Effect of postmenopausal hormonal replacement therapy on mammographic density and parenchymal pattern

PURPOSE

To measure changes and predictors of change in mammograms obtained in postmenopausal women undergoing continuous combined hormonal replacement therapy (HRT).

MATERIALS AND METHODS

Mammograms of 41 postmenopausal women obtained before and 1 year after the initiation of HRT were evaluated blindly according to the quantitative density percentage method and the Wolfe classification system.

RESULTS

Mammographic densities increased compared with baseline values in 73% of subjects (mean increase, 6.7%; 95% confidence interval, 2.5%, 11.0%; P = .003). A shift in Wolfe classification from lower to greater parenchymal density was noted in 24% of subjects (P = .016). Multivariate analysis results indicated that the lower the tissue density percentage before treatment, the greater the increase in density percentage after treatment.

CONCLUSION

An increase in mammographic density was demonstrated in most subjects undergoing continuous combined HRT and was most pronounced in subjects with a lower baseline density percentage.

Single oral dose fluconazole compared with conventional clotrimazole topical therapy of Candida vaginitis. Fluconazole Vaginitis Study Group

OBJECTIVES

Candida vaginitis is currently treated with a wide range of intravaginal preparations usually prescribed over several days. Fluconazole with its marked activity against Candida species and favorable pharmacokinetics offered a safe, effective, and convenient alternative to topical therapy in a single-dose regimen.

STUDY DESIGN

We conducted a multicenter, randomized, prospective, single-blinded study of 429 patients with acute Candida vaginitis, comparing the efficacy and safety of a single oral 150 mg dose of fluconazole with 7-day clotrimazole 100 mg vaginal treatment. Posttherapy evaluations and mycologic eradication rates were conducted.

RESULTS

No statistically significant differences were seen between fluconazole and clotrimazole in the clinical, mycologic, or therapeutic responses. At the 14-day evaluation clinical cure or improvement was seen in 94% of fluconazole-treated patients and 97% of clotrimazole-treated patients. Mycologic and therapeutic cures were seen in 77% and 76% of the fluconazole and 72% of the clotrimazole groups, respectively. At the 35-day evaluation 75% of both groups remained clinically cured, and 56% of the fluconazole and 52% of the clotrimazole group were considered therapeutic cures. In both treatment groups patients with a history of recurrent vaginitis (33/84) compared with those without a history of recurrent vaginitis (177/266) were significantly less likely to respond clinically and mycologically (p < 0.001). Twenty-seven percent of the fluconazole-treated patients and 17% of the clotrimazole-treated patients reported mild side effects only.

CONCLUSION

Fluconazole administered as a single 150 mg oral dose proved to be as safe and effective as 7 days of intravaginal clotrimazole therapy for Candida vaginitis. Therapy of vaginitis should be individualized, taking into consideration severity of disease, history of recurrent vaginitis, and patient preference.

Purpose in life, boredom, and volunteerism in a group of retirees

In a pilot study of 40 retirees, those who volunteered more than 10 hours per week scored significantly higher on the Purpose In Life test than those who volunteered 10 or fewer hours per week. A significant negative correlation of -.75 was obtained between scores on purpose in life and boredom proneness.

RFLP analysis of human chromosome 11 region q13 in multiple symmetric lipomatosis and multiple endocrine neoplasia type 1-associated lipomas

Six lipomas from patients affected by Multiple Symmetric Lipomatosis (MSL) and by Multiple Endocrine Neoplasia Type 1 (MEN 1) were analyzed for loss of heterozygosity on chromosome 11 region q12-13 using four RFLPs. Allelic loss for the D11S146 locus was found only in one visceral MEN 1-associated lipoma. Lipomas that exhibited a lack of allelic lesions were analyzed for an eventual abnormal amount or a defective function of the Gs protein by studying the Gs alpha subunit gene, codons 201 and 207, by PCR and TGGE techniques. All the samples were negative for activating mutations.

