Unsuspected endometrial pathology in the subfertile woman

Routine sampling of the endometrium is not considered necessary in the investigation of female infertility in the presence of normal menstruation. We present the cases of five women diagnosed with endometrial pathology during the course of fertility investigations. Three women had atypical polypoid adenomyoma, one had complex endometrial hyperplasia and one had stage 1 endometrial adenocarcinoma. Only the latter described any abnormality in menstruation. No woman had polycystic ovarian syndrome nor any other reason in her history to suspect endometrial pathology. Two women had abnormal transvaginal ultrasound findings. Atypical polypoid adenomyoma is frequently associated with subfertility. Although usually biologically benign, malignant transformation has been reported. With current trends of increasing obesity and later age at attempted conception, the possibility of discovering endometrial pathology during fertility investigation is likely to increase. We believe that a thorough menstrual history and careful assessment of the endometrium is warranted in all women with fertility problems. A transvaginal pelvic ultrasound should be performed in the follicular (early) phase of the cycle. If this ultrasound examination and the woman's menstrual history are both normal, no further evaluation of the endometrial cavity is routinely required. Sonohysterography is superior to pelvic ultrasound in detecting intracavitary pathology and is thus recommended prior to IVF treatment. Hysteroscopy is the gold standard in the detection of intrauterine pathology and is well tolerated in the office setting. Where abnormality is suspected or detected at screening, futher investigation and concomitant treatment is essential. This is ideally performed via hysteroscopy with endometrial sampling or excision of focally abnormal areas.

Intrauterine growth restriction due to uteroplacental vascular insufficiency leads to increased hypoxia-induced cerebral apoptosis in newborn piglets

Uteroplacental vascular insufficiency in humans is a common cause of intrauterine growth restriction (IUGR) and is associated with an increased incidence of perinatal asphyxia and neurodevelopmental disorders compared to normal weight newborns. Experimental models that provide an opportunity to analyze the pathogenesis of these relationships are limited. Here, we used neonatal pigs from large litters in which there were piglets of normal birth weight (for controls) and of low birth weight (for uteroplacental vascular insufficiency). Hypoxia was induced in paired littermates by reducing the fraction of inspired oxygen to 4% for 25 min. Brain tissue was collected 4 h post-hypoxia. Cerebral levels of apoptosis were quantified morphologically and verified with caspase-3 activity and TUNEL. Expression of Bcl-2, Bcl-XL and Bax proteins was investigated using immunohistochemistry. Cellular positivity for Bcl-2 was consistently higher in the non-apoptotic white matter of the hypoxic IUGR animals compared with their littermates and reached significance at P < 0.05 in several pairs of littermates. Alterations in Bax showed a trend towards higher expression in the hypoxic IUGR littermates but rarely reached significance. The IUGR piglets showed a significantly greater amount of apoptosis in response to the hypoxia than the normal weight piglets, suggesting an increased vulnerability to apoptosis in the IUGR piglets.

Solid organ second malignant neoplasms among children diagnosed with malignant bone tumors treated on Children Cancer Study Group/Pediatric Oncology Group protocols after 1980

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Background: The growing number of individuals surviving childhood cancer has increased the awareness and recognition of long-term sequelae. One of the most worrisome complications following cancer therapy is the development of second malignant neoplasms (SMN), in particular, late-occurring solid second malignancies related radiation therapy. Methods: We describe the incidence of solid organ SMN in survivors of pediatric malignant bone tumors (MBT) treated on legacy CCG/POG protocols from 1980 to 2005. This retrospective cohort study included 2,842 patients, 1,686 treated for osteosarcoma (OS) and 1,156 treated for Ewings Sarcoma (ES). The cohort included 56% males and 44% females, with a median age at primary diagnosis of 13 years. The median length of follow-up was 4.3 years (range: 0 to 20.9 years). Results: At the time of the analysis, 64% of patients in this study are alive. Seventeen patients with solid organ SMN were identified, and included three patients with breast cancer, three with malignant fibrous histiocytoma, two with osteosarcoma, and 9 patients with other solid organ malignancies. The standardized incidence ratio (SIR=observed/expected cases) was 2.9 (95% confidence interval [CI], 1.4–5.4) for patients treated for OS and 5.0 (95%CI 2.6–9.4) for patients treated for ES. The median time from diagnosis to develop solid organ SMN was 7 years (range: 1 to 13 years). The 10-year cumulative incidence of solid organ SMN for the entire cohort was 1% (95%CI 0.6–2%). In univariate analysis, treatment with etoposide, cyclophosphamide or radiotherapy were each associated with a higher than expected incidence of cancer with SIR of 4.8 (95% CI, 2.5–9.5), 5.8 (95% CI, 3.5–9.5) and 4.1 (95% CI, 2.4–7.1), respectively. Conclusions: Solid organ SMNs are rare after treatment for OS and ES, although higher in patients treated for ES. Recurrence remains the most significant problem for patients diagnosed with MBT and development of improved therapies with fewer long-term consequences remains paramount. However, solid organ cancers are likely to increase with longer follow-up. Therefore, surveillance should focus on monitoring for both recurrence of primary malignancies and development of SMN.

