Vascular and other serious infections with Mycobacterium bovis after bacillus of Calmette-Guérin therapy for bladder cancer

Intravesical application of bacillus of Calmette-Guérin (BCG) has proved to be an effective form of treatment for some stages of bladder cancer. Infrequent, serious complications of this treatment have become apparent as its use has become more widespread. We report a case of Mycobacterium bovis mycotic abdominal aortic aneurysm and a case of M. bovis mycobacteremia that developed as complications of intravesical BCG therapy. These cases are discussed in the context of a review of reported complications of intravesical BCG therapy and a review of measures currently advocated to prevent them.

Immune system stimulation by probiotics

The immune system consists of organs and several cell types. Antigen interaction with these cells induces a cellular immune response mediated by activated cells and a humoral immune response mediated by antibodies. The cellular interactions are enhanced by adhesion molecules, and the activated cells release different cytokines. These complex cellular interactions induce a systemic immune response. If the antigen penetrates by the oral route, a secretory immune response is obtained, which is mediated by secretory IgA. The determination of the number of T or B cells, the quantitative or qualitative measure of the cytokines, antibody levels, or the study of cellular function such as phagocytic activity is used to evaluate the state of the immune system. The effects of lactic acid bacteria on the systemic immune response and on the secretory immune system are described. Potential health benefits of lactic acid bacteria include protection against enteric infections, use as an oral adjuvant, the immunopotentiator in malnutrition, and the prevention of chemically induced tumors. The results showed that Lactobacillus casei could prevent enteric infections and stimulate secretory IgA in malnourished animals, but could produce bacteria translocation. Yogurt could inhibit the growth of intestinal carcinoma through increased activity of IgA, T cells, and macrophages.

Clinical comparison of the isolator and BacT/Alert aerobic blood culture systems

The performance characteristics of the Isolator (Wampole Laboratories, Cranbury, N.J.) and the BacT/Alert (Organon Teknika Corporation, Durham, N.C.) aerobic blood culture systems were compared for 6,009 blood culture sets obtained from patients with suspected bloodstream infections. The BacT/Alert aerobic bottle [BTA(O2)] was continuously agitated while it was incubated in 5% CO2 at 36 degrees C; culture plates prepared from the Isolator tube [I(O2)] were incubated in 5% CO2 at 37 degrees C. From 394 blood cultures, 416 clinically significant isolates of bacteria and yeasts were recovered. The overall yields for BTA(O2) and I(O2) were not significantly different (319 versus 336; P = 0.20). I(O2) recovered significantly more staphylococcus (P < 0.05) and yeast isolates (P < 0.01). BTA(O2) recovered significantly more aerobic and facultatively anaerobic gram-negative bacilli (P < 0.05). In blood culture sets which produced growth of the same organisms in both the BTA(O2) and I(O2) systems, the BTA(O2) system detected growth sooner, but more rapid identification was possible with the I(O2) system by virtue of earlier isolation of colonies on solid media.

Localized soft-tissue infections with Mycobacterium avium/Mycobacterium intracellulare complex in immunocompetent patients: granulomatous tenosynovitis of the hand or wrist

In immunocompetent patients, Mycobacterium avium/Mycobacterium intracellulare complex (MAC) has been associated with pulmonary infection in adults, cervical lymphadenitis in children, and disseminated infection in children and adults. MAC rarely has been recognized as a cause of localized soft-tissue infection in immunocompetent hosts. Six cases of granulomatous tenosynovitis due to MAC are reported; five cases occurred after local surgical procedures, trauma, or corticosteroid injection. In four cases, cure was achieved with combined medical and surgical intervention. In these six cases and 11 previously reported cases, both males and females were affected equally, usually in the fifth to seventh decades of life, and the distal upper extremity was predominantly involved. Surgical debridement with appropriate culture was critical for diagnosis and management. Antimycobacterial chemotherapy seemed to be a beneficial adjunctive measure in most cases but was clearly necessary for cure in only a few cases.

Caffeine clearance in subjects with constitutional unconjugated hyperbilirubinemia

To investigate the behaviour of caffeine (CAF) in patients with Gilbert's Syndrome (GS), a combined oral loading test of caffeine and chenodeoxycholic acid was performed in 14 healthy subjects and 71 patients with GS. Indocyanine green (ICG) kinetics was tested in 50 subjects with GS and in all control subjects. Fasting serum bile acids (SBA) and clearance after CDCA loading were within normal range in normal and GS subjects. No significant difference in levels either of bilirubin or of SBA was observed in GS cases with normal (52 cases, 488 +/- 63 ml/min) or impaired (19 cases, 338 +/- 30 ml/min) caffeine clearance. Eleven GS cases showed altered ICG clearance. No correlation was found between bilirubin and bile acids, CAF or ICG. Fasting SBA were normal even in cases of CAF or ICG altered kinetics, thus excluding structural damage in unconjugated hyperbilirubinemia. CAF altered kinetics in 27% of GS cases may suggest multiple deficits in the hepatocellular metabolism, thus confirming the heterogeneity of this syndrome.

