Validation study of nonsurgical diagnosis of endometriosis

OBJECTIVE

To determine whether the surgical diagnosis of endometriosis can be predicted using symptoms, signs, and ultrasound findings.

DESIGN

Prospective study (study sample); retrospective record review (test sample).

SETTING

Hospital of Desio (study sample) and Mangiagalli Hospital (test sample), Italy.

PATIENT(S)

Ninety women scheduled to undergo laparoscopy or laparotomy (study sample); 120 women who underwent laparoscopy (test sample).

INTERVENTION

The study sample group was interviewed before surgery about infertility and dysmenorrhea, dyspareunia, and noncyclic pelvic pain and each member had a pelvic examination and a transvaginal ultrasound. At surgery, endometriosis was noted. For the test sample, the same information was abstracted from medical records after laparoscopy.

MAIN OUTCOME MEASURE(S)

The ability of symptoms, signs, and ultrasound to predict endometriosis at surgery. A classification tree was developed with the study sample and evaluated with the test sample.

RESULT(S)

Ovarian endometriosis, but not nonovarian endometriosis, could be reliably predicted with noninvasive tools. Ultrasound and examination best predicted ovarian endometriosis, correctly classifying 100% of cases with no false positive diagnoses in the study sample. Similar results were found in the test sample.

CONCLUSION(S)

Noninvasive tools may be used to identify women with ovarian, but not nonovarian endometriosis, with excellent agreement with surgical diagnosis.

Seveso Women's Health Study: does zone of residence predict individual TCDD exposure?

The compound, 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD), is produced as an unwanted by-product of various chemical reactions and combustion processes, including the manufacture of chlorinated phenols and derivatives. In animals, TCDD exposure is associated with toxic, carcinogenic, developmental, and reproductive effects. In 1976, a chemical plant explosion in Seveso, Italy, exposed the residents in the surrounding community to the highest exposure to TCDD known in humans. Materials from an aerosol cloud of sodium hydroxide, sodium trichlorophenate and TCDD were deposited over an 18.1 km2 area. As evidence of the significant level of TCDD exposure, numerous animals died and 193 cases of chloracne were reported among residents of the area. Initially, the contaminated area was divided into three major exposure Zones (A, B, R) based on the concentration of TCDD in surface soils. To date, the majority of epidemiologic studies conducted in Seveso have used Zone of residence as a proxy measure of exposure. The purpose of the present study is to validate the use of Zone of residence in Seveso as a proxy measure of exposure against individual serum TCDD measurement, and to determine whether questionnaire information can improve the accuracy of the exposure classification. Using data collected from the Seveso Women's Health Study (SWHS), the first comprehensive epidemiologic study of the reproductive health of women in Seveso, we determined that Zone of residence is a good predictor of individual serum TCDD level, explaining 24% of the variance. Using questionnaire information could have improved prediction of individual exposure levels in Seveso, increasing the percent of the variation in serum TCDD levels explained to 42%.

Factors associated with age at natural menopause in a multiethnic sample of midlife women

An unprecedented number of women will experience menopause in the next decade. Although the timing of menopause affects long-term disease risk, little is known about factors that affect this timing. In the present 1995--1997 cross-sectional study, the Study of Women's Health Across the Nation, the relation of demographic and lifestyle factors to age at natural menopause was examined in seven US centers and five racial/ethnic groups. All characteristics were self-reported by women aged 40--55 years (n = 14,620). Cox proportional hazards models were used to estimate the probability of menopause by age. Overall, median age at natural menopause was 51.4 years, after adjustment for smoking, education, marital status, history of heart disease, parity, race/ethnicity, employment, and prior use of oral contraceptives. Current smoking, lower educational attainment, being separated/widowed/divorced, nonemployment, and history of heart disease were all independently associated with earlier natural menopause, while parity, prior use of oral contraceptives, and Japanese race/ethnicity were associated with later age at natural menopause. This sample is one of the largest and most diverse ever studied, and comprehensive statistical methods were used to assess factors associated with age at natural menopause. Thus, this study provides important insights into this determinant of long-term disease risk in women.

