Efficacy of high-level disinfection of endoscopes contaminated with Streptococcus equi subspecies equi with 2 different disinfectants

BACKGROUND

Prevention of spread of Streptococcus equi subspecies equi (S. equi) after an outbreak is best accomplished by endoscopic lavage of the guttural pouch, with samples tested by culture and real time, quantitative polymerase chain reaction (qPCR). Disinfection of endoscopes must eliminate bacteria and DNA to avoid false diagnosis of carrier horses of S. equi.

HYPOTHESIS/OBJECTIVES

Compare failure rates of disinfection of endoscopes contaminated with S. equi using 2 disinfectants (accelerated hydrogen peroxide [AHP] or ortho-phthalaldehyde [OPA]). The null hypothesis was that there would be no difference between the AHP and OPA products (based on culture and qPCR results) after disinfection.

METHODS

Endoscopes contaminated with S. equi were disinfected using AHP, OPA or water (control). Samples were collected before and after disinfection and submitted for detection of S. equi by culture and qPCR. Using a multivariable logistic regression model-adjusted probability, with endoscope and day as controlled variables, the probability of an endoscope being qPCR-positive was determined.

RESULTS

After disinfection, all endoscopes were culture-negative (0%). However, the raw unadjusted qPCR data were positive for 33% AHP, 73% OPA, and 71% control samples. The model-adjusted probability of being qPCR-positive after AHP disinfection was lower (0.31; 95% confidence interval [CI], -0.03-0.64) compared to OPA (0.81; 95% CI, 0.55-1.06), and control (0.72; 95% CI, 0.41-1.04).

CONCLUSION AND CLINICAL IMPORTANCE

Disinfection using the AHP product resulted in significantly lower probability of endoscopes being qPCR-positive compared to the OPA product and control.

Strangles, convalescent Streptococcus equi subspecies equi M antibody titers, and presence of complications

Background

Streptococcus equi subspecies equi infection elicits M protein antibody titers in equids. Interpretation of titers is not generally accepted.

Hypothesis

The magnitude of S. equi M protein (SeM) antibody titer after infection (titer ≥1:12 800) will be useful to monitor for the presence of complications or the risk of development of complications.

Animals

Forty‐eight horses on 1 farm involved in strangles outbreak.

Methods

Clinical and observational study. S. equi M protein antibody titers were measured on all horses 8 weeks after infection and select horses 12 and 28 weeks after infection. Horses were categorized: no disease, uncomplicated case, persistent guttural pouch (GP) infection, or complicated cases (metastatic abscesses, purpura hemorrhagica, secondary infections, and dysphagia). Category was compared to titer.

Results

Twenty‐eight of 48 (58%) developed clinical signs of S. equi infection. Of those, 11 (39%) had uncomplicated strangles, 9 (21%) had persistent GP infection, 5 (18%) were complicated cases, and 3 (11%) had both persistent GP infection and complications. Thirty‐three percent of horses (16 of 48) had SeM antibody titers ≥1:12 800 eight weeks after infection. Of horses with titers ≥1:12 800, 6 of 16 had evidence of complications. Of complicated cases, 6 of 8 had titers ≥1:12 800. In this outbreak, the sensitivity (75%; 95% CI [confidence interval] 45‐105) for a SeM antibody titer ≥1:12 800 detecting complications was higher than the specificity (43%; 95% CI 23‐64).

Conclusions and Clinical Importance

This outbreak demonstrates that SeM antibody titers can be increased after infection (≥1:12 800) in the absence of complications of strangles.

Seroprevalence, frequency of leptospiuria, and associated risk factors in horses in Kansas, Missouri, and Nebraska from 2016-2017

Leptospirosis is a worldwide veterinary and public health concern, and well recognized infectious disease of horses. Seroprevalence rates vary with geography, but many studies have confirmed a high exposure rate. The correlation between seropositivity and shedding status has not been made in horses, however. The aims of this study were to use semi-nested PCR on urine from apparently healthy horses to determine period prevalence of leptospiral shedding and to correlate these findings with MAT results to establish associations with client based survey data regarding horse management and environment. Serum and free-catch urine were collected from 204 healthy horses between May 2016-December 2017. Serum was used to determine GGT, creatinine concentrations, and six serovar MAT. Urine samples were submitted for PCR testing of leptospiral 23S rRNA. Client consent and survey data were collected for all subjects. Potential risk factors included drinking water source, exposure to livestock and dogs, geographical location, season, and precipitation. Two horses were positive on urine PCR for leptospirosis (shedding prevalence 1%), yet only one had a high reciprocal MAT titer of ≥ 800. Both horses were negative on urine PCR one month later without treatment. Approximately 77% of horses (157/204) were seroreactive (MAT reciprocal titer ≥ 100) with titers to serogroup Australis detected more frequently than others (47.5%; (97/204)). Apparently healthy horses infrequently shed Leptospira spp. in urine, yet seroreactivity in clinically normal horses is high (77%), confirming high exposure rates to Leptospira spp. in the Central Midwest.