Cholera in the United States

Cholera remains a threat to human health in many parts of the world, including the United States. The epidemiology of cholera is reviewed to prepare for identification and prevention of the disease in appropriate clinical settings. The clinical manifestations of cholera and the pathophysiology of the toxin-induced diarrhea are reviewed to introduce and to clarify appropriate therapeutic and preventive interventions.

Biochemical scores could reflect histological activity in chronic hepatitis C

Eighty-one patients with HCV positive chronic active hepatitis (CAH) were studied to correlate, in multivariate regression analysis, liver tests with the histological activity index (HAI). The median HAI value (9.4) divided the patients into two groups; 44 under the 9.4 value (moderate CAH) and 37 above (severe CAH). Multiple regression improved the significance of nine biochemical parameters related to HAI in univariate analysis, and backward stepwise analysis identified the combination of alanine-aminotransferase (ALT), gammaglobulins (gamma GL), gammaglutamyl transpeptidase (gamma GT) and prolyl-hydroxylase (PH) as the best relationship with HAI (R = 0.520, p < 0.0001). A biochemical activity index (BAI) calculated as: 2.304 + ALT x 0.013 + gamma GL x 1.76 + gamma GT x 0.008 + PH x 0.012 showed the higher significant difference between moderate (7.7 +/- 1.3) and severe (12.2 +/- 2) CAH (p < 0.0001). These results suggest that this BAI could be a pointer for checking activity of chronic liver diseases.

Ceftazidime as monotherapy for fever and neutropenia: experience in a community hospital

Fever and neutropenia is occurring in a wider variety of clinical settings, and the proper antibiotic therapy for its treatment is an area of debate. Our study is a retrospective analysis of the experience of the Oncology Division of the Medical Center of Baton Rouge, which used ceftazidime as monotherapy in the empiric treatment of fever and neutropenia. A total of 53 episodes in 38 patients were studied. Using ceftazidime as monotherapy in our study population was associated with an 8% mortality rate, indicating that monotherapy is a viable option for the treatment of fever and neutropenia.

Biochemical and immunohistochemical multiparametric analysis of steroid receptors and growth factor receptors in human normal endometrium in spontaneous cycles and after the induction of ovulation

This study was carried out with three aims: to assess the variations of receptors for beta-oestradiol and progesterone, and for epidermal growth factor (EGF), alpha-fibroblast growth factor (FGF) and beta-FGF, during a spontaneous cycle in normo-ovulatory patients, 2 days before, and 2 and 7 days after the day of ovulation; to compare the control group of patients with those given ovulation induction using a multiparametric approach; and to study the role of luteal supplementation with progesterone in two groups of patients treated by a luteinizing hormone-releasing hormone agonist plus human menopausal gonadotrophin. The results were assessed by biochemical analyses and by immunohistochemistry. In spontaneous cycles, a decrease in steroid receptors occurred during the luteal phase. There was an increase in EGF and EGF receptors which was induced by oestradiol secretion, and an increase during the luteal phase of alpha-FGF and beta-FGF, which are considered to be angiogenic factors. Comparisons between spontaneous and induced cycles showed a few variations in the endometrium but no differences were related to the type of ovulation induction.

Low serum albumin and the increased risk of amikacin nephrotoxicity

AIM

The purpose of the present study was to know the incidence and risk factors associated with amikacin nephrotoxicity in a cohort of patients form a general medial center.

STUDY DESIGN

Prospective follow-up of a cohort of 104 patients treated with intravenous amikacin for at least 36 hours. We assessed serum creatinine every other day and amikacin plasma levels at 48 and 96 hours after treatment was begun. Patients with other risk factors to develop acute renal failure were excluded. The study was conducted at the Hospital de Especialidades, Centro Médico de Occidente, Instituto Mexicano del Seguro Social.

