeletal muscle (plantaris). Furthermore, we sought to determine whether endurance exercise could antagonize the glucocorticoid-induced atrophy in the diaphragm. Rats were assigned to one of seven experimental groups (n = 10 per group) and injected daily over a 10-day period with either a sham solution or prednisolone acetate: group 1: control; sedentary and sham injected; group 2: control; exercise trained and sham injected; group 3; sedentary; prednisolone (0.5 mg.kg-1 x day-1); group 4: sedentary; prednisolone (1.0 mg.kg-1 x day-1); group 5: sedentary; prednisolone (2.0 mg.kg-1 x day-1); group 6: sedentary; prednisolone (5.0 mg.kg-1 x day-1); group 7: exercise trained; prednisolone (5.0 mg.kg-1 x day-1). Slope differences in the dose-response curves suggest that prednisolone-induced muscle atrophy in the plantaris was more severe than that in the diaphragm. Furthermore, high doses of prednisolone resulted in a differential effect on muscle bioenergetic enzyme activities in the plantaris and diaphragm. Prednisolone treatment (> or = 2 mg.kg-1 x day-1) resulted in a significant reduction in phosphofructokinase activity (expressed as microM substrate.min-1 x mg protein-1) and an increase in 3-hydroxyacyl-CoA dehydrogenase activity in the plantaris muscle. In contrast, prednisolone treatment did not influence phosphofructokinase activity (P > 0.05) in the diaphragm but decreased (P < 0.05) relative citrate synthase activity. Finally, 90 min daily of endurance exercise did not antagonize prednisolone-induced myopathy in either the diaphragm or the plantaris.

Biopsy diagnosis and conservative surgical treatment of adenomyosis

Fifteen patients with dysmenorrhoea and menorrhagia refractory to medical treatment were referred for surgical treatment. Pre-operative diagnosis of adenomyosis was suggested by vaginal ultrasound in 13 patients and was confirmed pre-operatively by myometrial biopsy in 5 and by transcervical myometrial biopsy at the time of endometrial resection in 7. Conservative surgery included endometrial resection (7), myometrial reduction by electrocautery (4), and myometrial excision (3). Marked improvement occurred in 4 of 7 patients after endometrial resection, 3 of 4 after myometrial reduction, and all of 3 having myometrial excision. Diagnosis of adenomyosis is improved by use of vaginal ultrasound and percutaneous or transcervical myometrial biopsy. Conservative surgical procedures including endometrial resection and myometrial reduction or excision may reduce the need for hysterectomy in the presence of adenomyosis.

Isolation and characterization of new wild-type isolates of bovine lentivirus

Two new isolates of bovine lentivirus, also known as bovine immunodeficiency-like virus (BIV), were obtained from a seropositive cattle herd in Florida. This is the first report of new isolates of BIV since the original BIV strain, R29, was isolated in 1969. The two new BIV isolates were derived from blood buffy coat cells cocultivated in vitro with fetal bovine lung cell cultures. The new isolates differed in vitro from the original R29 isolate in replication and syncytium formation in fetal bovine lung cells. Both new isolates were confirmed as BIV by immunofluorescence assay, Western blotting (immunoblotting), and polymerase chain reaction. Sequence analyses of the polymerase chain reaction pol gene product showed 92.6 and 93.6% homology to the published nucleotide sequence of BIV R29-127, a molecular clone derived from BIV R29. Each of the new BIV isolates was inoculated into two calves, and virus was recovered between 5 and 10 days postinoculation (p.i.), with BIV seroconversion between 10 and 21 days p.i. Virus was recoverable and antibody was detectable for at least 4 months p.i. Two calves developed a transiently elevated mononuclear cell count, similar to what was reported for BIV R29 in the original experimental calf inoculations. No other clinical abnormalities were observed.

