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OBJECTIVE: To evaluate the possible association between duration of sexual cohabitation and the risk of pregnancy-induced hypertension (PIH). STUDY DESIGN: A matched case-control design in which each case of PIH was compared with three controls. Information was obtained about use of barrier contraception, duration of intercourse prior to pregnancy and paternity. RESULTS: Sixty-eight cases were included in the study. For primiparous women, a shorter duration of sexual cohabitation without contraception was associated with a small and nonsignificant risk of PIH. For multiparous women, a greater length of time since stopping use of barrier contraception was associated with a greater risk of PIH. CONCLUSION: Advising nulliparous women to prolong the duration of sexual cohabitation prior to conception in an effort to decrease the risk of PIH is not justified, based on the findings of this study.

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A 30-year-old woman had uterine bleeding and hypotension after delivery. Hyponatremic seizures and a mild headache prompted early neuroimaging, which disclosed an enlarged nonhemorrhagic pituitary gland with subsequent involution consistent with pituitary apoplexy (Sheehan syndrome). Endocrinologic investigation confirmed a partial pituitary insufficiency with subsequent improvement to almost normal status.

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Between January 1977 and June 1985, 63 patients requiring supravesical diversion underwent ureterosigmoidostomy with an antireflux technique. Of the patients 49 had bladder cancer and 14 had other conditions. Two patients died in the postoperative period. Postoperatively, all patients were instructed to empty the rectum frequently, and received bicarbonate and potassium supplementation. Median followup was 41 months (range 3 to 70). Renal function remained stable in 92% of the patients. Radiographic deterioration occurred in 23% of the renal units, which was severe in 7%. These results indicate that the short and intermediate followup results with ureterosigmoidostomy are comparable to those of an ileal conduit. The method has the added advantage of being a form of continent diversion. We believe that ureterosigmoidostomy remains a viable and convenient alternative in select patients with bladder cancer who are not suitable for other forms of continent diversion or bladder substitution.

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Infection is a major limitation of implantable devices. Optimal antibiotic therapeutic regimes have not yet been defined. Implant-associated infections have a number of differentiating characteristics, which include the predominance of Staphylococcus epidermidis and other skin bacteria of normally low pathogenicity as the causative agents, together with a relative resistance to host defenses and to antibiotic therapy. These properties have been ascribed to the ability of the bacteria to exist on implant surfaces in the biofilm phase, which is protective. An assay of antibiotic activity using a standardized bacterial biofilm preparation of S. epidermidis is described. The assay is used to evaluate the relative efficacy of antibiotics to sterilize the biofilm, when they are used singly, or in double or triple combinations. The modulating effects of changing antibiotic concentrations and modifying the environment with CAPD variables (fresh and spent dialysis fluid, common PD solution additives) are also measured and the data summarized. It is hoped that, by using this and similar assays, individualized optimal therapeutic regimes of implant-associated infections may be logically planned.

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OBJECTIVE: To determine the efficacy of treatment of significant hirsutism with a GnRH agonist (GnRH-a) and estrogen and progestin replacement therapy. DESIGN: Clinical series. SETTING: Ambulatory gynecology clinic in a community hospital. PATIENTS: Ten women with significant hirsutism caused by polycystic ovarian disease. INTERVENTIONS: The patients were treated with leuprolide acetate 20 micrograms/kg per day in combination with E2 (2 mg) and medroxyprogesterone acetate (5 mg) for 6 months. MAIN OUTCOME MEASURE: Hirsutism scores and hair growth rates determined before and upon completion of treatment protocol. RESULTS: Hirsutism scores and hair growth rates significantly decreased by 23% and 26%, respectively. The duration of hirsutism was the only significant covariate for hirsutism scores and hair growth rates. Only two patients had minimal, irregular bleeding that was corrected by increasing the estrogen dose. CONCLUSION: The combination of a GnRH-a and estrogen replacement therapy was an effective and well-tolerated treatment in a small group of women with significant hirsutism caused by PCOD.

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Implant-associated infections offer resistance to antibiotic treatment and possibly do so because the causative bacteria which reside on the artificial surface are enclosed in a protective matrix (biofilm) shielding the bacteria against the action of host defenses and antibiotic action. We have investigated in vitro the effect of various antimicrobial agents on biofilms of Staphylococcus epidermidis, which is the main organism responsible for implant-associated infections. Rifampin was found to exert superior activity, albeit incomplete, against S. epidermidis biofilms using an assay system which enabled the determination of the kinetics of antibiotic action over five days. In a large screening study looking for agents capable of completing the action of rifampin, gentamicin was unexpectedly found to be antagonistic to rifampin. The present study was undertaken to investigate further the activity of gentamicin and five other aminoglycoside antibiotics using a wider range of concentrations (2.5-20 micrograms/mL). The main findings were a marked synergy with rifampin demonstrated by streptomycin, producing a bactericidal outcome, which contrasted sharply with the indifference or antagonism shown by the other aminoglycosides. We then studied in further detail the effect of separate combinations of streptomycin and gentamicin with rifampin over a wider concentration range of each agent (1.25-40 micrograms/mL). Streptomycin showed strong rapid synergy with rifampin even at the lowest concentration of each antibiotic. Gentamicin demonstrated a concentration-related antagonism towards rifampin which was independent of rifampin concentration. The data support the conclusion that streptomycin, like cell-wall active antibiotics, exerts a potent synergy with rifampin against S. epidermidis biofilms, and that the other aminoglycosides, predominantly gentamicin, strongly antagonize rifampin action.(ABSTRACT TRUNCATED AT 250 WORDS)

