Serum prolactin and TSH in an in vitro fertilization population: is there a link between fertilization and thyroid function?

PURPOSE

Measurements of TSH and prolactin are generally included in the evaluation of female infertility, but their value in women coming to in vitro fertilization (IVF) has been questioned.

METHODS

In this study, we sought to investigate whether prolactin or TSH, measured in 509 specimens collected prior to therapy, predicted outcome in a prospective study of couples undergoing IVF between 1994 and 2001.

RESULTS

TSH was higher in women whose fertility problem was attributed to a male factor, and prolactin was lower if the measurement was taken during menses. TSH and prolactin were positively correlated (p < 0.0001). Neither TSH nor prolactin levels correlated with overall IVF outcome; however, TSH levels were significantly higher among women who produced oocytes that failed to be fertilized and this finding persisted after adjustment for several covariates, including sperm motility. Among women who had a least one oocyte inseminated, the likelihood that they would have fewer than 50% of their eggs fertilized was significantly related to higher TSH levels in a multivariate model.

CONCLUSION

We conclude that TSH may predict poor fertilization in IVF and reflect the importance of thyroid hormones in oocyte physiology.

Emergency department use by adult medicaid patients after implementation of managed care

OBJECTIVE

To determine whether the advent of a mandatory Medicaid managed care (MMC) plan had any effect on emergency department (ED) utilization by adult Medicaid patients at an urban teaching hospital.

METHODS

This was a retrospective cohort study using four years of ED records encompassing the year prior to initiation of MMC (1994-95), the enrollment year (1995-96), and two years after the program had matured (1996-98).

RESULTS

Total ED census declined slightly, then returned to 1995 levels. Emergency department use by MMC patients declined steadily, with the 1998 figure of 5,888 representing a 40% decline over the pre-MMC volume of 9,849. Visits by MMC patients with acute illness or injury declined by 29%; MMC low-acuity visits decreased by 43%. Medicaid managed care low-acuity after-hours/weekend visits declined by 19%, then leveled off. The MMC enrollment was stable throughout the study period.

CONCLUSIONS

Mandatory managed care can be associated with considerable diminution in ED use by Medicaid patients. This decline is most pronounced in low-acuity triage categories, and least evident after hours and on weekends.

The interpretation and use of statistics in assisted reproductive technologies

This article has discussed some of the uses and limitations of currently available statistics for ART programs. A well-known example from statistics states that flipping a coin will produce "heads" 50% of the time and "tails" 50% of the time, provided that the coin is flipped enough times. Experience also shows that the result of individual flips cannot be predicted. Similarly, in ART, statistics can only give general probabilities and not meaningful predictions of the outcome of any particular cycle. Patients should be aware of the limits of statistical analysis as it applies to their individual treatment.

Variation of docosahexaenoic acid content in subsets of human spermatozoa at different stages of maturation: implications for sperm lipoperoxidative damage

The oxidation of phospholipid-bound docosahexaenoic acid (DHA) has been shown to be one of the major factors that limit the motile life span of sperm in vitro. Sperm samples show high cell-to-cell variability in life span and, consequently, in susceptibility toward lipid peroxidation. Therefore, we postulated that there is also cell-to-cell variability in DHA concentration in human spermatozoa. In this study, the concentration of DHA in subsets of human spermatozoa isolated by a discontinuous Percoll density gradient was determined by gas chromatography. Four subsets of human spermatozoa were isolated using a discontinuous Percoll gradient: fraction 1 was enriched in immature germ cells and immature sperm, fractions 2 and 3 contained, mostly, immature sperm with cytoplasmic droplets, and fraction 4 contained, for the most part, morphologically normal sperm, as determined by histochemical analysis. The results indicated that there were significant differences in DHA content in sperm from all 4 fractions. DHA content in sperm from fraction 1 was 2.5-fold higher than that found in fraction 4. DHA content in mouse sperm obtained from the seminiferous tubules was 3-fold higher than that found in mouse sperm obtained from the epididymis, consistent with the findings observed in ejaculated human sperm. The results of this study indicate (i) there is cell-to-cell variability in the concentration of DHA in human sperm and (ii) that there is a net decrease in DHA content in sperm during the process of sperm maturation.

Is the mouse a clinically relevant model for human fertilization failures?

This study compares failed fertilization oocytes from patients participating in an in-vitro fertilization (IVF) programme with failed fertilization oocytes from B6SJLF(1)/J mice, in order to characterize and describe the distribution of DNA in oocytes that do not undergo normal fertilization. Our goal is to evaluate the mouse IVF system as a model to gain insight into reasons for human fertilization failures. All oocytes were stained with the vital fluorescent dye, Hoechst 33342, which rapidly stains double-stranded DNA. Of the 237 human oocytes that had been scored as failed fertilization by brightfield microscopy, 61 (25.7%) showed the presence of at least one spermatozoon within the oocyte cytoplasm. In contrast, out of 69 failed fertilization mouse oocytes, only one oocyte showed the presence of a spermatozoon within its cytoplasm. Mouse failed fertilization oocytes exhibited a significantly lower internal sperm rate (P < 0.0001) than human failed fertilization oocytes. Human failed fertilization oocytes show a higher incidence of sperm penetration, but the cytoplasm fails to support pronuclear development, whereas, at least in this strain, mouse failed fertilization oocytes arise from an inability of the spermatozoa to penetrate the oocyte. This study suggests that the mouse is not a clinically relevant model for human fertilization failures.

Efficient human sperm pronucleus formation and replication in Xenopus egg extracts

We have achieved efficient in vitro reactivation and replication of human sperm nuclei in frog egg extracts by constructing a 4-step protocol that mimics the events of fertilization and pronucleus formation in mammalian eggs. With use of this protocol, 78-97% of human sperm nuclei from fertile donors synchronously swelled and completed full genome replication in about 2 h. We document the changes in nuclear structure that accompany efficient DNA synthesis and discuss future research and potential clinical implications of this new system.

