Adjuvant progestagen therapy for the treatment of endometrial cancer: review and meta-analyses of published randomised controlled trials

OBJECTIVE

To assess the efficacy of adjuvant progestagen therapy for the treatment of endometrial cancer.

DESIGN

Computerised literature review by MEDLINE backed up by a manual search of 16 journals published before January 1995, to identify relevant published randomised controlled trials. Trials were classified according to methodological quality criteria. Odds ratios and 95% confidence intervals (CIs) were calculated where data allowed.

SETTING

Institute of Epidemiology and Health Service Research, University of Leeds.

SUBJECTS

Patients presenting with endometrial cancer.

INTERVENTION

Adjuvant progestagen therapy.

OUTCOMES

Death (overall, cancer related and intercurrent) and relapse.

RESULTS

Six randomised controlled trials comparing adjuvant progestagen with no adjuvant therapy in the treatment of endometrial cancer were identified in the literature prior to January, 1995. Three trials had an acceptable method of randomisation. Meta-analysis demonstrated that overall survival was not improved by adjuvant progestagen therapy and may even have been adversely affected. Furthermore, this treatment was not associated with any reduction in relapse or death from endometrial cancer.

CONCLUSION

Current evidence does not support use of adjuvant progestagen therapy in the primary treatment of endometrial cancer.

Should there be a trial of home versus hospital delivery in the United Kingdom?

Images

Not clients, not consumers and definitely not maternants

OBJECTIVE

To determine appropriate terminology for addressing women in pregnancy.

DESIGN

100 women (aged 15-50) were asked to fill in a questionnaire using one of the six choices provided for addressing women in pregnancy.

SETTING

Antenatal clinic of a teaching hospital.

RESULTS

Preferences vary according to context but simple terms like mother-to-be and pregnant women were more popular than client, consumer and maternant.

CONCLUSION

No single terminology for addressing women in pregnancy wins all round approval but simple softer terms like Mother-to-be please a vast majority.

Clinical trials and rare diseases: a way out of a conundrum

Currently, clinical trials tend to be individually funded and applicants must include a power calculation in their grant request. However, conventional levels of statistical precision are unlikely to be obtainable prospectively if the trial is required to evaluate treatment of a rare disease. This means that clinicians treating such diseases remain in ignorance and must form their judgments solely on the basis of (potentially biased) observational studies experience, and anecdote. Since some unbiased evidence is clearly better than none, this state of affairs should not continue. However, conventional (frequentist) confidence limits are unlikely to exclude a null result, even when treatments differ substantially. Bayesian methods utilise all available data to calculate probabilities that may be extrapolated directly to clinical practice. Funding bodies should therefore fund a repertoire of small trials, which need have no predetermined end, alongside standard larger studies.

Photosensitization of the endometrium with topical 5-aminolevulinic acid

Photosensitization of the endometrium was attempted in vitro and in vivo by intrauterine administration of 5-aminolevulinic acid, which is converted to the photosensitizer protoporphyrin IX. Protoporphyrin IX was found in both functional and basal layers of the endometrial glands at concentrations nine and 10 times higher than myometrium in in vitro and in vivo experiments, respectively. Selective endometrial photosensitization is possible with topical 5-aminolevulinic acid, but it might not be distributed sufficiently evenly for use as a sensitizing agent in photodynamic ablation.

Fetal pelvi-ureteric junction obstruction: predictors of outcome

OBJECTIVE

To examine the relationship between pre-natal ultrasonographic findings typical of pelvi-ureteric junction (PUJ) obstruction and post-natal renal function in the affected kidney.

PATIENTS AND METHODS

This retrospective study comprised 35 infants in whom pre-natal ultrasonography had identified a unilateral pattern of dilatation of the renal pelvis and calices typical of PUJ obstruction. In each case, the presence of unilateral hydronephrosis had been confirmed post-natally by ultrasonography, and differential function and drainage evaluated by isotope renography. The results of isotope renography were compared with the severity and timing of onset of the fetal hydronephrosis.

