Hydrosalpinx: Tubal surgery or in vitro fertilisation? An everlasting dilemma nowadays; a narrative review

The decision on how to treat tubal diseases, specifically hydrosalpinx, is a difficult one. Ιt involves surgical, medical, social, emotional and economic factors. This narrative review aims to increase awareness of tubal disease diagnosis and treatment, to compare between tubal surgery and in vitro fertilisation (IVF) for tubal factor infertility, and to investigate the effect of the combination of both. This way, we can be more effective, safe and provide our patients with better treatment results. The review analysed randomised studies, trials and meta-analysis, which give new aspects on the treatment methods for tubal pathology before IVF. Recent papers published in English have been studied, alongside guidelines and committee opinions from previous years. Tubal surgery and IVF aim to exploit a woman's reproductive potential. IVF and endoscopic tubal surgery must be thought of as complementary, rather than competing techniques in tubal disease cases, in order to improve fertility outcome. The first-line treatment for young women less than 35 years old with minor tubal pathology, is tubal surgery. IVF should be offered if there are other factors in a couple's subfertility, if the patient is >38 years old, if moderate to severe tubal disease is present, and if it has been more than 12 months post-surgery.

Cyclosporine therapy during pregnancy in a patient with β-thalassemia major and autoimmune haemolytic anemia: a case report and review of the literature

Recent advances in the management of hemoglobinopathies offer an improved potential for safe pregnancy with favourable outcome in patients with β-thalassemia major. Autoimmune diseases that are common in women at reproductive age might be fulminant and hardly manageable in pregnant women with thalassemia. Thus immunosuppressant drugs like cyclosporine A could be necessary in order to maintain good maternal and foetal health. We present a case report of a 35-year-old woman with β-thalassemia major, splenectomy, autoimmune hemolytic anemia and insulin treated diabetes mellitus who was treated with cyclosporine A during her pregnancy, and delivered a healthy male infant. First line therapy with steroids was ineffective, due to deregulation of diabetes mellitus.

[Value of injection therapy for degenerative diseases of lumbar spine]

Local injection therapy is of great value in the border area between non-operative or operative treatment of discogenic and spinal stenotic radicular syndromes. With a series of deep periradicular infiltrations of local anesthetics and antiphlogistics it is possible to reduce the pain peaks in the spontaneous course of degenerative spinal diseases, so that planned surgery is no longer necessary. For the rare serious palsies immediate surgery is still necessary. On-going improvement is reached by physiotherapy and psychotherapy and with the back school.

A morphometric cadaver study of the anterior lumbar epidural space

INTRODUCTION

Free disc fragments end often up in the concavity of the anterior epidural space. This space consists of two compartments. The discrepancy between the impressive magnetic resonance imaging findings, clinical symptoms in patients and the problem of treatment options led us to the anatomical determination of anterior epidural space volumes.

MATERIALS AND METHODS

For the first time, the left and right anterior epidural volume between the peridural membrane and the posterior concavity of the lumbar vertebral bodies L3-S1 were determined for each segment. A CT scan and a polyester resin injection were used for the in vitro measurements.

RESULTS

The volumes determined in human cadavers using this method ranged from 0.23 ccm for L3 to 0.34 ccm for L5. The CT concavity volume determination showed this increase in volume from cranial to caudal, as well.

CONCLUSION

This volume is large enough to hold average-sized slipped discs without causing neurological deficits. A better understanding of the anterior epidural space may allow a better distinction of patient treatment options.

[Rupture of the anterior cruciate ligament. Diagnostics and therapy]

Rupture of the anterior cruciate ligament (ACL) is the most common ligamentous knee injury. The knee is stabilized by the cruciate ligaments and the collateral ligaments. The ACL originates from the inner surface of the lateral condyle of the femur, runs in an anterior medial direction and inserts at the tibial plateau in the intercondyle area. The most common injury is an indirect knee trauma, typically a joint torsion in sports. Patients often describe a snapping noise followed by hemarthrosis. Concomitant injuries are lesions of the medial collateral ligament, the medial meniscus (unhappy triad) and chondral fractures. The age peak is between 15 and 30 years with a higher incidence in females. The cardinal symptom of the ACL rupture is the giving way phenomenon. The clinical diagnosis is provided by a positive Lachman test, a positive pivot shift test and the anterior drawer test. Fractures can be excluded by X-ray examination. Magnetic resonance imaging (MRI) allows the evaluation of the internal knee structures. ACL repair is carried out by arthroscopically assisted bone-tendon-bone or semitendinosus grafting techniques. Early rehabilitation is important for a good functional outcome.