RESULTS

Ten patients developed nephrotoxicity (9.6%). According to the logistic regression model, the most powerful predictor of high nephrotoxicity probability was the serum albumin concentration. The lower the serum albumin concentration, the higher the risk of toxicity. The mean serum albumin in the group of patients with nephrotoxicity was 2.6 +/- 0.55 g/dL, while in the group of patients without toxicity it was 3.5 +/- 0.55 g/dL. No differences were observed in the age, sex, diagnosis, renal function and amikacin doses between both groups. Furthermore, low serum albumin concentration was also associated with amikacin accumulation in plasma. The group of patients with hypoalbuminemia (< or = 3.0 g/dL) had a significantly higher trough amikacin plasma level (assessed at 48 and 96 hours of the initiation of treatment) than those with normal serum albumin, with no differences among the age, sex, baseline renal function and received amikacin doses.

CONCLUSIONS

We conclude that serum albumin concentration is the most powerful predictor of amikacin nephrotoxicity. The risk factors observed in the present study are similar to those previously observed by us at the Instituto Nacional de la Nutrición Salvador Zubirán.

Granulosa cells improve human embryo development in vitro

A total of 17 couples with repetitive implantation failure after transfer of fresh or frozen-thawed embryos had half of their zygotes cultured in standard conditions and frozen at day 2 after insemination, and the other half cocultured with autologous granulosa cells and transferred at the morula or blastocyst stage at day 5 or 6 after oocyte retrieval. At the end of the culture period, supernatants of cocultures were recovered for steroid assays. Monolayers were stained for granulosa cell growth and morphological assessment. We observed that granulosa cells improve embryo development in vitro since 32 out of 60 (53%) reached the morula stage and 18 (30%) the blastocyst stage, leading to a total of 83% embryos available for transfer (compared with 3% without coculture). The ongoing pregnancy rate of these patients who were selected because they had at least three previous implantation failures, is only 5.9%, however, which is similar to the control group without coculture (6.3%). To conclude, granulosa cells improve embryo development but not the pregnancy rate after transfer of cocultured embryos in patients with multiple previous implantation failures.

Comparison of growth hormone responses to growth hormone-releasing factor and clonidine in women with normal or poor ovarian response to gonadotropin stimulation

OBJECTIVE

To assess the reliability of growth hormone (GH) secretion tests using provocative agents in women of different ovarian status.

DESIGN

Comparison of GH secretion in response to clonidine (Catapressan; Boehringer Ingelheim, Reims, France) and growth hormone-releasing factor (GH-RF).

SETTING

University Hospital, Hôpital Tenon, Paris, France.

PATIENTS

Women categorized as "normal" (n = 6) or "poor" responder (n = 7) to ovarian stimulation with gonadotropins, depending on the follicular development attained at previous IVF attempts.

INTERVENTIONS

Clonidine (0.300 mg administered orally) once and GH-RF (1 micrograms/kg IV) repeated twice. The tests were performed in random order in each individual on following cycles.

MAIN OUTCOME MEASURES

Basal and peak GH values, area under the curve (AUC).

RESULTS

Poor responder patients show significantly higher basal levels of FSH, GH, and insulin-like growth factor 1; FSH and basal GH levels are positively correlated. Peak GH levels and AUC are not significantly different in both categories of patients, whether GH-releasing factor or clonidine are used as provocative agents. True positive rate is 56.4% at the cutoff value of 7 micrograms/L, with no significant difference between the patients of the normally or poorly responding groups. At the 10-micrograms/L cutoff level, the true positive rate is almost half in the poor responder group (19.0% versus 38.9%), but the difference is not significant.

CONCLUSIONS

These results raise concern about using the GH secretory response to a single clonidine administration as a predictive test of the therapeutic benefit that could be obtained by co-stimulating the somatotropic axis during a treatment with gonadotropins in poor responder patients, especially when their FSH basal levels are elevated.

Induction of antioxidant enzymes and DT-diaphorase in human blood mononuclear cells by light stress

Human blood mononuclear cells exposed to visible light increase their antioxidant enzyme (superoxide dismutase, catalase, and glutathione peroxidase) and DT-diaphorase activities. The activities of CuZn-superoxide dismutase (3.70 +/- 0.25 U/mg protein), catalase (4.60 +/- 0.39 U/mg protein), and DT-diaphorase (1.40 +/- 0.11 mumol DCPIP/min.mg protein) increased 1.5-fold when mononuclear cells were exposed at 38 W/m2 for 4 h. Se-containing glutathione peroxidase activity (6.76 +/- 0.21 mU/mg protein) increased 1.3 times after 3 h of exposure to 38 W/m2. Conversely, Mn-superoxide dismutase (2.20 +/- 0.20 U/mg protein), succinate dehydrogenase (0.86 +/- 0.04 mumol DCPIP/min.mg protein), and cytochrome oxidase (0.54 +/- 0.04 min-1 (k')/mg protein) activities remained constant during this period of exposure. The treatment of cells with cycloheximide prevented the response triggered by light exposure. These results introduce new insight to the adaptive response of human cells to light stress suggesting that: (a) the response observed might be ascribed to synthesis of stress proteins rather than to activation of a preexisting pool, and (b) that DT-diaphorase and CuZn-superoxide dismutase may operate biologically in a concerted fashion resulting in antioxidant activity.