No significant financial relationships to disclose.

Epidemiology of the functional gastrointestinal disorders diagnosed according to Rome II criteria: an Australian population-based study

BACKGROUND

Population-based studies of the prevalence of all functional gastrointestinal disorders (FGID) using the Rome II criteria are lacking. It is also not certain whether subjects who meet the Rome II criteria for an FGID are different in terms of demographic and psychological characteristics from those subjects meeting exclusively the more restrictive Rome I criteria.

AIM

To determine whether using the more restrictive Rome I criteria would result in a more biologically determined group of FGID than when the Rome II is applied.

METHODS

Subjects included individuals aged 18 years and older (n = 1,225) from the Penrith population who were initially surveyed with the Penrith District Health Survey in 1997. Subjects were sent a self-report questionnaire that contained items on gastrointestinal symptoms applying the Rome II criteria. Subjects were also assessed on psychological and personality factors and on physical and mental functioning.

RESULTS

A total of 36.1% (n = 275) of respondents was diagnosed with an FGID according to Rome II criteria. The five most prevalent FGID were functional heartburn (10.4%), irritable bowel syndrome (8.9%), functional incontinence (7.6%), proctalgia fugax (6.5%) and functional chest pain (5.1%). Subjects meeting Rome II only criteria for FGID scored significantly higher on measures of psychological caseness and emotionality than Rome I only subjects, and these were independently associated with meeting Rome I only versus Rome II only criteria for FGID.

CONCLUSION

The Rome II criteria FGID are common and do not appear to identify a vastly different group of FGID sufferers compared with the earlier Rome I criteria.

Cultural competency and nursing care: an Australian perspective

AIMS

To propose a process that will facilitate cultural competence in Australian nursing practice.

BACKGROUND

Cultural diversity is a prominent feature of the Australian health system and is impacting significantly on nursing care quality. A fictitious, but typical clinical exemplar is profiled that identifies cultural insensitivity in care practices leading to poor quality outcomes for the health consumer and her family. Strategies are proposed that will reverse this practice and promote culturally competent nursing care and that locates overseas qualified nurses in this process.

CONCLUSION

This paper contributes to nursing care quality internationally by articulating strategies to achieve cultural competence in practice. Nurses must pay attention to interpersonal relationships and develop respect for the health consumer's value systems and ways of being, in order to protect their rights and avoid the tendency to stereotype individuals from particular cultures. The expertise of qualified nurses from different cultures can greatly assist this process.

Pontosubicular apoptosis (“necrosis”) in human neonates with intrauterine growth retardation and placental infarction

In a previous study of 37 autopsied stillbirths with non-dysmorphic intrauterine growth retardation (IUGR), 26 cases were associated with placental infarction, a morphologic marker of uteroplacental insufficiency. Nine of the 26 cases with both IUGR and placental infarction, where archival tissue was available, had grey matter ischaemic lesions that were subsequently identified as "pontosubicular necrosis". This lesion is now regarded as a localized form of apoptosis. A further eight third trimester stillbirth cases with both IUGR and placental infarction were ascertained prospectively. Sixteen of these 17 cases showed pontosubicular apoptosis, identified morphologically and verified using activated caspase-3 and TUNEL. Five of the 17 cases showed apoptosis in the frontal or temporal cortex as well. In this current study, pontosubicular apoptosis was strongly associated with IUGR and placental infarction in third trimester stillborns, suggesting that uteroplacental insufficiency leading to chronic fetal hypoxaemia may cause cerebral apoptosis.

