Arthroscopic capsular release of flexion contractures (arthrofibrosis) of the elbow

Twelve patients with flexion contractures of the elbow were managed by arthroscopic release of the proximal capsule and debridement of the olecranon fossa. Postoperatively the mean flexion contracture improved from 38 to 3 degrees with supination improving from 45 to 84 degrees and pronation improving from 80 to 88 degrees. All patients reported a decrease in pain level as well as improvement in motion. There was one severe complication in this series, in which a patient sustained a permanent posterior interosseous nerve palsy. Arthroscopic limited capsular release appears to be satisfactory management modality for flexion contracture of the elbow.

Structure-localization relationships of 11C-labeled phentermine derivatives: effect of aromatic substitution

A series of phentermine analogs, including the unsubstituted, the para-F, -Cl, -Br and -I, and the meta-CF3 derivatives, were labeled by [11C]methylation and evaluated in rats to determine the structure-localization relationships for this class of regional cerebral blood flow imaging agents. All the phentermines were well-localized in the brain; however, only the para-substituted agents were well-retained. Localization in the nontarget tissue was affected by the lipophilicity of the substituent. Comparison with the radioiodinated analogs showed virtually identical results, which suggests that the compounds were not significantly metabolized. The agent with the best biodistribution characteristics was the N-[11C]methyl-p-iodophentermine, with the p-bromo analog almost equivalent.

Hypothalamo-anterior pituitary gonadotropin-releasing hormone and substance-P systems during the 17 beta-estradiol-induced plasma luteinizing hormone surge in the ovariectomized female monkey

The present study examined the effects of 17 beta-estradiol benzoate (E2B) on the hypothalamic (HT) and anterior pituitary (AP) content of GnRH precursor (pro-GnRH-GAP), GnRH, GnRH-associated peptide (GAP), and substance-P (SP) during the various phases of the E2B-induced LH surge in cynomolgus monkeys. Changes in GnRH and GnRH-associated peptide (GAP) at both hypothalamic and AP levels were closely related at all times after E2B treatment. However, the pattern of change in the AP was very different from that in the HT. In the HT, pro-GnRH-GAP levels did not change significantly throughout the experimental period. In the AP, the pro-GnRH-GAP increased 48 h post-E2B treatment, the time of initiation of the LH surge. An 8-fold increase in AP GnRH occurred 30 h post-E2B treatment. There were no significant changes in the HT content of SP at any time after E2B treatment. However, there was a depletion of AP content by 48 h post-E2B, the time of the LH surge. These results demonstrate that E2 activates and deactivates in a coordinated manner the GnRH and SP systems of the HT-AP complex during initiation of the E2-induced LH surge. The observation that more significant changes occur in the AP than in the HT suggests that an important component of the E2 effect in inducing the LH surge may be directly at the AP level. This action involves changes in the contents of GnRH and SP in the AP.

Aromatic trivalent arsenicals: covalent yet reversible reagents for the agonist binding site of nicotinic receptors

The agonist binding site of nicotinic acetylcholine receptors (AChRs) includes a disulfide bond that is easily reduced with dithiothreitol to a pair of thiols, and can be then either reoxidized with dithiobis(nitrobenzoic acid) (DTNB) or irreversibly alkylated with bromoacetylcholine (BAC). Aromatic trivalent arsenicals form stable complexes with pairs of appropriately-spaced thiols, but not single thiols. Furthermore, once complexed in proteins, trivalent arsenicals can be removed with dimercaptans, such as 2,3-dimercaptopropanesulfonic acid (DMPS). In an effort to develop reagents that will covalently, yet reversibly label AChRs, we investigated the effects of two model arsenicals, p-aminophenyldichloroarsine (APA) and 4-bromoacetyl-aminophenylarsenoxide (BAPA) on two types of nicotinic receptors: AChRs from Torpedo electroplax and neuronal receptors from chick retina. APA and BAPA significantly decrease the number of 125I-alpha-bungarotoxin binding sites in reduced Torpedo AChRs. Furthermore, arsenylation of neuronal and Torpedo receptors with APA or BAPA (1) prevents reoxidation with DTNB, (2) is reversible with DMPS, and (3) protects against irreversible alkylation by BAC. In Torpedo receptors, the EC50 of protection against BAC alkylation with APA or BAPA is approximately 30 nM. APA arsenylation of Torpedo receptors persists up to 20 h, but can be reversed at any time with DMPS. These results suggest that heterobifunctional arsenicals could anchor labeling groups in the agonist binding site in order to map the agonist binding site, quantitate receptors, or purify and reconstitute functional receptors.