Awareness of human papillomavirus infection, testing and vaccination in midwives and midwifery students in Greece

Midwives play an important role in the implementation of cervical cancer screening. We assessed the knowledge of human papillomavirus (HPV) infection and of its relationship with cervical cancer in 107 midwives and 29 graduating midwifery students. The majority of midwives (78.5%) were aware that a viral infection causes cervical cancer, whereas only 48.3% of the students knew this (p = 0.003). Only one midwife (0.9%) was not aware of HPV infection compared with 10.3% of the students (p = 0.029). Midwives were also more knowledgeable of the relationship between HPV infection and cervical cancer and of the availability of a vaccine against HPV infection (p = 0.005 and p < 0.0001, respectively). In conclusion, Greek midwives have a satisfactory level of knowledge about cervical cancer and HPV infection, in contrast to midwifery students. It is important to better educate midwifery students in order to facilitate the incorporation of HPV testing and vaccination in clinical practice.

Steroid receptor expression in human endometrium during the follicular phase of stimulated cycles

BACKGROUND

No data are currently available regarding kinetics of human endometrial steroid receptors in stimulated cycles.

METHODS

In 31 patients (age <39 years) stimulated with gonadotrophins and GnRH antagonists for intrauterine insemination (IUI) an endometrial biopsy was performed on the first day after the end of menstruation and a second biopsy was performed two (Group 0 + 2, n = 10) or four (Group 0 + 4, n = 11) days after the first biopsy, or on the day of hCG administration (Group 0 + hCG, n = 10). Expression of progesterone (PR) and estrogen (ER) receptor was investigated by immunohistochemistry using monoclonal antibodies.

RESULTS

PR and ER levels were significantly increased in the second versus the first biopsy, in all groups analyzed (P = 0.01), in both stromal and glandular cells. Between the three groups compared, a significant increase in PR expression was observed for glandular cells (P = 0.03), with the highest value observed in Group 0 + 4. Moreover, the increase in PR expression in stromal cells differed between groups (P = 0.01), with the highest value observed in the Group 0 + hCG.

CONCLUSIONS

In stimulated cycles for IUI, ER expression in both glandular and stromal endometrial cells, after an initial increase, does not appear to change significantly during the follicular phase. On the contrary, during the same period of time, following an initial rise, PR expression in glandular and stromal cells continues to increase.

Laparoscopic laser sterilisation: An alternative option

The aim of this prospective study was to evaluate the safety and efficacy of female laparoscopic laser tubal sterilisation. A total of 265 women underwent laparoscopic laser sterilisation as a day-case procedure at Princess Royal University Hospital in Kent between 1996 and 2001. The fallopian tube was divided at the isthmic portion using a neodymium-yttrium aluminium garnet (Nd:YAG) laser probe. All procedures were completed laparoscopically and patients were discharged within 6 h of surgery. No perioperative complications were encountered. The mean follow-up duration was 36 months (range 2 - 7 years) and no intra- or extrauterine pregnancies were reported throughout the entire follow-up period. We conclude that laparoscopic Nd:YAG laser sterilisation appears to be a safe and effective day-case method of female sterilisation. Larger studies with longer follow-up are needed to further define its role as a reliable long-term contraceptive method.

[Angle of needle position for the epidural-perineural injection at the lumbar spine]

AIM

The aim of this study was to find the correct angle of the needle position for the epidural perineural injection at the lumbar spine without any help by imaging.

METHODS

In 11 human cadaver lumbar spines besides dura, nerve roots and bones all soft tissue had been removed to allow us to look into the anterior lateral epidural spaces between L3 and S1 in different angles with an operation microscope. The area between the dura (medial), facet joint (lateral) and the laminae (cranial and caudal) were photographed and planimetrically measured. This area is called the width of the injection canal.

RESULTS

Degenerative lumbar spines show a width of the injection canal of 29.61 mm(2) in L5/S1 with an angle of the needle position of 15 degrees to the midline. The optimal angle position of the needle brought a width of the injection canal in L4/5 only for 7.3 mm(2) and in L3/4 for 3.5 mm(2). In non-degenerative spines the injections canals were much wider.