Medicare expenditures on unsuccessful out-of-hospital resuscitations

Numerous studies have shown the futility of continued emergency department (ED) resuscitative efforts for victims of out-of hospital cardiac arrest when prehospital resuscitation has failed. Nevertheless, these patients continue to arrive in the ED, where they create a strain on resources. To assess the economic cost of this, Medicare expenditures were determined for resuscitative efforts on victims of atraumatic, out-of-hospital cardiac arrest subsequently pronounced dead in the ED. Charts of patients pronounced dead in the ED of a 65,000-visit urban teaching hospital during 1995 were reviewed. Selected patients met the following criteria: 1) Medicare recipient age 65 or over; 2) atraumatic, out-of-hospital arrest; 3) transported to the ED by an EMS crew authorized to perform advanced cardiac life support interventions. A total of 105 cases were identified that met inclusion criteria and for which Medicare had claims on file corresponding to the date of death. Ambulance service payments ranged from $105-$391; mean = $263. Physician service payments ranged from $8-$106; mean = $65. Payments for Medicare Part A (hospital facility) ranged from $59-$1,025; mean = $436. The total Medicare reimbursement was $80,197, mean = $764. This annualizes to a national expenditure projection of $58 million. Failed out-of-hospital resuscitation for Medicare patients is associated with poor outcome and high cost. Termination of these efforts in the prehospital arena is unlikely to affect outcome, and would result in considerable cost savings on physician and hospital facility charges. Compassionate protocols that recognize these principles should be developed and implemented.

Evaluation of the effects of omega-3 fatty acid-containing diets on the inflammatory stage of wound healing in dogs

OBJECTIVES

To ascertain the effects of dietary omega-3 (n-3) fatty acids on biochemical and histopathologic components of the inflammatory stage of wound healing.

ANIMALS

30 purpose-bred Beagles.

PROCEDURE

Dogs were allotted to 5 groups of 6. Each group was fed a unique dietary fatty acid ratio of omega-6 to n-3--diet A, 5.3:1; diet B, 10.4:1; diet C, 24.1:1; diet D, 51.6:1; and diet E, 95.8:1. Dogs were fed once daily for 12 weeks, then biopsy specimens were taken from 4-day-old wounds of each dog and analyzed by gas chromatography-mass spectrometry for: prostaglandin E2 (PGE2) metabolites, and ratios of omega-6 to n-3 fatty acids, arachidonic acid (AA) to eicosapentaenoic acid (EPA), adrenic acid to docosahexaenoic acid, and PGE2 to prostaglandin E3 (PGE3) metabolites.

RESULTS

Qualitative analysis was carried out on AA, EPA, adrenic acid, docosahexaenoic acid, and the major metabolite from the PGE2 and PGE3 pathway. These molecules were further quantified with respect to diet to determine significant differences. By analysis of the AA-to-EPA ratio, diet A was different from diets D and E and diets B and C were different from diet E (P < 0.05). By analysis of the PGE2-to-PGE3 metabolite ratio, diet A was different from diet E (P < 0.05). Though biochemical analysis indicated dietary dependence, histopathologic data indicated no significant difference with respect to diet groups.

CONCLUSION

The biochemical component of the inflammatory stage of wound healing can be manipulated by diet.

CLINICAL RELEVANCE

Omega-3 fatty acid-enriched diets can be used to control inflammation associated with dermatologic conditions.

Utility of dipstick urinalysis as a guide to management of adults with suspected infection or hematuria

BACKGROUND

This study was done to determine whether emergency department (ED) patient management decisions made on the basis of dipstick urinalysis are altered when results of urine microscopy become available.

METHODS

The study population was a prospective random sample of adult ED patients who had urinalysis ordered for detection of possible urinary tract infection (UTI) or hematuria. Clinicians were given the result of the dipstick urinalysis and were asked to formulate a management plan. Urine microscopy of the same specimen was obtained later, and the clinicians were asked if management was changed after results were known.

RESULTS

Of 166 urinalyses, 118 (71%) were ordered for suspected UTI, 32 (19%) for suspected hematuria, and 16 (10%) for both. Of 134 urinalyses, 58 (43%) were positive for leukocyte esterase or nitrites, and 15 of 48 (31%) were positive for blood. Microscopy prompted a management change in only 9 of 166 patients. Six changes resulted in therapy for UTI, one resulted in withholding of therapy for UTI, and two resulted in cancellation of plans for diagnostic imaging. When urinalysis was done only to detect hematuria, none of the 32 patients had a management change after microscopy.

CONCLUSION

Dipstick urinalysis for blood or UTI is a reliable diagnostic test in ED patients. In 94% of patients, subsequent findings on urine microscopy did not prompt a change in management. Microscopy added nothing to dipstick results when clinicians suspected conditions causing hematuria alone. Primary use of dipstick urinalysis, with microscopy in selected cases, would likely result in considerable cost and time saving without compromising patient care.

Bedside diagnostic testing of body fluids

Numerous bedside diagnostic modalities are appropriate for the practice of emergency medicine. The proliferation of sophisticated technology is likely to increase both the availability and accuracy of commercial testing products. If health care reform in the United States results in a relaxation of the CLIA regulations, there will be a rapid expansion of research and development aimed at the biotechnology market. How much this would pertain to hospital-based emergency practice remains to be seen. Cost containment pressures may act in both directions on the utilization of available bedside technology. Although these tests are often less expensive than centralized laboratory determinations, the ready availability of near-patient testing may result in an increase in use that negates the lower cost. As with other diagnostic modalities, a thoughtful, considered approach based on scientific evidence will be necessary to formulate the appropriate use of bedside testing in individual emergency practice settings.

Medicaid managed care and the emergency department: the first one hundred days

Spurred by concerns over increasing costs and variable quality, public and private third-party payors are moving their subscribers into managed care plans. A central feature of many of these plans is coordination of patient care through a primary care provider (PCP). In exchange for easy access to the PCP, patients are expected to limit their use of emergency services for episodic, primary, and urgent care problems. The State of Connecticut has begun a transition from a fee-for-service Medicaid plan into a managed care product. Because many Medicaid patients had freely used emergency services under the fee-for-service arrangement, urban teaching hospital emergency departments rapidly became a focus of efforts to control cost and change care-seeking behavior. The Hartford Hospital Emergency Department (ED) began screening, education, and referral of managed Medicaid patients in the fall of 1995 and recorded experiences with patients, administrators, and health care providers involved in the implementation of the managed care program. The first 3 mo following plan implementation were chaotic and frustrating for all parties, with many difficulties due to an unprepared infrastructure. Changes in ED operations and maturation of the payor and health care provider network eventually resulted in a reasonably smooth system accompanied by reductions in ED visit volumes of at least 15%. Continual evolution of role and goals will be necessary if EDs are to maintain an active presence in a health care system dominated by managed care plans.