Transition State Studies on the Dioxirane-Mediated Asymmetric Epoxidation via Kinetic Resolution and Desymmetrization

This paper describes an efficient kinetic resolution process of trisubstituted cyclic olefins via a chiral dioxirane generated in situ from a fructose-derived ketone and Oxone. The substrates presented include a variety of 1,3-disubstituted and 1,6-disubstituted cyclohexenes with the stereogenic centers at allylic positions. A sequential desymmetrization and kinetic resolution of 1,4-cyclohexadienes by the chiral dioxirane was also found to be feasible. The initially formed monoepoxides can be kinetically resolved by continuing the reaction, leading to the increase or decrease of the ee values of monoepoxides depending on the diene systems. In some cases, a prochiral directing group is not required and the first formed epoxide stereoselectively directs the second epoxidation. When the coupled desymmetrization and kinetic resolution is used synergistically, high enantiopurity can be obtained for an epoxide from an intrinsically less enantioselective substrate. The observed absolute and relative stereochemistry as well as the changing optical purity can be effectively rationalized by transition state analysis.

Inflammatory smears--is there a correlation between microbiology and cytology findings?

Cervical smear results reporting the presence of inflammation are regularly encountered by smeartakers, yet the significance of this finding is not clear. We wished to evaluate whether the presence of inflammation on smear test was associated with a higher incidence of lower genital tract infection. A retrospective review was carried out on women attending our colposcopy unit for their first visit during 2001. Results of 256 women were available for analysis. Evidence of inflammation was found in 9.7% of smears. Genital tract infection was found in 29.2% of women overall. Infection with more than one micro-organism was present in 8.9 percent. Forty eight percent of women having inflammatory changes on smear test had genital tract infection. This compared with 27.3% of women whose smear tests showed no evidence of inflammation. Prevalence of infection with Chlamydia trachomatis, Candida, Bacteroides and Gardnerella vaginalis was higher in the inflammatory smear group. This study shows that women with an inflammatory smear are more likely to harbour genital tract infection than women whose smear shows no evidence of inflammation. Chlamydia infection in particular has long-term fertility consequences through its potential to cause asymptomatic tubal damage: it was present in a substantial proportion of women with inflammation on smear (20%). Screening for lower genital tract infection via high vaginal swab and either intracervical swab or urinary screening for Chlamydia infection should be carried out in all women with smear tests reporting the presence of inflammation.

Hip fractures in centenarians

The centenarian population is increasing yet there is little about their morbidity and mortality rates following hip fracture. The aim was to review centenarians treated for proximal femoral fractures in Edinburgh describing treatment outcomes in relation to mortality, walking ability and residential status comparing centenarians with a the more typical hip fracture population. In this retrospective review, 18 centenarians sustaining hip fractures in Edinburgh between 1998 and 2002 were compared to 18 randomly selected "normal" hip fracture patients aged 75-83 years. Centenarian in-hospital, 1 and 4 month mortality was 11.1, 33.3 and 50%, respectively, versus 0, 0 and 5.6% in the normal group. Centenarian 4 month mortality was significantly greater than that of the normal group (Fisher's Exact Test, P = 0.00723). A total of 22.2% of centenarians regained pre-fracture walking ability compared to 58.8% of the normal patients. A total 28.6% of centenarians could continue living independently post-fracture compared to 69.2% of the normal group.

The value of the perinatal and neonatal autopsy

The postmortem historically has been considered a valuable diagnostic exercise which contributes to medical knowledge. Despite this, there has been a significant reduction in autopsy rates throughout the developed world. This audit was a retrospective study of autopsy reports of stillbirths and neonates [corrected] greater than 500 grams over a five year period from 1995 to 1999. The audit was performed to assess the impact of autopsy on the current practice of perinatal medicine. The audit compared the final pathological diagnosis to the clinical diagnosis. The pathological diagnosis was categorised as (I) diagnostic, (II) confirmative, (III) unexplained. The recurrence risk estimates as a result of necropsy were also identified, as were any additional findings that were felt to be relevant but did not belong to any of the above categories. A total of 262 perinatal deaths (including stillbirths) and neonatal deaths greater than 500 grams birth weight were recorded during this period. The autopsy rate was 81%. The 213 autopsies performed were assessed, of which 76 (36%) were found to be diagnostic, 108 (51%) confirmatory, and 29 (13%) were unexplained or revealed no new findings. Change in recurrence risk estimates was identified in 24 (11%) and additional relevant information was obtained in 38 (18%). There were a number of cases where an unexpected diagnosis was made as a result of autopsy; these diagnoses included a respiratory chain disorder in a twenty nine week infant, and an occult necrotising enterocolitis presenting with severe haemolysis post transfusion in a preterm infant. The perinatal post mortem examination remains an indispensable part of clinical management. It contributes to medical education and quality assurance. It can aid in the identification of inheritable diseases and provide information for accurate parental counseling.