RESULTS

Eleven kidneys (31%) appeared normal in the second trimester and dilatation only became apparent during the third trimester. Mean differential function in these kidneys was 48%. However, mean differential function was reduced (mean 38%) in those kidneys noted to be dilated between 16 and 24 weeks gestation. Differential function was loosely correlated with the severity of dilatation in early onset cases, i.e. the mean differential function was 42% for mild, 37% for moderate and 27% for severe dilatation. A considerable variation in differential function values was present in each group except for those with severe dilatation, which was a significant predictor of poor functional outcome when compared with mild and moderate dilatation combined (P < 0.01).

CONCLUSION

Fetal PUJ obstruction is a heterogeneous condition permitting only broad predictions of functional outcome. Severe dilatation detected on second trimester imaging predicted significant loss of function. Mild and moderate degrees of dilatation were associated with a one in three risk of functional impairment in the obstructed kidney.

A randomised trial of three methods of giving information about prenatal testing

OBJECTIVE

To test the effect of extra non-directive information about prenatal testing, given individually or in a class.

SETTING

Antenatal clinics in a district general hospital and a university hospital.

DESIGN

Randomised controlled trial; participants allocated to control group or offer of extra information individually or in class.

SUBJECTS

1691 women booking antenatal care before 15 weeks' gestation.

INTERVENTIONS

All participants received the usual information about prenatal tests from hospital staff. Individual participants were offered a separate session with a research midwife in which prenatal screening was described in detail. Class participants were offered the same extra information in an early prenatal class.

MAIN OUTCOME MEASURES

Attendance at extra information sessions; uptake rates of prenatal tests; levels of anxiety, understanding, and satisfaction with decisions.

RESULTS

Attendance at classes was lower than at individual sessions (adjusted odds ratio 0.45; 95% confidence interval 0.35 to 0.58). Ultrasonography was almost universally accepted (99%) and was not affected by either intervention. Uptake of cystic fibrosis testing, high in controls (79%), was lowered in the individual group (0.44; 0.20 to 0.97) and classes (0.39; 0.18 to 0.86). Uptake of screening for Down's syndrome, already low (34%) in controls, was not further depressed by extra information in classes (0.99; 0.70 to 1.39) and was slightly higher in the individual group (1.45; 1.04 to 2.02). Women offered extra information had improved understanding and were more satisfied with information received; satisfaction with decisions about prenatal testing was unchanged. The offer of individual information reduced anxiety later in pregnancy.

CONCLUSIONS

Ultrasonography is valued for non-medical reasons and chosen even by fully informed people who eschew prenatal diagnosis. The offer of extra information has no overall adverse effects on anxiety and reduces uptake of blood tests when background uptake rate is high (but not when it is already low). High uptake of prenatal blood tests suggests compliant behaviour and need for more information.

Maternal levels of serum-soluble CD8 and IL-2R are not significantly elevated in idiopathic preterm labour

OBJECTIVE

To search for evidence of immune activation in idiopathic preterm term labour by measuring the soluble markers of T cell activation, CD8 (sCD8) and interleukin-2 receptor (sIL2R).

DESIGN

Serum sCD8 and sIL-2R were measured by commercial ELISA in subjects undergoing idiopathic preterm labour (PTL; n = 15) and normal term labour (TL; n = 17). Two gestationally equivalent non-labouring groups were also included representing preterm (PTC; n = 10) and term (TC; n = 10) controls. Possible delayed responses in soluble activation markers were monitored in blood samples taken 48 h after delivery in both labouring groups (PTLp; n = 9: TLp; n = 9).

