Comparison of Endorette and dilatation and curettage for sampling of the endometrium in women with postmenopausal bleeding

MAIN QUESTION: To compare the diagnostic properties of Endorette and D&C in women with postmenopausal bleeding, to relate the properties to endometrial thickness as measured by ultrasound, and to assess the women's experiences of the two methods.

METHODS

In a prospective study, 133 consecutive women with postmenopausal bleeding were examined with transvaginal ultrasound. After measuring the endometrial thickness, Endorette sampling was performed without anesthesia. Dilatation and curettage (D&C) was carried out under general anesthesia within six weeks. After completion of each sampling procedure the women filled in a questionnaire regarding their experience of the sampling.

RESULTS

Endorette sampling failed in 16% (21/133) of the women. More than half (56%) of the women experienced moderate or strong pain during Endorette sampling, and the doctor underestimated the pain in 62% of the women. Endorette failed to diagnose two of seven (29%) endometrial cancers found at D&C. In one of these two cases, the examiner suspected that the Endorette device had not reached the uterine fundus. In women with endometrium < 7 mm, Endorette and D&C showed similar results with regard to obtaining a sufficient endometrial sample and to distinguishing normal endometrium, benign pathological endometrium and malignancy. In women with endometrium > or =7 mm, Endorette yielded insufficient samples significantly more often than D&C (23% vs 6%, p=0.02; the McNemar test) and missed all polyps and most (77%) hyperplasias diagnosed by D&C.

CONCLUSION

Endorette and D&C have similar diagnostic properties in women with postmenopausal bleeding and endometrium < 7 mm. D&C is superior to Endorette in women with endometrium > or =7 mm.

Transvaginal sonography, saline contrast sonohysterography and hysteroscopy for the investigation of women with postmenopausal bleeding and endometrium > 5 mm

OBJECTIVES

To determine the ability of transvaginal ultrasound, with or without saline infusion, to detect focally growing lesions in the uterine cavity in women with postmenopausal bleeding and endometrium > 5 mm, and to determine the accuracy of conventional ultrasound, saline contrast sonohysterography and diagnostic hysteroscopy under general anesthesia to diagnose endometrial polyps, submucous myomas and uterine malignancy.

DESIGN

In a prospective study, 105 women with postmenopausal bleeding and endometrium > 5 mm underwent conventional ultrasound examination and saline contrast sonohysterography. Diagnostic and operative hysteroscopy under general anesthesia was then performed. The presence of focally growing lesions and the type of lesion (endometrial polyp, submucous myoma, malignancy or unclear focal lesion) were noted at ultrasound examination and at hysteroscopy.

RESULTS

There was almost perfect agreement (96%) between saline contrast sonohysterography and hysteroscopy in the diagnosis of focally growing lesions. Saline contrast sonohysterography and hysteroscopy both had a sensitivity of approximately 80% with regard to diagnosing endometrial polyps (false-positive rates of 24% and 6%, respectively), whereas conventional ultrasound missed half of the polyps (sensitivity, 49%; false-positive rate, 19%). Hysteroscopy was superior to both saline contrast sonohysterography and conventional ultrasound with regard to discriminating between benign and malignant lesions (sensitivity, 84%, 44%, and 60%; false-positive rate, 15%, 6% and 10%, respectively). The risk of malignancy was increased seven-fold (odds ratio, 7.3; 95% confidence interval, 1.9-27.8) in women with distension difficulties at saline contrast sonohysterography, and two thirds of the women with a poorly distensible uterine cavity had a malignant diagnosis.

CONCLUSION

Saline contrast sonohysterography is as good as hysteroscopy at detecting focally growing lesions in the uterine cavity in women with postmenopausal bleeding. However, neither hysteroscopy nor saline contrast sonohysterography can reliably discriminate between benign and malignant focal lesions. Distension difficulties at saline contrast sonohysterography should raise a suspicion of malignancy.