Effects of oxidizing and reducing analogs of acetylcholine on neuronal nicotinic receptors

The synthesis and pharmacological characterization of dithiobisacetylcholine and dithiobis-N,N-dimethyl-4-acetylpiperazinium (two oxidizing analogs of acetylcholine), as well as those of their reduced counterparts, are described. Both the oxidizing and reducing analogs stimulate nicotinic receptors in the chick retina and block the binding of 125I-labeled neuronal bungarotoxin to retinal homogenates (IC50 values of 2 x 10(-6) to 6 x 10(-5) M). Both oxidizing compounds reverse the physiological effects of reduction by dithiothreitol on nicotinic function in intact chick retina, when applied for 2 sec (EC50 values of about 10(-5) M). This effect is selective, insofar as neither agent alters the effects of dithiothreitol treatment on receptors for N-methyl-D-aspartate. Reoxidation takes place at the disulfide located near the nicotinic receptor agonist binding site, inasmuch as reoxidation by these agents prevents affinity alkylation by bromoacetylcholine, and occupation by the competitive antagonist d-tubocurarine prevents reoxidation. Unlike thiocholine, a weak agonist with a free sulfhydryl that, paradoxically, is reported to oxidize nicotinic receptors in electroplax, the reduced forms, mercaptoacetylcholine and N,N-dimethylamino-4-mercaptoacetylpiperazinium, have no direct redox effects on retinal receptors, but they do protect the receptors against reduction by dithiothreitol.

Synthesis and binding to beta-adrenergic receptors of p-aminobenzyl analogues of practolol and atenolol

The p-aminobenzyl analogues (8a and 8b, respectively) of the cardioselective beta-adrenergic receptor antagonists practolol and atenolol were prepared from the corresponding phenoxymethyloxiranes in 30 and 13% yields, respectively. The dissociation constants for the beta-adrenergic receptor were measured in membrane preparations of rat heart and lung. In membranes from the heart (which contain mostly beta 1-adrenergic receptors), the affinities of the derivatives and parent compounds were similar. By contrast, in membranes from the lung (which contain mostly beta 2-adrenergic receptors), the derivatives were more potent than the parent compounds. Thus, the cardioselectivities of the p-aminobenzyl analogues 8a and 8b were about one-sixth those of the respective parents.

Late-onset congenital adrenal hyperplasia in a group of hyperandrogenic women

The aim of this study was to determine the prevalence of late-onset congenital adrenal hyperplasia (LOCAH) in a group of hyperandrogenic women presenting with menstrual disturbances and/or infertility. Thirty-five women were evaluated by basal hormonal profiles and underwent ACTH stimulation testing. In this study, 17.1% of women showed evidence of partial 21-OH deficiency (21-OHD), and 5.7% 3 beta-HSD deficiency. Neither basal hormonal levels nor clinical characteristics distinguished women with LOCAH from other hyperandrogenic women. And although the mean basal 17-OH progesterone (17-OHP) level in women with 21-OHD (152 +/- 66 ng/dl) was significantly higher than levels in other hirsute women, 4 of 6 (67%) women with 21-OHD had normal 17-OHP levels. Thus, to identify all affected individuals with partial 21-OHD, our data suggest that hyperandrogenic women with basal unsuppressed 17-OHP levels greater than 100 ng/dl should undergo dynamic testing. With regard to partial 3 beta-HSD deficiency, basal DHEA-S levels greater than the 95th percentile of other hirsute women may be used to screen for this deficiency. In conclusion, LOCAH due to partial steroid enzyme deficiencies are a frequent occurrence in women who present with symptoms of hyperandrogenism and ACTH stimulation remains an important tool in making the diagnosis of enzyme deficiencies.

Luteal phase defect: a review of pathophysiology

Corpus luteum function depends on normal granulosa and theca cell components, which in turn are stimulated by an adequate luteinizing hormone (LH) surge in both duration and amplitude of pulses with LH residual pulses of adequate amplitude during the 14-day luteal span. The granulosa component must be competent to 1) synergize with thecal androgen production for increased estrogen production, 2) develop LH receptors for progesterone production, and 3) mature the egg cytoplasmically. The theca component must be capable of inducing angiogenesis factor to increase follicular blood supply and must be responsive to an LH pulse and human chorionic gonadotropin for corpus luteum rescue. The corpus luteum defect with a normal 14-day span is related either to an inadequate granulosa cell or to an inadequate LH surge, but a fairly normal LH pulse and theca cell response. The short luteal phase defect is related to a poor LH surge and an absent or extremely poor LH pulse. Diagnostic studies have indicated that the endometrial biopsy is the most efficient diagnostic method. Severe luteal defects can be diagnosed by a progesterone assay if the entire cycle is assayed, but single or even multiple progesterone assays are unreliable. The etiology is multifactorial and usually is related to the hypothalamic-pituitary factors influencing the LH surge, rather than to ovarian factors. Factors may vary from cycle to cycle, making it important to determine that the defect is repetitive. The specific etiology is often difficult to determine; substitution progesterone therapy is the most satisfactory treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Basal follicle-stimulating hormone level is a better predictor of in vitro fertilization performance than age

