Clinical predictors of the effectiveness of tiotropium in adults with symptomatic asthma: a real-life study

Background

Long-acting muscarinic antagonist (LAMA) tiotropium improved lung function and reduced risks of exacerbation when added on to inhaled corticosteroids (ICS) with or without long-acting B₂ agonists (LABAs) in patients with uncontrolled asthma. However, studies predicting the effectiveness of tiotropium based on patients' clinical characteristics were limited.

Methods

We conducted this retrospective study at a single medical center from July 2016 to July 2017, and used asthma control test (ACT) to evaluate the effectiveness of tiotropium add-on therapy in patients with uncontrolled asthma. The effectiveness was shown by an increase in ACT score from baseline of 3 or greater after 3 months of tiotropium add-on therapy.

Results

Patients with uncontrolled asthma despite the use of low- or medium- to high-dose of ICS plus LABA (n=160) were analyzed. Among patients having good response (n=112, ACT score increased ≥3 points) to tiotropium (TGR group) and patients having poor response (n=48, ACT increased <3 points) to tiotropium (TPR group), their baseline characteristics including age, asthma and chronic obstructive pulmonary disease (COPD) overlap (ACO), cigarette use, initial FEV1, serum IgE level, eosinophil count, and BMI were significantly different. Univariate analysis showed that old age, ACO, cigarette use, initial FEV1 <80%, and BMI >30 were predictors of the effectiveness of tiotropium. Patients with high serum total IgE level >430 µg/L and eosinophil count >0.6×10⁹/L had a negative impact on response to tiotropium. Multivariate logistic regression analysis demonstrated that the independent factor of poor response to tiotropium was high serum IgE level >430 µg/L.

Conclusions

Tiotropium add-on therapy in patients with uncontrolled asthma was effective. However, patients with serum total IgE level >430 µg/L were less likely to benefit from tiotropium.

Medical thoracoscopy removal of a self-expandable metallic stent migration into pleural cavity

Pleuroscopy, also known as medical thoracoscopy (MT), is an important tool for pleural disease management. Removal of foreign body (FB) by MT was reported in a few reports because it can identify the position of a FB in the pleural cavity and can be used for its urgent removal. In this study, we describe the case of a male patient with a ruptured lung abscess and a rare complication of self-expandable metallic stent (SEMS) migration into the pleural cavity via a bronchopleural fistula after the management of obstructive airway disease. An experienced pulmonologist successfully removed the SEMS from the pleural cavity using semi-rigid pleuroscopy under local anesthesia and conscious sedation in a bronchoscopy suite.

Comparison of the effects of the three major tyrosine kinase inhibitors as first-line therapy for non-small-cell lung cancer harboring epidermal growth factor receptor mutations

Introduction

Patients with advanced lung adenocarcinoma harboring epidermal growth factor receptor (EGFR)-activating mutations have good response rate and longer progression-free survival (PFS) when treated with the tyrosine kinase inhibitors (TKI) compared with platinum-based chemotherapy. However, studies comparing the effectiveness of these drugs as first-line therapy in such patients are limited.

Results

We analyzed 422 patients with EGFR-mutated advanced lung adenocarcinoma receiving first-line gefitinib (n = 195, 46.2%), erlotinib (n = 123, 29.1%), or afatinib (n = 104, 24.6%). The PFS of the afatinib group was longer (12.2 months) than that of the gefitinib group (9.8 months) (p = 0.035) but similar to that of the erlotinib group (11.4 months) (p = 0.38). In patients without brain metastasis (BM), subgroup analysis showed that the afatinib group had significantly longer PFS (13.1 months) than erlotinib (11.7 months) and gefitinib (9.8 months) groups (p = 0.010). Patients with exon 19 deletions in the afatinib and erlotinib groups had potentially long PFS (p = 0.073). Efficacy of afatinib was similar between the 30 mg and 40 mg arms (median PFS 16.1 months vs. 10.3 months; p = 0.923).

Conclusions

Afatinib may be the optimal EGFR-TKI for advanced lung adenocarcinoma harboring EGFR-activating mutations, particularly in the absence of BM. Patients with exon 19 deletions taking afatinib had potentially long PFS. An afatinib dose of 30 and 40 mg has similar effect.