Cellular stress by light and rose bengal in human lymphocytes

Human lymphocyte cultures were supplemented with 10(-8)-10(-4) M Rose Bengal and irradiated with fluorescent light (Philips 40-W daylight-fluorescent lamp, 380-550 nm) and chromosomal aberrations and catalase and superoxide dismutase activities in the cells were determined. Chromosomal lesions and both enzymatic activities increased additively or synergistically in human lymphocytes after Rose Bengal supplementation and fluorescent light irradiation. Chromosomal lesions (expressed as chromosomal aberrations/cells) were (a) 0.12 +/- 0.03, (b) 0.18 +/- 0.12, (c) 1.58 +/- 0.11 and (d) 3.20 +/- 0.17 in the following conditions: (a) control; (b) after 3 h light irradiation, (c) supplemented with 10(-5) M Rose Bengal and (d) with dye treatment and light irradiation. Superoxide dismutase activity was: (a) 16.5 +/- 1.5; (b) 19.5 +/- 1.2; (c) 29.2 +/- 1.5 and (d) 35.4 +/- 2.1 U/mg protein and catalase activity was: (a) 10.3 +/- 0.5, (b) 12.8 +/- 0.7, (c) 22.4 +/- 0.5 and (d) 27.6 +/- 1.1 U/mg protein in the same experimental conditions. These findings suggest that Rose Bengal supplementation plus fluorescent light irradiation of human lymphocytes lead to the synthesis of superoxide dismutase and catalase in a manner similar to the heat-shock response. A threshold of chromosomal damage (about 2 chromosomal aberrations/cell) is apparently required to activate oxidative stress genes.

[Hyperstimulation for in vitro fertilization with the "step-down" technique. Preliminary results from a prospective randomized study with and without LHRH agonists]

Twenty six normo-ovulatory patients < 38 years with tubal or idiopathic infertility and normal sperm were treated for IVF by FSH +/- hMG and randomized into four groups: with and without LHRH agonist, "step-up" or "step-down" stimulation. In the step down protocol, after 4 days with 4 amps plasmatic FSH reached its top level, then decreased. Despite reduction to only two amps, estradiol continued to increase in all the 5 women without agonist, whereas 3/7 with the long protocol were considered as low responders and stopped. The fertilization/cleavage rate was 69.2% in step-down and 45.7% in step-up (p < 0.04) with the short protocol, and respectively 65.6% and 41.9% (p < 0.03) with the long one. The pregnancy rate was equivalent in all groups.

[3 beta-hydroxysteroid dehydrogenase defect: frequency of presentation in a sample of Chilean hirsute women]

The defect of 3 beta hydroxysteroid dehydrogenase (3 beta HSD) is frequent among hirsute women and clearly dependent on the ethnic composition of the studied population. Our aim was to study the frequency of 3 beta HSD deficit in a group of Chilean hirsute women. Basal and post ACTH concentrations of cortisol, 17 hydroxyprogesterone and 17 hydroxypregnenolone were measured by RIA in 40 hirsute post puberal women and in 15 normal age matched female volunteers. Criteria for considering a 3 beta HDS deficit were 17 hydroxypregnenolone values and 17 hydroxypregnenolone/17 hydroxyprogesterone and 17 hydroxypregnenolone/cortisol ratios after ACTH stimulation over the 95% confidence intervals of normal women. Basal dehydroepiandrosterone sulphate and testosterone levels were also measured in hirsute women. All samples were obtained during the follicular phase of the menstrual cycle. ACTH stimulated hormone values and ratios were diagnostic for 3 beta HDS deficit in 7.5% of hirsute women. Basal testosterone was over 80 ng/dl in 47.5% and dehydroepiandrosterone sulphate over 3.9 micrograms/ml in 52.5% of these women. There was no correlation between dehydroepiandrosterone or testosterone values and ACTH stimulated hormone values. It is concluded that 3 beta HSD is frequent in hirsute women and that its diagnosis requires the determination of ACTH stimulated 17 hydroxypregnenolone values and 17 hydroxypregnenolone/17 hydroxyprogesterone ratio.