Establishing an NP-staffed minor emergency area

Patients with problems of high acuity need fully trained emergency physicians and nurses. Some patients with nonurgent problems can be cared for within the emergency department (ED) in a lower-cost setting designed and staffed specifically for this purpose. Staffing a fast track or minor emergency area (MEA) with nurse practitioners (NPs) is one way to satisfy the ED's care needs. One site analysis of the effectiveness of NPs indicates that patients are satisfied with their care, that nurses' interpersonal skills are better than those of physicians, that technical skills are equivalent, that patient outcomes are equivalent or superior and that NPs improve access to care. A nurse practitioner-staffed minor emergency area provides high quality care for approximately 21% of this site's adult emergency department population. Patients are triaged based on set criteria, allowing for short treatment times. The physical layout, triage criteria, and the NPs' scope of practice in the level 1 trauma center's ED are detailed.

An ultrastructural analysis of an oocyte from an in vitro fertilization patient with repeated polyspermic fertilization

OBJECTIVE

Our goal was to determine any ultrastructural anomalies in an oocyte from a patient with a history of polyspermy.

RESULTS

Ultrastructural observations of the cortical ooplasm of several oocytes from each of three control patients showed a large population of intact cortical granules. Conversely, one oocyte from a patient with repeated polyspermic fertilization contained a relative paucity of granules in the cortex. Quantitative analysis of the cortices of control oocytes indicated that there were 17.02 +/- 0.52 cortical granules present per measured field of view, compared with 4.40 +/- 2.92 granules per field in the other oocyte.

CONCLUSIONS

The presence of sufficient cortical granules is necessary for normal (monospermic) fertilization to occur. When contrasted to the cortical granule population of oocytes from several control patients, the cortex of one oocyte from the other patient showed few of these organelles. Therefore, the absence of a sufficient number of granules may have precluded normal fertilization from occurring in the eggs of this patient.

Changes in membrane integrity, cytoskeletal structure, and developmental potential of murine oocytes after vitrification in ethylene glycol

A systematic approach was taken to assess and optimize a protocol for intracellular vitrification by introducing high concentrations of the cryoprotectant agent (CPA) ethylene glycol (EG) into unfertilized murine oocytes. The effects of EG on membrane integrity, microfilament organization, and developmental potential were evaluated. During exposure to 0.5-2 M EG, oocytes showed maximum shrinkage to 55.5% of the isotonic volume within the first minute and reexpanded to their initial volume within 15 min. Transferral of oocytes to higher concentrations of EG (4-8 M EG) for 1-5 min after 15 min of equilibration at 2 M EG was tolerated well. Microfilament organization appeared normal after this equilibration period. During prolonged exposure (> 5 min) to high concentrations of EG (> 4 M), membrane blebs were noticed on the surface of the cells, and microfilament distribution was disturbed. After treatment with 6 M EG and vitrification with 6 M EG + f2p40.5 M sucrose, there were no significant differences in development to the two-cell and blastocyst stages between CPA-treated, vitrified, and control oocytes. These results indicate that EG is an effective CPA for mouse oocyte vitrification protocols without any observed compromise in morphology and developmental functions.

Establishing an NP-staffed minor emergency area

A nurse practitioner-staffed minor emergency area provides high quality care for approximately 21% of their adult emergency department population. Patients are triaged based on set criteria, allowing for short treatment times. The physical layout, triage criteria and the NPs' scope of practice in the Level I trauma center's ED are detailed.

Sperm morphology and in vitro fertilization outcome: a direct comparison of World Health Organization and strict criteria methodologies

OBJECTIVE

To perform a direct comparison of two sperm morphology methodologies with regard to IVF outcome.

DESIGN

Blinded comparison of two methods of morphology assessment using the same morphology slides.

PATIENTS

Data were obtained from 132 couples in a consecutive series of patients undergoing IVF.

MAIN OUTCOME MEASURES

Two practical end points were selected for analysis for each couple: the presence of any fertilization and the number of fertilized eggs. Normal traditional morphology was defined as > or = 40% normal forms in a sample and normal strict criteria was defined as > or = 4%.

RESULTS

Traditional morphology demonstrated a higher sensitivity and negative predictive value than strict criteria (87% versus 61%, and 68% versus 36%, respectively). Positive predictive value and specificity were also numerically greater but did not reach statistical significance. Abnormal traditional morphology, but not strict criteria, was associated with reduced fertilization even among samples with normal sperm concentration and motility. Samples with normal morphology were associated with a greater number of fertilized eggs per couple than those with abnormal morphology: this difference was 3.2 fertilized eggs for traditional morphology and 1.6 for strict criteria. Overall, for samples with < 40% by traditional morphology only one case yielded more than two fertilized eggs. In contrast, up to five fertilized eggs were noted for the lowest strict criteria scores.

CONCLUSIONS

Comparison of traditional morphology and strict criteria with regard to IVF outcome favored traditional morphology in several areas. In particular, low scores were more predictive of poor IVF outcome.

Abdominal pain in the ED: stability and change over 20 years

Abdominal pain (AP) is a common presenting complaint in emergency department (ED) patients. A 1972 study reported that unsupervised surgical residents in a university hospital ED were unable to make a specific diagnosis in 41% of 1,000 AP patients. In the intervening time, ED availability of diagnostic technology has increased, and the reference hospital acquired full-time emergency medicine (EM) faculty. To assess what changes occurred in the evaluation and epidemiology of AP, a similar study was done at the same hospital. The study design was a review of records of 1,000 consecutive ED patients with AP seen in 1993 at a 58,000-visit public Level I trauma center ED. The percentage of ED patients (4% to 5%) with AP was unchanged. Frequency of hospital admission dropped from 27.4% (1972) to 18.3% (1993). There was marked increase in the specificity of diagnoses, with only 24.9% in 1993 diagnosed as undifferentiated abdominal pain (UDAP). There were eight cases of missed appendicitis in 1972 and none in 1993. One 1993 patient with acute cholecystitis was initially misdiagnosed as having UDAP. Advances in technology and EM faculty presence were temporally associated with improved diagnostic accuracy in patients with AP in a university hospital ED. As compared with 20 years ago, fewer patients required hospitalization, more were assigned a specific diagnosis, and there were fewer cases of missed surgical disease.