Bayesian Geostatistical Analysis and Ecoclimatic Determinants of Corynebacterium pseudotuberculosis Infection among Horses

Kansas witnessed an unprecedented outbreak in Corynebacterium pseudotuberculosis infection among horses, a disease commonly referred to as pigeon fever during fall 2012. Bayesian geostatistical models were developed to identify key environmental and climatic risk factors associated with C. pseudotuberculosis infection in horses. Positive infection status among horses (cases) was determined by positive test results for characteristic abscess formation, positive bacterial culture on purulent material obtained from a lanced abscess (n = 82), or positive serologic evidence of exposure to organism (≥1:512)(n = 11). Horses negative for these tests (n = 172)(controls) were considered free of infection. Information pertaining to horse demographics and stabled location were obtained through review of medical records and/or contact with horse owners via telephone. Covariate information for environmental and climatic determinants were obtained from USDA (soil attributes), USGS (land use/land cover), and NASA MODIS and NASA Prediction of Worldwide Renewable Resources (climate). Candidate covariates were screened using univariate regression models followed by Bayesian geostatistical models with and without covariates. The best performing model indicated a protective effect for higher soil moisture content (OR = 0.53, 95% CrI = 0.25, 0.71), and detrimental effects for higher land surface temperature (≥35°C) (OR = 2.81, 95% CrI = 2.21, 3.85) and habitat fragmentation (OR = 1.31, 95% CrI = 1.27, 2.22) for C. pseudotuberculosis infection status in horses, while age, gender and breed had no effect. Preventative and ecoclimatic significance of these findings are discussed.

Transient Fanconi syndrome in Quarter horses

Two Quarter horses with weight loss had glucosuria, euglycemia, and a mild metabolic acidosis suggesting a proximal renal tubular defect. Further testing revealed transient generalized aminoaciduria, lactic aciduria, and glucosuria, indicating Fanconi syndrome. Both horses recovered with supportive therapy. This is the first report of acquired Fanconi syndrome in horses.

Babesia equi-induced anemia in a Quarter Horse and subsequent regulatory response

CASE DESCRIPTION

A 7-year-old Quarter Horse gelding used for unsanctioned racing was examined because of fever and anorexia.

CLINICAL FINDINGS

Physical examination revealed fever, tachycardia, and tachypnea. Results of a CBC indicated anemia and mild thrombocytopenia. Results of microscopic examination of a blood smear indicated piroplasms in erythrocytes, consistent with Babesia spp. Regulatory authorities were contacted, and results of serologic testing at the National Veterinary Services Laboratories confirmed acute Babesia equi infection.

TREATMENT AND OUTCOME

Equids on the home premises of the index horse were placed under quarantine. Those equids were tested for piroplasmosis, and 6 of 63 horses had positive results for B equi. Another horse that had previously been housed on the index premises also had positive results for B equi. Competent tick vectors for piroplasmosis organisms were not identified. All 8 horses with piroplasmosis were Quarter Horses that participated in unsanctioned racing and were trained by the same person. Two of the horses were illegally removed from the index premises; these 2 horses and the other horse with piroplasmosis that was previously housed on the index premises could not be found. The other 5 horses with piroplasmosis were euthanized. Investigators concluded that transmission of B equi among horses was most likely iatrogenic.

CLINICAL RELEVANCE

The United States has been considered piroplasmosis free. However, veterinarians should consider piroplasmosis in horses with signalments and clinical signs similar to those of the index horse of this report. Regulatory authorities should be contacted regarding horses in which piroplasmosis is suspected.

A retrospective wound review of standard four-port laparoscopic cholecystectomy: is there need for single-port laparoscopic surgery?

BACKGROUND

This study was designed to assess the satisfaction or otherwise of a proportion of the U.K. population who have undergone standard four-port laparoscopic cholecystectomy within the past 18 months. The results should indicate whether there is potential demand for a new, improved approach to surgery.