Atraumatic severe streptococcal axillary cellulitis

Axillary streptococcal cellulitis is rare but has been known to clinicians for years. Usually associated with trauma, it may, however, occur in previously healthy individuals who for unknown reasons can be slowly responsive to appropriate antibiotics.

Infections in the compromised host

The normal defense mechanisms against infection include (1) normal skin and mucous membranes, (2) humoral immunity, (3) phagocytic system, and (4) cellular immunity. The compromised (immunocompromised) host is an individual who has one or more deficiencies in these defense mechanisms. This article reviews potential infections in the compromised host as well as an approach to evaluation of these patients.

Is there an indication for embryo reduction?

The selective reduction of embryos in multiple pregnancies poses numerous medical, technical, ethical and psycho-social problems. In a retrospective study, we analysed nine hundred and twenty-two pregnancies obtained using medically assisted procreation between May 1982 and May 1990. Among 922 successful pregnancies, 372 were singleton, 102 were twin and 13 were triplet. Data from this analysis and from a French multicentre study of 262 embryo reduction procedures demonstrated the value of an embryo quality score for minimizing the risk of multiple pregnancy and the existence of extremely infrequent, ethically acceptable indications for embryo reduction. These indications included ultrasound-proven malformations of one fetus, multiple pregnancies in patients with extensive uterine scarring, and multiple pregnancy despite the appropriate use of preventative measures which can be expected to make this technique unnecessary in the future.

Hormonal secretions in singleton pregnancies arising from the implantation of fresh or frozen embryos after oocyte donation in women with ovarian failure

OBJECTIVE

To determine whether levels of human chorionic gonadotropin (hCG), 17 beta-estradiol (E2), and progesterone (P) are different in the peri-implantation phase of fresh versus frozen embryos.

DESIGN

Hormonal secretions were measured on days 9 and 11 after implantation and at 4, 5, and 6 weeks gestation.

PATIENTS

Thirty-one pregnancies were achieved in 65 patients with ovarian failure. Seventeen singleton pregnancies developed after implantation of 4 frozen and 13 fresh embryos.

RESULTS

Human chorionic gonadotropin and E2, contrary to P, were higher in cases of fresh embryos from the 9th day after transfer to the 5th week at which time they become statistically significant (respectively, for hCG and E2, 5,800.3 +/- 332.3 versus 2,027.3 +/- 916.3 [mean +/- SD] mIU/mL for hCG and 562.3 +/- 215 versus 291 +/- 152 pg/mL for E2).

CONCLUSIONS

This difference might be explained by either the higher number of fresh embryo replaced or by the fact that the number of blastomeres and also their metabolic activity could be reduced after freezing and thawing.

Immunoadjuvant activity of oral Lactobacillus casei: influence of dose on the secretory immune response and protective capacity in intestinal infections

Lactobacilli, often used as effectors of host functions, could play an important role in maintaining human health by controlling other intestinal microorganisms capable of producing harmful effects. Using an experimental model, we studied the effect of different oral doses of Lactobacillus casei on the secretory IgA response and the protective capacity of the microorganism in preventing intestinal infections. The optimization of the protective dose of Lb. casei by previous feeding and the use of the lactobacillus as an immunological way to control enteric infections were investigated. We found that conventional mice were protected against infection with Salmonella typhimurium and Escherichia coli by previous feeding for 2 consecutive days with a daily Lb. casei dose of 1.2 x 10(9) cfu/mouse. Previous feeding for 7 d proved less effective, and feeding for 5 d afforded no protection at all. We were also able to demonstrate that the protective effect of Lb. casei against Sal. typhimurium and Esch. coli was connected mainly with the high level of IgA antipathogen antibodies present in intestinal secretions. beta-Glucuronidase (EC 3.2.1.31) and beta-galactosidase (EC 3.2.1.23) activities, measured both in the intestinal fluid and histological samples, showed a marked increase in intestinal inflammatory response on day 5 of feeding. These results show that Lb. casei plays an important role in the prevention of enteric infections, a low dose being enough for protection against intestinal infections by increasing IgA secretion into the intestinal lumen, thus providing adequate defences for the mucosal surface. A previously administered dose of this magnitude could therefore be used as an oral adjuvant in preventing enteric infections.