Comparison of CT and MRI in the pre-operative staging of rectal adenocarcinoma and prediction of circumferential resection margin involvement by MRI

OBJECTIVE

It has been suggested that MRI may be used as the sole modality of choice in pre-operative staging in rectal cancers. Knowledge of tumour stage and a threatened Circumferential Resection Margin (CRM) pre-operatively are essential for planning neo-adjuvant therapy and as predictors of local recurrence. At present most units utilize CT scanning to assess these parameters. The aim of our study was two fold: firstly to examine the accuracy of preop CT and MRI staging of rectal cancers compared with final histology and secondly to assess the accuracy of MRI in predicting penetration of the mesorectal envelope (ME).

PATIENTS AND METHODS

All patients with biopsy proven rectal adenocarcinoma underwent thin slice MRI and CT scan pre-operatively. Forty-seven patients have been prospectively entered into the study: 24 male (median age 68 years; range 38-91 years). Eleven patients were unsuitable for surgery leaving 36 patients available for study.

RESULTS

CT correctly staged patients with T1/T2 rectal cancers more often than MRI (77% vs. 43%, P = 0.226). Patients with T1/T2 tumours were overstaged more often by MRI compared with CT (54% vs. 23%, P = 0.226). A greater proportion of patients with T3 tumours were correctly staged by MRI than CT (76% vs. 41%, P = 0.08); and more T3 disease was understaged by CT than MRI (54 vs. 18%, P = 0.032). CT and MRI staged T4 disease equally. In the assessment of mesorectal envelope integrity, MRI had a sensitivity of 80% and a specificity of 84%. The positive predictive value was 44% and the negative predictive value 96%.

CONCLUSIONS

These results suggest significant differences between accurate pre-operative "T" staging by CT and MRI for rectal cancer. MRI has the potential however, to accurately assess mesorectal envelope invasion. Further analysis is required to assess whether MRI can be used as the sole modality in pre-operative staging of rectal cancers.

Tolerability of topiramate in children and adolescents

OBJECTIVE

To examine the tolerability of topiramate (TPM) in paediatric practice.

METHODOLOGY

A retrospective cohort study of patients aged less than 18 years commenced on TPM by paediatric neurologists. Patients were identified from the dispensing databases of two paediatric tertiary referral hospitals and from the authority prescription records of four paediatric neurologists. The clinical data were obtained from the patients' medical records.

RESULTS

There were 159 patients who were identified as having been commenced on TPM and follow-up data were available for 127 (80%) patients. The median (range) age at commencement of TPM was 8.1 (0.5-17.9) years, with 12 patients aged less than 2 years. After 4 years, 60% of patients had ceased the medication. Treatment limiting adverse effects included aggression/psychosis (n = 10), cognitive impairment/sedation (n = 6), anorexia/weight loss (n = 4) and desquamation (n = 1). Prior aggression (hazard ratio 5.91 (2.12-16.44)) and female gender (hazard ratio 2.94 (1.02-8.41)) were risk factors for ceasing TPM because of an adverse event. Thirty percent of children commenced on TPM experienced a treatment limiting adverse effect within 2 years of commencement.

CONCLUSIONS

The frequency of treatment limiting adverse events in children receiving topiramate is higher than previously reported.

An improved synthesis of a ketone catalyst for asymmetric epoxidation of olefins

An efficient synthesis of a ketone catalyst for asymmetric epoxidation of olefins from D-glucose in six steps is described.

Polyneuritis cranialis with contrast enhancement of cranial nerves on magnetic resonance imaging

The disorder of multiple cranial nerve palsies without spinal cord involvement is referred to as polyneuritis cranialis (PC) and is rare. It is thought to be an acute post-infective polyneuropathy or a variant of Guillain-Barré syndrome. Electrophysiological evidence of demyelination has been reported, but no radiological abnormalities of the affected cranial nerves have been noted. We report a case of PC where contrast enhanced magnetic resonance imaging (MRI) showed enhancement of the peripheral segments of the oculomotor and abducens nerves. This case illustrates the utility of MRI in the assessment of cranial nerve palsies.

Major colorectal cancer resection should not be denied to the elderly

AIMS

Adjuvant therapy after surgery for colorectal cancer is often denied to the elderly for various reasons. This study was to determine morbidity and mortality risk after surgery in the elderly and whether this is affected by adjuvant therapy.

METHODS

Data were collected prospectively and entered on a database for all patients undergoing resection of colorectal cancer between January 1994 and July 2000. A total of 304 patients were included, 65 aged 80 years and over.