METHODS

Patients who underwent laparoscopic cholecystectomy between October 2008 and October 2009 in two geographically separated general hospitals were identified from hospital databases. Notes were reviewed to confirm the technique and lack of conversion to an open procedure. Those who had immediate complications were excluded. A telephone questionnaire was conducted to answer questions related to long-term cosmetic and general satisfaction of the current procedure.

RESULTS

Of the patients surveyed, 93% were happy or extremely happy with the current procedure, 48% experienced some wound-related issues (pain, infection), and 65% of those were at the umbilicus (a possible reflection of location and retrieval site for gallbladder). Cosmesis was rated less important than hospital cleanliness and experience of the surgeon.

CONCLUSIONS

Overall satisfaction was high with the existing technique. The high rate of umbilical wound problems is an issue that will not be eradicated by introduction of single-port laparoscopic surgery.

Age-related changes in metabolic properties of equine skeletal muscle associated with muscle plasticity

The purpose of the present study was to determine the age-related changes in myosin heavy chain (MHC) composition and muscle oxidative and glycolytic capacity in 18 horses ranging in age from two to 30 years. Muscle samples were collected by excisional biopsy of the semimebranosus muscle. MHC expression and the key enzymatic activities were measured. There was no significant correlation between horse age and the proportions of type-IIA and type-IIX MHC isoforms. The percentage of type-I MHC isoforms decreased with advancing age. Muscle citrate synthase activity decreased, whereas lactate dehydrogenase activity increased with increasing age. Muscle 3-OH acyl CoA dehydrogenase activity did not change with ageing. The results suggest that, similar to humans, the oxidative capacity of equine skeletal muscle decreases with age. The age-related changes in muscle metabolic properties appear to be consistent with an age-related transition in MHC isoforms of equine skeletal muscle that shifts toward more glycolytic isoforms with age.

Exercise training increases oxidative capacity and attenuates exercise-induced ultrastructural damage in skeletal muscle of aged horses

Exercise training improves functional capacity in aged individuals. Whether such training reduces the severity of exercise-induced muscle damage is unknown. The purpose of the present study was to determine the effect of 10 wk of treadmill exercise training on skeletal muscle oxidative capacity and exercise-induced ultrastructural damage in six aged female Quarter horses (>23 yr of age). The magnitude of ultrastructural muscle damage induced by an incremental exercise test before and after training was determined by electron microscopic examination of samples of triceps, semimembranosus, and masseter (control) muscles. Maximal aerobic capacity increased 22% after 10 wk of exercise training. The percentage of type IIa myosin heavy chain increased in semimembranosus muscle, whereas the percentage of type IIx myosin heavy chain decreased in triceps muscle. After training, triceps muscle showed significant increases in activities of both citrate synthase and 3-hydroxyacyl-CoA-dehydrogenase. Attenuation of exercise-induced ultrastructural muscle damage occurred in the semimembranosus muscle at both the same absolute and the same relative workloads after the 10-wk conditioning period. We conclude that aged horses adapt readily to intense aerobic exercise training with improvements in endurance, whole body aerobic capacity, and muscle oxidative capacity, and heightened resistance to exercise-induced ultrastructural muscle cell damage. However, adaptations may be muscle-group specific.

Ureteral ligation prevents the haemodynamic effect of frusemide in pentobarbitol anaesthetised horses

Frusemide reduces pulmonary vascular pressures in resting horses and attenuates exercise-induced increases in these pressures in exercising horses. The mechanism underlying these effects of frusemide is unclear. We tested the hypothesis that the haemodynamic effects of frusemide are dependent on diuresis by examining the effect of frusemide in anaesthetised horses in which diuresis was prevented by ligation of ureters. Twenty four horses were assigned randomly to one of 4 treatments: 1) frusemide (1 mg/kg bwt i.v.) and intact ureters; 2) frusemide and ligated ureters; 3) saline placebo and ligated ureters; and 4) frusemide and phenylbutazone (4.4 mg/kg bwt i.v. 12 h and 15 min before frusemide) and ligated ureters. Frusemide administration to anaesthetised horses with intact ureters increased plasma total protein concentration and reduced mean right atrial, pulmonary artery and aortic pressures. There was no significant effect of frusemide administration on haemodynamic variables or plasma total protein concentration in horses with ligated ureters. The combination of frusemide and phenylbutazone increased mean right atrial, pulmonary artery and aortic pressures in horses with ligated ureters. This study demonstrates that, in anaesthetised horses, the haemodynamic effect of frusemide is dependent upon diuresis. We interpret these results as providing further evidence that the haemodynamic effect of frusemide in horses is attributable to a reduction in plasma and blood volume.