RESULTS

(1) Excluding the 48 h postpartum samples, no statistically significant differences were revealed following a Kruskall-Wallis analysis of variance (ANOVA) for levels of sIL-2R (P = 0.093) and sCD8 (P = 0.098). Including the postpartum samples, however, gave statistically significant differences for each (sIL-2R: P = 0.033; sCD8: P = 0.006). (2) No statistically significant difference was revealed by direct comparison of the two labouring groups alone (Wilcoxon-Mann-Whitney test: P > 0.05). (3) Significantly lower levels of sCD8 were found in the PTL subgroup which had histological evidence of inflammation (Wilcoxon-Mann-Whitney: P = 0.003).

CONCLUSIONS

Statistical analysis of our data suggests that idiopathic preterm labour is not commonly associated with significant elevations in circulating sCD8 or sIL-2R levels compared with normal term labour. Where significant changes in the levels of these markers do arise, our evidence points to a delayed effect of labour per se rather than infection as the most probable cause.

Comparing fetal pulse oximetry with scalp pH

OBJECTIVE

To determine whether pulse oximetry has the potential to replace scalp blood pH sampling in infants with abnormal cardiotocographs.

STUDY DESIGN

The average scalp oximetry reading in labor recorded with an experimental N400 system was compared with fetal scalp blood pH.

RESULTS

The average oximetry readings were unrelated to the pH of aerobically sampled fetal scalp blood. There was no subgroup of acidemic infants with a low oximetry reading.

CONCLUSION

Pulse oximetry readings with present technology do not reflect scalp pH. The equipment is improving, but at this time pulse oximetry is not a simple alternative for scalp capillary blood sampling.

Clinical significance of fetal choroid plexus cysts

Choroid plexus (CP) cysts are commonly detected on routine mid-trimester ultrasound scan. When associated anomalies are detected, the risk is sufficient to justify an invasive diagnostic test such as amniocentesis. However, the risk when no associated anomalies are detected is much less well defined. This information is required to determine the appropriate management in cases of apparently isolated CP cysts. We thought the only way to resolve the difficulties in counselling prospective parents was to conduct a prospective study in a large unselected population. A registry of fetal CP cysts detected over 3 years in the Yorkshire Region was compiled and we identified 524 CP cysts. These cases were then amalgamated and analysed with 1361 cases from prospective studies reported in the world English literature and a further 71 unpublished cases identified from a 2 year prospective series from Ninewells Hospital, Dundee. The risk of chromosomal abnormalities was 1 in 150 (95% CI 1 in 85, 1 in 261) when no fetal anatomic abnormalities, apart from the CP cysts themselves, were detected antenatally. The risk increased to approximately 1 in 3 if any other associated ultrasound abnormalities were detected antenatally. The risk did not appear to be related to whether or not cyst size diminished as gestation progresses, whether they were unilateral or bilateral, and whether they were small or large in size (60-80% < 10 mm). 76% of aneuploidic cases were trisomy 18 and 17% were trisomy 21. The risk of Down's syndrome in fetuses with CP cysts but no other anomalies detected antenatally is 1 in 880. The probability of a chromosomal abnormality is high when CP cysts are associated with any other antenatally detected anomaly, indicating a clear need to offering amniocentesis. The predictive value is much lower when no other anomalies are detected. In such cases, it is probably advisable to regard CP cysts as an indication for detailed ultrasound assessment, rather than invasive testing.

Clinical ethics committee

An informal clinical ethics committee was set up to advise on ethical problems in prenatal diagnosis in Leeds. It was used twice in six months but was not called on again in the subsequent year, and we describe this experience. In North America similar committees are often used to advise on clinical moral dilemmas, and we review the published evidence from there and discuss some of the advantages and problems. Our committee's advice may have altered clinicians' actions considerably, but perhaps doctors in Britain are not yet ready to surrender this aspect of clinical autonomy.