DISCUSSION

The epidural-perineural injection into the anterolateral epidural space only makes sense in the segment L5/S1. Here the L5 nerve root is reached as well as the S1 root - the main causes of sciatica. In upper segments the injection canal is far smaller even at optimal injection angles. In case of nerve root compression at L4 and upwards other epidural injection techniques should be used such as the epidural dorsal loss of resistance technique or the transforaminal technique.

CONCLUSION

With some training it is possible to perform epidural-perineural injection for sciatica without the help of imaging.

[Conservative treatment of lumbar spinal stenosis--a review]

AIM

The aim of this study is to provide an analysis of the literature and our own experience in the conservative treatment of lumbar spinal stenosis. Although lumbar spinal stenosis is treated mostly non-operatively there are only a few reports in the literature about the results of conservative treatment. All the recent articles about surgical procedures for LSS mention ineffective preoperative treatment without explaining it. So far there have been no randomised clinical trials to obtain evidence regarding the clinical outcome of non-surgical management.

METHOD

We provide an actual overview about the conservative treatment of LSS referring only to retrospective studies, guidelines and expert opinions. Solely the treatment of LSS with epidural steroids, which is recommended by most of the authors, has been evaluated by several randomised controlled studies with a high level of evidence.

RESULTS

As far as we can summarise at present, a multidisciplinary conservative treatment programme is most effective not only for discogenic low-back pain but also for LSS with a concentration on physiotherapy, behavioural therapy, epidural injections and a special back training which is presented in this paper.

CONCLUSION

Patients with LSS should receive a trial of the proposed conservative, aggressive treatment before surgery is considered.

Heparin-induced thrombocytopenia type II: a serious hazard in preemptive renal transplantation: a case report

Heparin-induced thrombocytopenia (HIT) type II (HIT II), is an immune-mediated complication of heparin therapy, associated with arterial and venous thrombosis. Herein we have reported a case of a 23-year-old woman who developed HIT following a living related donor, preemptive, renal transplantation. The patient was preoperatively exposed to both unfractionated and low-molecular-weight heparin as she underwent five hemodialysis sessions. HIT caused right common and external iliac vein and renal graft artery thrombosis, resulting in graft loss. Heparin-free hemodialysis was continued, and the patient was successfully treated with anticoagulation by the direct thrombin inhibitor lepirudin for both the thromboses and for hemodialysis. Finally, she was accepted for the continuous ambulatory peritoneal dialysis program. This report highlighted the importance of clinical awareness as far as previous heparin exposure is concerned for establishing an early diagnosis and delivering treatment of this life-threatening prothrombotic complication of heparin administration.

ISO/IEC 17025 Sysmex R-500 Hematology Reticulocyte Analyzer Validation

The Sysmex R-500 (R-500) Hematology Analyzer is a bench-top system appropriate for the analysis of limited batches of blood samples. The R-500 provides percentage proportional (RET%), absolute reticulocyte (RET#), and absolute red blood cell (RBC#) counts. The system was validated at the Doping Control Laboratory of Athens, according to the International Committee for Standardization in Hematology, International Standards Organization (ISO/IEC) 17025, and World Antidoping Agency (WADA) specifications. The instrument calibration was performed according to the manufacturer and validation parameters comprised linearity, precision, uncertainty (intermediate and long-term precision), comparability, effect of drift, carryover, stability, and accuracy. The linearity and the comparability studies for RET#, RET%, and RBC# were expressed in regression factors (R2) and coefficients of correlation [r(x, y)], respectively. For the precision studies, the coefficients of variation for RET#, RET%, and RBC# were 9.49%, 9.83%, and <1.5%, respectively. For the intermediate precision studies, the coefficients of variation for RET#, RET%, and RBC# were 3.1%, 3.6%, and 0.6%, respectively. Carryover was found to be negligible. Sample stability was demonstrated at both room temperature and at 4 degrees C over a 24-hour period. Comparability studies for the R-500 were performed using a Sysmex SE-9500. The total evaluation led to the conclusion that the R-500 is an accurate and precise analyzer and because of to its relatively limited size, it can be considered a portable instrument, capable to be used in sports competition and training sites, where doping control and health tests are conducted. The analytical methodology of RET% measurement by the R-500 has been incorporated into the Doping Control Laboratory of Athens' Scope of Accreditation according to the ISO/IEC 17025 and WADA specifications.