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The purpose of this study was to evaluate the accuracy of clinical diagnosis of acute pelvic inflammatory disease (PID). Data were obtained on 176 consecutive women admitted to St. Elizabeth Hospital Medical Center with a clinical diagnosis of PID. All underwent diagnostic laparoscopy. PID was established laparoscopically in 134 (76.1%) of the patients. Statistical tests for significant associations between PID and each of 21 clinical indicators of the disease were conducted using the chi 2 and Mann-Whitney tests. Stepwise logistic regression was performed on those variables whose univariate tests of significant association with PID resulted in P values < 0.20. An optimal set of PID indicators consisted of adnexal tenderness, lower abdominal pain of < one week's duration and an elevated white blood cell count. Use of these indicators resulted in a test with an estimated sensitivity and specificity of 86.6% and 45.7%, respectively. Estimated predictive values for positive and negative test results were 0.84 and 0.52, respectively. These results confirm the fact that laparoscopy is the definitive diagnostic modality in PID.

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Routine laboratory testing of the susceptibility of infecting strains of S. epidermidis to antibiotics is based on the assumptions that the infection is in contact with the stable environment of blood or tissue fluid and that the bacteria are in a susceptible phase of growth. In infections of the continuous ambulatory peritoneal dialysis (CAPD) intraperitoneal catheter, the bacteria are commonly in the resistant biofilm phase of growth, are applied to the surface of the catheter, and are exposed to the nonphysiological impact of peritoneal dialysis solutions. The possible impact of these two variables is not examined in routine testing of antibiotic susceptibility. We describe an assay of antibacterial action on a strain of S. epidermidis in the biofilm phase, exposed to a neutral control environment and to dialysis solutions, both fresh and spent. Rifampin, which has an incomplete action in a neutral control environment, was used as a sensitive indicator of possible synergistic or antagonistic interaction of the biofilm bacteria with the dialysis environments. We demonstrated that peritoneal dialysis solutions (1.5% dextrose), both fresh and spent, were synergistic with rifampin action against S. epidermidis biofilms, converting the incomplete killing action to a total bactericidal outcome, clinically essential for cure. Fresh dialysis solution was more active than spent, but in both instances the synergy was complete, indicating that the crucial complementation of the bactericidal action of rifampin was independent of pH. These findings have implications in the management of catheter-associated infections due to rifampin-susceptible strains of S. epidermidis.

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The progestin-induced withdrawal bleeding test has often been used in patients with amenorrhea to assess endogenous estrogen (E) production. The endometrial thickness measured by vaginal ultrasonography with a 5 MHz transducer is also dependent on E stimulation of the endometrium. In this study, 70 consecutive patients were evaluated with both the progestin-induced withdrawal bleeding test and a measurement of the endometrial thickness by vaginosonography. An endometrial thickness of 1.5 mm or less was selected to predict absence of bleeding after a progesterone (P) challenge test. This resulted in a sensitivity of 94% with a 95% confidence interval (CI) of 0.70 to 1.00 and a specificity of 93% with a 95% CI of 0.82 and 0.98. The positive and negative predictive values were 79% and 98%, respectively. This study shows that the endometrial thickness measured by vaginosonography can predict the results of the P challenge test in patients with amenorrhea.

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In this work we examined the neuronal input to one of the serotoninergic centers in the brain, median raphe nucleus (MR). Special consideration is given to projections of the hypothalamus. To describe the afferents to MR, a retrograde transport technique was used after microinjection of WGA-apoHRP-Gold complex under pressure and subsequent gold-silver intensification on formaldehyde-fixed rat brain sections. Optimal conditions were obtained when the coordinates of the injection site were A +/- 1.5, L +/- 0.15, and H +/- 2.7 according to Paxinos and Watson (The Rat Brain in Stereotaxic Coordinates. New York: Academic Press, '82). Results obtained under these conditions show a heterogeneous distribution of labeled neurons throughout the brain, including a large proportion (+/- 65%) of hypothalamic neurons. Extra-hypothalamic neurons projecting to MR were from the prefrontal cortex, lateral and medial habenular nuclei, the pontine area of the central grey, interpeduncular nucleus, dorsal raphe nucleus, oculomotor and trochlear nuclei, dorsal and laterodorsal tegmental nuclei, parabrachial nuclei, and lateral and interpositus cerebellar nuclei. Hypothalamic neurons connected to MR were found to be from medial and lateral preoptic areas, lateral hypothalamus, dorsomedian nucleus, the perifornical area, and the complex of mammillary bodies. Many other discrete regions contained different densities of labeled perikarya: the medial preoptic nucleus, paraventricular nucleus, retrochiasmatic area, arcuate nucleus, lateral magnocellular nucleus, and the posterior area. The MR appears as an integrative center receiving many neuroanatomically and functionally heterogeneous inputs from the whole brain.