An IL6 promoter polymorphism is associated with a lifetime risk of development of Kaposi sarcoma in men infected with human immunodeficiency virus

Kaposi sarcoma (KS) is an angioproliferative inflammatory condition that occurs commonly in patients infected with human immunodeficiency virus (HIV). Inflammatory cytokines and growth factors promote the development of KS. Because physiologically important cytokine polymorphisms modulate host inflammatory responses, we investigated the association between KS and common regulatory polymorphisms in 5 proinflammatory cytokine genes encoding interleukin (IL) IL-1alpha, IL-1beta, tumor necrosis factor (TNF) alpha, TNF-beta, and IL-6 and in the IL-1 receptor antagonist (IL1RN). We also examined the contribution of stromal-derived factor 1 and chemokine receptor 5 (Delta32) polymorphisms to KS development. The population consisted of 115 HIV-infected men with KS and 126 deceased HIV-infected men without KS. The only strong association was observed between an IL6 promoter polymorphism (G-174C) and susceptibility to KS in HIV-infected men (P =.0035). Homozygotes for IL6 allele G, associated with increased IL6 production, were overrepresented among patients with KS (P =.0046), whereas allele C homozygotes were underrepresented (P =.0062). Substantial in vitro evidence indicates that IL-6 contributes to the pathogenesis of KS. Our results show that IL6 promoter genotypes associated with altered gene expression are risk factors for development of KS. Identification of a genetic risk factor for development of KS has important clinical implications for prevention and therapy.

Physiotherapy for children with cystic fibrosis

Physiotherapy is an important part of the daily routine of patients with cystic fibrosis. It is one of a number of treatments used to help improve the quality of life. Airway clearance techniques aim to relieve respiratory symptoms by physical means, helping removal of tracheobronchial secretions, and thereby preventing or slowing deterioration in respiratory function. Exercise is used to monitor patient progress, maintain thoracic mobility, and improve well being and morale. Cystic fibrosis patients require ongoing assessment throughout life; physiotherapists can help to minimize the effect of the treatment burden by being as flexible as possible with regard to where, when and how they assess and plan treatments with their patients.

Seveso Women's Health Study: a study of the effects of 2,3,7,8-tetrachlorodibenzo-p-dioxin on reproductive health

Although reproductive effects of 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) exposure have been reported in numerous investigations of animals, studies of this association in humans are limited. In 1976, an explosion in Seveso, Italy exposed the surrounding population to among the highest levels of TCDD recorded in humans. The relatively pure exposure to TCDD and the ability to quantify individual level TCDD exposure from sera collected in 1976 for the Seveso cohort affords a unique opportunity to evaluate the potential dose-response relationship between TCDD exposure and a spectrum of reproductive endpoints. The Seveso Women's Health Study (SWHS) is the first comprehensive study of the reproductive health of a human population exposed to TCDD. The primary objectives of the study are to investigate the relationship of TCDD and the following endpoints: (1) endometriosis; (2) menstrual cycle characteristics; (3) age at menarche; (4) birth outcomes of pregnancies conceived after 1976; (5) time to conception and clinical infertility; and (6) age at menopause. Included in the SWHS cohort are women who were 0-40 yr old in 1976, who have adequate stored sera collected between 1976 and 1980, and who resided in Zones A or B at the time of the accident. All women were interviewed extensively about their reproductive and pregnancy history and had a blood draw. For an eligible subset of women, a pelvic exam and transvaginal ultrasound were conducted and a menstrual diary was completed. More than 95% of the women were located 20 yr after the accident and roughly 80% of the cohort agreed to participate. Data collection was completed in July 1998, serum TCDD analysis of samples for analysis of endometriosis as a nested case-control study was completed in October 1998, and statistical analysis of these data should be completed in early 1999. Serum samples are now being analyzed in order to relate TCDD levels with the remaining reproductive outcomes.

[The relationship between health and job quitting in female workers of the electronics assembly industry in Tijuana]

OBJECTIVE

To examine the health, labor and social factors which contribute to quitting work in two transnational electronic parts factories in Tijuana, Mexico.

MATERIAL AND METHODS

A cohort study of 725 women employed either at a Japanese or an American electronic parts factory in Tijuana was performed between January 1992 and March 1994. The sample was stratified in two time intervals < or = 30 or > 30 days of work. Follow up was continued until quitting or end of the observation period, by recollecting data regarding health, social and occupational variables from different logs and reports provided by the employer. Reasons for quitting and accuracy of data obtained from logs and reports were evaluated through a follow up interview applied to 46% (n = 148) of the women who had quit, and were located approximately 12 months after ceasing to work (SD = 6.7).