Simultaneous DNA 'fingerprinting', diagnosis of sex and single-gene defect status from single cells

Sex and cystic fibrosis status have been previously diagnosed separately at the single cell level. We have developed a sensitive, reliable, accurate and rapid (within 5-6 h) system for the simultaneous diagnosis of sex, cystic fibrosis and a DNA 'fingerprint' within a single reaction from a variety of single cells. As contamination cannot be totally excluded, particularly at the single cell level, DNA 'fingerprinting' can be used to assess the risk of contamination. High sensitivity with single cells is combined with very high specificity (estimated matching probability of 10(-7)-10(-8)), allowing the source of the amplified cell to be identified with a very high degree of probability. Fluorescent primers were multiplexed for six tetranucleotide microsatellite sequences to determine the DNA fingerprint; the amelogenin gene was used to diagnose sex, and primers for the CFTR region were used to determine cystic fibrosis (CF) status. Analysis of the fluorescent product was undertaken using an automated DNA sequencer with Genescan software. This technique has many applications such as prenatal and preimplantation diagnosis, forensic identification of small or degraded samples, and detection of contamination sources. DNA fingerprints of single haploid spermatozoa and other cells can be assessed, so ensuring the detection of both diploid and haploid contamination during preimplantation diagnosis.

Beta 1 integrins in third trimester human placentae: no differential expression in pathological pregnancy

Integrins are a group of cell surface receptors that play important roles in cell-cell and cell-extracellular matrix interactions. The expression of trophoblast cell surface integrin subunits changes during placental development in normal pregnancy but the functional significance is unknown. The aim of this study was to investigate the expression of beta 1 integrins and their extracellular matrix ligands in human placenta and membranes in normal and pathological pregnancy using an avidin-biotin-peroxidase technique. Expression of the beta 1 integrins was similar in all study groups. Whilst there was some heterogeneity of expression of specific integrin alpha chains this was not characteristic of defined subject groups, variations occurring within all groups. Two distinct trophoblast subpopulations were demonstrated in the chorion laeve according to differential expression of beta 1 integrins. Trophoblast immediately adjacent to maternal decidua, which expressed alpha 1 rather than alpha 2, also comprised the majority of trophoblast in the basal plate; possession of the alpha 1, alpha 3, alpha 5, alpha 6 rather than alpha 2, alpha 3, alpha 5, alpha 6 phenotype may be important in the invasive potential of trophoblast populations. The results obtained in the present study indicate that the integrin phenotypes of third trimester uteroplacental tissues are similar in normal and pathological pregnancy, including pre-eclampsia, before and after labour.

Assessment and management of fetal agenesis of the corpus callosum

Prenatal counselling for fetal agenesis of the corpus callosum is difficult as the prognosis until now has been so uncertain. We have reviewed the current world English literature to provide the best probabilistic information for prospective parents. In total, there are 70 cases where the diagnosis was made prenatally. The diagnosis of apparently isolated agenesis of the corpus callosum (in the absence of other sonographically detectable anomalies) appears to carry an excellent prognosis, with an 85 per cent chance of a normal developmental outcome and a 15 per cent risk of handicap. Fetal karyotyping is recommended as there is a 1 in 10 risk of aneuploidy. If other anomalies are detected prenatally, the outcome is very poor. Termination of pregnancy is advised in these circumstances.

A randomised double blind placebo controlled trial of fish oil in high risk pregnancy

OBJECTIVE

To determine whether n-3 fatty acid (EPA/DCHA) prophylaxis is beneficial in high risk pregnancies.

DESIGN

A randomised, double blind, placebo controlled trial.

SETTING

Antenatal clinic of St James's University Hospital, Leeds.

SUBJECTS

Two hundred and thirty-three pregnant women at high risk of developing proteinuric or nonproteinuric pregnancy induced hypertension or asymmetrical intrauterine growth retardation.

INTERVENTION

Active treatment was 2.7 g of MaxEpa daily (1.62 g of eicosapentaenoic acid and 1.08 g of docosahexaenoic acid). Placebo were matching air-filled capsules.

MAIN OUTCOME MEASURES

Occurrence of proteinuric, nonproteinuric pregnancy induced hypertension or birthweight < 3rd centile.