Methods

We conducted this retrospective study at a single medical center from January 2013 to March 2017 and used PFS to evaluate the effectiveness of gefitinib, erlotinib, and afatinib in patients with advanced lung adenocarcinoma harboring EGFR mutations.

Feasibility and Safety of Pleuroscopic Cryobiopsy of the Pleura: A Prospective Study

Background

The aim of this study was thus to evaluate the feasibility and safety of taking biopsy specimens by cryoprobe from the parietal pleura during semirigid pleuroscope.

Methods

In a single-center, observational, prospective study, patients with exudative pleural effusion (EPE) were evaluated with a semirigid pleuroscope between January 2015 and July 2017. Each patient underwent pleural biopsy using flexible forceps and flexible cryoprobe through pleuroscope following diagnostic thoracentesis and closed pleural biopsy (CPB).

Results

A total of 92 patients (median age 64 years) were included in the study, most of whom were men (65.2%). Cytological cell block (CCB) and CPB made definitive diagnoses in 32/92 (34.8%) and 25/92 (27.5%), respectively; flexible forceps biopsy (FFB) and cryoprobe biopsy (CB) established definitive diagnoses in 84/92 (91.3%) and 91/92 (98.9%), respectively. The sample obtained by CB (9.4 ± 4.9 mm) was significantly larger than the other two methods: FFB (4.2 ± 2.3 mm) or CPB (1.9 ± 1.0 mm) (P < 0.0001). The immunohistochemical (IHC) staining was more easily performed with CB (98.9%) compared to either FFB (87.0%) or CPB (13.0%). There were no significant complications or procedure-related deaths.

Conclusions

Based on these results, CB during semirigid pleuroscope has a high diagnostic yield, differentiating EPE of unknown etiology with satisfactory effectiveness and safety.

Comparison between endobronchial ultrasound-guided transbronchial biopsy and CT-guided transthoracic lung biopsy for the diagnosis of peripheral lung cancer: a systematic review and meta-analysis

BACKGROUND

With the release of the National Lung Screening Trial results, the detection of peripheral pulmonary lesions (PPLs) is likely to increase. Computed tomography (CT)-guided percutaneous transthoracic needle biopsy (PTNB) and radial probe endobronchial ultrasound (r-EBUS)-guided transbronchial lung biopsy (TBLB) are recommended for tissue diagnosis of PPLs.

METHODS

A systematic review of published literature evaluating the accuracy of r-EBUS-TBLB and CT-PTNB for the diagnosis of PPLs was performed to determine point sensitivity and specificity, and to construct a summary receiver-operating characteristic curve.

RESULTS

This review included 31 publications dealing with EBUS-TBLB and 14 publications dealing with CT-PTNB for the diagnosis of PPLs. EBUS-TBLB had point sensitivity of 0.69 (95% CI: 0.67-0.71) for the diagnosis of peripheral lung cancer (PLC), which was lower than the sensitivity of CT-PTNB (0.94, 95% CI: 0.94-0.95). However, the complication rates observed with EBUS-TBLB were lower than those reported for CT-PTNB.

CONCLUSIONS

This meta-analysis showed that EBUS-TBLB is a safe and relatively accurate tool in the investigation of PLC. Although the yield remains lower than that of CT-PTNB, the procedural risks are lower.

Interventional pulmonology for patients with central airway obstruction: An 8-year institutional experience