RESULTS

The estimated cumulative probabilities of quitting were 67% during the first year and 81% during the second. Newcomers to the work force, a day shift and the company is nationality were predictors the of quitting within 30 days. Smoking, surgical antecedents and paid leave due to illness were predictors for quitting after 30 days. In contrast, quitting rate after 30 days was lower in women with a history of chronic disease.

CONCLUSIONS

Quitting work is high and selective among workers female electronic factories. While occupational factors are associated with workers quitting early, health factors are stronger predictors for quitting after 30 days.

Smoking and blood pressure patterns in normotensive pregnant women

This paper examines the relationship between smoking levels and blood pressure patterns of normotensive pregnant women in a prospective cohort of 2193 primiparous and 3176 multiparous, normotensive, Caucasian women selected from the Child Health and Development Studies in Oakland, California, 1959-67. Regression lines were fitted to each woman's blood pressure; mean intercept and slope estimates of the individual regressions were used to create summary profile lines for each smoking dose. Multivariable regression analysis controlled for maternal age, number of visits to the doctor after 20 weeks' gestation, body mass index and maternal education level. Overall, smokers had lower average diastolic blood pressure (smokers vs. nonsmokers adjusted mean: primiparas, 66.1 vs. 67.2 mmHg; and multiparas, 64.0 vs. 64.7 mmHg) but higher systolic blood pressure (smokers vs. nonsmokers adjusted mean: primiparas, 117.0 vs. 116.0; and multiparas, 112.5 vs. 110.0) than nonsmokers among primiparous and multiparous pregnant women after adjusting for potential confounders. However, these differences are small and there was no clear dose-response relationship between smoking level and blood pressure.

Women who quit maquiladora work on the U.S.-Mexico border: assessing health, occupation, and social dimensions in two transnational electronics plants

This cohort study of 725 women examined the health, occupational, and social factors that contribute to quitting work in two transnational electronics maquiladoras (assembly plants) in Tijuana, Mexico. The estimated cumulative probabilities of quitting were 68% and 81% by 1 and 2 years of employment. After adjusting for other factors, women who had a history of smoking or surgery and those who returned to work after a paid leave due to illness were more likely to quit. In contrast, women with a history of chronic illness had lower quitting rates. The nationality of the company and the work shift also significantly influenced quitting rates, but demographic characteristics and health care visits did not have a significant effect. Women selectively leave maquiladora employment, often due to health-related events. The healthy worker effect is difficult to measure in a mobile population with high turnover.

Can specialists reduce costs? The case of referrals to orthopaedic surgeons

This study investigates whether timely referral to specialists, in this case orthopaedic surgeons, potentially can reduce the costs of a health care episode. Five musculoskeletal diagnoses were chosen, and the diagnostic and treatment history of approximately 2500 persons with these five diagnoses was traced to determine when in the course of their treatment episode they were referred from nonorthopaedist to orthopaedist care and how much their episode of care cost. It was found that the average episodic costs for those who were referred earlier in the episode of care was lower than for those referred later. The implication is that there are likely to be numerous identifiable health conditions that should be flagged for early referral to specialists to reduce costs. It also questions the validity of the presumption that specialist care is necessarily more expensive.

5-Fluorocytosine-mediated apoptosis and DNA damage in glioma cells engineered to express cytosine deaminase and their enhancement with interferon

To explore the antitumor mechanism of bacterial cytosine deaminase plus 5-fluorocytosine (CD/5-FCyt) in combination with interferons (IFNs), glioma cells were transduced with recombinant retroviruses expressing CD. The transduced glioma cells become sensitive to the nontoxic prodrug 5-FCyt. Apoptosis, DNA damage, bystander effect, and inhibition of thymidylate synthase (TS) and DNA synthesis are associated with CD/5-FCyt-mediated glioma cell killing. Furthermore, IFNs enhance this effect by increasing DNA damage and further inhibiting TS activity. The bystander effect is mediated by the release of cytotoxic metabolites of 5-FCyt into the extracellular milieu triggering apoptosis and DNA damage. Our data indicate that the use of CD/5-FCyt in combination with IFNs may provide a more effective approach for the treatment of brain tumors.