RESULTS

There were 84 deaths, 21 (30%) in the over 80s, and 63 (26%) in the under 80s (P=0.51). The 'in-hospital' mortality was 10.1% in the over 80s and 3.8% in the under 80s (P=0.056). In the over 80s the colon was more affected than the rectum (P=0.002). The over 80s were less likely to be offered adjuvant therapy, 7.2% vs 42.1% (P<0.001). The 5 year survival (all-cause mortality) in the over 80s was 58.5% and 47.6% in the under 80s (P=0.25). Cox's regression analysis of all patients identified the following factors to be independently related to overall survival: age>80 years, post-operative leak, increasing Dukes stage and distant recurrence of disease.

CONCLUSION

This study has demonstrated that surgery should not be denied to elderly patients with colorectal cancer as despite a higher post-operative morbidity and mortality rate and with the absence of adjuvant therapy, favourable long-term outcome can be achieved by resectional surgery alone.

Friedreich's ataxia with chorea and myoclonus caused by a compound heterozygosity for a novel deletion and the trinucleotide GAA expansion

Friedreich's ataxia (FRDA) is the most common hereditary ataxia, affecting about 1 in 50,000 individuals. It is caused by mutations in the frataxin gene; 98% of cases have homozygous expansions of a GAA trinucleotide in intron 1 of the frataxin gene. The remaining 2% of patients are compound heterozygotes, who have a GAA repeat expansion in one allele and a point mutation in the other allele. FRDA patients with point mutation have been suggested to have atypical clinical features. We present a case of compound heterozygotes in a FRDA patient who has a deletion of one T in the start codon (ATG) of the frataxin gene and a GAA repeat expansion in the other allele. The patient presented with chorea and subsequently developed FRDA symptoms. The disease in this case is the result of both a failure of initiation of translation and the effect of the expansion. This novel mutation extends the range of point mutations seen in FRDA patients, and also broadens the spectrum of FRDA genotype associated with chorea.

An improved survival model of hypoxia/ischaemia in the piglet suitable for neuroprotection studies

The purpose of this study was to develop a newborn piglet model of hypoxia/ischaemia which would better emulate the clinical situation in the asphyxiated human neonate and produce a consistent degree of histopathological injury following the insult. One-day-old piglets (n=18) were anaesthetised with a mixture of propofol (10 mg/kg/h) and alfentinal (55.5 microg/kg/h) i.v. The piglets were intubated and ventilated. Physiological variables were monitored continuously. Hypoxia was induced by decreasing the inspired oxygen (FiO(2)) to 3-4% and adjusting FiO(2) to maintain the cerebral function monitor peak amplitude at < or =5 microV. The duration of the mild insult was 20 min while the severe insult was 30 min which included 10 min where the blood pressure was allowed to fall below 70% of baseline. Control piglets (n=4 of 18) were subjected to the same protocol except for the hypoxic/ischaemic insult. The piglets were allowed to recover from anaesthesia then euthanased 72 h after the insult. The brains were perfusion-fixed, removed and embedded in paraffin. Coronal sections were stained by haematoxylin/eosin. A blinded observer examined the frontal and parietal cortex, hippocampus, basal ganglia, thalamus and cerebellum for the degree of damage. The total mean histology score for the five areas of the brain for the severe insult was 15.6+/-4.4 (mean +/-S.D., n=7), whereas no damage was seen in either the mild insult (n=4) or control groups. This 'severe damage' model produces a consistent level of damage and will prove useful for examining potential neuroprotective therapies in the neonatal brain.

Soluble CD137 (4-1BB) ligand is released following leukocyte activation and is found in sera of patients with hematological malignancies

Expression of CD137 ligand (4-1BBL), a member of the TNF family of proteins, has been reported on several types of APCs, various carcinoma cells, and can be induced on activated T cells. In this study, we report that the soluble ligand was released constitutively at low levels from leukocytes and at higher levels following cellular activation. Release from cells was blocked by addition of a metalloproteinase inhibitor which concomitantly caused the accumulation of 4-1BBL on the cell surface. In addition, we show that a soluble form of 4-1BBL was present at high levels in the sera of some patients with various hematological diseases, but only at low levels in healthy donors. Soluble 4-1BBL was active in that it competed with recombinant 4-1BBL for binding to the 4-1BB receptor and was able to costimulate IL-2 and IFN-gamma release from peripheral T cells. These results indicate that the release of soluble 4-1BBL from the cell surface is mediated by one or more sheddases and likely regulates 4-1BB-4-1BBL interactions between cells in vivo. Cleavage of 4-1BBL to an active soluble form would alter both proximal and distal cellular responses, including cell survival and costimulatory or inflammatory responses, that are mediated through the 4-1BB pathway. This, in turn, would likely alter disease progression or outcome.