Safety and effectiveness of tinzaparin sodium in the management of recurrent pregnancy loss

PURPOSE

To assess the safety and efficacy of tinzaparin sodium for the management of recurrent pregnancy loss.

METHODS

The study included 62 women with a history of recurrent pregnancy loss and at least one factor of thrombophilic disorder. Of these, 31 received 50 IU/kg of tinzaparin sodium daily (Group A), and 33 received 100 mg of aspirin daily (Group B).

RESULTS

Group A subjects (receiving tinzaparin sodium) had six new abortions, whereas Group B subjects (receiving aspirin) had 11 (significant difference). Cases of intrauterine growth restriction (none in Group A and 2 in Group B), placental abruption (one in Group A and 4 in Group B), and preeclampsia (one in Group A and 3 in Group B) were comparable between the two groups. Finally coagulation disorders (none in Group A and 6 in Group B) were significantly fewer in Group A.

CONCLUSION

A 50 IU/kg daily dose of tinzaparin sodium seems to be effective for the management of recurrent abortion and has high standards of safety.

Injektionstherapie an der Wirbelsäule ohne Bildsteuerung

Nerve root blocks and epidural perineural injections are main part in the conservative treatment of degenerative spine diseases. These injections should be done without imaging because degenerative spine diseases - discogenic oder spinal stenotic - tend to recurrence and danger arises from too many imaging with cumulative ionizing radiation over the years, especially in younger people. After certain training it is possible to perform spinal injections without imaging only considering topographic anatomical landmarks like in any other local anesthesia for surgical reasons. Repetitive periradicular injections desensitize the nerve root by local anesthetics and reduce its inflammatory swelling by steroids. The decompensated symptomatic deformity turns back into an asymptomatic compensated status.

(Modic-)Signalveränderungen vertebraler Endplatten und ihr Bezug zu einer minimalinvasiven Injektionstherapie lumbaler Bandscheibenvorfälle

PURPOSE

To study the influence of (Modic) signal alterations (SA) of the cartilage endplate (CEP) of vertebrae L3-S1 on the outcome of an in-patient minimally invasive treatment (MIT) using epidural injections on patients with lumbar disc herniation (LDH).

MATERIALS AND METHODS

The MR images of 59 consecutive patients with LDH within segments L3/L4 - L5/S1 undergoing in-patient minimally invasive treatment with epidural injections were evaluated in a clinical study. The (Modic) signal alterations of the CEP were recorded using T1- and T2-weighted sagittal images. On the basis of the T2-weighted sagittal images, the extension and distribution of the SA were measured by dividing each CEP into 9 areas. The outcome of the MIT was recorded using the Oswestry Disability Index (ODI) before and after therapy and in a 3-month follow-up. Within a subgroup of patients (n = 35), the distribution and extension of the signal alterations were correlated with the development of the ODI.

RESULTS

Segments with LDH showed significantly more (p < 0.001) SA of the CEP than segments without LDH. Although the extension of the SA was not dependent on sex, it did increase significantly with age (p = 0.017). The outcome after MIT did not depend on the sex and age of the patients nor on the type of LDH. The SA extension tended to have a negative correlation with the outcome after MIT after 3 months (p = 0.071). A significant negative correlation could be established between the SA extension in the central section of the upper endplate and the outcome after 3 months (p = 0.019).

CONCLUSION

1. Lumbar disc herniation is clearly associated with the prevalence of (Modic) signal alterations. 2. Extensive signal alterations tend to correlate with a negative outcome of an MIT using epidural injections. 3. Such SA in the central portion of the upper CEP correlate significantly with a negative treatment result. 4. The central portion of the upper CEP being extensively affected by (Modic) SA is a negative predictor for the success of a minimally invasive pain therapy.

Akute Herz-Kreislaufreaktionen bei zervikaler Spinalnervenanalgesie

AIM

The frequency of cardiovascular adverse effects of cervical nerve root infiltration was investigated by means of a prospective study.

METHOD

The hemodynamic and respiratory parameters systolic and diastolic blood pressure, heart rate, respiratory rate and oxygen saturation were monitored continuously in 56 patients undergoing cervical spine nerve root infiltration (injection of 10 ml Lidocain 0.5 %, mean depth of injection 5 cm). The monitored time frame ranged from 5 minutes before to 10 minutes after its administration, an additional holter-monitoring began 1 day prior to the injection.