Correlation of glioma cell regression with inhibition of insulin-like growth factor 1 and insulin-like growth factor-binding protein-2 expression

To explore the antitumor effect of insulin-like growth factor 1 (IGF-I) antisense RNA and the interaction of IGF-I with insulin-like growth factor-binding proteins (IGFBPs) in glioma cells, a recombinant retrovirus expressing IGF-I antisense RNA was constructed and introduced into C6 glioma cells. IGF-I antisense RNA reverses the transformed phenotype in glioma cells and inhibits glioma cell growth by blocking overexpression of endogenous IGF-I. Expression of IGFBP-2 is increased in glioma cells as compared with normal adult glial cells. IGF-I antisense RNA also inhibits expression of IGFBP-2 in glioma cells, but does not influence expression of the other IGFBPs. Although IGFBP-2 in conditioned medium from wild-type C6 cell cultures itself does not directly influence glioma cell growth, it synergistically enhances exogenous IGF-I-mediated DNA synthesis in IGF-I-negative C6 cells. These findings indicate the inhibitory effect of IGF-I antisense RNA on growth and development of glioma cells. IGF-I-dependent glioma cell growth may, in some circumstances, require IGFBP-2 as a cofactor. The antitumor effect of IGF-I antisense RNA is also associated with inhibition of IGFBP-2 expression.

Should soybean agglutinin purging be performed in breast cancer patients undergoing autologous stem cell transplantation? A retrospective analysis of 48 patients

High-dose chemotherapy (HDC) followed by autologous stem cell transplantation (ASCT) has gained an increasing role in the treatment of high-risk Stage II-III and/or metastatic breast cancer patients. Several investigators reported on a high rate of tumor cells contaminating the bone marrow and peripheral blood stem cell collection. Nevertheless, the clinical implication of reinfusion of tumor cells with the stem cells to the relapse rate is still uncertain. In this retrospective analysis we compare the outcome and the toxicity of 29 patients with high-risk Stage II-III and 19 metastatic breast cancer patients who underwent HDC with ASCT. Thirteen patients underwent transplant with soybean agglutinin (SBA)-purged graft, while 35 consecutive patients received unmanipulated graft. Engraftment was significantly faster for the nonpurged transplant. No differences in disease-free survival, freedom from relapse, or overall survival were noted in both groups during a median follow up time of 14 months. We conclude that tumor cell purging using SBA in breast cancer patients is not warranted. New purging methods are needed to assess the role of tumor cell purging in breast cancer patients.

Self-reported stress and reproductive health of female lawyers

We studied the prevalence and relationship of stress and working conditions with adverse reproductive outcomes in a cohort of female US law-school alumnae. A total of 584 female lawyers (74% response), aged 25 to 63, responded to a mailed questionnaire. Job hours per week was a strong predictor of job stress. In a logistic regression analysis, women working > 45 hours/week were five times as likely to report high stress as those working < 35 hours/week. Marriage and length of time on the job showed a small inverse association with stress. Women who worked more than 45 hours/week during their first trimester of pregnancy were more likely to report high stress at work during pregnancy. After being adjusted for confounding factors, weekly job hours during the first trimester of pregnancy showed a strong independent association with spontaneous abortion risk (odds ratio [OR], 3.0; 95% confidence interval [CI], 1.4 to 6.6). Seven or more alcohol drinks/week was also independently associated with spontaneous abortion risk (OR, 4.8; 95% CI, 1.5 to 18.1). Self-reported stress during pregnancy was positively but not statistically significantly associated with spontaneous abortion (OR, 1.4; 95% CI 0.8 to 2.3).

Quantitative anatomic measures and comorbid medical illness in late-life major depression

The authors examined the individual and relative roles of atrophy, comorbid medical illness, and cerebrovascular risk factors in the pathogenesis of late-life major depressive disorder (MDD). They used magnetic resonance imaging techniques to study 28 subjects with late-life MDD, 29 healthy control subjects, and 34 subjects with probable dementia of the Alzheimer type (DAT). Depressed subjects showed increases in cerebrospinal fluid volumes comparable to the DAT group but significantly different from control subjects. High-intensity signals, but not measures of atrophy correlated significantly with cerebrovascular risk factor scores. A logistic regression revealed that both brain atrophy and medical illness are associated with an increased risk of developing MDD. Data suggest that both atrophy and comorbid medical illness increase the likelihood of developing MDD in late life.