A pregnancy after planned partial endometrial resection

A 28-week pregnancy is reported after a planned partial endometrial resection in an infertile patient. The fetus died 32 hours after birth because of prematurity consequent to premature membrane rupture and premature labour. A partial placenta accreta was dealt with at Caesarean section. Complete endometrial resection may not be required to cure menorrhagia. It may be possible to control menorrhagia by targeting specific areas of endometrium associated with menorrhagia. Fertility may be retained by leaving the fundal and peritubal endometrium. The increased risks of pregnancy complications following endometrial resection suggest that more information is required to design endometrial resection so as to both cure menorrhagia and to sustain successful pregnancy.

The cytoskeletal protein talin contains at least two distinct vinculin binding domains

We have mapped the vinculin-binding sites in the cytoskeletal protein talin as well as those sequences which target the talin molecule to focal contacts. Using a series of overlapping talin-fusion proteins expressed in E. coli and 125I-vinculin in both gel-overlay and microtitre well binding assays, we present evidence for three separable binding sites for vinculin. All three are in the tail segment of talin (residues 434-2541) and are recognized by the same fragment of vinculin (residues 1-258). Two sites are adjacent to each other and span residues 498-950, and the third site is more than 700 residues distant in the primary sequence. Scatchard analysis of 125I-vinculin binding to talin also indicates three sites, each with a similar affinity (Kd = 2-6 x 10(-7) M). We also detect a substoichiometric interaction of higher affinity (Kd = 3 x 10(-8) M) which remains unexplained. By expressing regions of the chicken talin molecule in heterologous cells, we have shown that the sequences required to target talin to focal contacts overlap those which bind vinculin.

IVF and related technology. The present and the future

OBJECTIVE

To describe the current status of in-vitro fertilisation (IVF) and related technologies, including: the indications for the procedures and the problems associated with the use of stimulated cycles; the use of frozen embryos and donor eggs; and the newer procedures of gamete micromanipulation for male infertility, immature egg collection as a possible alternative to the stimulated cycle, and preimplantation genetic diagnosis.

DATA SOURCES AND STUDY SELECTION

The clinical experience and research at Monash IVF and the Centre for Early Human Development, Monash University, were reviewed in association with key original or review articles in the world literature.

DATA SYNTHESIS

Cumulative pregnancy rates for IVF and the gamete intrafallopian transfer (GIFT) procedure at Monash IVF demonstrate that 29% of IVF patients and 55% of GIFT patients will have a live baby, the average number of treatments pursued being 3.4. Analogues of gonadotrophin releasing hormone (GnRH) have improved pregnancy rates, reduced blood sampling, and prevented natural ovulation. Disadvantages of stimulated cycles include a higher risk of multiple pregnancy, a higher risk of hyperstimulation, and behavioural changes due to the effects of drugs. Natural cycles or immature egg collection at incidental laparoscopy may become alternatives to the use of the stimulated cycle. In Australia the GIFT procedure is more successful than IVF and is nearly always used if the fallopian tubes are normal. Multiple pregnancies may be reduced, particularly triplets, by reducing the number of eggs or embryos transferred to two when egg or embryo quality is high. Embryo freezing has made a small but important contribution to overall pregnancy rates by enabling patients to use excess eggs and embryos. The social and legal concerns resulting from the use of frozen embryos have required new ethical and legal considerations. Donor eggs have made a small contribution to achieving pregnancy in women with absent or inappropriate eggs and increased the chance of conception in women over the age of 40. Micromanipulation of sperm and eggs has enabled fertilisation and conception when sperm are defective in quantity or quality. Sampling of cells in early embryos enables genetic diagnosis and may be used in selecting chromosomally normal embryos in IVF procedures or in couples at risk of recessive genetic disease.

CONCLUSION

Assisted reproductive technology has developed over a decade to become useful for couples with infertility which cannot be cured by simpler treatments. The birth rates are comparable to natural conception and the incidence of congenital malformation is not increased. The costs and complexity of treatment have been reduced to in turn reduce the stress and social inconvenience of therapy. Problems related to the high risk of multiple pregnancy and the use of the stimulated cycle are being reduced and new techniques for severe male infertility and the detection of genetic abnormalities in the embryo are being introduced.