Patients with central airway obstruction (CAO) may need endobronchial intervention to relieve their symptoms. This report is on a single-center experience of using interventional bronchoscopy in terms of complications and survival. This retrospective study was conducted in a university hospital and involved 614 patients (464 men, 150 women; mean age, 60.2 years) with benign (n = 133) and malignant (n = 481) tracheobronchial disease who received 756 endobronchial intervention procedure during the period 2008 to 2015. Survival was analyzed using the Kaplan-Meier method, while the log-rank test was used for comparisons. A total of 583 patients (95%) achieved endoscopic success after interventional bronchoscopy. Four (0.7%) died within 24 hours of the procedure, while the major morbidities were halitosis (n = 41, 6.7%) and iatrogenic pneumonia (n = 24, 3.9%). Repeat procedures due to recurrent airway obstruction were done on 45 patients with benign conditions and on 60 with malignancies. The median survival after the procedure in patients with lung cancer, other metastatic cancer, and esophageal cancer was 166, 228, and 86 days, respectively. Between patients with inoperable lung cancer and CAO after therapeutic bronchoscopy and patients without CAO, there was no statistically significant difference in survival (P = 0.101). Interventional bronchoscopy is a safe and effective procedure that may be recommended for CAO. Patients with lung metastases have similar lengths of survival as patients with primary lung cancer. Patients with advanced lung cancer and CAO have similar survival as those without CAO.

Improved diagnostic yield of bronchoscopy in peripheral pulmonary lesions: combination of radial probe endobronchial ultrasound and rapid on-site evaluation

BACKGROUND

Rapid on-site evaluation (ROSE) of cytologic specimens is a useful ancillary technique in needle aspiration procedures of pulmonary/mediastinal lesions, but few reports had been carried out to confirm the utility in the diagnosis of peripheral pulmonary lesions (PPLs) by radial probe endobronchial ultrasound (R-EBUS).

METHODS

To evaluate the impact of ROSE on the diagnostic yield of R-EBUS for PPLs, we retrospectively analyzed the diagnostic yields of transbronchial biopsy (TBB) or brushing using R-EBUS for patients with PPLs in a tertiary university hospital from December 2012 to December 2014.

RESULTS

A total of 815 patients with PPLs were included. A definite diagnosis was made by R-EBUS-guided TBB or brushing for 627 patients (76.9%). A total of 279 patients (34.2%) were examined by a ROSE technique. The combination of R-EBUS guided TBB or brushing with ROSE raised the diagnostic yield in the diagnosis of PPLs, especially difficult cases: right apical and left apical-posterior segment locations, small PPLs <3 cm without bronchus signs on computed tomography (CT) scan, PPLs with pleural effusions, and the position of probe is not within.

CONCLUSIONS

ROSE can improve the PPLs diagnostic yield when using R-EBUS guided TBB or brushing.

Lung cancer screening with low-dose computed tomography: Experiences from a tertiary hospital in Taiwan

BACKGROUND/PURPOSE

Lung cancer screening using low-dose computed tomography (CT) has been reported to reduce lung cancer-specific mortality for smokers at high risk. However, despite different characteristics of lung cancer in Asia, there are few data concerning this specific population for screening. We aim to analyze the performance of lung cancer screening with low-dose CT concurrent with chest radiography in Taiwan, with reference to international experience.

METHODS

During the 1-year period from January 2012 to December 2012, we conducted a retrospective, single-center population-based screening program for lung cancer in the setting of annual medical examinations. Participants were asymptomatic adults without prior history of any cancer. Low-dose CT and chest radiography were offered to all individuals. Baseline CT evaluations were defined as positive if any noncalcified nodule≥4 mm in diameter, which were then classified as solid, pure ground-glass or partial ground-glass opacity.

RESULTS

Of 3339 individuals, we detected 34 cancers, yielding an overall cancer detection rate of 1.02%. There was a particularly high cancer detection rate of 6.2% (8/129) in the high-risk group aged younger than 50 years with a positive family history of all types of cancers in first-degree relatives. Adenocarcinomas accounted for 88% (30/34) of cancers and 99% of them were early-stage (including carcinoma in situ and Stage I). The probability of cancers was significant higher in nodules with interval growth (odds ratio 257.89, p = 0.0002). There was no significant difference in the probability of cancers between ground glass opacity nodules and solid nodules (odds ratio 1.16, p=0.72). Of all screen-detected cancers, 61.76% (21/34) were chest radiographically occult.

CONCLUSION

Low-dose CT is effective to detect early lung cancers. Further establishment of selection criteria for lung cancer screening, specifically for Asian individuals, is definitely warranted.

