Proper orthogonal and dynamic mode decomposition of sunspot data

High-resolution solar observations show the complex structure of the magnetohydrodynamic (MHD) wave motion. We apply the techniques of proper orthogonal decomposition (POD) and dynamic mode decomposition (DMD) to identify the dominant MHD wave modes in a sunspot using the intensity time series. The POD technique was used to find modes that are spatially orthogonal, whereas the DMD technique identifies temporal orthogonality. Here, we show that the combined POD and DMD approaches can successfully identify both sausage and kink modes in a sunspot umbra with an approximately circular cross-sectional shape. This article is part of the Theo Murphy meeting issue 'High-resolution wave dynamics in the lower solar atmosphere'.

SAT0229 PROTEOMIC ANALYSIS REVEALS ASSOCIATION BETWEEN IMMUNE-METABOLIC BIOMARKERS AND CLINICAL SYMPTOMS IN SICCA PATIENTS

Background:

Sjögren’s syndrome (SS) is a systemic autoimmune disease whose main characteristic is involvement of the exocrine glandular system. Thus, its most common clinical manifestation is eye and mouth dryness which, alongside fatigue and pain, contributes to poor health-related quality of life (HRQoL). A growing body of evidence recognises the adipose tissue as an active endocrine organ secreting bioactive mediators involved in metabolic and inflammatory disorders. A relationship between obesity and symptoms in SS has not yet been elucidated.

Objectives:

To explore potential associations between obesity-related immune-metabolic biomarkers and clinical symptoms in SS and sicca patients.

Methods:

Proteomics analysis of 184 cardio-immuno-metabolic proteins was assessed on sera from 53 SS (50 females (F), 3 males (M); mean age 54 years) and 60 sicca (56 F, 4 M; mean age 57 years) patients. Participants were enrolled in the Birmingham Optimising Assessment in Sjögren`s Syndrome (OASIS) cohort and examinations included the EULAR SS Patient Reported Index (ESSPRI), Schirmer’s test, unstimulated whole saliva, minor labial salivary gland biopsy, EuroQoL-5 dimension (EQ-5D) tool, immunological parameters, body max index (BMI) and Hb1Ac. Participants with SS fulfilled 2016 ACR/EULAR criteria. Non-SS sicca patients were anti-Ro antibody negative, displayed objective oral and/or ocular dryness, and did not have a physician diagnosis for SS. Linear regression analysis and univariate models were performed to identify the key predictors of symptoms.

Results:

HRQoL as measured as EQ-5D utility values, symptoms as assessed by ESSPRI, and BMI did not differ between the SS and sicca group. However, strong correlations between BMI (or fat or fat-free mass) and EQ-5D and ESSPRI scores were found in the sicca but not in the SS group. Among several proteins investigated, ADM, TNFRSF13B, FGF23, IL10RB, CD5, CD40, IL1RA, TNRSFN9, TNFRSF10A, TNFRSF11A, TRAILR2, GAL9, SPON2, ACE2, LEP, CD4, IL12B, SLAMF1, PD-L1 positively correlated with symptoms in the sicca group (R ≥ 0.3; Holm’s adjusted P ≤ 0.05). Adrenomedullin (ADM) showed the strongest correlation with ESSPRI (R = 0.56; P < 0.0001); age (R = 0.45; P = 0.0003); BMI (R = 0.43, P = 0.0008); Ocular Surface Disease Index (R = 0.32, P = 0.03); EQ-5D utility value (R = -0.45, P = 0.001) and VAS patient (R = -0.41, P = 0.008). There was no association between ADM and gender, Schirmer`s test, disease and symptom duration (P > 0.05). ADM was independently associated with ESSPRI scores in non-SS sicca patients when corrected for BMI, age, HbA1c, depression and anxiety scores. None of the above mentioned proteins correlated with clinical symptoms in the SS group.

Conclusion:

The study suggests that obesity-related immune-metabolic factors may play a role in regulating the symptoms in non-SS sicca patients. ADM appears to be a strong independent predictor of symptoms in these patients but not in SS.

Disclosure of Interests:

Valentina Pucino: None declared, Jason D. Turner: None declared, Florian Kollert Employee of: Novartis, Saaeha Rauz: None declared, Andrea Richard: None declared, Jon Higham: None declared, Ana Poveda-Gallego: None declared, Simon J. Bowman Consultant of: Astrazeneca, Biogen, BMS, Celgene, Medimmune, MTPharma, Novartis, Ono, UCB, xtlbio, Glapagos, Speakers bureau: Novartis, Francesca Barone: None declared, Benjamin Fisher: None declared

SAT0215 HISTORY OF TONSILLECTOMY IS ASSOCIATED WITH GLANDULAR INFLAMMATION IN SJÖGREN’S SYNDROME

Background:

The palatine tonsils are secondary lymphoid-organs that serve as the first line of defense against pathogens. Whether history of tonsillectomy (TE) is associated with the phenotype of Sjögren`s syndrome (SjS) has not been investigated to date.

Objectives:

To test whether TE is linked to SjS phenotype and disease activity scores.