Developing a research unit within a hospital social work department

This article describes the establishment of a research unit as an integral part of a hospital social work department on the basis of the authors' experience in a cancer center over a 13-year period. Methods are described for building support within the institution, for the process of initiating the unit, for deciding on study topics, and finally for bridging the gap between clinical and research staff. The evolution of the relationship between clinical and research staff was characterized by four different phases: curiosity, competitiveness, cooperation, and collaboration. A childhood bereavement project is used to exemplify the developmental processes and the ongoing interaction of research and clinical staff. The professional practice of all staff benefited from the increased academic rigor and productivity, although some staff remained unconvinced of the value of such a major research effort. The benefits and costs of the unit are also discussed.

The process of resident selection: a view from the residency director's desk

In 1992, the Executive Council of the Association of American Medical Colleges recommended that a computerized application system be investigated. Under this system, the application package would include: 1) a standardized application form, 2) a personal statement, 3) a dean's letter, 4) transcripts, 5) a chairman's letter, and 6) United States Medical Licensing Examination (USMLE) scores. To investigate the value residency directors placed on these items, all directors from Accreditation Council for Graduate Medical Education--approved residency programs in obstetrics and gynecology and family practice residency programs were surveyed. The directors were asked to prioritize the usefulness of the proposed components of the Electronic Residency Application Service application package. Transcripts, the dean's letter, and USMLE scores ranked highest (in descending order) for the obstetrics and gynecology residency directors for making decisions about "inviting a student for an interview," whereas the dean's letter, personal statement, and transcripts ranked highest for the family practice residency directors. Both ranked the interview as most valuable in ranking a student in the residency match. Although these two disciplines do not represent all fields, our study indicates that residency programs are not homogeneous in their value systems and that certain characteristics may predict those values.

LIFENET/INTERNET and the health science librarian

The Medical Library Center of New York, a cooperative library agency for the health sciences, developed a program to offer an electronic communications system (LIFENET) with access to the Internet for its members. Information on documentation and training as well as statistics on the subsequent use of the system and of the Internet are discussed in the article. Specific examples of how health science librarians are using the system include bibliographic verification, reference, research on integrated library systems, production of duplicate journal lists, and professional activities such as electronic mail and discussion groups (listservs).

The manganese superoxide dismutase of Escherichia coli K-12 associates with DNA

Superoxide dismutases (SODs) are vital components in the resistance of aerobic organisms to the toxicity of oxygen. Escherichia coli contains two highly homologous cytoplasmic SODs, a manganese- and an iron-containing enzyme (MnSOD, FeSOD). We previously demonstrated that MnSOD and FeSOD have different physiological functions and that MnSOD is more effective in preventing oxidative damage to DNA. In this report, purified E. coli MnSOD was shown to bind nonspecifically to DNA by electrophoretic mobility shift assay and nitrocellulose-filter binding methodologies. From electrophoretic mobility shift assay, the equilibrium dissociation constants for interaction with a variety of double-stranded and single-stranded oligonucleotides ranged from 1.5 +/- 0.2 to 8.4 +/- 1.3 microM at 20 degrees C. This range of concentrations corresponds to MnSOD concentrations in aerobically grown E. coli. In vivo binding of MnSOD to DNA was supported by colocalization of MnSOD and the E. coli nucleoid in immunoelectron microscopy. Both MnSOD and DNA were inhomogeneously distributed in the cytosol, the concentration of each being higher in the center of the cell and relatively low near the inner membrane. In contrast, there was no evidence for physiologically relevant interaction of FeSOD with DNA. Binding to DNA in vitro was weak, Kd > 40-220 microM, concentrations 7-40 times higher than found in vivo. In addition, the cytoplasmic distribution of FeSOD did not correlate with DNA. FeSOD concentration was higher near the inner membrane and lower in the center of the cytosol. These results demonstrate that E. coli MnSOD associates with DNA in vitro and in vivo. Combined with prior data demonstrating that MnSOD preferentially protects DNA in vivo while an equal enzymatic activity of FeSOD does not (Hopkin, K. A., Papazian, M. A., and Steinman, H. M. (1992) J. Biol. Chem. 267, 24253-24258), our data suggest that E. coli MnSOD acts as a "tethered antioxidant"; association of MnSOD with DNA localizes dismutase activity near a target of oxidative stress and increases protection of DNA from oxidative damage. This model has implications for the therapeutic use of SODs as antioxidants.