Endobronchial Ultrasound Changed the World of Lung Cancer Patients: A 11-Year Institutional Experience

OBJECTIVES

The role of advanced bronchoscopic diagnostic techniques in the detection and staging of lung cancer has increased sharply in recent years. The development of endobronchial ultrasound (EBUS) improved minimally invasive mediastinal staging and diagnosis of peripheral lung lesions (PLLs). We investigated the impact of using EBUS as a diagnostic method for tissue acquisition in lung cancer patients.

METHODS

In a single center observational retrospective study, 3712 subjects were diagnosed with lung cancer from 2003 to 2013 (EBUS was introduced in 2008). Thus, we divided the data into two periods: the conventional bronchoscopy period (2003 to 2007) and the EBUS period (2008 to 2013).

RESULTS

A total of 3712 patients were included in the analysis. Comparing the conventional bronchoscopy period with the EBUS period data, there has been a significant reduction in the use of diagnostic modalities: CT-guided biopsy (P < 0.0001) and pleural effusion cytology (P < 0.0001). The proportion of subjects diagnosed using bronchoscopy significantly increased from 39.4% in the conventional period to 47.4% in the EBUS period (P < 0.0001). In the EBUS period, there has also been a significant increase in the proportion of patients proceeding directly to diagnostic surgery (P < 0.0001). Compared to bronchoscopy, the incidence of complications was higher in those who underwent CT guide biopsy. The incidence of iatrogenic pneumothorax significantly decreased in the EBUS period.

CONCLUSIONS

Advanced bronchoscopic techniques are widely used in the diagnosis of lung cancer. At our institution, the increasing use of EBUS for providing lung cancer diagnosis has led to a significant reduction in other diagnostic modalities, namely CT-guided biopsy and pleural effusion cytology. These changes in practice also led to a reduction in the incidence of complications.

A medical cost estimation with fuzzy neural network of acute hepatitis patients in emergency room

Taiwan is an area where chronic hepatitis is endemic. Liver cancer is so common that it has been ranked first among cancer mortality rates since the early 1980s in Taiwan. Besides, liver cirrhosis and chronic liver diseases are the sixth or seventh in the causes of death. Therefore, as shown by the active research on hepatitis, it is not only a health threat, but also a huge medical cost for the government. The estimated total number of hepatitis B carriers in the general population aged more than 20 years old is 3,067,307. Thus, a case record review was conducted from all patients with diagnosis of acute hepatitis admitted to the Emergency Department (ED) of a well-known teaching-oriented hospital in Taipei. The cost of medical resource utilization is defined as the total medical fee. In this study, a fuzzy neural network is employed to develop the cost forecasting model. A total of 110 patients met the inclusion criteria. The computational results indicate that the FNN model can provide more accurate forecasts than the support vector regression (SVR) or artificial neural network (ANN). In addition, unlike SVR and ANN, FNN can also provide fuzzy IF-THEN rules for interpretation.

Type 1 Diabetes and Increased Risk of Subsequent Asthma: A Nationwide Population-Based Cohort Study

The association between type 1 diabetes mellitus (T1DM) and asthma remains controversial and has led to new interest in these 2 disorders. The purpose of this study was to examine the associations among young people with T1DM and asthma and offer a clinical demonstration of the balance between Th1 and Th2 responses.We conducted a retrospective cohort study by using data from the National Health Insurance (NHI) system of Taiwan. The cohort consisted of 3545 T1DM cases and 14,180 controls established during the 1998 to 2011 period. Of the 3545 T1DM patients, 55.1% were girls and 26.5% were in the age group <8 years.The overall incidence of asthma was 47% higher in the T1DM cohort than in the control cohort (6.49 vs 4.42 per 1000 person-y), with an adjusted hazard ratio (HR) of 1.34 (95% confidence interval [CI] = 1.11-1.62). Moreover, T1DM patients who visited the emergency room (ER) more than twice for diabetes had a higher adjusted HR of 17.4 (95% CI = 12.9-23.6) of developing asthma. The adjusted HR of asthma was 38.6 (95% CI = 28.5-52.2) in T1DM patients who had been hospitalized more than twice for diabetes.We observed a significantly higher incidence of asthma in young patients with T1DM than in the general population. Among young people of T1DM with more ER visits or frequent hospitalization because of diabetes mellitus were associated with risk of asthma, may indicate that poor glycemic control significantly contributes to asthma risk.