Methods:

A total of 183 patients from the Optimising Assessment in Sjögren`s Syndrome (OASIS) cohort with SjS or non-SjS sicca syndrome were analysed. Patients with SjS fulfilled 2016 ACR/EULAR classification for primary SjS; sicca patients had objective and/or subjective dryness, but were anti-Ro/SSA negative and had no physician diagnosis of SjS. One SjS patient who had TE around the time of symptom onset was excluded.

Results:

Of the total cohort, 116 were diagnosed with SjS (86.2% SSA/Ro positive) and 67 with non-SjS sicca syndrome. Overall, 29% (53/183) had TE; 24.1% of the SjS patients (28/116) and 37.3% of the sicca patients (25/67). The prevalence of TE was higher in sicca than in SjS (p=0.043). The median age at TE was 8 (range 3-50) years and did not differ between SjS and sicca patients (p=0.629). Neither age at first symptoms (p=0.093) nor disease duration (p=0.623) were associated with TE in patients with SjS. SjS patients with TE showed a higher average histological focus score (2.1 (1.2-2.8) vs. 1.3 (0.0-4.3); p=0.049), and were more likely to have activity in the glandular (53.6 vs. 20.5%; p=0.001) and constitutional (39.3 vs. 14.9%, p=0.014) domains of the ESSDAI, and lower levels of IgG (12.2 (7.8-35.6) vs. 15.6 (5.7-56.4) g/l; p=0.012) and IgA (2.3 (0.9-6.6) vs. 2.9 (0.7-9.4) g/l; p=0.032). Whereas there was no difference in EQ5D utility values (p=0.718), VAS global health was significantly lower in the patients with SjS who had TE (58 (10-78) vs. 70 (10-97); p=0.021). There was no association between the status of TE and autoantibodies (SSA, SSB, RF), lachrymal and salivary glands function (Schirmer`s test, unstimulated saliva flow), complement (C3, C4), serum levels of free light chains, β2-microglobulin, ESSPRI, or total ESSDAI (all p-values >0.1). Of 181 patients, 12.7% (23/283) had appendectomy (AE); 10.5% (12/114) of the SjS patients and 16.4 %(11/67) of the sicca patients (p=0.258). With the exception of lower unstimulated salivary flow (0.086 (0.01-0.43) vs. 0.11 (0.0-1.3) ml/min; p=0.026) in SjS patients with AE, there were no differences in disease phenotype between SjS patients with and without AE (all p-values >0.1).

Conclusion:

History of TE in SjS is associated with higher average focus scores and with glandular swelling. It could be speculated that the absence of palatine tonsils is compensated by enhanced lymphocytic infiltrates in the salivary glands. Further research is required to determine if TE is a risk factor for both SjS and non-SjS sicca and to determine the role of the tonsils in the generation of hypergammaglobulinaemia in SjS.

Disclosure of Interests:

Florian Kollert Employee of: Novartis, Valentina Pucino: None declared, Saaeha Rauz: None declared, Andrea Richard: None declared, Jon Higham: None declared, Ana Povedo-Gallego: None declared, Rachel M. Brown: None declared, Timothy Bates: None declared, Simon J. Bowman Consultant of: Astrazeneca, Biogen, BMS, Celgene, Medimmune, MTPharma, Novartis, Ono, UCB, xtlbio, Glapagos, Speakers bureau: Novartis, Francesca Barone: None declared, Benjamin Fisher: None declared

Taking the Pressure Off the Patient - Understanding Digital Rectal Examinations on a Real Subject

Better understanding of palpation techniques during unsighted physical examinations has mostly been limited to qualitative and quantitative studies of performance of experts whilst conducting examinations on plastic benchtop models. However, little is known about their performance when conducting such examinations on real subjects.

OBJECTIVE

The aim of this paper is to better understand palpation techniques of experts whilst conducting a Digital Rectal Examination on a real subject.

METHODS

We recruited four consultants from relevant specialties and asked them to conduct two DREs on a Rectal Teaching Assistant whilst wearing small position and pressure sensors on their examining finger. We segmented the relevant anatomy from an MRI taken of the pelvic region, registered 3D models and analysed retrospectively performance in relation to executed tasks, supination/pronation, palpation convex hull and pressure applied.

RESULTS

Primary care consultants examined the anatomy more holistically compared to secondary care experts, the maximum pressure applied across experiments is 3.3N, overall the pressure applied on the prostate is higher than that applied to rectal walls, and the urologist participant not only applied the highest pressure but also did so with the highest most prominent frequency (15.4 and 25.3 Hz).

CONCLUSIONS

The results of our research allow for better understanding of experts' technical performance from relevant specialities when conducting a DRE, and suggest the range of pressure applied whilst palpating anatomy.

SIGNIFICANCE

This research will be valuable in improving the design of haptics-based learning tools, as well as in encouraging reflection on palpation styles across different specialities to develop metrics of performance.

Validation of an Oral Disease Severity Score (ODSS) tool for use in oral mucous membrane pemphigoid

BACKGROUND

Mucous membrane pemphigoid (MMP) is a rare autoimmune bullous disease predominantly affecting the oral mucosa. Optimal management relies upon thorough clinical assessment and documentation at each visit.