Vaginal retention of 2% butoconazole nitrate cream: comparison of a standard and a sustained-release preparation

The purpose of this study was to establish the length of time that butoconazole nitrate 2% standard cream and sustained-release cream could be detected in the vagina after a single administration of 5 g of cream that contained 100 mg of butoconazole. Sixteen healthy subjects received a single vaginal dose of either the standard (8 patients) or the sustained-release preparation (8 patients). Participants returned daily for vaginal examination and collection of specimens to determine the presence of the drug. The specimens were analyzed for butoconazole content using high-performance liquid chromatography. All subjects in both groups had detectable levels of butoconazole present in the vagina for the first 2 days of the study. The sustained-release cream was demonstrated to be present in the vagina in 7 subjects on the third day, 5 on the fourth day, and 1 on the seventh day, while only 1 subject who received standard cream retained it on the third day and none did so thereafter. Analysis of these data demonstrated a median vaginal retention time of 2.57 days with the standard cream and 4.20 days for the sustained-release preparation (P = 0.0024).

A case study: massage, relaxation, and reward for treatment of alopecia areata

Alopecia areata, a common cause of hair loss, is generally considered the consequence of an autoimmune process. Both physiological and psychological factors have been implicated. Previous studies have not incorporated behavior modification in their treatment designs. In this study, three treatment techniques (hair massage, relaxation procedures, and monetary reward) were applied to a 16-year-old male with a five-year history of alopecia areata. Comparison for seven months without treatment versus seven months with treatment showed that loss of hair was markedly reduced after three months of treatment. During the last four months of the study, new hair growth was evidenced.

Residency directors' responses to the concept of a proposed electronic residency application service

BACKGROUND

In 1992, the Executive Council of the Association of American Medical Colleges (AAMC) recommended that the feasibility of the proposed Electronic Residency Application Service (ERAS) be investigated. This action was based on concerns that the current system was inefficient, costly, and disruptive to students, medical schools, and residency programs. The purpose of this study was to explore residency directors' opinions about the benefits and barriers to the introduction of such a system.

METHOD

All directors from family practice and obstetrics-gynecology residency programs were surveyed in early 1993. Three forced-choice and three open-ended questions elicited opinions concerning benefits and potential barriers to the implementation of ERAS. T-tests and chi-square tests for independence were used to examine differences for continuous and categorical variables.

RESULTS

Overall, 544 residency directors (81%) responded to the questionnaire: 339 (86%) in family practice, and 205 (75%) in obstetrics-gynecology. Eighty percent of the respondents in family practice and 75% of those in obstetrics-gynecology were in favor of the initiation of ERAS. Perceived benefits included increased "efficiency," "simplicity," "standardization," and "completeness." Concerns included "technical problems," "loss of flexibility," "lack of a personal touch," "costs," and "lack of security."

CONCLUSIONS

It is appropriate for the AAMC to take the lead in investigating the computerization of this important process. It is essential, however, to gather data from all three consumers of this potentially valuable service as an important step in the project's development.

Particle digestibility is required for induction of the phosphatidylserine recognition mechanism used by murine macrophages to phagocytose apoptotic cells

One of the characteristic features of programmed cell death in vivo is the rapid recognition and removal of apoptotic cells by macrophages. Although there are several potential mechanisms by which the macrophage can identify a cell as apoptotic, it has been shown recently that murine-elicited macrophages stereospecifically recognize phosphatidylserine (PS) exposed on the surface of apoptotic cells. The particulate stimulus, beta-1, 3-glucan, stimulates bone marrow-derived macrophages to express several characteristics of inflammatory macrophages, and induced these cells to recognize PS on apoptotic cells; this activity was correlated with the ability to form rosettes with PS-expressing RBC. Induction of PS recognition in bone marrow-derived macrophages was associated with digestibility of the stimulus, because L, but not D amino acid particles or latex, were able to stimulate macrophage recognition of PS. The requirement for digestibility could be bypassed by the addition of exogenous TGF-beta, which induced macrophage recognition of PS after stimulation with either latex or D amino acid particles. That endogenously produced TGF-beta played a role in the glucan-stimulated response was indicated by the ability of anti-TGF-beta antibodies to inhibit digestible particle-induced recognition of PS. The induction of the PS recognition mechanism correlated well with the expression of other markers for the inflammatory phenotype. These studies indicate that the PS receptor may be a marker for the inflammatory phenotype, which appears to be induced by the phagocytosis of particulate digestible stimuli. Endogenously produced TGF-beta is suggested to play an autocrine or paracrine priming role in the induction of the PS receptor.