A study of 1,478 consecutive in vitro fertilization (IVF) cycles was made to determine if basal follicle-stimulating hormone (FSH) levels and age were independent predictors of IVF performance. Regression analyses indicated independent contributions of both basal FSH and age in predicting cancellation rate, peak estradiol, number of oocytes retrieved, fertilized, and transferred, and total and ongoing pregnancy rates. Miscarriage rate was unrelated to both age and basal FSH. Follicle-stimulating hormone level was a better predictor than age for all outcome variables examined and remained a significant predictor after accounting for age, etiology of infertility, and semen quality. The combined use of age and basal FSH in counseling patients improves the accuracy of prognosis, and may provide an index of functional ovarian reserve ("ovarian age").

Controlled preparation of the endometrium with exogenous steroids for the transfer of frozen-thawed pre-embryos in patients with anovulatory or irregular cycles

We have reported a 36% pregnancy rate (eight of 22 transfers) with the transfer of cryopreserved-thawed embryos in patients with anovulatory or irregular cycles following a protocol using pituitary suppression with leuprolide acetate after preparation of the endometrium with transdermal E2 and i.m. P. This protocol is simple, easy to follow, and safe and could be used in future for all patients with cryopreserved pre-embryos.

Alterations in luteal phase progesterone and estradiol production after leuprolide acetate therapy before ovarian stimulation for in vitro fertilization

The impact of pituitary suppression with a gonadotropin-releasing hormone agonist (GnRH-a) on the luteal phase of in vitro fertilization (IVF) cycles was examined in 21 women who underwent identical stimulation regimens with and without leuprolide acetate pretreatment. The areas under the serum progesterone curves, measured over the 1st 10 days of the luteal phase, were significantly greater in the GnRH-a cycles compared with the non-GnRHa cycles, but when calculated per oocyte retrieved were similar in GnRH-a and non-GnRH-a cycles. In contrast, the areas under the luteal phase serum estradiol curves were significantly less in the GnRH-a cycles. These data suggest that GnRH-a treatment is accompanied by potentially beneficial alterations in the systemic steroidal milieu of the luteal phase of IVF cycles.

Ovarian stimulation for in vitro fertilization in low-responder patients using pulsatile intravenous follicle stimulating hormone

There is a subset of patients who fail to respond adequately to exogenous gonadotropin stimulation for in vitro fertilization (IVF). In this study, six such low-responder patients who had inadequate stimulations with high-dose intramuscular (im) follicle stimulating hormone (FSH) were treated in a subsequent cycle with pulsatile intravenous (iv) FSH. A paired analysis was performed to compare the cycles using high-dose im FSH with those using pulsatile iv FSH. Trough serum FSH levels were significantly higher with pulsatile iv FSH. No significant difference was noted in the stimulation characteristics or the number or quality of oocytes retrieved and embryos transferred. No pregnancies occurred in either group. While pulsatile iv administration of gonadotropin increases serum FSH levels, it does not appear to have a major impact on follicular stimulation or outcome in low-responder patients undergoing IVF.

Killing of Mycobacterium tuberculosis by neutrophils: a nonoxidative process

To determine the role of oxygen radicals in the killing of Mycobacterium tuberculosis by neutrophils, the effects of free-radical inhibitors and enzymes, catalase, superoxide dismutase, taurine, deferoxamine, and histidine were evaluated. Changes in the viability of M. tuberculosis were determined by agar plate colony counts and a radiometric assay. No impairment in killing was seen with any of the inhibitors or enzymes. Patients with chronic granulomatous disease (CGD) have a defect in the NADPH oxidase pathway, causing their neutrophils to be unable to generate oxygen radicals. If these radicals are involved in killing, then CGD neutrophils should be less effective killers of M. tuberculosis than normal neutrophils. There was no evidence by either measure of M. tuberculosis viability that CGD neutrophils were less bactericidal than normal neutrophils. Killing by normal neutrophils was also effective in the absence of serum. These results lead to the conclusion that the mechanism by which M. tuberculosis is killed by neutrophils is independent of the oxygen metabolic burst.