A role of PDGFRalpha in basal cell carcinoma proliferation

Activation of the hedgehog pathway, through the loss of patched (PTC) or the activation of smoothened (SMO), occurs frequently in basal cell carcinoma (BCC), the most common human cancer. However, the molecular basis of this neoplastic effect is not understood. The downstream molecule Gli1 is known to mediate the biological effect of the pathway and is itself up-regulated in all BCCs. Gli1 can drive the production of BCCs in the mouse when overexpressed in the epidermis. Here we show that Gli1 can activate platelet-derived growth factor receptor alpha (PDGFRalpha) in C3H10T(1/2) cells. Functional up-regulation of PDGFRalpha by Gli1 is accompanied by activation of the ras-ERK pathway, a pathway associated with cell proliferation. The relevance of this mechanism in vivo is supported by a high level expression of PDGFRalpha in BCCs of mice and humans. In the murine BCC cell line ASZ001, in which both copies of the PTC gene are inactivated, DNA synthesis and cell proliferation can be slowed by re-expression of PTC, which down-regulates PDGFRalpha expression, or by downstream inhibition of PDGFRalpha with neutralizing antibodies. Therefore, we conclude that increased expression of PDGFRalpha may be an important mechanism by which mutations in the hedgehog pathway cause BCCs.

Overcoming the language barrier in visual field testing

PURPOSE

To evaluate the effect of using recorded instructions in patients' native language compared with interpreter-assisted instructions on the reliability and duration of the visual field test.

PATIENTS AND METHODS

Sixty patients referred for visual field testing were included in the study. Thirty-five had limited or no knowledge of the Hebrew language, and 25 control patients were fluent in Hebrew, the native language. None had previous experience with automated perimetry. Patients were randomized to receive recorded instructions on the visual field test in their native language or translator-assisted instructions by the technician before performing the test. For each patient, the time required for instructions and test performance and the reliability indices were documented.

RESULTS

The method of instruction (recorded or interpreter-assisted) did not affect the time required for patient instructions (66 +/- 24 seconds and 57 +/- 30 seconds, respectively), the time for test performance (7.2 +/- 1.5 minutes and 7.8 +/- 1.8 minutes, respectively), and test reliability as measured by the rate of fixation losses. Regardless of the method of explanation, the time required for instructions and for performing the test were significantly shorter for Hebrew speakers than for non-Hebrew speakers.

CONCLUSION

The use of a recorded explanation in the patient's native language before visual field testing is an applicable method for patient instruction. Clinics in areas with multilingual populations may use this method to save technicians time, without adversely affecting the time required for performing the test and its reliability.

Genetic determinants of basal cell carcinoma risk

Basal cell carcinomas are can be induced by ionizing radiation, in particular in patients with the rare autosomal dominant basal cell nevus syndrome (BCNS). These patients also are prone to medulloblastomas, and curative ionizing radiation therapy for the latter is followed soon by the development of sheets of basal cell carcinomas in the overlying skin. Positional cloning of the gene mutant is BCNS patients has identified the hedgehog signaling pathway as crucial to the development of all basal cell carcinomas and presumably to this susceptibility to post-ionizing radiation carcinogenesis. Thus this pathway is a candidate for susceptibility to second, post-therapy cancers in the broader population.

Potassium/sodium selectivity in wheat and the amphiploid cross wheat X Lophopyrum elongatum

The early response of K(+) and Na(+) net fluxes to different external NaCl and KCl levels has been studied in wheat (Triticum aestivum L.) and the amphiploid cross wheat X Lophopyrum elongatum (Host) Löve in culture solution experiments. We found that during the first 24 h of exposure to 100 or 200 mM NaCl, at low K(+) levels, the amphiploid absorbed, translocated and allocated to the youngest leaf less Na(+) than the wheat parental line. During that period, the amphiploid retained more K(+) than wheat. Short-term uptake studies with 86Rb and 22Na showed that K(+)(86Rb) and Na(+) influxes were not involved in genotypic differences in K(+)(86Rb) and Na(+) net uptake observed after 6 h of exposure to salt stress. Differences in K(+)(86Rb) net uptake could be attributed to differences in K(+)(86Rb) efflux and/or to K(+)(86Rb) accumulation by root vacuoles. The possibility that differential shrinkage of protoplast volume plays a role in the genotypic difference in K(+) retention cannot be ruled out. On the other hand, Na(+) efflux did not contribute significantly to differences in Na(+) net uptake between these genotypes. Hence, differences in Na(+) net uptake were attributed to differences in the transport of Na(+) to the shoot. The presence in the amphiploid of fast acting mechanisms able to enhance Na(+)/K(+) selectivity at different plant levels minimizes the early build-up of Na(+) concentration, and K(+) substitution by Na(+), in the growing tissue of the leaf.