Amiodarone use is associated with increased risk of stroke in patients with nonvalvular atrial fibrillation: a nationwide population-based cohort study

Atrial fibrillation (AF), the most common sustained arrhythmia requiring treatment worldwide, is one of the major causes of ischemic stroke. Although amiodarone is commonly used for rhythm control in AF, its relationship with stroke has rarely been addressed.We evaluated 16,091 patients who were diagnosed with AF (Classification of Diseases, 9th Revision, Clinical Modification [ICD-9-CM] 427.31 and 427.32) between 1998 and 2011; the date of AF diagnosis was set as the index date. Patients with a history of stroke (ICD-9-CM 430-438) who received amiodarone before the index date or during the following 30 days, or who experienced stroke within 30 days of receiving amiodarone were excluded. Finally, 7548 patients with AF were included in this study and divided into 2 groups according to whether they received amiodarone (Anatomical Therapeutic Chemical code C01BD01) during the study period.The risk of ischemic stroke in AF patients receiving amiodarone was 1.81-fold (95% confidence interval [CI] 1.52-2.16), 1.79-fold (95% CI 1.50-2.14), and 1.78-fold (95% CI 1.49-2.13) higher than in those who did not receive amiodarone, according to crude, Model 1, and Model 2 Cox proportional hazard regression models, respectively. In a demographically stratified analysis, the risk of ischemic stroke was significantly higher in patients aged <65 years, with no comorbidities, who were also taking digoxin or had a low CHA2DS2VASc score.Amiodarone treatment is associated with an increased risk of stroke in patients with AF, especially in those who have an initial low risk of stroke. Antiplatelet drugs and warfarin could reduce the stroke risk in AF patients receiving amiodarone. However, as the combination of digoxin and amiodarone increases the risk of stroke in these patients, the combination of these 2 drugs should be avoided.

A bacteria injection scheme for in situ bioaugmentation

This article presents an innovative design for inoculating the desired organisms to stratified geological layers at desired rates during in-situ bioaugmentation. The new delivery system consists of intermittent porous tubes connected in series with impermeable polyethylene tubes that run horizontally in each stratified layer of a contaminated aquifer. A bioaugmentation test using the new delivery system was conducted to inject an enriched culture of Escherichia coli (E. coli). Results of the test indicated that the distribution of E. coli through each porous tube was fairly uniform. A mathematical model previously developed to calculate the distribution of water flow through each porous tube was modified to calculate the distribution of E. coli. Geological layers often have different hydraulic conductivities. By controlling the permeability and the length of porous tubes placed in stratified layers, the new design provides a means to selectively deliver aqueous bacteria to various layers at desired rates according to aquifer heterogeneity.

Differentiation of bacteria cell wall using Raman scattering enhanced by nanoparticle array

We have fabricated surface-enhanced Raman scattering (SERS) substrates based on arrays of silver nanoparticles grown on porous anodic alumina templates. Using this nanotechnology platform, label-free and high-speed detection of bacteria are achieved. SERS spectra of various bacteria including Staphylococcus Aureus (Gram-positive bacterium), Klebsiella Pneumoniae (Gram-negative bacterium), and Mycobacterium Smegmatis (Mycobacterium) were recorded. The highly reproducible SERS-based technological platform is capable of differentiating different kinds of bacteria by PCA, LDA, clustering analysis, and SVM methods, which provides promising opportunity for biosensing of clinical microbes.

The association of clinical findings and exposure profiles with melamine associated nephrolithiasis

BACKGROUND

Little is known about the exposure profiles of melamine in children. We evaluated the association of clinical findings, exposure patterns and biomarkers with nephrolithiasis in children with potential exposure to melamine.

METHODS

A case-control study was conducted in children aged 0-16 years with potential exposure to contaminated dairy products. Cases were defined as nephrolithiasis detected by renal ultrasonography. On the basis of different brands of contaminated dairy products consumed, subjects were classified into high exposure, low exposure and control groups with estimated melamine exposure levels of higher than 2.5 ppm, 0.05-2.5 ppm and lower than detection limits <0.05 ppm. We measured urine melamine for those with nephrolithiasis and age-matched and gender-matched controls within the subset of the study population.