Effect of NaCl and NaHCO3 on serum ionised calcium and blood gas status during sprinting

Sodium bicarbonate is often administered to horses before racing in an attempt to delay fatigue and improve performance. We examined the effect of acid-base status on serum ionised calcium concentration (iCa) during high intensity exercise in 8 Standardbred mares. In a randomised, blinded, cross-over study, mares were administered each of 3 treatments, NaCl (0.7 g/kg bwt), NaHCO3 (1 g/kg bwt) in 3 l water, or 3 l of water only, 4 h before performing a standardised exercise test to fatigue on a treadmill. Mixed venous blood samples were collected as the horses ran for 5 min at 3 m/s, to fatigue at a predetermined speed (approximately 113% VO2max) and for 5 min at 3 m/s. There was no effect of treatment on time to fatigue (P = 0.744). NaHCO3 attenuated (P<0.05) the exercise-induced decrease in venous pH (mean +/- s.e. 6.97, 6.95 and 7.06 +/- 0.02 at end of sprint for water, NaCl and NaHCO3, respectively). Both serum total calcium concentration (tCa) and iCa increased (P<0.05) with running. NaHCO3 decreased iCa (P<0.05) compared to water; iCa of 1.58 and 1.44 +/- 0.04 mmol/l before exercise and 1.69 and 1.49 +/- 0.05 end sprint, for water and NaHCO3 treatments, respectively. These results demonstrate an effect of NaHCO3 on iCa during exercise. Further study is necessary to determine the effect of alterations in iCa on exercise performance.

Nephrosplenic entrapment in the horse: a retrospective study of 174 cases

The clinical findings and outcome of 161 horses diagnosed with 174 episodes of nephrosplenic entrapment (NSE) were reviewed retrospectively. The median age at presentation was 5 years (9 months to 24 years), and duration of colic was 2-92 h. Nasogastric reflux was present in 49 of 113 horses (43.4%) and was significant (> or = 21) in 32 (28.3%) horses. The recurrence rate was 13/161 (8.1%). Thirteen horses (13/174, 7.5%) had other lesions including small intestinal obstruction (4), 360 degrees large colon torsion (5), gastric rupture (2), thromboembolic colic (1) and small colon infarction (1). Of 115 cases, in 107 horses treated by surgery alone, 2 horses required a large colon resection, and 8 (8/107, 7.5%) horses died or were subjected to euthanasia. Twenty-six of 35 horses (74%) were successfully corrected by rolling under general anesthesia and, of the 9 horses taken to surgery after rolling, 4 had other lesions and 2 were corrected at surgery. Phenylephrine was used in 20 of 35 horses that were rolled and 2 horses required surgery after rolling with phenylephrine. Five horses were jogged after phenylephrine administration and all were successfully corrected. Eleven horses presented with the left colon located between the spleen and the body wall were treated successfully by fasting and/or i.v. fluids. One horse had a gastric rupture after rolling. The overall success rate was 92.5%. In conclusion, NSE is a condition associated with a good prognosis for medical or surgical correction. A small number of horses may have additional gastrointestinal lesions, which may affect outcome.

The effect of supramaximal exercise on equine platelet function

When blood is collected into sodium citrate in the proportion of 9 parts blood:1 part sodium citrate, the concentration of plasma sodium citrate in the sample will depend on the packed cell volume (PCV) of the blood sample. This difference in plasma sodium citrate concentration secondary to alterations in PCV significantly affects human platelet aggregation responses. Since horses attain a high PCV in response to high-intensity exercise we investigated the effect of differences in sample plasma sodium citrate concentration on equine platelet aggregability. In addition, low molecular weight heparin (LMWH) was evaluated as an alternative anticoagulant for assessment of platelet aggregability during strenuous exercise in horses. Blood samples were collected pre-exercise and at fatigue after supramaximal treadmill exercise into either 3.8% sodium citrate (9 parts blood:1 part sodium citrate) or 20 u LMWH/ml of blood. Platelet aggregation responses to 1.25 mumol/l adenosine diphosphate (ADP) were measured via optical aggregometry. For samples collected into sodium citrate, aggregability was significantly less than pre-exercise values in samples collected at fatigue and in pre-exercise samples in which sodium citrate concentrations were adjusted to equal those in fatigue samples. However, samples collected into LMWH showed significantly increased platelet aggregability in samples collected at fatigue when compared to pre-exercise samples. In conclusion, higher plasma sodium citrate concentration had a marked inhibitory effect on equine platelet aggregation responses. Low molecular weight heparin was a good alternative anticoagulant for assessment of equine platelet function and results indicate that equine platelet aggregability was enhanced in response to supramaximal exercise.