Ovarian stimulation for in vitro fertilization using pure follicle-stimulating hormone with and without gonadotropin-releasing hormone agonist in high-responder patients

There is a distinct pattern of response to gonadotropin stimulation in some patients marked by high peak estradiol (E2) levels, multifollicular ovarian response, and elevated basal luteinizing hormone (LH)/follicle-stimulating hormone (FSH) ratios. We reviewed the stimulation profiles of five such high-responder patients who failed to conceive during in vitro fertilization with ovarian stimulation using pure FSH. All patients had baseline LH/FSH greater than 1.5 and peak E2 greater than 800 pg/ml. One cycle was canceled prior to hCG administration because of marked ovarian response (E2 greater than 2500 pg/ml, multiple small follicles). In a subsequent cycle, all patients were pretreated with the gonadotropin releasing-hormone agonist (GnRHa) leuprolide acetate for 10-14 days prior to initiation of FSH for ovarian stimulation. Leuprolide was continued until the day of hCG administration. During cycles using GnRHa, there was a statistically significant decrease (P less than 0.05) in serum FSH on day 3 (less than 5 vs 8.3 mIU/ml), serum E2 on day 3 (14.6 vs 34.6 pg/ml), and peak serum E2 (1197.6 vs 1923.0 pg/ml). Patients during cycles with GnRHa had a greater number of preovulatory (8.6 vs 3.0) and total (12.4 vs 6.0) oocytes retrieved (P less than 0.05). The fertilization rate of preovulatory oocytes was also higher during cycles using GnRHa (83 vs 64%). Two pregnancies occurred in the cycles pretreated with GnRHa. These preliminary data indicate that in high-responder patients, a combination of GnRHa and pure FSH results in lower E2 levels during the stimulation cycle and a greater number of total and mature oocytes retrieved and fertilized.

Non-functional ovarian cysts do not affect ipsilateral or contralateral ovarian performance during in-vitro fertilization

Reports on the significance of ovarian cystic structures during in-vitro fertilization (IVF) have been conflicting. This study examined the effect of such structures on ovarian performance during IVF. Twenty-one patients with one or more cystic structures of 20-50 mm in diameter, detected on day 6 of the menstrual cycle, were compared to 35 non-cystic controls. Differences (cyst versus non-cyst) included basal oestradiol (E2) levels (40 +/- 4.8 versus 29 +/- 2.0 pg/ml; P less than 0.01), ampoules of gonadotrophins administered (24 +/- 2 versus 16 +/- 1; P less than 0.001) and peak E2 concentrations (415 +/- 45 versus 744 +/- 88 pg/ml; P less than 0.05). There were no differences in the number of follicles aspirated or oocytes retrieved. In 19 patients with unilateral structures, the ipsilateral ovary produced fewer follicles (2.5 +/- 0.5 versus 3.9 +/- 0.6; P less than 0.05); however, there were no differences in the number or maturity of oocytes recovered. Since the numbers of oocytes recovered were equivalent in the presence or absence of ovarian cystic structures, their presence is not an indication to cancel an IVF cycle.

High-dose follicle-stimulating hormone stimulation at the onset of the menstrual cycle does not improve the in vitro fertilization outcome in low-responder patients

In an attempt to improve their outcome with in vitro fertilization (IVF), 34 low-responder patients were stimulated with six ampules of follicle-stimulating hormone (FSH) daily starting on day 1 (n = 17) or day 2 (n = 17) of their menstrual cycles. The stimulated cycles showed a mean peak estradiol of 443 +/- 173 pg/mL, mean days of human chorionic gonadotropin of 7.6 +/- 1.4, 2.67 +/- 1.5 preovulatory oocytes per retrieval, and 2.56 +/- 1.3 oocytes per transfer. Three clinical pregnancies resulted after 25 embryo transfer cycles (12%). With paired analysis, we compared 8 patient cycles with prior six ampules of FSH stimulation starting on day 3; all parameters examined showed no significant differences. In a comparison of 22 patient cycles with prior 4 ampules of FSH stimulation on cycle day 3, no significant differences in any parameters were observed except in the higher number of ampules used in the present study. We conclude that high-dose FSH stimulation at the onset of the menstrual cycle does not improve the IVF outcome in low-responder patients.