Particle digestibility is required for induction of the phosphatidylserine recognition mechanism used by murine macrophages to phagocytose apoptotic cells

One of the characteristic features of programmed cell death in vivo is the rapid recognition and removal of apoptotic cells by macrophages. Although there are several potential mechanisms by which the macrophage can identify a cell as apoptotic, it has been shown recently that murine-elicited macrophages stereospecifically recognize phosphatidylserine (PS) exposed on the surface of apoptotic cells. The particulate stimulus, beta-1, 3-glucan, stimulates bone marrow-derived macrophages to express several characteristics of inflammatory macrophages, and induced these cells to recognize PS on apoptotic cells; this activity was correlated with the ability to form rosettes with PS-expressing RBC. Induction of PS recognition in bone marrow-derived macrophages was associated with digestibility of the stimulus, because L, but not D amino acid particles or latex, were able to stimulate macrophage recognition of PS. The requirement for digestibility could be bypassed by the addition of exogenous TGF-beta, which induced macrophage recognition of PS after stimulation with either latex or D amino acid particles. That endogenously produced TGF-beta played a role in the glucan-stimulated response was indicated by the ability of anti-TGF-beta antibodies to inhibit digestible particle-induced recognition of PS. The induction of the PS recognition mechanism correlated well with the expression of other markers for the inflammatory phenotype. These studies indicate that the PS receptor may be a marker for the inflammatory phenotype, which appears to be induced by the phagocytosis of particulate digestible stimuli. Endogenously produced TGF-beta is suggested to play an autocrine or paracrine priming role in the induction of the PS receptor.

Development of functional diversity in mouse macrophages. Mutual exclusion of two phenotypic states

The objective of this study was to investigate the mechanisms that contribute to the generation of macrophage functional diversity. Exposure of mouse bone marrow-derived macrophages to beta-1,3-glucan, a particulate inflammatory stimulus, or polyinosinate-polycytidylate (poly[I:C]), a stimulus of macrophage cytocidal activation, induced distinct and stimulus-specific patterns of gene expression. These changes were characterized by an up-regulation of the expression of the acid hydrolase beta-glucuronidase and platelet-derived growth factor B following incubation with beta-1,3-glucan and a stimulation of the expression of the complement component Bf, beta-interferon, and the reactive nitrogen intermediates NO2/NO3 during incubation with poly[I:C]. The induction of Bf expression by poly[I:C] could not be explained on the basis of distinct subpopulations of cells since in situ hybridization with a mouse Bf cRNA probe revealed a uniform and substantial increase in Bf expression by the entire population of cells. Incubation of macrophages with beta-1,3-glucan before stimulation with poly[I:C] was found to strongly attenuate the expression of Bf and beta-interferon. Conversely, incubation with poly[I:C] prior to exposure to beta-1,3-glucan substantially blocked the stimulation of beta-glucuronidase and platelet-derived growth factor B expression, indicating that these two responses were expressed in a mutually antagonistic fashion. However, after removal of either stimulus and following a period in which the primary response was allowed to decay, the cells regained their capacity to subsequently respond to either the same stimulus or to a different stimulus. Collectively, these findings indicate, first, that the heterogeneity of gene expression seen in response to poly[I:C] represents an adaptive response of the entire macrophage population rather than the restricted responses of distinct subpopulations of cells. Second, macrophages respond to these stimuli in a sequential fashion. These findings thus have a significant bearing on our understanding of the regulation of macrophage heterogeneity in host defense.