RESULTS

There was no difference in an intention to treat analysis between the placebo and active treatment groups for occurrence of proteinuric pregnancy induced hypertension (relative risk (RR) = 0.88; 95% CI 0.47-1.66), nonproteinuric pregnancy induced hypertension (RR = 0.89; 95% CI 0.48-1.64), birthweight < 3rd centile (RR = 0.89; 95% CI 0.48-1.64), or the duration of pregnancy (difference of mean durations = 0.1 days; 95% CI -4.8 to 4.9 days). Analyses stratified by use of tobacco, and analyses excluding known major protocol violators gave essentially identical results.

CONCLUSION

There is no evidence from this study for any useful effect of fish oil supplementation for women at high risk of adverse outcomes from a pregnancy, but a small protective effect remains a possibility.

Cyclo-oxygenase distribution in human placenta and decidua does not change with labour after term or preterm delivery

Our objective was to determine, in an immunohistochemical study, the distribution of cyclo-oxygenase in placental and decidual tissues before and after labour at varying gestations. Subjects were pregnant women undergoing singleton delivery after idiopathic preterm labour at less than 34 weeks' gestation (n = 13); spontaneous term labour at 37-42 weeks' gestation (n = 11); preterm caesarean section at less than 34 weeks' gestation for pre-eclampsia or intrauterine growth retardation (n = 8); elective term caesarean section at 37-42 weeks' gestation for cephalopelvic disproportion (n = 7). Within the placental basal plate cyclo-oxygenase was localised in decidual stromal cells, extravillous trophoblast, and the apical border of villous syncytiotrophoblast, both before and after labour, regardless of gestational age. Within the placental membranes, decidual stromal cells showed intense cytoplasmic cyclo-oxygenase labelling and the chorion laeve strong membrane-associated cyclo-oxygenase reactivity before and after labour, regardless of gestational age. The amnion showed a heterogeneous staining pattern. After labour at term there was either positive cytoplasmic (5/10) or apical staining (5/10). Cyclo-oxygenase was demonstrated in an apical distribution in only 50% of the other subject groups. Cyclo-oxygenase is present in both decidua and placental tissues prior to the onset of labour at term. Demonstration of decidual and trophoblastic cyclo-oxygenase in both preterm and term subjects suggests that differential availability of cyclo-oxygenase is unlikely to be important in preterm delivery. Research into the withdrawal of inhibition or increased substrate availability is most likely to shed light on the signal pathways involved in the onset of labour, regardless of gestation.

Placental heat shock proteins: no immunohistochemical evidence for a differential stress response in preterm labour

The aetiology of idiopathic preterm labour remains obscure. The hypothesis that a stress response induced by low-grade bacterial infection in utero-placental tissues was investigated. Distribution of cognate and inducible isoforms of heat shock proteins (HSP) 70 kD, HSP 60 kD and HSP 90 kD were investigated in an immunohistochemical study of placental and decidual tissues before and after labour at varying gestations. Subjects were pregnant women undergoing singleton delivery after idiopathic preterm labour at less than 34 weeks' gestation (n = 23); spontaneous term labour at 37-42 weeks' gestation (n =24); preterm caesarean sections at less than 34 weeks' gestation for preeclampsia or intrauterine growth retardation (n=14); elective caesarean section at 37-42 weeks' gestation for cephalopelvic disproportion (n = 6). HSP expression was constant throughout the third trimester of pregnancy and did not change following the onset of labour, regardless of gestational age. A stress response in decidual tissues as determined by immunohistochemical analysis is apparently not associated with preterm labour.

Health services research--what it is, how to do it, and why it matters

The term 'Health Services Research' (HSR) has achieved only recent currency in the UK. The purpose of this short article is to explain what it is, to say how it differs from clinical research even when using similar methods, and to argue that it is likely to become of rapidly increasing importance to health policy-makers and managers.