Laparoscopic endocorporeal mobilization followed by extracorporeal sutureless anastomosis for the treatment of carcinoma of the left colon

Surgery has become progressively more reliant on technology. The technique of colonic anastomosis utilizing the biofragmentable anastomotic ring (BAR) is one such example. The benefits of therapeutic laparoscopy have been applied to the arena of colorectal surgery. A case is presented that combines these two modalities in a patient with colon cancer, laparoscopic mobilization of the large bowel, exteriorized resection, and BAR anastomosis.

[Neonatal shigellosis]

BACKGROUND

Neonatal shigellosis is rare and is usually encountered in unsanitary countries. It is occasionally responsible for manifestations of bacteremia such as septic shock and rash.

CASE REPORT

A boy was born at 40 weeks of gestational age, while the end of labor was marked by temperature at 38 degrees C. His weight was 3,640 g and his height was 49.5 cm. The temperature of the newborn was 38 degrees C at 1 hour of life. He had hepatomegaly and X-rays showed abdominal distension. Gastric aspirates taken at that time showed Gram-negative bacilli and Gram-positive cocci. The patient was given amoxicillin intravenously and netilmicin intramuscularly. The infant still had a fever at 33 hours of life and produced aqueous stools containing blood and mucus. At H40, he developed shock requiring infusion of human albumin. He was given cefotaxime and was admitted to the intensive care unit, where a hepatosplenomegaly was also noted. He was given respiratory support, albumin infusion, dobutamine and dopamine. Antibiotics included cefotaxime, gentamicin and metronidazole. His total white cell count was 2,400/mm3, with 71% mature neutrophils; his platelet count was 190,000/mm3. Stool cultures showed the presence of Shigella flexneri, but blood cultures did not grow. A generalized rash was seen 4 days later; this persisted for less than 24 hours, while the platelet count was 25,000/mm3. The patient was then given ceftriazone and gentamicin. His stool cultures contained Shigella flexneri on the 4th and 9th day, but not on the 14th day. His mother had diarrhea 7 weeks before delivery, but stool cultures before and after delivery did not grow.

CONCLUSION

Diagnosis of neonatal shigellosis is difficult. Cutaneous manifestations, possibly indicating bacteremia, have been seen in older children but never in the neonates.

Lack of demonstrable chromosome allele loss in hepatocellular adenoma

Several studies of loss of constitutional genetic heterozygosity in the development of hepatocellular carcinoma have been carried out with the aim of determining the location of relevant tumour suppressor genes, but there is as yet no report of a similar investigation in hepatocellular adenomas. In this study we analyzed six such patients searching for evidence of chromosome allele loss, or loss of heterozygosity, with 25 DNA probes recognising restriction fragment length polymorphisms. The 25 probes have been assigned to 21 chromosome arms. None of those probes detected allele loss in any of the 6 tumours. One of the patients had a synchronous hepatocellular carcinoma. Chromosome 17p allele loss was detected in her hepatocellular carcinoma but not in the adenoma. The study suggests that chromosome allele loss is not a frequent genetic change in the development of hepatocellular adenoma.

Identification and characterization of glycoprotein gH of human herpesvirus-6

Sequence analysis of an 8-kb BamHI-G DNA fragment from human herpesvirus-6 variant A strain GS (HHV-6A(GS)) has identified a gene encoding a glycoprotein homologous to glycoprotein gH of other herpesviruses and this gene was designated as HHV-6 gH (Josephs et al., J. Virol. 65, 5597). The open reading frame (ORF) of HHV-6A(GS) gH gene was amplified by polymerase chain reaction and was expressed as a trpE fusion protein in bacteria. Stable fusion protein was made only with constructs containing amino acids 15 to 469 of the ORF and this fusion protein was used to raise rabbit antisera. In the in vitro transcription-translation analysis of the gH gene, addition of microsomal membranes resulted in the processing of an unprocessed precursor to a polypeptide product of about 108 K. These in vitro-synthesized precursor and product forms were immunoprecipitated by the rabbit antibodies against the gH fusion protein. Rabbit anti-gH antibodies neutralized the infectivity of both HHV-6 variant A strain GS and variant B strain Z-29, and immunoprecipitation reactions identified a virion envelope-associated 102 K polypeptide as the glycoprotein gH of HHV-6 variants A and B. In addition to the 102 K glycoprotein, nonglycosylated polypeptides of about 58 and 164 K with different partial peptide maps were also consistently coimmunoprecipitated from [35S]methionine-labeled HHV-6A(GS)-infected cells, but not from HHV-6B(Z-29)-infected cells. The similarity in the molecular weights of glycoprotein gH among the two strains belonging to the two variant groups of HHV-6 and neutralization of infectivity of both groups by rabbit antibodies against HHV-6A(GS) gH suggests conserved functions of glycoprotein gH among the two variant groups of HHV-6.

