Endometriosis: identification by carbonic anhydrase autoantibodies and clinical features.

Reliably diagnosing endometriosis traditionally requires surgery. To evaluate a possible non-surgical method, a case-control series of unexplained infertility patients undergoing diagnostic laparoscopy were scored by clinical criteria and reactivity to human carbonic anhydrase II by Western blotting. The CA II autoantibodies were found in none of the fertile controls, 38 percent of infertile controls, 55 percent of stage 1, 50 percent of stage 2, 73 percent of stage 3, and 85 percent of stage 4 endometriosis patients. Advanced endometriosis was associated with more intense reactivity. Combining clinical and antibody scores for infertile groups showed a positive association with disease stage with positive predictive values of 76 to 95 percent, negative predictive values of 90 to 60 percent, and a likelihood ratio of 18.3. It is concluded by us that CA II immunoreactivity, clinical, and combined scores all identified stages 2 to 4 endometriosis patients. However, based on predictive values and likelihood ratios, the combined score is best at identifying endometriosis non-surgically.

Autoantibodies to specific enzymes: a review.

There are two categories of autoantibodies to specific enzymes: immunoglobulin-complexed enzymes and circulating autoantibodies directed to enzymes in tissue or tissues. Immunoglobulin-complexed enzymes may result in elevated serum enzyme activity. They are found more frequently in elderly patients and have limited clinical significance. Immunoglobulin association with the enzyme must be demonstrated to distinguish this macroenzyme from other high molecular weight enzyme complexes. Autoantibodies to specific enzymes or regulators of enzyme activity do possess specific disease associations. The titers or presence of these autoantibodies may predict morbidity or response to therapy. These autoantibodies may be detected by Western blotting, enzyme-linked immunosorbent assays, tissue immunofluorescence, radioimmunoassay, immunoprecipitation flow cytometry or inhibition of enzyme activity. For example, anti-pyruvate dehydrogenase inhibits the activity of purified enzyme, but not relatively intact mitochondrial preparations. Most evidence suggests that the production of autoantibodies to specific enzymes represents an epiphenomenon secondary to tissue damage rather than a primary event in the pathogenetic pathway.

Pneumatic retinopexy failures. Cause, prevention, timing, and management.

BACKGROUND: Pneumatic retinopexy is a procedure for reattaching the retina by injecting an expanding gas bubble and using either laser or cryopexy. The procedure is controversial because there may be a lower initial success rate, and intraocular gas may increase the risk of proliferative vitreoretinopathy. METHODS: The authors performed a retrospective review of 107 unpublished consecutive cases of pneumatic retinopexy together with a literature review of 25 statistical series with primary attention to failures. Univariate and multivariate analyses were carried out on the data set, and adjusted odds ratios for risk factors associated with failure were calculated using logistic regression. RESULTS: Initially, 74 (69%) of 107 patients had successful results, and with re-operations the success rate increased to 98%. Failure of the procedure to achieve retinal reattachment occurred soon after the initial procedure, with 86% of recorded failures occurring within the first month. The initial cause of failure was new or missed breaks in 14.9%, reopened initial breaks in 11.2%, and breaks never closed in 4.6%. Risk factors that showed a correlation with failure were patients being male (adjusted odds ratio = 2.65), eyes with preoperative visual acuity worse than 20/50 (adjusted odds ratio = 1.21), eyes with four quadrants of retinal detachment or total detachment (adjusted odds ratio = 2.03), aphakic or pseudophakic eyes (adjusted odds ratio = 1.91), and eyes with additional pathologic findings (adjusted odds ratio = 3.14). Poor visual outcome was associated with initial visual acuity less than 20/50 (adjusted odds ratio = 15.7) and eyes with four quadrants of retinal detachment or total detachment (adjusted odds ratio = 5.01). CONCLUSIONS: Failures of pneumatic retinopexy occur early in the postoperative course. Factors known to be associated with failure of retinal reattachment using scleral buckling also were associated with failure in pneumatic retinopexy. A higher success rate in females was noted, suggesting that educational efforts may need to be greater in males. Poorer visual results occurred in patients with poor initial vision and in eyes with four quadrants of retinal detachment or total detachments.

A new classification of the retinoschises.

BACKGROUND: Two classifications of retinoschisis were published in the 1960s. A marked expansion of our knowledge of the diseases that give rise to retinoschisis indicates the need for an updated classification. METHODS: The new classification is based on the authors' clinical experience, an extensive review of the literature, and a survey of 20 vitreoretinal specialists. RESULTS: There are three types of retinoschisis: degenerative, hereditary, and secondary. Degenerative retinoschisis is very common and has been published extensively. In addition to the well known X-linked hereditary retinoschisis, there are less common pedigrees with autosomal recessive or autosomal dominant patterns. There are at least 18 ocular diseases that may show varying degrees of secondary retinoschisis. CONCLUSION: The many types of retinoschisis are divided into these major categories. The multiplicity of types is emphasized by the plural form of the term: "the retinoschises."