Conservative therapy of plantar puncture wounds

In order to define the natural history and complication rate of plantar puncture wounds receiving conservative initial therapy, a prospective, uncontrolled case series study with standardized protocol was conducted in a university hospital emergency department. The eligible patients were between the ages of 18-59 years and presented within 24 hours of sustaining an uncomplicated plantar puncture wound without preexisting impediments to wound healing or wound assessment. Patients were treated with surface cleansing alone and were kept non-weight bearing for 24 hours. Patients were followed by telephone at 48 hours, 1 week, 1 month, and 6 months. Five infections and two retained foreign bodies occurred in 63 patients, for a complication rate of 11.9%. Only the presence of symptoms 48 hours postinjury was associated with a higher risk of complication. No findings at initial presentation predicted a subsequent complication.

Epidemiology and prevention of blood and body fluid exposures among emergency department staff

Emergency Department (ED) staff are vulnerable to occupational exposure to infectious blood and body fluids (BBF). Universal precautions are often ignored in the ED setting. Identification of body locations at high risk of BBF exposure may allow development of site specific protective garments that minimize risk and inconvenience. All permanent staff (92) in a 58,000 visit public university hospital ED with potential for BBF exposure were surveyed. Respondents estimated the number of BBF contacts sustained during the past year, describing their most recent contact in detail. Seventy-eight of 91 (85%) responded, reporting average rates of 54.1 intact skin, 1.5 nonintact skin, and .87 mucous membrane BBF contacts per full-time employee per year. Of the most recent incidents, 94% involved blood, 22% involved vomit or urine, and 11% involved saliva. Eighty-eight percent of BBF contacts were to unprotected skin or mucous membranes, either when no barrier was worn or at the gap between gloves and sleeves. Most (66%) were distal to the elbow; 13% involved the face. Use of long gloves or another continuous protective barrier from the fingers to the elbow, in addition to increased use of face masks or shields, would markedly reduce the rate of ED BBF contacts with a minimum of inconvenience.

Free segmental paw pad grafts in dogs

After removal of 1 metatarsal pad and formation of a granulation tissue bed, free segmental 6- x 8-mm grafts from digital pads were sutured into recessed same-size recipient sites in the granulation tissue. In 5 dogs, the grafted area had been denervated by excision of a segment of the tibial nerve at the level of the tarsus. The grafted area was not denervated in the remaining 5 dogs. In both groups of dogs, the grafts placed around the periphery of the wound healed, blocked ingrowth of delicate epithelium from the surrounding skin, and provided a tough keratinized epithelium that covered the wound's center. As healing progressed, the grafts coalesced as the wounds contracted. Weight bearing resulted in graft expansion to provide functional weight-bearing tissue. Dogs of the denervated group had clinical and histologic evidence of collateral sensory reinnervation of the denervated area. However, with the exception of 1 dog, results of sensory nerve action potential tests indicated that reinnervation may not have been by way of regeneration across the excisional gap in the nerve. Evaluation of reinnervation of the tibial autonomous zone in 2 additional dogs revealed clinical evidence that collateral reinnervation began between 19 and 28 days after nerve excision and progressed proximad to distad. Results of sensory nerve action potential tests indicated that reinnervation may not have been via regeneration across the excision site. Results of fluorescent tracer studies did not have positive findings regarding the route of collateral reinnervation. Segmental paw pad grafts can be used effectively to provide weight-bearing tissue on a dog's limb. With local nerve damage on the distal portion of the limb, collateral innervation can grow into the area to reinnervate tissues, including pad grafts.

Aeromedical evacuation of rural victims of nontraumatic cardiac arrest

STUDY OBJECTIVES

To determine if the deployment of a helicopter-borne nurse/paramedic team contributed to survival of victims of nontraumatic cardiac arrest in a rural setting.

DESIGN

Retrospective chart review.

SETTING

A university hospital-based helicopter aeromedical program serving a primarily rural region with a volunteer basic life support/advanced life support ground emergency medical services system.

PARTICIPANTS

Victims of nontraumatic cardiac arrest, older than 15 years, in cardiac arrest at the time of request for air evacuation.

MEASUREMENTS AND MAIN RESULTS

Eighty-four patients were identified who met the study inclusion criteria between January 1, 1986, and December 31, 1989. Basic life support care was always available before aeromedical crew arrival; advanced life support care was available in 58% of cases before helicopter arrival. Resuscitative efforts were terminated in the field in 55 cases; of 29 patients transported to the emergency department, only ten (12%) survived to hospital admission. Only one patient (1%) survived to hospital discharge; this patient was resuscitated by ground advanced life support providers before helicopter arrival.

CONCLUSION

Despite providing improved availability of advanced life support care in some cases, deployment of aeromedical teams had a negligible effect on patient survival from nontraumatic cardiac arrest in a rural setting.

A multifactorial analysis of the pregnancy outcome in a successful embryo cryopreservation program

OBJECTIVE

To determine which factor, or factors, may influence the success of an embryo-freezing program.

DESIGN

Prospective.

SETTING

An established, private IVF clinic.

PATIENTS

This study comprises data from 185 consecutive thaw cycles (161 patients) that resulted in embryo replacement. The influence of the following factors, with regard to pregnancy outcome, was specifically addressed: embryo quality, day of the endogenous LH surge, number of thawed embryos replaced, length of time frozen, E2 level at the time of the hCG trigger in the stimulated cycle, and patient age at the time of freezing.

RESULTS

An overall pregnancy rate (PR) of 27.6% per ET was achieved in this study. Regardless of the day of the LH surge, patients who had at least one good quality embryo (the "sponsoring embryo") conceived 35% of the time. Patients who lacked a sponsoring embryo frozen conceived 15% of the time. Patients who were 39 years of age or younger had a PR of 31% per transfer. None of the 22 patients who were 40 or older conceived. No other factor examined had any effect on pregnancy outcome.

CONCLUSIONS

Good quality frozen/thawed embryos are a major factor in achieving a consistently high PR. Poorer quality embryos are capable of implantation but at a significantly reduced rate. Patient age was also found to be significant in predicting pregnancy. Neither the day of the LH surge, number of embryos transferred, length of time frozen, nor the E2 level appears to have any effect on the establishment of pregnancy.