RESULTS

Severe complications such as syncopes were not observed in any of the 56 patients, 4 patients developed presyncopes. None of the registered parameters showed a significant change. In a group of patients with known, pre-existing cardiovascular morbidity, no significant changes occurred either. No relevant cardiac arrhythmias were observed.

CONCLUSION

The observed cardiovascular complications were not severe. Most probably, the observed reactions were vasavagal presyncopes. Supine positioning led to immediate recovery in all of these patients. A complete hemodynamic monitoring and the placement of an intravenous line do not seem to be absolute necessities in the routine cervical nerve root infiltration.

[Effects of lumbar spinal nerve analgesia on the cardiovascular system]

AIM

The frequency of cardiovascular adverse effects of lumbar paravertebral nerve root infiltration was investigated.

METHOD

117 patients with sciatic pain were included prospectively. 60 % of these suffered from known cardiovascular diseases. In 50 patients, cardiac rhythm was investigated by Holter monitoring. In 100 patients blood pressure, heart rate, respiratory rate and oxygen saturation were registered continuously from 5 minutes before to 15 minutes after the administration of a paravertebral nerve root infiltration by means of a non-invasive monitoring system.

RESULTS

A minor rise in systolic and diastolic blood pressure, heart rate and respiratory rate as well as a normalization of these parameters after the nerve root infiltration, were found. These findings were similar for patients with and without pre-existing cardiovascular diseases. No relevant cardiac arrhythmias could be determined. 5 of the 117 patients suffered from presyncope after the nerve root infiltration. These individuals were significantly (p = 0.002) younger than those without presyncope (32.4 +/- 9.3 vs. 55.8 +/- 14.6 years). Presyncope was more frequent during the first treatment with lumbar paravertebral nerve root infiltration in comparison to repeated application of this therapy [4/27 (14.8 %) vs. 1/90 (1.1 %), p = 0.003]. 80 % of the patients who had experienced a presyncope reported a history of similar events.

CONCLUSION

According to our findings, cardiovascular monitoring for lumbar paravertebral nerve root infiltrations in the treatment of sciatica does not appear to be required. Patients with a presyncope seem to be characterized by age, first treatment and a history of (pre-)syncopes. In these cases, intravenous fluid substitution might be of help in counteracting vasovagal circulatory reactions.

[Fentanyl-TTS in the treatment of pain caused by arthrosis]

AIM

Efficacy and tolerability of analgesic treatment with fentanyl-TTS (Durogesic) for pain caused by arthrosis was investigated.

METHOD

Treatment with fentanyl-TTS was started for the first time in patients with severe pain caused by coxarthrosis and/or gonarthrosis and was prospectively documented for 30 days. Pain was assessed by the patient with an 11-step numerical analogue scale and by the physician with 5 questions (5-step scale) adapted from the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC).

RESULTS

A total of 243 patients (166 women, 77 men) with a mean age of 67 years (range 28 - 94) was treated. In the patient's rating, pain at rest as well as in motion decreased significantly from 6.4 +/- 2.1 to 2.9 +/- 2.0 and from 8.1 +/- 1.5 to 4.2 +/- 21, respectively (p < 0.001 for both comparisons). The sum score for the 5 questions with a detailed pain assessment by the physician decreased from 18.8 +/- 3.2 to 11.2 +/- 42 (p < 0.001). A significant pain reduction was also observed for each of the 5 single questions. At the end of observation the proportions of patients with no pain or impairment under different conditions were 5 % (climbing stairs), 14 % (walking), 26 % (standing), 33 % (lying/sitting), and 44 % (sleeping). The most common adverse events were nausea, vomiting, obstipation, and dizziness. Treatment with fentanyl-TTS was usually well-tolerated.

CONCLUSION

Severe pain caused by arthrosis can be well treated with fentanyl-TTS with a favourable safety profile.

Activation of the fibrinolytic system and utilization of the coagulation inhibitors in sepsis: comparison with severe sepsis and septic shock

OBJECTIVES

To determine whether the fibrinolytic system is activated and coagulation inhibitors are utilized in sepsis, to compare the findings detected in sepsis with those found in severe sepsis and septic shock, and to compare the role played by different infectious pathogens on fibrinolysis and coagulation inhibitors.