RESULTS

The duration of consumption of contaminated products was longer in children with nephrolithiasis in the high exposure group than in controls (median (IQR) 12.0 (3.3-24.0) vs 6.0 (4.0-7.0) months; p = 0.048). High melamine exposure levels were significantly associated with nephrolithiasis (OR 61.04 (95% CI 12.73 to 292.84)). The risk was found to increase with estimate melamine exposure levels (p for trend <0.001). Two among 10 affected subjects with nephrolithiasis showed elevated urine melamine levels. In comparison, levels of all 20 controls were lower than the detection limit.

CONCLUSIONS

The risk of melamine-associated nephrolithiasis was related to duration of consumption of contaminated products and estimated melamine exposure levels. Though urine melamine was not a sensitive test, it might serve as an exposure biomarker in melamine-associated nephrolithiasis.

Anomalous scaling and refined similarity of an active scalar in a shell model of homogeneous turbulent convection

Anomalous scaling in the statistics of an active scalar is studied in a shell model of homogeneous turbulent convection. We extend refined similarity ideas for homogeneous and isotropic turbulence to homogeneous turbulent convection and attribute the origin of the anomalous scaling to variations of the entropy transfer rate. We verify the consequences and thus the validity of our hypothesis by showing that the conditional statistics of the active scalar and the velocity at fixed values of entropy transfer rate are not anomalous but have simple scaling with exponents given by dimensional considerations, and that the intermittency corrections are given by the scaling exponents of the moments of the entropy transfer rate.

Reaction of cyanoacetylene HCCCN(XΣ+1) with ground-state carbon atoms C(P3) in cold molecular clouds

The reaction of the simplest cyanopolyyne, cyanoacetylene [HCCCN(X (1)Sigma(+))], with ground-state atomic carbon C((3)P) is investigated theoretically to explore the probable routes for the depletion of the famed interstellar molecule HCCCN, and the formation of carbon-nitrogen-bearing species in extraterrestrial environments particularly of ultralow temperature. Six collision complexes (c1-c6) without entrance barrier as a result of the carbon atom addition to the pi systems of HCCCN are located. The optimized geometries and harmonic frequencies of the intermediates, transition states, and products along the isomerization and dissociation pathways of each collision complex are obtained by utilizing the unrestricted B3YLP6-311G(d,p) level of theory, and the corresponding CCSD(T)/cc-pVTZ energies are calculated. Subsequently, with the facilitation of Rice-Ramsperger-Kassel-Marcus (RRKM) and variational RRKM rate constants at collision energy of 0-10 kcal/mol, the most probable paths for the titled reaction are determined, and the product yields are estimated. Five collision complexes (c1-c3, c5, and c6) are predicted to give the same products, a chained CCCCN (p2)+H, via the linear and most stable intermediate, HCCCCN (i2), while collision complex c4 is likely to dissociate back to C+HCCCN. The study suggests that this class of reaction is an important route to the destruction of cyanoacetylene and cyanopolyynes in general, and to the synthesis of linear carbon-chained nitriles at the temperature as low as 10 K to be incorporated in future chemical models of interstellar clouds.

Multiobjective water resources systems analysis using genetic algorithms--application to Chou-Shui River Basin, Taiwan

Multipurpose operation is adopted by most reservoirs in Taiwan in order to maximize the benefits of power generation, water supply, irrigation and recreational purposes. A multiobjective approach can be used to obtain trade-off curves among these multipurpose targets. The weighting method, in which different weighting factors are used for different purposes, was used in this research work. In Taiwan, most major reservoirs are operated by rule curves. Genetic algorithms with characteristics of artificial intelligence were applied to obtain the optimal rule curves of the multireservoir system under multipurpose operation in Chou-Shui River Basin in central Taiwan. The model results reveal that different shapes of rule curves under different weighting factors on targets can be efficiently obtained by genetic algorithms. Pareto optimal solutions for a trade-off between water supply and hydropower were obtained and analyzed.