Comparison of plasma and follicular fluid hormone profiles following stimulation with HMG, with or without LHRH agonists, for in-vitro fertilization

Plasma and follicular fluid (FF) hormone assays for follicle stimulating hormone (FSH), luteinizing hormone (LH), prolactin (PRL), oestradiol (E2), progesterone (P), delta-4-androstenedione (A4) and testosterone (T) were performed on the day of oocyte retrieval in two groups of normo-ovulatory women enrolled in an in-vitro fertilization (IVF) programme: 24 were treated using the decapeptyl agonists DTRP6, of luteinizing hormone-releasing hormone (LHRH) in the long protocol associated with human menopausal gonadotrophin (HMG) (49 FF) and 14 were stimulated with HMG alone (33 FF). In both FF and plasma the mean concentration of P was greater, and the E2/P ratios as well as the LH levels were lower in the agonist-treated group. In this group the follicular concentration of P was greater and the E2/P ratio lower when pregnancy occurred following IVF. The hormonal modifications may be due to greater functional maturity of the granulosa cells.

Ovarian stimulation using human menopausal gonadotrophins with or without LHRH analogues in a long protocol for in-vitro fertilization: a prospective randomized comparison

In order to evaluate the exact role of GnRH agonists, we have undertaken a randomized prospective study comparing two groups of 90 normo-ovulatory patients, aged less than 38 years and with tubal infertility with no male factor. Luteinizing hormone releasing hormone analogue (DTRP6 administered in a long protocol, for at least 15 days) was associated with human menopausal gonadotrophin (HMG) induction in group I. In group II, stimulation was performed using HMG alone (three ampoules per day in general, from days 2 to 7 of the cycle). Apart from the well known results demonstrated in the literature of a reduced incidence of inadequate responses, an absence of premature luteinization and a greater number of oocytes per retrieval (8.8 +/- 4.9 versus 6.8 +/- 3.2, P less than 0.01 in group II), this study confirms the higher pregnancy rate (21.1 versus 12.2% per cycle and 24.7 versus 17.1% per oocyte retrieval, not significant) and underlines the higher plasma progesterone levels and lower E2/P ratio in group I from D - 1 to D + 5, which could explain a better maturation of the oocytes and the endometrium.

Delayed life-threatening pneumonitis secondary to procarbazine

A patient with advanced Hodgkin's disease being treated with MOPP chemotherapy presented with delayed life-threatening pulmonary toxicity secondary to procarbazine. The pulmonary toxicity began 1 week after procarbazine had been discontinued and once recognized was successfully treated with intravenous steroids.

Prevention of gastrointestinal infection using immunobiological methods with milk fermented with Lactobacillus casei and Lactobacillus acidophilus

The protective effect of feeding milk fermented with a mixture of Lactobacillus casei sp. and Lb. acidophilus sp. against Salmonella typhimurium infection in mice was compared with that obtained feeding milks fermented with these microorganisms individually. The survival rate obtained after oral infection with Sal. typhimurium was 100% in mice pretreated by feeding during 8 d with the mixture of Lb. casei and Lb. acidophilus fermented milks. Similar treatments with the individual milks were ineffective. Moreover, mice became more susceptible to infection with Sal. typhimurium after such treatment. The colonization of liver and spleen with the pathogen was markedly inhibited by the pretreatment with the mixture of fermented milk, while such inhibition was not observed using the Lb. casei and Lb. acidophilus milks. The highest levels of anti-salmonellae antibodies in serum and in intestinal fluid were found in the group of mice fed with the mixture and with Lb. casei fermented milk respectively. However, this latter milk was not effective in protecting against Sal. typhimurium. When the mice were first infected with Sal. typhimurium and then fed with the mixture of fermented milks, pathogen colonization was not prevented. The results suggest that the augmentation of resistance to salmonellae caused by the treatment with Lb. casei- + Lb. acidophilus-fermented milk was due to the anti-salmonellae protective immunity mainly mediated by the mucosal tissue. Milk fermented with this mixture could be used as an immunobiological method to prevent gastrointestinal infection.

Pregnancies following ovum donation in gonadal dysgenesis

Between February 1987 and February 1989, 13 women with primary ovarian failure due to gonadal dysgenesis were treated with embryo transfer following ovum donation in 22 cycles. Eight pregnancies were obtained (36.7% per transfer); four births of normal children, two spontaneous abortions and two other pregnancies currently ongoing (between 5 and 8 months). An association of percutaneous oestradiol, oestradiol valenate and intravaginal progesterone was used as hormone substitution and embryo transfer was only performed following assessment of the endometrium during a previous cycle. Apart from the day of embryo transfer, which was the same for all patients (the 2nd day after initiation of progesterone) various prognostic factors were analysed. These were the type of gonadal dysgenesis (45 XO, 46 XX or 46 XY), the number of embryos replaced, whether they had been frozen, whether the egg donor was anonymous and finally the influence of the hormone substitution protocol. Only the number of embryos replaced and the substitution protocol seemed to influence the implantation rate. The other parameters, and in particular the type of gonadal dysgenesis, seemed to have no effect on the results. The pregnancy rate per transfer was 30% for 45 XO (10 transfers), 25% for 46 XX (eight transfers) and 75% for 46 XY (four transfers).