Crocodiles as dinosaurs: behavioural thermoregulation in very large ectotherms leads to high and stable body temperatures

Empirical field data describing daily and seasonal cycles in body temperature (Tb) of free-ranging Crocodylus porosus (32–1010 kg) can be predicted by a mathematical analysis. The analysis provides a mechanistic explanation for the decreased amplitude of daily cycles in Tb and the increase in ‘average’ Tb with increasing mass. Assessments of ‘average’ daily Tb were made by dividing the integral of the difference between measured values of Tb and minimum operative temperature by the period of integration, to yield a thermal index expressing relative ‘warmth’ of crocodiles. The average daily Tb of a 1010 kg crocodile was 3.7 degreesC warmer than that of a 42 kg individual in summer and 1.9 degreesC warmer than that of a 32 kg individual in winter. The success of this mathematical approach confirms that crocodiles are simple ectotherms and that there is unlikely to be a significant contribution to their thermal biology from physiological mechanisms. Behaviour, however, is very important even in large individuals. Crocodiles in the field typically move daily between land and water in cycles that vary seasonally. We predicted Tb for the reverse of these behavioural cycles, which more than doubled seasonal fluctuations in Tb compared with the observed fluctuations. We were also able to predict the Tb of very large, dinosaur-sized crocodiles in a similar climate to that at our study site. A 10 000 kg ‘crocodile’, for example, would be expected to have a Tb of 31 degreesC in winter, varying by less than 0.1 degreesC during a day when operative temperatures varied by nearly 20 degreesC, from 20 to 38 degreesC. The study confirms that, in low latitudes at least, large dinosaurs must have had an essentially high and stable value of Tb, without any need for endothermy. Also, access to shade or water must have been crucial for the survival of large dinosaurs at low latitudes. Furthermore, the finding of increasing ‘average’ Tb as ectotherms grow larger may have implications for the metabolic rates of very large reptiles, because the Q10 effect could counteract the downscaling of metabolic rate with mass, an effect that seems not to have been recognised previously.

Comparison of Surveys of Kangaroos in Queensland Using Helicopters and Fixed-Wing Aircraft

Kangaroo harvest quotas for each Australian state have been set mainly as proportions of population estimates derived from aerial surveys. Estimating population size from strip transect counts using fixed- wing aircraft has become an established technique, but counts must be adjusted by correction factors to ensure population estimates are both accurate and repeatable. Surveys of kangaroos in Queensland are currently conducted with helicopters using line transect methodology, but cost restricts their use to relatively small survey blocks. Nevertheless, they return more accurate and repeatable estimates of kangaroo density than surveys with fixed-wing aircraft. A comparison of the above two techniques was made along the same transect lines in seven survey blocks (5000-10,000 km2) in southern and western Queensland, allowing an assessment of the comparative accuracy of the fixed-wing method. For red kangaroos (Macropus rufus), required correction factors of 0.7-3.1 were similar to those used previously. However, for eastern grey kangaroos (M. giganteus), substantially larger correction factors of 3.4-10.2 were needed to approach true density. For wallaroos (M. robustus), correction factors of 3.8-4.8 were required, but can be considered conservative because helicopter-derived density estimates are known to be underestimated by a factor of 2-3. Further work is needed to establish how correction factors for each species should be applied on a broader scale and whether they lead to repeatable estimates of kangaroo density. Key words: aerial survey, line transect, correction factors, strip transect, wallaroo.