Open trial of oral fleroxacin versus amoxicillin/clavulanate in the treatment of infections of skin and soft tissue

In a multicenter, prospective, randomized trial, fleroxacin was compared with amoxicillin/clavulanate potassium (AMX/CP) for the treatment of infections of skin and soft tissue. Fleroxacin was given at a dosage of 400 mg once daily, and AMX/CP was given at a dosage of 500 mg/125 mg three times a day. Each was administered for 4-21 days. Adult patients with the clinical diagnosis of skin or soft tissue infections were eligible for enrollment. Patients were randomized in a 2:1 ratio. A total of 191 patients were enrolled; 126 took fleroxacin, and 65 took AMX/CP. Of these patients, 42 in the fleroxacin group and 26 in the AMX/CP group were evaluable for both clinical and bacteriologic efficacies. Patients with abscesses comprised the largest single category in each group. Principle reasons for exclusion included: patients lost to follow-up (17 [13%] fleroxacin, 12 [18%] AMX/CP); failure to isolate a causative pathogen (19 [15%] fleroxacin, 9 [14%] AMX/CP); and resistance to study drug (11 [9%] fleroxacin, 2 [3%] AMX/CP). Staphylococcus aureus was the most commonly isolated pathogen. Streptococcus group A, Staphylococcus coagulase-negative, Escherichia coli, and Proteus species, in decreasing order, were the next most common pathogens. Clinical and bacteriologic efficacy was excellent in both groups, with a cure rate of > or = 90%. There were two bacteriologic failures in each group. Patients taking fleroxacin complained of slightly more adverse events, which involved primarily the digestive and central nervous systems. The rate of withdrawal from the study because of adverse events was 4% in both groups. Fleroxacin, 400 mg given once daily, is safe and as effective as AMX/CP in the treatment of skin and soft tissue infections in adults.

Use of metyrapone to treat pituitary-dependent hyperadrenocorticism in a cat with large cutaneous wounds

Metyrapone, a drug that inhibits cortisol production, was used to lower plasma cortisol concentration and alleviate skin lesions caused by pituitary-dependent hyper-adrenocorticism in a cat. Plasma cortisol concentration was documented by ACTH stimulation test results. During metyrapone treatment, alopecia, thin skin, and large cutaneous wounds resolved. Metyrapone was administered orally at a dosage of 65 mg/kg of body weight, every 12 hours. Metyrapone may be used in conjunction with surgery in the management of pituitary-dependent hyperadrenocorticism in cats.

The greyhound dog as a model for studying pressure ulcers

Because of their angular conformation, short hair, and thin skin, greyhounds are particularly subject to development of pressure ulcers. Greyhounds, therefore, can serve as a model to study pressure ulcers, either naturally occurring pressure ulcers or induced dermal pressure lesions. A method for inducing dermal pressure lesions was developed using a short-limb walking cast on one pelvic limb of the dog. Physical characteristics, dermal thromboxane B2 concentrations, and histopathologic changes were used to determine the severity of the lesions. Different lesion severities can be induced over the calcaneal tuberosity depending upon the amount of padding in the cast and the length of time the cast is in place. The technique for inducing a mild dermal pressure lesion is described.

Progestins inhibit murine oocyte meiotic maturation in vitro

The in vitro culture of fully grown mammalian oocytes results in spontaneous meiotic maturation from prophase arrest to metaphase II. This maturation can be inhibited by steroid hormones in both murine and porcine oocytes. Using selected steroids, we have examined the structure-activity relationships of steroids and oocyte inhibition. Experiments with androgens, estrogens, glucocorticoids, and progesterone revealed that at least one steroid from each class was inhibitory. Progesterone, however, was two to three times more effective than steroids from other classes. Examination of a variety of progestins showed that most substitutions decreased or abolished the inhibitory activity. Hydroxy group substitutions at different carbon atoms and substitutions at the 4-ene group lessened the inhibitory effectiveness, with the exception of 5 beta-dihydroprogesterone, which was as effective as progesterone. However, several steroids with substitutions at the C17 acetyl group were more active than progesterone, including 20 beta-dihydroprogesterone which was the most inhibitory steroid tested (ID50 = 5 microM). The progesterone agonist R5020 was also very active (ID50 = 8 microM). This is the first report of a detailed examination of the steroid-induced inhibition of murine oocytes. A comparison between the results reported here and previous reports of steroid-induced inhibition in porcine oocytes reveals differences in the response of oocytes from the two families. The structure-activity relationships of the inhibitory steroids examined here suggest that the steroids are acting via a receptor-mediated system.

Severe renal oxalosis in five young Beefmaster calves

Severe renal oxalosis was diagnosed in 4 male and 1 female purebred Beefmaster calves from herds in southeastern and northwestern United States. Clinical signs included weakness, anorexia, lethargy, alopecia, dehydration, and diarrhea. Results of serum biochemical analysis for 2 calves were consistent with end-stage renal disease. Calves died 2 days to 6 weeks after birth. At necropsy, renal calyces were dilated and contained pale yellow granular calculi. Histologically, there was renal interstitial fibrosis, and cortical and medullary tubules were distended with calcium oxalate crystals. Oxalate crystals were also in the tracheal glands of 1 calf. Severe renal oxalosis in young purebred calves, on widely varied diets, with no known exposure to exogenous oxalates is suggestive of an inherited metabolic defect resulting in primary hyperoxaluria.

Ofloxacin versus cephalexin for treating skin and soft tissue infections

Patients with acute localized skin or soft tissue infections were randomized to receive either ofloxacin (300 mg orally, b.i.d.) or cephalexin (500 mg orally, b.i.d.). Among 401 enrolled patients, 382 were evaluable for safety and 148 for microbiologic response. Microbiologic cure occurred in 93.4% of ofloxacin-treated patients and in 94.0% of those treated with cephalexin. Clinical cure or improvement, respectively, was found in 85.2% and 11.1% of patients treated with ofloxacin, and 83.6% and 14.9% of patients receiving cephalexin. Adverse effects (primarily associated with the gastrointestinal tract and central nervous system) were considered to be drug-related in 7.9% of those receiving ofloxacin and 4.8% of those receiving cephalexin. Thus, ofloxacin is as effective and well tolerated as cephalexin and a good alternate antibiotic for treating skin and skin structure infections caused by a variety of pathogens.

Prevalence of folate deficiency in emergency department patients with alcohol-related illness or injury

To assess the prevalence of folate deficiency in emergency department patients with alcohol-related illness or injury, a prospective, nonconsecutive case series with nonrandomized controls was used. All patients presenting to a 60,000-visit public hospital emergency department with alcohol-related illness or injury were eligible; patients were excluded if they had received folate in our health care facility within the previous 4 months. An alcohol and brief dietary history was obtained, and a complete blood cell count and red blood cell folate level was performed on each patient. Analysis was undertaken by chi 2 to evaluate the prevalence of folate deficiency in the alcohol-related versus the control population. One hundred three patients were entered into the study. Three patients were subsequently excluded from analysis. Of 52 study patients, three (5.8%) were found to be folate deficient. Of 48 controls, two (4.2%) were found to be folate deficient. This difference is not statistically significant (P greater than .05, chi 2; mean difference 1.6%, 95% confidence interval -6.9% to 10.1%). The prevalence of folate deficiency in patients presenting to this emergency department with alcohol-related illness or injury is low, and does not differ from the general emergency department population. Empiric folate therapy in these patients is not indicated.