Leukopenia secondary to mycobacterium leprae

Hansen's disease (HD) is one of the major infectious diseases in the world with an estimated total of 12 million cases. Physicians in North America, however, rarely see HD or its manifestations. Hematological manifestations of HD have been reported but are not well appreciated. We report a patient with leukopenia while under treatment for active HD who demonstrated mycobacterial involvement of the bone marrow.

Treatment of hyperstimulation during in-vitro fertilization

In 33 patients treated with a combination of an LHRH agonist (LHRH-A) and gonadotrophin in a long protocol, a biological hyperstimulation occurred (E2 greater than 2500 pg/ml on the day of HCG administration and 4722 +/- 1190 pg/ml the day after, with greater than 10 follicles greater than 12 mm on each ovary). The replacement of fresh embryos were deferred and LHRH-A was continued, and an endometrial biopsy was performed on the theoretical day of replacement (2 days after oocyte recovery). With this technique, we obtained a mean number of 17.9 +/- 7 oocytes, a fertilization rate of 49% and a replacement rate of 87% in a deferred cycles. The overall pregnancy rate of frozen-thawed embryos was 27% in the seven spontaneous cycles, 12 induced cycles and 10 artificial cycles. Only one severe hyperstimulation occurred and this case emphasizes that caution remains necessary even with this technique.

[Treatment of ovarian polycystic syndrome in vitro. Physiopathogenetic considerations]

More than 60% of patients with polycystic ovary disease (PCO) cannot conceive after repeated ovulation inductions with Clomifene citrate although there is ovulation or more frequently follicle luteinization. Because of hyperstimulation, therapy with hMG has been superseded by low doses of purified FSH with variable results according to authors. It has been even claimed that there was no benefit to replace hMG with FSH. However, on the basis of the PCO physico-pathology, namely LH hypersecretion and androgen hyperproduction, it would be rational to associate the desensitization of the pituitary with LH-RH agonist and the ovary stimulation with variable doses of hMG or purified FSH. In the series where such therapy associating LH-RH agonists with purified FSH was applied, the results concerning suppression of LH and androgen secretion, and the occurrence of pregnancy were interesting. However, the risk of hyperstimulation still occurred. Thus, the first part concerns the critical review of these results while, in the second part, our experience in in vitro fecundation will be reported.

[Evaluation criteria of the condition of the endometrium in relation to the presence of ovocytes]

18 patients with ovarian failure received cyclic steroid replacement therapy including estrogens and progesterone for embryo transfer. Hormonal results and endometrial histology are reported. The temporal window of endometrial receptivity 13 discussed, shedding some light on the respective role of embryo and endometrium in the implantation process.

[Adjuvant activity of lactic bacteria: perspectives for its use in oral vaccines]

The effect of the oral and subcutaneous administration of Lactobacillus casei, Lactobacillus acidophilus, Lactobacillus bulgaricus and Streptococcus thermophilus on humoral antibody production and delayed type hypersensitivity response against sheep red blood cells (SRBC) was studied. The species of the genus Lactobacillus proved to be more effective in both cases, effects being stronger when working with viable bacteria than with non-viable cells. The stimulation of primary cellular and humoral immune responses reached optimal activity with a dose of 6 x 10(9) cells. The plaque-forming cells (PFC) and the circulating antibody titers to the SRBC antigen obtained in the groups treated with lactobacilli were 2 to 3 times higher than those of the non-treated control group. In mice fed with the different lactic acid bacteria circulating antibody against these microorganisms failed to be detected, but when they were administered by subcutaneous route a strong response to antilactic acid bacteria was stimulated. S. thermophilus was not effective in increasing the immune response. These results suggest that the lactobacilli by oral route, exert a strong adjuvant activity which is responsible for the enhanced host immune responses obtained. In this respect, lactobacilli could be considered as the most promising oral adjuvant.