The value of vaginal ultrasound in the management of menorrhagia

Vaginal ultrasonography has been carried out on 97 patients with menorrhagia who were either not responding to or not suitable for drug therapy. Ultrasonography demonstrated normal uteri in 33, benign uterine enlargement in 4, bicornuate uteri in 2, intracavitary polyps or fibromyomas in 9, possible adenomyosis in 13 and intramural or subserous fibromyomas in 36. The ultrasound diagnosis markedly increased the accuracy of clinical diagnosis and assisted in the proper choice of treatment which included the avoidance of surgery and the selection of patients most suited to endometrial resection, intrauterine resection of polyps and fibromyomas, and open or laparoscopic myomectomy and hysterectomy. The routine use of high resolution vaginal ultrasound in the management of menorrhagia is recommended.

Mood Change and Perceptions of Vitality: A Comparison of the Effects of Relaxation, Visualization and Yoga

The effects of three different procedures, relaxation, visualization and yogic breathing and stretch (pranayama) on perceptions of physical and mental energy and on positive and negative mood states have been assessed in a group of normal volunteers ( N=71, age range 21–76).

Pranayama produced a significantly greater increase in perceptions of mental and physical energy and feelings of alertness and enthusiasm than the other two procedures ( P<0.5). Relaxation made subjects significantly more sleepy and sluggish immediately after the session than pranayama ( P < 0.05). Visualization made them more sluggish but less content than pranayama ( P<0.05) and more upset than relaxation after the second session ( P<0.05).

?Thus, a 30 min programme of yogic stretch and breathing exercises which is simple to learn and which can be practised even by the elderly had a markedly ‘invigorating’ effect on perceptions of both mental and physical energy and increased high positive mood. A more extensive investigation is planned to establish whether such a programme can readily be incorporated into everyday life, and with what long-term results.

Mood change and perceptions of vitality: a comparison of the effects of relaxation, visualization and yoga

The effects of three different procedures, relaxation, visualization and yogic breathing and stretch (pranayama) on perceptions of physical and mental energy and on positive and negative mood states have been assessed in a group of normal volunteers (N = 71, age range 21-76). Pranayama produced a significantly greater increase in perceptions of mental and physical energy and feelings of alertness and enthusiasm than the other two procedures (P < 0.5). Relaxation made subjects significantly more sleepy and sluggish immediately after the session than pranayama (P < 0.05). Visualization made them more sluggish but less content than pranayama (P < 0.05) and more upset than relaxation after the second session (P < 0.05). Thus, a 30 min programme of yogic stretch and breathing exercises which is simple to learn and which can be practised even by the elderly had a markedly 'invigorating' effect on perceptions of both mental and physical energy and increased high positive mood. A more extensive investigation is planned to establish whether such a programme can readily be incorporated into everyday life, and with what long-term results.

Percutaneous ultrasound guided uterine needle biopsy

OBJECTIVE

To determine the safety, accuracy and usefulness of percutaneous ultrasound guided uterine needle biopsy.

SETTING

Transabdominal uterine biopsy was performed with an ultrasound directed biopsy gun. The biopsy was performed as an outpatient procedure under local anaesthesia.

MAIN OUTCOME MEASURES

The safety, accuracy and clinical value of the procedure; a comparison of the clinical and ultrasound diagnoses with the biopsy and surgical histological diagnoses; and the effect of the biopsy result on the choice of treatment by the surgeon and patient.