Carbonic anhydrase antibody in sera from patients with endometriosis.

Sera from 16 of 23 (69.6%) patients with endometriosis, a potential autoimmune disease, and 2 of 17 (11.8%) control individuals had autoantibodies against the bovine carbonic anhydrase (CA) molecular weight marker, as determined by the Western blot technique. The reactivity of these antibodies to purified human CA I, human CA II, and two preparations of bovine CA II were investigated. Of the 16 endometriosis patients who were reactive to the bovine CA molecular weight marker, 14 were reactive to at least one purified human CA isoenzyme tested, 8 were reactive to at least one purified bovine CA II, and 2 did not react with any of the CA isoenzymes tested. Variation in cross-reactivity between species and in the biochemical characteristics of various CA isoenzyme preparations may partially explain these findings. Autoantibodies to CA isoenzymes have recently been reported in other autoimmune diseases. Further investigation is required to determine the significance of CA autoantibody production in patients with endometriosis.

Quality improvement in the laboratory assessment of in vitro fertilization.

There has been a trend to use fewer laboratory tests during ovarian hyperstimulation prior to oocyte recovery, in vitro fertilization, and embryo transfer. Estradiol is routinely monitored during ovulation induction protocols. Estradiol rises steadily to supraphysiologic concentration during ovarian hyperstimulation. Review of the College of American Pathologists proficiency testing data from 1990 reveal that the within-method interlaboratory coefficient of variation meets the proposed maximum allowable analytical error of 11.8%. The luteinizing hormone level increases during ovarian hyperstimulation with a skewed distribution. Molecular variants exist that may bind with different affinities to monoclonal antibodies used in two-site sandwich assays. Polyclonal radioimmunoassays usually overestimate luteinizing hormone concentration. The College of American Pathologists proficiency testing data reveal that only three of eight methods with greater than 20 participants had a within-method interlaboratory coefficient of variation that met the proposed maximum allowable analytical error of 10% or less. International standardization of reference standards, antibodies, and labeling methods may improve the performance of this assay. The low pregnancy rate experienced by in vitro fertilization protocols suggests that additional laboratory tests need to be developed to monitor the receptivity of the endometrium for implantation and the quality of the oocyte and embryo.

Pneumatic retinopexy. A two-year follow-up study of the multicenter clinical trial comparing pneumatic retinopexy with scleral buckling.

The authors report 2-year follow-up information on 179 of 198 eyes (90%) enrolled in a previously published multicenter, randomized, controlled clinical trial comparing pneumatic retinopexy (PR) with scleral buckling (SB) for the management of selected retinal detachments. Scleral buckling was compared with PR with regard to redetachment after the initial 6-month follow-up period (1% versus 1%), overall attachment (98% versus 99%), subsequent cataract surgery (18% versus 4%; P less than 0.05), preoperative visual acuity (no significant difference), and final visual acuity of 20/50 or better in eyes with macular detachment for a period of 14 days or less (67% versus 89%; P less than or equal to 0.05). Reoperations after a failed PR attempt did not adversely affect visual outcome. After 2 years, PR continues to compare favorably with SB.

The complication of pneumatic retinopexy.

There have been 26 published series with a total of 1274 detachments operated with pneumatic retinopexy. Eighty percent were reattached with a single procedure and 98% with reoperations. New breaks occurred in 13% and PVR in 4%. The complications published in 101 papers on pneumatic retinopexy in the last 5 years are analyzed as to frequency, prevention, management, and results.

Solitary intraocular lymphoma as an initial presentation of widespread disease.

A patient presented with a large peripapillary choroidal mass as the initial manifestation of widespread, poorly differentiated, large cell lymphoma. The choroidal tumor had clinical and ultrasonographic characteristics of a uveal malignant melanoma. A systemic evaluation and fine-needle aspiration biopsy specimens of the abdomen and choroid established the diagnosis of a lymphoma. On rare occasion, other neoplasms can simulate the diagnostic pattern of uveal melanoma, and fine-needle aspiration biopsy can be crucial in establishing the correct diagnosis.

A small-group instruction experiment in medical education.

The authors challenge the assumption that the passive lecture-based curriculum that dominates most preclinical medical education optimizes learning for all students. For this reason, an experiment was conducted in which medical students were given the option of taking some courses as small groups in a Socratic format rather than in lectures; 67 percent of the students applied for the small-group option. Personality factors, measured by the Myers-Briggs Type Indicator, were used to determine whether there was any correlation between learning preferences and personality types. Most of the students preferred having more opportunities for small-group instruction. Most students and faculty members found the experience profitable; a significantly greater proportion of students of the intuitive-feeling personality type reacted positively to the experience than did other personality types. The small-group classes required more faculty time than did lectures, and this often prevented faculty support of the Socratic approach.