Impact of parental terminal cancer on latency-age children

The underlying psychological and emotional components of distress were examined in 87 children with a parent in the terminal phase of cancer. Common fears, concerns, misperceptions, and behavioral consequences are analyzed, as are more severe psychological and behavioral reactions. Implications for psychoeducational parent-guidance intervention are discussed.

Pulmonary sporotrichosis treated with itraconazole

A 62-year-old woman had chronic cavitary pulmonary sporotrichosis refractory to medical management over an 8-year period. She was treated with oral itraconazole and had an apparent microbiologic and clinical response; however, the patient succumbed to progressive pulmonary hypertension. The early use of oral itraconazole for treatment of pulmonary sporotrichosis is advocated.

The PROEF diet--a new postoperative regimen for oral early feeding

OBJECTIVE

The purpose of this study was to determine if immediate postoperative feeding of a new oral elemental diet (PROEF diet) would be tolerated by patients and to determine its effect on gastrointestinal function after cesarean section.

STUDY DESIGN

One hundred eighteen patients undergoing cesarean section were randomly assigned by a computer-generated list of numbers to receive either the PROEF diet (60 patients) or routine postoperative dietary management (58 patients). Gastrointestinal morbidity was analyzed by an independent-samples t test.

RESULTS

The PROEF diet group has a more rapid return of normal bowel sounds, 10.3 versus 14.5 hours (p = 0.001), and earlier acceptance of a regular diet, 2.0 versus 2.3 days (p = 0.008).

CONCLUSION

The PROEF diet was well tolerated in cesarean section patients with no increase in gastrointestinal morbidity when compared with a control group of patients. This dispels the classic teaching that postoperative patients may not have oral intake until the return of normal bowel function. Further study is necessary to support the theoretic benefits that may accrue from early feeding of an elemental diet.

Language and the psychoanalytic process: psychoanalysis and Vygotskian psychology. II

This paper follows our previous one, where we described a psychoanalytic conception of language, thought, and internalization that is informed by the thinking of Lev Vygotsky. Here, several aspects of the analytic process which allow for the understanding of ineffable experiences in the analysand's history and the analytic situation are investigated: specifically, primal repression, metaphor, and the role of speech in free association. It is suggested that Freud's notion of primal repression be revived and redefined as one aspect of the descriptive unconscious. Some implications of primal repression for transference and resistance are explored. The metaphoric in its broad sense is examined as one example of how early dynamic experiences embedded in the process of language acquisition can be reached within the clinical situation. It is proposed that an understanding of free association is enhanced by awareness of distinctions between inner, egocentric, and social speech. The basic rule can be interpreted as an invitation for the analysand to use inner speech in collaboration with the analyst as best he or she can. Further, the aliveness and degree of superficiality of the analysis can be seen as a function of the analyst's ability to appreciate the properties of inner speech and foster the conditions in the analysis that allow for its unfolding.

Right internal mammary artery graft angioplasty through a right brachial artery approach using a new custom guide catheter: A case report

Angioplasty of right internal mammary artery grafts may present problems because of the variable origin of the mammary artery and its angulation from the subclavian artery. We report a case of successful angioplasty using a custom designed guide catheter, after failed attempts using conventional guide catheters.

An investigation into some implications of a Vygotskian perspective on the origins of mind: psychoanalysis and Vygotskian psychology, Part I

The Russian psychologist Lev Vygotsky proposed an analysis of language, thought, and internalization that has direct relevance to the current concerns of psychoanalysts. Striking methodological and conceptual similarities and useful complementarities with psychoanalysis are discovered when one peers beneath the surface of Vygotskian psychology. Our adaptation of Vygostsky's views expands upon Freud's assigned role to language in the topographic model. We suggest that the analysand's speech offers several windows into the history of the individual, through prosody, tropes, word meaning, and word sense. We particularly emphasize Vygotsky's views on the genesis and utilization of word meanings. The acquisition of word meanings will contain key elements of the internal climate present when the word meaning was forged. Bearing this in mind, crucial theoretical questions follow, such as how psychoanalysis is to understand the unconscious fantasies, identifications, anxieties, and defenses associated with the psychodynamics of language acquisition and later language usage. We propose that the clinical situation is an ideal place to test these hypotheses.