Programmed ovulation induction and oocyte retrieval for in vitro fertilization

Forty-two patients underwent programmed ovulation induction for oocyte retrieval. They were treated in the preceding cycles with a progestagen, ethynodiol diacetate, at a dose of 2 mg twice daily. Two groups were defined based upon the stimulation protocol: Group A1 was stimulated with clomiphene citrate and human menopausal gonadotropin (hMG), and Group A2 with follicle-stimulating hormone (FSH) and hMG. They were compared to two randomized control groups of patients who received the same induction but were classically monitored. There was a high proportion of spontaneous ovulations in the programmed group (8/42) compared to the nonprogrammed group (0/42). There was a nonsignificant difference in the number of oocytes obtained or embryos replaced per cycle. Four pregnancies were obtained in the programmed group (24% per transfer), against 10 in the nonprogrammed patients (32% per transfer). The results of this method seem to be better using FSH for ovulation stimulation and a verification of the serum estradiol on the day of induction with human chorionic gonadotropin (hCG) and the following day (semiprogrammed method).

Disseminated blastomycosis in a pregnant woman successfully treated with amphotericin-B. A case report

An 18-year-old woman developed disseminated blastomycosis in the 30th week of pregnancy. She was treated with amphotericin-B. Simultaneous maternal-infant blood levels at birth were 1.9 and 1.3 micrograms/mL, respectively. The amphotericin-B level in the amniotic fluid was 0.3 microgram/mL at delivery. The infant was normal and without ill effects from either the blastomycosis or the amphotericin-B. The skin lesions and pulmonary infiltrates in the mother improved rapidly, without unexpected side effects from the therapy. The limited experience with amphotericin-B indicates that it is both well tolerated and effective in this clinical situation.

Comparison between long and short protocols of LHRH agonist in the treatment of polycystic ovary disease by in-vitro fertilization

Two groups of patients with polycystic ovary disease were treated with analogues of LHRH to compare long and short protocols of pituitary desensitization. In group 1 (n = 15), decapeptyl was administered for 30 days associated with stimulation by pure FSH. In group 2 (n = 12) Buserelin was given for 15 days with the same ovarian stimulation. Patients were randomly assigned to the two groups. Six patients in each group had received treatment, for at least 4 months, to induce ovulation with clomiphene citrate or HMG and failed to conceive, despite the absence of a tubal factor. The best results were obtained using the long protocol. Androgen concentrations, particularly delta 4-androstenedione, were significantly lower on the day of oocyte retrieval in group 1 than in group 2 (2.52 +/- 0.73 ng/ml versus 4.44 +/- 2.62, respectively (P less than 0.02). Polycystic follicular formation was less pronounced in group 1 and no clinical hyperstimulations occurred in this group. The pregnancy rate was comparable in the two groups (six ongoing pregnancies in 21 cycles in the 15 patients in group 1 versus three pregnancies in 12 cycles in the 12 patients in group 2).

Pregnancies after replacement of frozen-thawed embryos in a donation program

Eighteen patients with primary (n = 8) or secondary (n = 10) ovarian failure were enrolled in a donation program. In 15 cases, the oocytes were donated anonymously; in 3 cases, they were donated by the sister of the recipient. All the recipients had cyclic steroid replacement therapy that included estrogens and progesterone administered by the transdermal and tranvaginal routes, respectively. The embryos obtained were cryopreserved and replaced with no attempt at synchronization between donor and recipient. Steroid hormonal patterns were within the range for the normal menstrual cycle and endometrial biopsies taken on day 21 or 22 of the treatment cycles were independently assessed as being representative of day 21 +/- 2. Four of 12 transfers were successful (31%): 1 patient aborted at 6 weeks, and the three others were delivered, one normally and two by cesarian sections. The authors' practice suggests the following: (1) steroid supplementation by transdermal and transvaginal routes is effective, (2) synchronization between donor and recipient is no longer required with the use of frozen-thawed embryos, and (3) the "temporal window" is large since all the replacements were done on day 14 of the cycle.

Prognostic value of pre-ovulatory serum progesterone, LH and oestradiol-17 beta levels in stimulated cycles for in-vitro fertilization

The prognostic value of a decrease in oestradiol-17 beta (E2) on the day after HCG injection in stimulated cycles has been related to a premature increase in plasma progesterone (P) on the day before HCG injection. This retrospective study was carried out on 363 patients who were divided into four groups. Patients in group A were given clomiphene citrate plus human menopausal gonadotrophin (HMG) to stimulate follicle growth, and they were subdivided into subgroups A1 and A2 who showed an increase or a decrease in E2 levels after HCG injection. The changes in E2 were greater than 10% of the levels on the previous day. Patients in group B were stimulated by HMG and were similarly subdivided into subgroups B1 and B2 according to their E2 levels. The number of oocytes recovered and the incidence of pregnancy was significantly higher in A2 as compared with A1, and higher but not significantly so in B2 versus B1. Moreover, in subgroups A1 and B1 the day before the decrease of E2 was marked by a significant rise in LH before the HCG injection. We suggest that oocyte recovery is deferred in these cases.