Inhaled iloprost in eight heart transplant recipients presenting with post-bypass acute right ventricular dysfunction

BACKGROUND

During heart transplantation, weaning from cardiopulmonary bypass may be particularly laborious as a result of superimposed acute right ventricular dysfunction in the setting of pre-existing pulmonary hypertension. Research in recent years has focused on inhaled vasodilatory treatment modalities which selectively target the pulmonary circulation.

METHODS

We present a series of eight patients in whom inhaled iloprost, a synthetic prostacyclin analog, was used to treat pulmonary hypertension and right ventricular dysfunction detected by transesophageal echocardiography during a heart transplant procedure. In addition to conventional inotropic support, 20 mug of inhaled iloprost was administered via nebulized aerosol for a 20-min period. Complete sets of hemodynamic measurements were obtained before inhalation and during and after cessation of the inhalation period.

RESULTS

Inhaled iloprost decreased the transpulmonary gradient at the end of the inhalation period relative to baseline (8.2 +/- 1.6 mmHg vs. 11.2 +/- 0.9 mmHg, P < 0.05). The mean pulmonary artery pressure to systemic artery pressure ratio decreased over this period (0.24 +/- 0.07 vs. 0.44 +/- 0.09, P < 0.05). A statistically significant decrease in the pulmonary vascular resistance to systemic vascular resistance ratio was also observed (0.10 +/- 0.02 vs. 0.19 +/- 0.02, P < 0.05). Improved indices of right ventricular function were observed in echocardiographic monitoring.

CONCLUSION

During heart transplantation procedures, episodes of pulmonary hypertension can be successfully treated with inhaled iloprost administration, without untoward side-effects or significant systemic impact.

Determination of potential dermal and inhalation operator exposure to malathion in greenhouses with the whole body dosimetry method

One of the steps during the authorization process of plant protection products (PPP) in the European Union is to evaluate the safety of the operator. For this purpose, information on the probable levels of operator exposure during the proposed uses of the PPP is required. These levels can be estimated by using existing mathematical models or from field study data. However, the existing models have several shortcomings, including the lack of data for operator exposure levels during spray applications by hand lance, especially in greenhouses. The present study monitored the potential dermal and inhalation operator exposure from hand-held lance applications of malathion on greenhouse tomatoes at low and high spraying pressures. The methodology for monitoring potential exposure was based on the whole body dosimetry method. Inhalation exposure was monitored using personal air pumps and XAD-2 sampling tubes. For the monitoring of hand exposure, cotton gloves were used in two trials and rubber gloves in another three. The total volumes of spray solution contaminating the body of the operator were 25.37 and 35.83 ml/h, corresponding to 0.05 and 0.07% of the applied spray solution, respectively, in the case of low pressure knapsack applications and from 160.76 to 283.45 ml/h, corresponding to 0.09-0.19% of the spray solution applied, in the case of hand lance applications with tractor-generated high pressure. Counts on gloves depended on the absorbance/repellency of the glove material. The potential inhalation exposures were estimated at 0.07 and 0.09 ml/h in the case of low pressure knapsack applications, based on a ventilation rate of 25 l/min. Both potential dermal operator exposure (excluding hands) and potential inhalation exposure were increased by a factor of approximately 7 when the application pressure was increased from 3 to 18 bar in greenhouse trials with a tractor-assisted hand lance, the rest of the application conditions being very similar.

Etiology of leg ulcers, healing and recurrence rates in octo- and nonagenarians

BACKGROUND

A high proportion of leg ulcers refractory to ambulatory compression therapy have a mixed etiology. This study evaluates this mixed etiology and the healing and recurrence rate in octo- and nonagenarians.

METHODS

The study group comprised 101 patients with 119 legs affected by ulcers. Concomitant diseases, ulcer size, healing time and time for the ulcer to recur were documented.

RESULTS

Sixty-four ulcers were of venous origin [healing rate (HR): 45.3%, recurrence rate [(RR): 10.3%], 23 ulcers were complicated by 1 additional disease process (HR: 47.8%, RR: 45.5%), 13 ulcers were complicated by 2 or more concomitant diseases (HR: 46.2%, RR: 16.6%) and 19 ulcers (HR: 26.3%, RR: 20%) were of non-venous origin.