Effects of buyang huanwu decoction on peripheral nerve regeneration using silicone rubber chambers

This study investigated the effect of buyang huanwu decoction on the regeneration of a 10-mm gap of rat sciatic nerve created between the proximal and distal nerve stumps, which were sutured into silicone rubber tubes. Empty silicone rubber tubes with no further treatment were used as controls. Six weeks after implantation, 89% of the animals orally administered the buyang huanwu decoction exhibited regeneration across the nerve gaps, whereas only 70% had regenerated in the control group. Both qualitative and quantitative histology of the regenerated nerves revealed a more mature ultrastructural organization with significantly higher numbers of myelinated axons, larger endoneurial areas, higher axon densities and a larger percentage of axon area per total nerve area in the buyang huanwu group than in the controls. These results showed that the buyang huanwu decoction had a growth-promoting effect on the regenerated nerves.

Small cell carcinoma of the endometrium with concomitant pelvic inflammatory disease

BACKGROUND

Small cell carcinoma of the endometrium is a rare disease entity characterized by bulkiness and predisposition to necrosis. Clinical presentations include postmenopausal bleeding, lower abdominal mass, chronic abdominal pain and menorrhagia. We present a case of small cell carcinoma of the endometrium with concomitant pelvic inflammatory disease. The literature is also reviewed.

CASE

A 64 year old female presented was admitted with the principal complaints of fever, lower abdominal pain and malodorous vaginal discharge. Bimanual examination revealed cervical motion tenderness with a WBC of 9400 cells/microL and increased levels of neutrophils, band cells and C-reactive protein. Sonography revealed an adnexal echocomplex compatible with tubo-ovarian abscess. Culture of the vaginal discharge revealed the presence of E. coli. Symptoms persisted despite three days of antibiotics administration so a laparotomy was performed with a friable hemorrhagic uterus revealed and an area of necrosis evident in the left adnexa. Malignancy was confirmed from frozen section. Total abdominal hysterectomy, with bilateral salpingooophorectomy and optimal debulking, was performed. The final pathology report confirmed small cell carcinoma of the endometrium.

CONCLUSION

Malignancy and pelvic inflammatory disease have overlapping clinical characteristics. Once pelvic inflammatory disease is suspected in a postmenopausal patient, malignancy should also be suspected, and a thorough examination and a tumor-marker analysis performed.

Raloxifene versus continuous combined estrogen/progestin therapy: densitometric and biochemical effects in healthy postmenopausal Taiwanese women

We treated 116 healthy postmenopausal women (age 47-66 years, mean 57 years) in Taiwan with either raloxifene (RLX) 60 mg (n = 92) or 0.625 mg conjugated equine estrogen plus 5 mg medroxyprogesterone acetate (CCEP, n = 24) daily for 12 months in a randomized, double-masked, active-controlled fashion. The results showed that both regimens increased bone mineral density (BMD) at hip sites (means: RLX 2.5-4.9%, CCEP 4.6-7.9%, all p<0.005 compared with baseline), and the difference between the two regimens was not significant. The spinal BMD increased significantly in both groups (1.4% with RLX and 6.0% with CCEP, both p<0.01), and more with CCEP (p<0.003). Osteocalcin levels and urinary type I collagen C-telopeptide/creatinine ratios decreased significantly in both regimens, but the decreases were significantly larger with CCEP. Compared with baseline, both RLX and CCEP decreased the total cholesterol (median 4.9% and 8.6% respectively, p<0.001) and LDL-cholesterol (median 11% and 19% respectively, p<0.001), and increased HDL-cholesterol (median 8.6% and 10.7% respectively, p<0.01). Both regimens increased triglyceride levels (median 3.2% and 18.9% respectively, both p<0.05), although to a lesser extent with RLX than with CCEP (p<0.05). Only 3 subjects (3.3%) reported vaginal bleeding in the RLX group, as compared with 31% (7/22) with CCEP (p<0.05). We conclude that in healthy, postmenopausal Taiwanese women, RLX 60 mg given daily has favorable results in BMD, bone turnover and serum lipids, although the dosage we used showed a potency less than that of conventional CCEP.