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Endorphins represent a family of brain peptides having an opioid core structure responsible for their morphinomimetic activity. We present an overview of the biology of endorphins including their origin, neuroanatomical distribution, regulatory mechanisms and interaction with opioid receptors taking neuronal cellular function in situ as our focal point of interest. Differential biochemical processing and regulatory mechanisms both at the pre- and post-translational level in the various brain areas contribute to the biochemical and functional diversity of peptides generated from common precursors in keeping with the selective needs and functions of neuronal circuits. Physiological significance requires interaction of the various endogenous ligands thus generated with appropriate receptors, sometimes located well beyond the distance of a synaptic cleft as demonstrated by the diverging ligand/receptors neurochemical topographical maps. Physiological analysis reveals a multitude of potential interactions between peptides and classical neurotransmitters in part as a result of their common subcellular location within individual synaptic vesicles but also in relation to qualitatively different post-synaptic effects and metabolism, enhancing the complexity of their potential role in neuronal function. Endorphins may contribute to major neuroendocrine systems such as analgesia, endocrine and autonomic function, mental function and behavior. Their implication in various neuropsychiatric and endocrine clinical disorders will be briefly reviewed.

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We report 14 patients with a slowly progressive syndrome featuring ataxia, choreoathetosis, and ocular motor apraxia in both the horizontal and vertical planes. Although the neurological signs were indistinguishable from those of ataxia-telangiectasia, the onset tended to be later and none of the patients had evidence of multisystemic involvement. Specifically, there was no tendency to frequent infections, and immunoglobulins, alpha-fetoprotein, T- and B-lymphocyte markers, and chromosomes 7 and 14 were normal in all tested patients. The simultaneous absence of telangiectasias and of other nonneurological manifestations made ataxia-telangiectasia an unlikely diagnosis. We suggest that these patients suffer from an unusual type of spinocerebellar degeneration. This syndrome has been observed in different populations from three continents, with a genetic pattern suggesting recessive autosomal inheritance.

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The data on 62 patients with germinal testicular tumors seen at King Faisal Specialist Hospital and Research Centre between January 1977 and June 1983 were analyzed to determine the epidemiologic and clinical characteristics of the disease in Saudi Arabia. Fifty-seven patients were Saudis. The geographic distribution of Saudi patients seemed to coincide with population concentrations. Testicular seminomas (TS) and non-seminomatous testicular tumors (NSTT) comprised 50% each. The mean age was 41 and 27.8 years for TS and NSTT, respectively. Fifteen patients had cryptorchidism of the involved testicle. Three patients with NSTT had a history of trauma to the involved testicle. The most common presentations were painless testicular swelling (51.6%), painful swelling (16%), and abdominal or inguinal swelling (21%). The delay between the onset of symptoms and referral (mean 15 months) was considerable. Eighty percent of patients with NSTT and 45% of those with TS had advanced disease at referral.

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We performed 1-stage complete genital reconstruction on 20 female subjects with congenital adrenal hyperplasia. The blood and nerve supply to the glans was retained by preserving the neurovascular bundle, as well as the ventral mucosal strip. Preservation of the neurovascular bundle was simplified. The phallic skin was used to form labia minora and a flap vaginoplasty was performed simultaneously. There were no operative complications and all 20 patients had satisfactory results.

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Thirty Saudi patients with pure testicular seminoma were treated at King Faisal Specialist Hospital and Research Centre in Riyadh, Saudi Arabia, between January 1977 and June 1983. Disease characteristics in Saudi Arabia including clinical findings, response to therapy, and prognosis are described and compared to those in other populations reported in the literature. Symptom durations were 3 to 42 months. Many of the patients presented with an extensive tumor burden and a poor performance status. There was a higher incidence of anaplastic seminoma and of cryptorchidism than in other series and a relatively high incidence of elevated betahuman chorionic gonadotropin (B-HCG). Patients initially underwent funiculo-orchiectomy. Twenty-two patients received radiation therapy and four received chemotherapy. Patients with limited disease responded well to orchiectomy and radiation therapy. However, those with extensive tumor burden had an unsatisfactory response to radiation therapy. Preradiation chemotherapy is recommended for patients with massive retroperitoneal metastases, nodal disease above the diaphragm, or extranodal disease and patients with minimal or moderate sized retroperitoneal nodal disease associated with an elevated B-HCG.

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We report 2 cases of herniation following repair of posterior urethral strictures. Both patients underwent transpubic bulboprostatic urethral anastomosis and omentoplasty, which resulted in a perineal hernia in one and a pubic hernia in the other.

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Fifteen patients with post-circumcision squamous cell carcinoma of the penis are discussed (13 were referred from the southwestern region of Saudi Arabia). Carcinoma developed in circumcision scars on the penile shaft. Excision was the only effective treatment and resulted in disease control in approximately 64 per cent of those treated surgically. Radiation therapy and chemotherapy did not seem to be effective in these patients.

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