DESIGN AND SETTING

Prospective study comparing patients with sepsis, severe sepsis, and septic shock and healthy volunteers in the general intensive care unit of a tertiary university hospital.

PATIENTS

Eighty-two consecutive septic patients (47 with sepsis, 18 with severe sepsis, and 17 with septic shock), and 14 healthy volunteers (controls).

MEASUREMENTS AND RESULTS

After blood sampling we measured activation markers of fibrinolysis [plasmin/alpha(2)-antiplasmin complexes (PAP), complexes of tissue plasminogen activator/plasminogen activator inhibitor (tPA/PAI), fibrin(ogen) degradation products (FDPs), D-dimmers fibrin degradation products (D-d)], the utilization marker of antithrombin III (ATIII) thrombin/antithrombin complexes (TAT), several factors of fibrinolysis [plasminogen, tissue plasminogen activator (tPA), plasminogen activator inhibitor 1 (PAI-1), alpha(2)-antiplasmin], and the natural coagulation inhibitors [ATIII, protein C (PrC), protein S (PrS)]. In sepsis, PAP, FDPs, D-d, and TAT were increased to 439.8+/-32.35 microg/l, 57% positive, 49% positive, and 3.46+/-0.27 microg/l, respectively, compared with control subjects (205.57+/-28.58 microg/l, 0% positive, 7% positive, and 1.61+/-0.1 microg/l, respectively). These markers further increased in severe sepsis and septic shock. With the exception of a decrease in ATIII and an increase in tPA and PAI-1, coagulation inhibitors and factors of fibrinolysis were not changed in sepsis. In severe sepsis and mainly in septic shock, coagulation inhibitors (ATIII, PrC) and plasminogen were markedly decreased, whereas tPA and PAI-1 were further increased. All changes were independent of the causative infectious pathogen.

CONCLUSIONS

Fibrinolysis is strongly activated and ATIII is utilized in sepsis. These findings are further enhanced in severe sepsis and septic shock. In sepsis only ATIII is decreased. In contrast, in severe sepsis and mainly in septic shock plasminogen and the main coagulation inhibitors (i.e., ATIII, PrC) are depleted, indicating exhaustion of fibrinolysis and coagulation inhibitors. Finally, Gram-positive, Gram-negative and other micro-organisms produce identical impairment.

Coagulation system and platelets are fully activated in uncomplicated sepsis

OBJECTIVE

To test the hypothesis that the coagulation system and platelets are activated in sepsis, the uncomplicated and usually earliest stage of the septic process, and to compare the findings detected in sepsis with those found in severe sepsis and septic shock.

DESIGN

Prospective study comparing patients with sepsis, severe sepsis, and septic shock, and healthy volunteers.

SETTING

General intensive care unit in a tertiary university hospital.

PATIENTS

Seventy-four consecutive septic patients (45 with sepsis, 15 with severe sepsis, and 14 with septic shock). Fourteen healthy volunteers served as control subjects.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

After blood sampling, molecular activation markers of coagulation (prothrombin fragments 1 and 2, fibrinopeptide A, thrombin-antithrombin complexes, and monomers of fibrin) and of platelets (beta-thromboglobulin and platelet factor 4), several coagulation factors, global tests of coagulation (prothrombin time and activated partial thromboplastin time), and platelet count (PTL) were measured. In sepsis, prothrombin fragments 1 and 2, fibrinopeptide A, thrombin-antithrombin complexes, and monomers of fibrin were increased to 2.52+/-0.21 nmol/L, 20.88+/-2.52 ng/mL, 33.8+/-2.9 microg/L, and 69% positive, respectively, compared with control subjects (0.86+/-063 nmol/L, 1.14+/-0.15 ng/mL, 16.07+/-1.01 microg/L, and 0%, respectively). Beta-Thromboglobulin and the beta-thromboglobulin-to-platelet factor 4 ratio were also increased to 107.87+/-11.87 IU/mL and 8.86+/-1.06, compared with controls (18.36 +/-2.99 IU/mL and 2.67+/-0.52, respectively). With the exception of a decrease in factor XII and an increase in fibrinogen, coagulation factors, global coagulation tests, and PTL were not changed in sepsis. In severe sepsis and mainly in septic shock, coagulation factors were markedly decreased, global coagulation tests were prolonged, and PTL was reduced. All changes were independent of the causative infectious pathogen.