Body temperatures and activity patterns of Tasmanian devils (Sarcophilus harrisii) and eastern quolls (Dasyurus viverrinus) through a subalpine winter

During a field study of carnivorous dasyurid marsupials in subalpine Tasmania, the trapping success for Tasmanian devils (Sarcophilus harrisii), but not for spotted-tailed quolls (Dasyurus maculatus) or eastern quolls (Dasyurus viverrinus), was significantly lower when winter weather conditions turned to sleet or snow or when deep snow lay on the ground. This field study was instigated to determine if devils and eastern quolls spend more time in burrows in severe weather conditions and if they enter torpor. Torpor is known to occur in eutherian mammals as large as devils and in a similar-sized congeneric marsupial, the western quoll (Dasyurus geoffroyi). Using radiotelemetry, body temperatures of Tasmanian devils and eastern quolls ranging freely in their natural habitat were monitored throughout winter. Neither species was observed in torpor, even under prolonged severe weather conditions, and the number of hours spent active not did differ between summer and winter or between moderate and severe winter weather conditions. Body temperatures averaged 36.5 degrees C (SD = 0.079, range of 33.5 degrees-38.6 degrees C) for the three male eastern quolls and 35.7 degrees C (SD = 0.575, range of 31.3 degrees-37.5 degrees C) for the four (male and female) devils. A diel cycle in body temperature occurred in both species; temperatures rose each evening when animals became active, remained high throughout the night despite ambient temperatures falling to the diel minima, and were lower during the day when the individuals were inactive in dens. The amplitude of this cycle was greater in eastern quolls (1.1 degrees C, SD = 0.142) than in devils (0.6 degree C, SD = 0.252).

Trends in numbers and changes in the distribution of feral goats (capra hircus) in the South Australia pastoral zone

Trends in numbers and changes in the distribution of feral goats in the South Australian pastoral zone (217300 km*2) during 1978-94 were determined by winter aerial surveys. Only the presence or absence of goats on sample units was scored between 1978 and 1988. On the assumption of a random distribution of goat groups, these indices were transformed to densities of goat groups. Between 1989 and 1994 actual goat numbers were recorded on each sample unit, allowing goat density to be estimated. Goats were consistently at their highest densities in the south-east of the pastoral zone, a region dominated by open mallee scrub and chenopod shrubland. Densities of goat groups fluctuated from a low in 1984, following a drought, to a peak in 1990, following above-average rainfalls, when there were an estimated 193700 +/- 29600 goats in the pastoral zone. This estimate is conservative because it is uncorrected for the visibility bias associated with sighting groups and undercounting their sizes. The estimate also excludes the Flinders Ranges for which a similar number of goats has been estimated.

Hibernation in a monotreme, the echidna (Tachyglossus aculeatus)

The body temperatures of five echidnas in Australia's Southern Alps were monitored by radio telemetry from February to December 1987. All five hibernated throughout the winter, showing very low body temperatures (4-9 degrees C, close to ambient) when torpid, compared with 28-33 degrees C in a typical day during the active season. Spontaneous arousals from hibernation occurred every 2-3 weeks, during which body temperatures rose rapidly to over 30 degrees C for several hours before dropping to be close to ambient again. The identification of "classical" hibernation in a monotreme, with a similar pattern to that seen in Eutheria and in an animal as large as the largest eutherian hibernator, has important implications for current ideas about the evolution of endothermy.

Sonographic depiction of endometrial changes occurring with ovulation induction

Endometrial thickness and texture were evaluated with serial pelvic sonograms in ten normal, menstruating women and 107 patients undergoing ovulation induction for in vitro fertilization. Serial sonograms were performed in the control group every other day throughout the menstrual cycle, whereas the sonographic examinations of the ovulation induction patients were performed daily in a four- to eight-day time interval after their medications were completed and prior to laparoscopy for follicular aspiration. Endometrial thickness increased (defined as a persistent change greater than or equal to 1 mm) in 21 of 53 women (40 percent) who received human menopausal gonadotropin (HMG). Of the 54 women treated with clomiphene citrate (CC), five of 12 (42 percent) at 50 mg daily, 13 of 33 (39 percent) at 100 mg daily, and one of nine (11 percent) at 150 mg daily were found to have endometrial thickening. Although the frequencies of endometrial thickening in the high-dose CC and HMG groups were not significantly different (P = 0.09), the peak estradiol (E2) levels in the CC (150 mg) group (E2 = 944 +/- 165 pg/ml) were significantly higher (P less than 0.001) than those in the HMG group (E2 = 584 +/- 26 pg/ml). The relatively low frequency of endometrial thickening in women receiving CC (150 mg) despite very high E2 levels, and the decreased incidence of endometrial thickening relative to increasing dosages of CC may reflect an antiestrogenic effect of CC on the endometrium. In those patients undergoing ovulation induction, the texture of the endometrium remained the same in 98 cycles and changed during nine.(ABSTRACT TRUNCATED AT 250 WORDS)