Activation of kappa-opioid receptors in the nucleus ambiguus does not affect cardiovascular function or outcome following acute hemorrhage in the rat

The central cardiovascular response to hemorrhage is believed to be regulated, in part, by specific brain cardioregulatory nuclei, including the nucleus ambiguus (NA) of the hindbrain. Since endogenous opioid peptides and opiate receptors have been localized to this brain region, activation of endogenous opioid systems in the NA may affect the cardiovascular response to acute hemorrhage. The present study examined the effects of intracerebral microinjection of kappa-receptor agonists into the NA prior to acute fixed-volume hemorrhage in awake rats. 15 min prior to fixed volume hemorrhage (7.5 ml/300 g), male Sprague-Dawley rats (n = 59) received a microinjection of either (1) the synthetic kappa-receptor agonist U-50,488H (10 nM) or (2) U-50,488H (100 nM) or (3) the endogenous kappa-receptor agonist dynorphin 1-17 (1 nM) or (4) Des-Tyr dynorphin 2-17, inactive at opiate receptors (1 nM) or (5) equal volume saline. With the exception of the first 10 min post-hemorrhage, where intracerebral injection of both dynorphin 1-17 and dynorphin 2-17 caused a transient suppression of mean arterial blood pressure (P < 0.05 when compared to saline-treated controls), microinjection of the kappa-agonists dynorphin 1-17 or U-50,488H had no effect on blood pressure, heart rate or mortality when compared to control animals. These results suggest that activation of kappa-opiate receptors in the NA does not markedly influence cardiovascular response to acute hemorrhage.

Seroepidemiology of viral infections among intravenous drug users in northern California

Intravenous drug users are frequently exposed to parenterally transmitted viral infections, and these infections can spread to the general population through sexual activity. We investigated the prevalence of serologic markers for human immunodeficiency virus type 1 (HIV-1), human T-cell lymphotropic virus type I/II (HTLV-I/II), hepatitis B virus (HBV), and hepatitis C virus (HCV) in intravenous drug users and their sexual contacts. Of 585 drug users from northern California tested for these serologic markers, 72% were reactive for the antibody to HCV, 71% for the antibody to hepatitis B core antigen, 12% for HTLV-I/II antibodies, and 1% for the HIV-1 antibody. The prevalence of serologic markers for these four viruses correlated with the duration of intravenous drug use, the ethnic group, and the drug of choice. More than 85% of subjects infected with either HCV or HBV were coinfected with the other virus. All persons reactive to HTLV-I/II antibodies had antibodies for either HBV or HCV. Of 81 sexual contacts tested, 17% had evidence of HBV infection while only 6% were reactive for HTLV-I/II antibodies and 4% for the antibody to HCV. None of this group was infected with HIV-1. We conclude that HTLV-I/II and HCV are inefficiently transmitted to sexual contacts while HBV is spread more readily. Programs designed to discourage the sharing of drug paraphernalia, such as needle and syringe exchanges, should decrease the risk of parenterally spread viral infections in intravenous drug users and thus slow the spread of these infections to the general population.

Net patient revenues lag behind increases in expenses

Total net patient revenues for the nation's hospitals lagged behind increases in expenses during the first nine months of 1990, according to data from the American Hospital Association's National Hospital Panel Survey. And hospitals in some regions, particularly in the Northeast, saw more troubling performance than others. Meanwhile, the number of inpatient days dropped 1.1 percent during the same period.

Environmental and biological monitoring for lead exposure in California workplaces

Patterns of environmental and biological monitoring for lead exposure were surveyed in lead-using industries in California. Employer self-reporting indicates a large proportion of potentially lead-exposed workers have never participated in a monitoring program. Only 2.6 percent of facilities have done environmental monitoring for lead, and only 1.4 percent have routine biological monitoring programs. Monitoring practices vary by size of facility, with higher proportions in industries in which larger facilities predominate. Almost 80 percent of battery manufacturing employees work in job classifications which have been monitored, versus only 1 percent of radiator-repair workers. These findings suggest that laboratory-based surveillance for occupational lead poisoning may seriously underestimate the true number of lead poisoned workers and raise serious questions regarding compliance with key elements of the OSHA Lead Standard.