Effect of "standard order" deletion on emergency department coagulation profile use

STUDY OBJECTIVES

To determine whether the test ordering of physicians working in a teaching hospital emergency department could be influenced by modification of automated laboratory order sets.

DESIGN

Prospective, using data from the same ED before and after intervention.

SETTING

A 58,000-visit public university hospital ED.

TYPE OF PARTICIPANTS

Emergency physicians caring for adult patients admitted from the ED to the ward medical services.

INTERVENTION

Beginning July 1, 1989, coagulation studies were deleted from the automated admission order sets used in the study hospital ED.

MEASUREMENTS AND MAIN RESULTS

Patient charts were examined to assess the effect of coagulation study deletion on the frequency and appropriateness of coagulation test ordering. A tripling of the percentage of patients who did not receive coagulation parameter testing was noted (P less than .0001, chi 2). In no case were the tests omitted when a high-yield indication for their use was present. This resulted in an estimated reduction of $20,000 per year in patient charges.

CONCLUSION

Modification of ED "standard orders" can result in reduction of laboratory use without an adverse effect on patient care.

Healing of segmental grafts of digital pad skin in dogs

Pad grafts would be indicated in instances of severe paw trauma when there has been loss of the major weight-bearing pads (ie, metatarsal and metacarpal pads) as well as loss of the digital pads. A practical technique for replacing pad tissue on the remaining paw tissue could avert limb amputation for lack of weight-bearing tissue in the area. Small segmental digital pad grafts were placed in granulation tissue beds in dogs. Although the grafts were from thick pad skin, they healed well. However, intervening wound areas did not become covered with the heavier keratinized epithelium of the pads. The thinner, more rapidly growing, less keratinized epithelium from the wound edges covered most of the wound.

Soft tissue infections in the emergency department: the case for the use of 'simple' antibiotics

Cellulitis, infected wounds, abscesses, and other bacterial infections of skin and soft tissue are commonly seen in the practice of emergency medicine. Informal observations in a teaching hospital suggest that newer agents having a broader antibiotic spectrum are frequently used for empiric outpatient treatment of mild to moderate soft tissue infections, so information from a prospective study was analyzed to determine whether this practice is appropriate. Healthy adult volunteers were enrolled in a study of the aerobic bacteriology and response to treatment of skin and soft tissue infections. Patients were randomized to receive a 10-day regimen of cephalexin (500 mg bid or qid) or ofloxacin (300 or 400 mg bid). Clinical response was assessed on two follow-up visits. Of 72 patients enrolled, 45 (63%) had cultures positive for pathogens. Cultures in 31 patients (43%) were positive for Staphylococcus aureus, five (7%) grew gram-negative rods, and five (7%) grew streptococcal species. Clinical response rates exceeded 95% in both the cephalexin- and ofloxacin-treated patients. Pathogens isolated from skin and soft tissue infections treated in the emergency department are not exotic or multiply resistant. The bacteriologic profile and clinical course of uncomplicated soft tissue infections indicate that treatment with a "simple" antibiotic, such as cephalexin, will result in resolution of the infection in nearly all cases. Broader spectrum antibiotics are not required for initial treatment of soft tissue infections in the emergency department.

Ofloxacin versus cephalexin in the treatment of skin, skin structure, and soft-tissue infections in adults

A multicenter study was conducted to compare the safety and efficacy of oral ofloxacin with that of cephalexin in microbiologic eradication of skin and skin-structure pathogens and the clinical treatment of skin and skin-structure infections. The subjects, 335 adult patients with acute localized infections of the skin, skin structure, or soft tissue, were randomly assigned to receive 400 mg of ofloxacin orally every 12 hours or 500 mg of cephalexin orally every six hours for 10 days. At admission, 398 aerobic pathogens were isolated, the most common being Staphylococcus aureus (160 isolates), Streptococcus pyogenes (49), coagulase-negative staphylococci (30), Staphylococcus epidermidis (25), and Pseudomonas aeruginosa (10). Of 317 isolates tested against ofloxacin, 96% were susceptible, and of 325 tested against cephalexin, 85% were susceptible (P less than 0.001). Microbiologic and clinical outcome were evaluated in 73 ofloxacin-treated patients and in 65 cephalexin-treated patients. The causative pathogens were eradicated in 95% of the ofloxacin group and in 92% of the cephalexin group. In the ofloxacin group, 75% were clinically cured and 23% improved, and in the cephalexin group, 74% and 23%, respectively. Drug-related adverse experiences were reported by 14% of the 161 ofloxacin-treated patients and by 11% of the 162 cephalexin-treated patients; gastrointestinal disturbances were reported by 8% and 7% and nervous system effects by 6% and 1%, respectively (P less than 0.05). It is concluded that both ofloxacin and cephalexin are safe and effective in the treatment of skin and soft-tissue infections.

New directions in the diagnosis and therapy of urinary tract infections

Urinary tract infections are among the most common bacterial infections. To provide appropriate and cost-effective treatment, physicians need to stratify patients with urinary complaints into uncomplicated or complicated categories. This can be accomplished by the history, presenting symptoms, risk factors, and physical examination. Complicated urinary tract infections occur in patients with a history of recurrent infections, signs or symptoms of upper tract disease, or coexisting conditions such as pregnancy, immunosuppression, or structural anomalies of the urinary tract. Uncomplicated urinary tract infections occur in otherwise healthy women who have a history of lower tract symptoms of short duration. Symptoms of urinary tract infection include some combination of dysuria, frequency, urgency, hematuria, and suprapubic pain. An uncomplicated urinary tract infection is not accompanied by fever or flank pain. The microbiology of uncomplicated urinary tract infection is predictable, with Escherichia coli and other Enterobacteriaceae, Staphylococcus saprophyticus, and Enterococcus causing more than 90% of urinary tract infections. A history, brief physical examination, and urinalysis are all that is necessary to diagnose a urinary tract infection. Some of the specialized dipsticks and rapid screens are as accurate as microscopic examination in detecting urine white cells. A presumptive diagnosis can be made when a patient has clinical symptoms and some combination of pyuria, hematuria, or bacteriuria. Urine cultures are unnecessary in uncomplicated urinary tract infections and add substantially to the cost of therapy. Pitfalls in the diagnosis include other entities causing dysuria, such as vaginitis, vulvar lesions, physical or chemical irritants, and sexually transmitted diseases. Appropriate therapy requires selection of a drug and determination of the length of treatment. A minor infection should be treated with easy, safe, cost-effective therapy. For urinary tract infections, there are too many antibiotic options, ranging from a single, parenteral dose to a 14-day course of oral medication. Early optimism about single-dose oral therapy has been replaced by evidence suggesting that 3 days of therapy is probably the best. This will eradicate simple urinary tract infections in virtually all patients and decrease the incidence of relapse, whereas patients who are treatment failures usually have occult upper tract infection. Drug choices for short-course therapy include representatives from the penicillin, sulfa, and quinolone families. Selection of a specific drug requires consideration of costs, allergies, side effects, and spectrum of activity. A knowledge of local microbial sensitivity profiles and individual patient tolerance is helpful in guiding the clinician to the appropriate therapeutic regimen.