CONCLUSIONS

This study showed that venous reflux in combination with local or systemic disease in our elderly patient group increases the chance of recurrence. Non-venous ulcers appear to have a reduced healing rate possibly due to the underlying pathology.

Endovaginal color Doppler sonographic evaluation of ectopic pregnancy in women after in vitro fertilization and embryo transfer

The aim of this study was to evaluate the value of endovaginal color Doppler ultrasonography in the early diagnosis of ectopic pregnancy in women after in vitro fertilization and embryo transfer, and to correlate the sonographic findings with ss-hCG serum levels. Thirty-five patients had proven ectopic pregnancies and 4 other patients had heterotopic pregnancies. The diagnosis was disclosed correctly in all cases by endovaginal color Doppler US by identifying an adnexal mass with placental flow and a nongravid uterus called a "cold uterus". An intrauterine sac with "double ring sign" was found in all normal intrauterine pregnancies when the hCG levels exceeded 1000 IU/l but in none of the patients with ectopic pregnancy (EP). These findings suggest the efficacy of the discriminatory hCG serum level of 1000 IU/l in the investigation of EP. In conclusion, this study describes the diagnostic importance of transvaginal color Doppler US in correlation with hCG serum levels in the early detection of EP avoiding life-threatening complications and improving patient outcome.

Prospective study of a modified gonadotropin-releasing hormone agonist long protocol in an in vitro fertilization program

OBJECTIVE

To determine if pituitary suppression is still maintained if GnRH agonist (GnRH-a) is discontinued as gonadotropin stimulation is begun in a long protocol.

DESIGN

Prospective, randomized study.

SETTING

An outpatient IVF-GIFT program.

PATIENTS

One hundred seventy-three patients entering an IVF-GIFT program.

INTERVENTIONS

Gonadotropin-releasing hormone agonist in long protocol was either discontinued or continued as gonadotropin stimulation was begun.

MAIN OUTCOME MEASURES

Luteinizing hormone (LH), E2, and P levels, egg numbers, fertilization rate, number of embryos transferred, day of gonadotropin stimulation, and pregnancy rates (PRs).

RESULTS

Pituitary suppression was maintained although GnRH-a was discontinued as gonadotropin stimulation was begun. No spontaneous LH surge was seen, and PRs were increased in the IVF patients.

CONCLUSION

This study indicates that the advantages gained from use of GnRH-a in the long protocol are not compromised by its early discontinuation.

Oocyte donation in menopausal women aged over 40 years

In order to investigate the pregnancy potential of menopausal women over 40 years of age by use of donor eggs, we retrospectively analysed the results of our ovum donation programme. Forty-one clinical pregnancies were established in 134 recipient cycles. The recipients were divided into three age groups (40-43, 44-47 and > or = 48 years) in order to investigate the implantation rate with respect to age. The 30.6% pregnancy rate per embryo transfer cycle and 9.7% implantation rate per embryo appeared to be constant in all age groups studied. Fourteen pregnancies ended in miscarriage, there was one ectopic pregnancy and 25 healthy babies have been delivered. The oldest woman to deliver was 54 years of age. This report highlights the question of age limit for application of the new reproductive technologies, and especially of oocyte donation.

Continuation of a donor oocyte pregnancy in menopause without early pregnancy support

A case of successful impregnation of a functionally agonadal 45-year-old woman with donor eggs is reported. The placental takeover period was attained with no early exogenous E2 and P support. This case report highlights the need for further research on the ovarian function at menopause and the steroid hormonal requirements of early gestation.