CONCLUSION

Coagulation system and platelets are strongly activated in sepsis. In this stage, only factor XII is decreased. In contrast, in severe sepsis and mainly in septic shock, most of the coagulation factors are depleted, PTL is decreased, and global coagulation tests are prolonged, indicating exhaustion of hemostasis. Finally, Gram-positive, Gram-negative, and other microorganisms produce identical impairment of coagulation.

Elevated serum prolactin concentrations in phenylketonuric patients on a 'loose diet'

OBJECTIVE

High levels of phenylalanine (Phe) have been shown to reduce dopamine (DA) and noradrenaline (NA) production. We have therefore evaluated whether increased serum Phe concentrations lead to increased prolactin (PRL) secretion in phenylketonuria.

PATIENTS

Forty-two patients with classical phenylketonuria were divided into two groups. Group A (n = 19) adhered very strictly to their special diet (Phe = 0.09 +/- 0.039 mmol/l) and Group B (n = 23) were on a 'loose diet' (Phe = 0.77 +/- 0.45 mmol/l). Thirty healthy children of comparable age served as controls.

MEASUREMENTS

PRL was measured by RIA, and Phe and tyrosine (Tyr) with an amino-acid autoanalyser. Adrenaline (A), noradrenaline (NA), and dopamine (DA) were measured by HPLC.

RESULTS

Serum PRL in group B patients (1595 +/- 57 mU/l) was significantly raised compared to Group A patients (243 +/- 57 mU/l) and controls (201 +/- 55 mU/l) (P < 0.001). Serum DA, A and NA in group B were lower than in group A patients and controls. Serum Phe in group B patients was significantly correlated to serum PRL (r = 0.59) and DA (r = -0.41). Irregular menses were observed in 1/10 women from group A but in 10/13 in group B.

CONCLUSION

High serum phenylalanine concentrations in phenylketonuric patients not strictly adhering to their diets are correlated with high serum PRL and low serum dopamine concentrations, and a high prevalence of menstrual irregularities.

Detection of Chlamydia trachomatis in asymptomatic women: relationship to history, contraception, and cervicitis

The presence of Chlamydia trachomatis antigen was examined in 400 endocervical samples collected from an equal number of asymptomatic sexually active women. The overall prevalence was found to be 4%, using the enzyme-linked immunosorbent assay. Chlamydia infection was correlated with younger age (5.8%, p < 0.05), a history of pelvic inflammatory disease (30%, p < 0.0001), and more than four lifetime sexual partners (7.9%, p < 0.01). Women who used oral contraception had more infections (9.7%), than did women who used the intrauterine contraceptive device (4.8%, p > 0.05), condom (0%, p < 0.01) or no contraception (3.1%, p < 0.05). Infection was strongly associated with cervical erythema (8.2%, p < 0.0001), ectopy (7%, p < 0.05), friability (20%, p < 0.0001), and endocervical discharge (100%, p < 0.0001). These results support the view that Chlamydia trachomatis infection is associated with younger age, intense sexual life, and use of oral contraceptives. Given that the majority of infected women revealed cervical pathology, the detection of chlamydia in the high-risk female population with cervical changes seems to be essential.

Copper intrauterine contraceptive device and pregnancy rate

Between August 1983 and August 1992, 1995 women aged 20-43 years were fitted with 2736 copper intrauterine contraceptive devices (MLCu250, MLCu375, Nova-T, Gravigard, Anticon). Insertion of the IUD was performed during menstruation by a skilled team of gynecologists. The women were instructed to self-check the IUD tail after each menstrual period. All the women were examined after one month and were followed-up every six months. The 1995 acceptors accumulated a total use of 69,350 months. During this period 39 accidental pregnancies occurred (Pearl Index 0.62, cumulative net pregnancy 1.95 per 100 women). Thirty-six pregnancies were intrauterine and three were ectopic. Most of the accidental pregnancies occurred during the first 12 months of use. The pregnancy rate of IUD users was negatively correlated with age. It is concluded that fitting the Cu-IUD intramenstrually, teaching the user to self-check herself and having frequent re-examinations seems to decrease the pregnancy rate in Cu-IUD users.