Real-time ultrasound for the detection of deep venous thrombosis

PURPOSE

Accurate diagnosis of deep venous thrombosis (DVT) is a clinical problem in emergency practice. A prospective trial was conducted comparing real-time ultrasound with contrast venography in the diagnosis of proximal DVT.

METHODS

Seventy patients whose clinical presentations mandated diagnostic evaluation for DVT had real-time ultrasound of the involved leg followed by contrast venography. Initial readings of ultrasound and venography were compared with each other and with final readings to assess reliability of interpretation.

RESULTS

Final ultrasound readings agreed with final venogram readings in all patients. Negative initial ultrasound readings agreed with final venogram readings in 56 of 56 patients (negative predictive value, 100%; 95% confidence interval, 94 to 100). Eighteen patients had positive initial ultrasound readings compared with 14 who had positive final venogram readings (positive predictive value, 78%; 95% confidence interval, 55 to 91).

CONCLUSION

Negative real-time ultrasonography reliably excludes proximal DVT. Positive ultrasound reliably diagnoses proximal DVT only in experienced hands.

Development of hypoparathyroidism after excision of laryngeal rhabdomyosarcoma in a dog

An uncommon neoplasm of the larynx, rhabdomyosarcoma, was diagnosed in a 6-year-old 14-kg neutered female Spitz. In addition to the progressive onset of expected clinical signs of the tumor (exercise intolerance, respiratory stridor, inability to bark), the dog experienced hyperthermic crisis. Laryngectomy was successful in eradicating the local neoplastic tissue; however, unusual postoperative complications developed and included acute complications of pharyngotracheal fistula and hypoparathyroidism, and long-term complications of periodic collapse of the tracheal stoma and intolerance to heat. Probable causes and successful management of these complications are described. At 22 months after laryngectomy, the dog was admitted for a solitary hepatic metastasis. While hospitalized, the dog died of apparent asphyxiation attributable to stoma collapse.

Metastatic thyroid solid-follicular carcinoma in the cervical portion of the spine of a dog

A metastatic thyroid solid-follicular carcinoma in the cervical portion of the spine was responsible for severe tetraparesis in a dog. Myelography revealed an extradural compressive lesion dorsal and to the right of the midline of C3. Histologic examination was used to diagnose the mass as a solid-follicular thyroid carcinoma. The primary tumor was not evident on cervical palpation or radiography. A dorsal laminectomy centered over C3 was performed, and all visible tumor was removed from the spine. The owner declined any further treatment for the dog.

Effect of intestinal resection on two juvenile horses with granulomatous enteritis

Two horses were presented with lethargy, weight loss, anorexia, and swelling of the limbs and ventral body wall. One horse, a 12-month-old American Paso Fino colt, also had acute abdominal pain. The other horse, a seven-month-old Tennessee Walking Horse (TWH) filly passed diarrheic stools during the initial examination. Each horse had low serum protein, neutropenia, and a normal packed cell volume (3.2 g/dl, 1300 cells/ul, and 38%, respectively, for the colt, and 2.4 g/dl, 696 cells/ul, and 44%, respectively for the filly). After intravenously administering plasma, the colt's PCV dropped to 23%, and the filly's dropped to 30%. During exploratory surgery, 3.5 and 2.0 meters of thickened terminal small intestine were removed from the colt and filly respectively, and a jejunocecostomy performed. The results of histologic examination of resected intestine were consistent with a diagnosis of equine granulomatous enteritis (EGE). Both horses showed clinical improvement within two days after surgery. The colt developed a neutrophilia (20,500 cells/ul) within 24 hours of surgery. Serum protein concentrations remained stable and gradually elevated to normal or near normal values of 7.0 g/dl (colt) and 5.8 g/dl (filly) by two weeks. The colt was killed four months after surgery because of signs of abdominal pain. Postmortem examination revealed a small intestinal volvulus associated with an adhesion. The TWH filly remains clinically normal 13 months after surgery.

Differential effects of testosterone and dibutyryl cyclic AMP on the meiotic maturation of mouse oocytes in vitro

Fully grown, meiotically immature mouse oocytes were isolated and cultured under varying conditions with the aim of determining a) whether the inhibitory effects of testosterone on oocyte meiotic maturation require the synthesis of new oocyte proteins and b) if the meiosis-inhibiting effects of testosterone and dibutyryl cyclic AMP (dbcAMP) are distinct and can be differentiated. We found that the inclusion of puromycin in culture medium containing testosterone has no effect on the meiosis-inhibiting potency of testosterone or upon the reversibility of testosterone effects. We conclude that testosterone inhibits oocyte meiosis by a mechanism that is independent of protein synthesis. We also found that oocytes exposed to testosterone recover more rapidly, as evidenced by the timing of germinal vesicle breakdown (GVBD) following placement in a control medium, than do oocytes exposed to dbcAMP. Through further investigation of this phenomenon we have determined the sequence of testosterone and dbcAMP effects relative to the time course of GVBD. A testosterone-sensitive event occurs 20 min prior to GVBD, while the dbcAMP-sensitive event precedes GVBD by 41 min. The nature of this difference may involve the differential interaction of testosterone and dbcAMP with a set of puromycin-sensitive proteins that are required for GVBD. When oocytes were initially cultured in medium containing both puromycin and either testosterone or dbcAMP and then moved to medium containing puromycin alone the incidence of GVBD was reduced relative to oocytes never exposed to puromycin. This observation suggests that mouse oocytes contain proteins that are required for GVBD and that experience a high turnover rate. The degree of reduction in GVBD was a function of the length of puromycin exposure and was significantly greater in dbcAMP- than in testosterone-exposed oocytes. If oocytes were initially cultured in medium containing puromycin and dbcAMP, the rate of GVBD upon removal of dbcAMP was initially slow but increased with time. This observation is consistent with the hypothesis that dbcAMP inhibits oocytes at a point prior to the functioning of the puromycin-sensitive proteins. However, if oocytes were cultured in medium containing puromycin and testosterone the rate of GVBD following testosterone removal was not significantly reduced relative to oocytes that were not exposed to puromycin. This observation suggests that testosterone acts to inhibit meiosis at a site beyond the function of the puromycin-sensitive proteins or that testosterone causes a reduction in the turnover rate of these proteins.(ABSTRACT TRUNCATED AT 400 WORDS)