Endocrine and clinical effects of estradiol and testosterone pellets used in long-term replacement therapy

Ten women with estrogen deficiency symptoms because of premature menopause [3], gonadal dysgenesis [3], or surgical menopause [4] received subcutaneous implants consisting of 25--75 mg estradiol (E2) with or without 75 mg testosterone (T). All had elevated plasma FSH, and LH, and low E2 prior to treatment. Plasma levels of FSH, LH, E2, T and estrone (E1) were measured by specific radioimmunoassay techniques prior to treatment, three times a week for the first week and once a week for up to 76 weeks after implantation. Mean plasma E2 levels rose abruptly and reached a maximum of 190 +/- 35 pg/ml within 2 weeks. They fluctuated around 150 pg/ml for 46 weeks, then gradually declined, but remained above pretreatment values for more than 68 weeks. Plasma E1 increased to a lesser extent resulting in E2:E1 ratio between 1 and 5. Elevated FSH and LH titers became suppressed within 4--6 weeks. The lowest average E2 increased occurred after 25 mg implant and was associated with incomplete FSH and LH suppression. There were no differences in maximal E2 levels reached after 50 mg or 75 mg implant, however, after 75 mg implant, E2 levels appeared less variable and were sustained for a longer period of time, averaging 125 pg/ml for 70 weeks. Plasma FSH and LH concentrations were suppressed below pretreatment levels in all patients. The degree of suppression was related to the dose of E2 implanted and, therefore, to plasma E2 levels. The FSH and LH suppression appeared more complete in women with gonadal dysgenesis than in those with premature or natural menopause. Plasma T rose abruptly to a peak mean level of 2.5 +/- 1.6 ng/ml within 2 weeks of implantation. A precipitous and steady decline with return to preimplantation titers between 17th and 18th week were then observed. The E2:E1 ratio during the first 18 weeks after implantation was significantly higher in women who received E2 implant alone than in those who received E2 + T implant. Clinically, all patients had symptomatic improvement within 24--48 hours. Regular withdrawal bleeding followed administration of oral progestogen for up to 76 weeks after implantation in six patients with intact uterus.

Variable effects of danazol on endometriosis at 4 low-dose levels

Danazol was administered in a daily dose of 100, 200, 400, or 600 mg for 6 months in a double-blind fashion to 27 women with pelvic endometriosis. Symptoms and pelvic findings were observed and recorded monthly. Laparoscopy and laparoscopic biopsies were performed before and on the last day of treatment to evaluate the extent of endometriosis and the effect of the drug. The findings were documented with drawings and photography. The degree of clinical improvement varied with the daily dose used, from just over 50% on a regimen of 100 mg/day to 83% on a regimen of 600 mg/day. Laparoscopic improvement in the extent of endometriosis was noted in all patients but residual disease was common. The degree of laparoscopic improvement appeared to be related to the dose of danazol and to the effect of the drug on the menstrual cycle. The highest, 81%, laparoscopic improvement was observed in patients who developed amenorrhea during the study. After the completion of treatment, 6 patients required operation for residual endometriosis or for its early recurrence. The recurrence of endometriosis during 24 months of follow-up was observed in 29% of patients. Six of 15 infertile patients conceived spontaneously within 6 months after treatment in spite of mild (5) or moderate (1) residual disease. There was no difference in the extent of endometriosis between infertile patients who did or did not conceive. There was, however, a statistically significant difference in the adhesion score between these 2 groups. The authors conclude that danazol may be less effective in doses lower than the standard 800 mg/day. However, downward adjustment of the individual dose may be attempted on the basis of the development of amenorrhea and clinical improvement.

Conception following insemination with a freeze-preserved retrograde ejaculate

Retrograde ejaculation, an infrequent cause of male infertility, may be the sequela of prostate or bladder neck surgery or the result of interruption in the sympathetic innervation to the bladder neck. The diagnosis is established by history and examination of the urine. In infertile couples artificial insemination homologous (AIH) using retrograde ejaculate recovered from the bladder has been successfully accomplished, but conception has occurred only in isolated cases. A literature review of the subject is presented. The technique of semen recovery from the bladder is time-consuming and uncomfortable to the patient, while the quality of the semen recovered is variable and the risk of iatrogenic urinary tract infection is increased. To avoid the above problems, and to have sperm available for AIH at the time of induced ovulation in an anovulatory wife, we were able to freeze-preserve ejaculate recovered from the bladder for future use. A case of conception following AIH with freeze-preserved retrograde ejaculate is presented.