Equivalency of human menopausal gonadotropin and follicle-stimulating hormone stimulation after gonadotropin-releasing hormone agonist suppression

This study compares the use of human menopausal gonadotropin (hMG) versus follicle-stimulating hormone (FSH), after gonadotropin-releasing hormone agonist (GnRH-a) suppression for in vitro fertilization. Thirty-seven patients were randomized to ovarian stimulation with either hMG or pure FSH. The GnRH-a leuprolide acetate was administered to all patients beginning in the midluteal phase of the prior cycle and continuing until the day of human chorionic gonadotropin (hCG) administration. There were no significant differences between hMG and FSH cycles with regard to the day of hCG administration, mean peak estradiol levels, number of ampules of medication used, and number of oocytes aspirated, embryos transferred, or pregnancies. We conclude that there is no significant difference between hMG and FSH stimulation when used in conjunction with GnRH-a.

Effect of a gonadotropin-releasing hormone analogue on the glucose metabolism in a diabetic patient

We report a case of an insulin-dependent diabetic female who received leuprolide acetate and Depo-Lurpon for the treatment of endometriosis. Their use was associated with hyperglycemia and a deterioration in glucose control that necessitated changes in insulin dosage.

High-dose follicle-stimulating hormone (FSH) ovarian stimulation in low-responder patients for in vitro fertilization

Follicle-stimulating hormone (FSH) was used in high doses (6 ampoules/day:6FSH) for ovarian hyperstimulation for in vitro fertilization in women with a previous poor response to stimulation with the equivalent of "4FSH." Luteinizing hormone levels did not differ between stimulations, but both FSH and estradiol levels were higher in the 6FSH compared to the 4FSH cycle. There were fewer cancellations in the 6FSH cycle, but similar numbers of preovulatory oocytes were retrieved, fertilized, and transferred. The pregnancy rates per attempt and retrieval were higher in the 6FSH cycle. We conclude that raising and maintaining FSH levels during stimulation in low responders reduced cancellations and may improve in vitro fertilization outcome.

Gonadotropin stimulation protocols in the Norfolk IVF program--1988

A standard FSH/hMG stimulation protocol applied to all patients does not yield optimum results. In the Norfolk program it has been found that the determination of FSH/LH ratio on day 3 of the menstrual cycle provides a predictive signal of the likelihood of a good or bad response to a standard protocol. If the FSH is high in relation to LH, the patient will likely be a low responder and/or approaching the menopause. A regime of high-dose pure FSH seems to improve the number of eggs in this group and therefore the pregnancy rate. On the other hand, if the FSH/LH ratio is very low, that is, the patient has a high LH, the patient is generally a high responder and produces many eggs, but in some instances the quality of eggs is suspect, and the pregnancy rate is low in a particular subset of high responders. The use of GnRHa and/or minimal stimulation with FSH or hMG seems to improve the pregnancy rate.

Impact of leuprolide acetate on the response to follicular stimulation for in vitro fertilization in patients with normal basal gonadotropin levels

Fifteen women with normal basal gonadotropin levels and adequate responses to conventional gonadotropin stimulation for in vitro fertilization (IVF) were pretreated with leuprolide acetate (LA) beginning in the midluteal phase prior to a repeat IVF attempt. A significantly longer duration of stimulation requiring a significantly higher total dosage of gonadotropins was observed in LA cycles. The number of preovulatory oocytes retrieved and preembryos transferred was significantly higher in LA cycles. Six of 15 women (40%) had cryopreservation of supernumerary preembryos in LA cycles, versus none in non-LA cycles; 22% of preovulatory oocytes aspirated in LA cycles were available for cryopreservation for future transfer. Five pregnancies occurred in the 15 LA cycles. IVF patients with normal basal gonadotropin levels and normal responses to conventional gonadotropin stimulation benefit from LA pretreatment.

In-vitro fertilization and embryo transfer in patients with endometriosis: impact of a gonadotrophin releasing hormone agonist

In this study, in-vitro fertilization (IVF) cycles were examined in patients with endometriosis who received gonadotrophin releasing hormone agonist (GnRHa) therapy in an effort to improve their response to stimulation. Twelve patients treated with an identical gonadotrophin stimulation protocol, with and without GnRHa, were evaluated using paired analysis. In the GnRHa cycles, the total number of oocytes retrieved and transferred per cycle was higher than in the control cycles. In addition, use of the agonist lowered the cancellation rate from 33 to 0%, while a trend towards better pregnancy results was observed. When analysed according to the stage of the disease, the patients with stage III or IV endometriosis had a more dramatic improvement with GnRHa. These data suggest that GnRHa therapy may be beneficial in some patients with endometriosis undergoing IVF.