Ultrastructural observations of human and mouse oocytes treated with cryopreservatives

The effects of the cryopreservative agents dimethylsulfoxide (DMSO) and propanediol (PROH) on mature human and mature mouse oocytes have been examined with transmission electron microscopy. Treatment of CD-1 mouse oocytes and human preovulatory oocytes in a stepwise manner with either DMSO or PROH up to 1.5 M appears to trigger the exocytosis of 70-80% of the cortical granules in all oocytes. Successive stages in premature dehiscence, including a loss in granule electron density, fusion of the granule-limiting membrane with the oolemma, and extrusion of the cortical granule core into the perivitelline space, have been observed in all human oocytes studied. In addition, all human DMSO- and PROH-treated oocytes exhibited crypt-like invaginations and clusters of endocytic vesicles that subtend the oolemma. The presence of these crypts and pinocytotic vesicles in treated oocytes may suggest a mechanism for the retrieval of cortical granule membrane that is inserted into the original plasmalemma during exocytosis. The paucity of cortical granules in treated mouse and human oocytes as it potentially relates to an impaired ability to elicit the cortical reaction at fertilization is discussed.

Multiple authorship, basic research, and other trends in the emergency medicine literature (1975 to 1986)

As emergency medicine comes of age, it is interesting to examine the scientific nature of the specialty as reflected in the literature. Representative volumes of three emergency medicine journals were reviewed for number and type of article, institutional origin, article length, and number of authors. For Annals of Emergency Medicine, (AEM) volumes for 1975, 1980, and 1985 were studied. For The American Journal of Emergency Medicine (AJEM) and The Journal of Emergency Medicine (JEM), articles from the first 12 months of publication (1983 to 1984) and the complete 1986 issue were examined. Analysis of the scientific sections of the journals discloses some interesting trends. While the average article length has remained about the same (four to six pages), the average number of authors per article has steadily risen. The percentage of articles listing an academic origin has remained steady in AEM and JEM, but has risen in AJEM. Multicenter collaborations and basic science articles are appearing with significantly increased frequency. A noteworthy trend is the rise in multiple authorship of articles. There have been significant p less than 10(-4] increases in the number of multiple-authored (more than three authors) articles in AEM and JEM. As reflected by the literature, scientific progress in EM is maintaining a rapid pace. However, there are increasing numbers of papers with multiple authors. Listing of multiple authors on papers has prompted criticism of the literature in other medical specialties. If this trend continues, there may be a risk of compromising the integrity of the published research.

Pregnancy after gamete intrafallopian transfer in a woman with primary infertility and in utero exposure to diethylstilbestrol. A case report

In utero exposure to diethylstilbestrol (DES) has an adverse effect on reproductive performance and may be associated with infertility. Gamete intrafallopian transfer (GIFT) is a new reproductive technique that has been advocated as an alternative to in vitro fertilization in women with at least one normally functioning fallopian tube. The process involves the translaparoscopic placement of oocytes and sperm into the fallopian tube. The technique has been successful in treating infertility due to endometriosis, male factors and immunologic factors as well as unexplained infertility. We accomplished the first successful GIFT procedure in a woman with significant uterine effects from prenatal DES exposure. This technique may prove to be an effective treatment for infertile women with DES exposure who have no adequate explanation for their infertility.

Emergency department patient literacy and the readability of patient-directed materials

There are 20 million American adults who cannot read. The demographics of the illiterate population suggest that they represent a significant proportion of patients cared for in a teaching hospital emergency department. This study was designed to assess whether readability of written material given to patients in a university hospital ED matched the literacy level of these patients. Data were gathered from 111 consecutive adult ED patients. Results of the survey showed that although the median education level of ED patients was 10th grade, more than 40% could not be expected to read at the 8th grade level, and at least 20% could be considered functionally illiterate. Readability of ED patient-directed materials was measured using the Fry index. Hospital and commercially generated patients education materials ranged from 8th to 13th grade level; a patient-directed brochure from Virginia ACEP is written at a college reading level. Comprehension of the "leaving against medical advice" (AMA) form or a consent for surgery would require at least an 11th grade education. This study shows that there is an alarming discrepancy between ED patient literacy levels in our sample and the reading skills required to comprehend important written medical and legal information. More than 50% of ED patients in a teaching hospital may read below the level required to understand standard discharge instructions. In addition, understanding the "operative consent" and leaving AMA forms requires a level of education beyond that of the majority of ED patients. If patient-directed written material is to serve its purpose, then ED patient populations should be surveyed and the reading level of written material adjusted accordingly.

Incarceration of a section of small intestine by remnants of the ductus deferens in steers

A 13-month-old Charolais steer was examined because of anorexia and weight loss of 1 week's duration. Initially, the steer passed tarry feces for 2 days, but no feces were passed for 4 days before examination. Palpation per rectum disclosed moderate distention of the small intestine and dark tenacious mucus in the rectum. Standing celiotomy was performed through the right paralumbar fossa, and a 60-cm segment of small intestine was found to be entrapped by a fibrous band between the caudal abdominal wall and the pelvic inlet. The band was transected and the intestine was freed. The intestine was judged to be viable and the abdomen was closed. Histologically, the fibrous band consisted of ductus deferens and adnexa; the intestine had become incarcerated through a rent in the mesoductus. Small intestine entrapment through a rent in the right mesoductus was diagnosed in 20 additional steers over a 10-year period. In all cases, the steers had been castrated when weighing more than 100 kg, by manual traction on the testicle and spermatic cord through a scrotal incision. Alternate means of castration that prevent disruption of the abdominal mesoductus may prevent development of this condition.