Characterization of auxin conjugates in Arabidopsis. Low steady-state levels of indole-3-acetyl-aspartate, indole-3-acetyl-glutamate, and indole-3-acetyl-glucose

Amide-linked indole-3-acetic acid (IAA) conjugates constitute approximately 90% of the IAA pool in the dicot Arabidopsis, whereas ester-linked conjugates and free IAA account for approximately 10% and 1%, respectively when whole seedlings are measured. We show here that IAA-aspartate Asp, IAA-glutamate (Glu), and IAA-glucose (Glc) are present at low levels in Arabidopsis. Nine-day-old wild-type Arabidopsis seedlings yielded 17.4 +/- 4.6 ng g(-1) fresh weight IAA-Asp and 3.5 +/- 1.6 ng g(-1) fresh weight IAA-Glu, and IAA-Glc was present at 7 to 17 ng g(-1) fresh weight in 12-d-old wild-type seedlings. Total IAA content in 9-d-old Arabidopsis seedlings was 1, 200 +/- 178 ng g(-1) fresh weight, so these three IAA conjugates together made up only 3% of the conjugate pool throughout the whole plant. We detected less than wild-type levels of IAA-Asp and IAA-Glu (7.8 +/- 0.4 ng g(-1) fresh weight and 1.8 +/- 0.3 ng g(-1) fresh weight, respectively) in an Arabidopsis mutant that accumulates conjugated IAA. Our results are consistent with IAA-Asp, IAA-Glu, and IAA-Glc being either minor, transient, or specifically localized IAA metabolites under normal growth conditions and bring into question the physiological relevance of IAA-Asp accumulation in response to high concentrations of exogenous IAA.

Dynein light chain binding to a 3'-untranslated sequence mediates parathyroid hormone mRNA association with microtubules

The 3'-untranslated region (UTR) of mRNAs binds proteins that determine mRNA stability and localization. The 3'-UTR of parathyroid hormone (PTH) mRNA specifically binds cytoplasmic proteins. We screened an expression library for proteins that bind the PTH mRNA 3'-UTR, and the sequence of 1 clone was identical to that of the dynein light chain LC8, a component of the dynein complexes that translocate cytoplasmic components along microtubules. Recombinant LC8 binds PTH mRNA 3'-UTR, as shown by RNA electrophoretic mobility shift assay. We showed that PTH mRNA colocalizes with microtubules in the parathyroid gland, as well as with a purified microtubule preparation from calf brain, and that this association was mediated by LC8. To our knowledge, this is the first report of a dynein complex protein binding an mRNA. The dynein complex may be the motor that is responsible for transporting mRNAs to specific locations in the cytoplasm and for the consequent is asymmetric distribution of translated proteins in the cell.

Indole glucosinolate and auxin biosynthesis in Arabidopsis thaliana (L.) Heynh. glucosinolate mutants and the development of clubroot disease

Mutants and wild type plants of Arabidopsis thaliana were analysed for differences in glucosinolate accumulation patterns, indole-3-acetic acid (IAA) biosynthesis and phenotype. A previously identified series of mutants, termed TU, with altered glucosinolate patterns was used in this study. Only the line TU8 was affected in shoot phenotype (shorter stems, altered branching pattern). Synthesis of IAA and metabolism were not much affected in the TU8 mutant during seedling development, although the content of free IAA peaked earlier in TU8 during plant development than in the wild type. Indole glucosinolates and IAA may, however, be involved in the development of clubroot disease caused by the obligate biotrophic fungus Plasmodiophora brassicae since the TU3 line had a lower infection rate than the wild type, and lines TU3 and TU8 showed decreased symptom development. The decline in clubroot formation was accompanied by a reduced number of fungal structures within the root cortex and slower development of the fungus. Indole glucosinolates were lower in infected roots of TU3 and TU8 than in control roots of these lines, whereas in wild-type plants the differences were not as prominent. Free IAA and indole-3-acetonitrile (IAN) were increased in infected roots of the wild type and mutants with normal clubroot symptoms, whereas they were reduced in infected roots of mutants TU3 and TU8. These results indicate a role for indole glucosinolates and IAN/IAA in relation to symptom development in clubroot disease.

How often does oral treatment of toenail onychomycosis produce a disease-free nail? An analysis of published data

OBJECTIVE

To analyze studies on oral treatment of toenail onychomycosis so as to aid clinicians and patients in making informed decisions.