RESULTS

There were no complications. Accuracy was validated in all seven patients who subsequently had surgical procedures and more extensive myometrial histological investigation. Biopsy diagnosis improved clinical diagnosis in nine of the ten patients, and altered or assisted in the ultrasound diagnosis in eight of the ten patients. Decisions concerning choice of treatment by the doctor or patient were assisted by the biopsy result in seven patients.

CONCLUSION

Percutaneous ultrasound guided uterine needle biopsy is a useful procedure in the diagnosis of myometrial disease.

Disseminated cutaneous and vascular invasion by Fusarium moniliforme in a fatal case of acute lymphocytic leukemia

A 35 year old female patient with acute lymphocytic leukemia developed fusariosis in which dissemination appeared to be limited to cutaneous and vascular invasion. The first evidence of fungemia occurred nearly seven months after initial hospitalization. The fungus was identified as Fusarium sp. and was considered a contaminant. Two weeks later blood cultures were again positive for Fusarium sp. and the patient was placed on amphotericin B and 5-fluorocytosine therapy. The following day developing lesions were noted on her forearms and face; lesions ultimately spread to her trunk, abdomen, and lower extremities. Skin lesion biopsy sections revealed abundant septate and branching hyphae throughout the dermis and within capillaries. Twenty-six days after the initial isolation the patient died. Post-mortem blood cultures gave rise to the same fungus, which was identified as Fusarium moniliforme. Postmortem cultures and stains of spleen, liver, lung, and brain specimens were all negative for fungi. The primary source and portal of entry of the organism remained undetermined.

Laparoscopic culdotomy

Laparoscopic culdotomy has been performed in 32 patients. The indications for the procedure included the removal of organs or tissue excised by operative laparoscopy, excision of vaginal endometriosis involving the pouch of Douglas and drainage of a pelvic haematoma. The surgical technique is described and no complications resulted from this technique. Laparoscopic culdotomy has advantages for the removal of lumps exceeding 1 cm, and for the drainage of a pelvic haematoma or pelvic abscess. It is also an integral step in the removal of infiltrating endometriotic lesions in the pouch of Douglas which are attached to the vagina.

Which central venous catheter for neonatal use?

Complications in 100 percutaneous central venous catheters used for parenteral nutrition were monitored prospectively in patients on a regional neonatal medical and surgical unit. Infants were randomly allocated to receive either a Vygon Epicutaneous catheter or Dow Corning silastic tubing. The majority of lines -63 - were removed electively when parenteral feeding was no longer required. The most common serious complication was catheter sepsis for which 11 lines were removed; all patients made a complete recovery. Minor mechanical complications were encountered with 17 catheters. There was no difference in performance or complication rate comparing the two types of catheter. Percutaneous central venous catheters provide a suitable and safe means of administration of parenteral nutrition to preterm infants over an extended period of time.

Ultrasound diagnosis and laparoscopic excision of an interstitial ectopic pregnancy

Interstitial tubal pregnancy occurs in about 5% of ectopic tubal pregnancies and is associated with an increased risk of severe haemorrhage (1). Diagnosis prior to rupture of the pregnancy into the peritoneal cavity is very important to avoid haemorrhage. Its presence has been considered to be a contraindication to laparoscopic surgery (2), although most ectopic pregnancies can be managed laparoscopically by an experienced endoscopist. We report the diagnosis of an interstitial pregnancy by ultrasound before rupture and treatment by laparoscopic excision of the pregnancy.

Laparoscopic adnexectomy--indications, technique and results

Laparoscopic adnexectomy was performed successfully in 38 patients in whom the procedure was attempted. Failure may result from inexperience of the surgeon or when preliminary dissection near bowel suggests trauma is likely. The duration of the operation was between 15 and 105 minutes, blood loss was minimal and all but 2 patients were discharged within 24 hours of surgery. Pain was relieved in 33 of 35 patients in whom this was the dominant symptom. In 1 patient a small ovarian remnant implanted on the bladder was removed at subsequent laparoscopy. Preliminary experience of this procedure suggest it may be preferable to laparotomy because of the reduced risk of wound complications, pain, time in hospital and duration of convalescence.