DATA SOURCES

Studies dealing with treatment of toenail onychomycosis were identified by means of 2 MEDLINE search strategies. One was a title search using the word "toenail"; the other search used the combined Medical Subject Headings "onychomycosis" and "therapy".

STUDY SELECTION

Articles were read to ascertain that they (1) described results in toenails, (2) used both culture and microscopy, and (3) included a clinical evaluation. Not included were case reports, series of fewer than 15 subjects, reports that combined fingernail onychomycosis and toenail onychomycosis in their statistics, and articles reporting only the total number of toenails cured without providing data as to how many subjects were cured.

DATA EXTRACTION

This elimination process left 26 articles, which were then analyzed by means of a checklist that included a morphologically normal nail, mycological findings, and methodological items including recurrence rate, intent-to-treat analysis, placebo group, and whether terms were defined.

DATA SYNTHESIS

When there was sufficient data, the frequency with which the treatment achieved normal mycological results, a clinically normal nail, and a disease-free nail (normal-appearing nail plus normal mycological results) was calculated. Confidence intervals were calculated for disease-free nail results.

CONCLUSIONS

Standard courses of terbinafine achieved a disease-free nail in approximately 35% to 50% of patients. For itraconazole, the relevant disease-free nail rate was about 25% to 40%. Disease reappearance is an important issue; unfortunately data are lacking as to its frequency.

Do treatment process factors mediate the relationship between type A-type B and outcome in 12-Step oriented substance abuse treatment?

AIMS

One underutilized strategy for enhancing treatment research is to examine intervening factors that link client characteristics to endpoint outcomes. This study tested the hypothesis that Type B substance abusers would demonstrate difficulties engaging in the treatment process, and that these problems would mediate their poorer outcomes.

DESIGN

Longitudinal naturalistic study.

SETTING

Two intensive 12-Step substance abuse treatment programs.

PARTICIPANTS

A sample of 115 men and women seeking treatment.

MEASUREMENT

Empirical clustering techniques were used to divide the sample, and the link between type, process factors, and 12-month outcomes was examined.

FINDINGS

Hypotheses were not supported. Type Bs did not demonstrate difficulties with the treatment process, but had greater problems sustaining gains posttreatment. Contrary to prediction, Type Bs were better matched to self-help affiliation than Type As.

CONCLUSIONS

Findings argue for a more optimistic perspective on treating Type Bs, and for the utility of Type A-Type B in informing treatment research.

Determinant capture by MHC class II DR3 during processing of mycobacteria leprae 65kD heat shock protein by human B cells

Using T cell immunoblotting we have characterised the immunogenic fragments derived from the Mycobacteria Leprae 65kD heat shock protein that become associated with MHC class II DR3 during processing by a human B cell line. After 5 h incubation with antigen, a peptide of approximately 12kD (approximately 110 amino acids) was the only major fragment found associated with the class II MHC. The association of this oligopeptide was abolished if an excess of a synthetic peptide representing the minimal epitope was included in the culture or when cells were incubated at 4 degrees C. This suggests that the generation of this moiety is dependent on cell metabolism and that its binding to MHC is specific. This large fragment may represent an intermediate in the processing pathway, directly demonstrating the role of MHC in determinant capture during antigen degradation.

Does intermittent "pulse" topical 5-fluorouracil therapy allow destruction of actinic keratoses without significant inflammation?

BACKGROUND

Topical 5-fluorouracil (5-FU) is effective in removing actinic keratoses but causes unsightly and painful erosions. Intermittent "pulse" 5-FU therapy has been described as being an effective and comfortable technique for destroying actinic keratoses.

OBJECTIVE

The purpose of this study was to determine the efficacy and cutaneous side effects of intermittent 5-FU therapy.

METHODS

Efficacy of treatment was evaluated by three experienced dermatologists separately comparing randomly arranged before and after photographs. Degree of skin reaction was graded from photographs taken during treatment.

RESULTS

Of 13 patients treated with intermittent 5-FU, two had an excellent result, three a good result, but eight failed to show discernible improvement. Efficacy was linked to the degree of skin irritation.

CONCLUSION

Pulse 5-FU failed to clear actinic keratoses in most patients. Intermittent 5-FU treatment does not dissociate its therapeutic efficacy from its undesirable erosive effects. Pulse therapy is a less intensive way of employing 5-FU and may be of value in patients unwilling to accept the erosions and discomfort that accompany the traditional course of daily 5-FU applications.