OBJECTIVES

The primary aim of this study was to validate the Oral Disease Severity Score (ODSS) for the assessment of oral involvement in MMP. We also compared its inter- and intraobserver reliability with those of the oral parts of the Mucous Membrane Pemphigoid Disease Area Index (MMPDAI), Autoimmune Bullous Skin Disorder Intensity Score (ABSIS) and Physician's Global Assessment (PGA).

METHODS

Fifteen patients with mild-to-moderately severe oral MMP were scored for disease severity by 10 oral medicine clinicians from four U.K. centres using the ODSS, the oral sections of MMPDAI and ABSIS, and PGA. Two clinicians rescored all patients after 2 h.

RESULTS

In terms of reliability, the interobserver ODSS total score intraclass correlation coefficient (ICC) was 0·97, MMPDAI activity 0·59 and damage 0·15, ABSIS total 0·84, and PGA 0·72. The intraobserver ICCs (two observers) for ODSS total were 0·97 and 0·93; for MMPDAI activity 0·93 and 0·70 and damage 0·93 and 0·79; for ABSIS total 0·99 and 0·94; and for PGA 0·92 and 0·94. Convergent validity between ODSS and MMPDAI was good (correlation coefficient 0·88). The mean ± SD time for completion of ODSS was 93 ± 31 s, with MMPDAI 102 ± 24 s and ABSIS involvement 71 ± 18 s. The PGA took < 5 s.

CONCLUSIONS

This study has validated the ODSS for the assessment of oral MMP. It has shown superior interobserver agreement over MMPDAI, ABSIS and PGA, and superior intraobserver reliability to MMPDAI. It is quick and easy to perform. What's already known about this topic? There are no validated scoring methodologies for oral mucous membrane pemphigoid (MMP). Proposed disease activity scoring tools for MMP include the Mucous Membrane Disease Area Index (MMPDAI) and the Autoimmune Bullous Skin Disorder Intensity Score (ABSIS). The Oral Disease Severity Score (ODSS) has been validated for use in oral pemphigus vulgaris (PV). It has been shown to be reliable and sensitive in both lichen planus (LP) and MMP. What does this study add? The ODSS has been shown to be a thorough, sensitive and reproducible, yet quick scoring tool for the assessment of oral involvement in MMP. Its versatility for use in oral PV, MMP and LP is an added advantage over other scoring methodologies. What are the clinical implications of this work? We propose that the ODSS be used as a clinical scoring tool for monitoring activity in oral MMP in clinical practice as well as for use in multicentre studies.

Real-time Visualisation and Analysis of Clinicians' Performance during Palpation in Physical Examinations

OBJECTIVE

Motivated by the fact that palpation skills are challenging to learn and teach, particularly during Digital Rectal Examinations (DRE), and the lack of understanding of what constitutes adequate performance, we present a visualisation and analysis system that uses small position and pressure sensors located on the examining finger, allowing the quantitative analysis of duration, steps and pressure applied.

METHODS

The system is first described, followed by an experimental study of twenty experts from four clinical specialties performing ten DREs each on a benchtop model using the proposed system. Analysis of the constitutive steps was conducted to improve understanding of the examination. A Markov model representing executed tasks and analysis of pressure applied is also introduced.

RESULTS

The proposed system successfully allowed the visualisation and analysis during the experimental study. General Practitioners and Nurses were found to execute more tasks compared to Urologists and Colorectal Surgeons. Urologists executed the least number of tasks and were the most consistent group compared to others.

CONCLUSION

The ability to "see through" allowed us to better characterise the performance of experts when conducting a DRE on a benchtop model, comparing the performance of relevant specialties, and studying executed tasks and the pressure applied. The Markov model presented summarises task execution of experts and could be used to compare performance of novices against that of experts.

SIGNIFICANCE

This approach allows for the analysis of performance based on continuous sensor data recording that can be easily extended to real subjects and other types of physical examinations.

Standardizing bimanual vaginal examination using cognitive task analysis

OBJECTIVE

To create a standardized universal list of procedural steps for bimanual vaginal examination (BVE) for teaching, assessment, and simulator development.

METHODS

This observational study, conducted from June-July 2012 and July-December 2014, collected video data of 10 expert clinicians performing BVE in a nonclinical environment. Video data were analyzed to produce a cognitive task analysis (CTA) of the examination steps performed. The CTA was further refined through structured interviews to make it suitable for teaching or assessment. It was validated through its use as a procedural examination checklist to rate expert clinician performance.

RESULTS

BVE was deconstructed into 88 detailed steps outlining the complete examination process. These initial 88 steps were reduced to 35 by focusing on the unseen internal examination, then further refined through interviews with five experts into 30 essential procedural steps, five of which are additional steps if pathology is suspected. Using the CTA as a procedural checklist, the mean number of steps performed and/or verbalized was 21.6 ± 3.12 (72% ± 10.4%; range, 15.9-27.9, 53%-93%).

CONCLUSION

This approach identified 30 essential steps for performing BVE, producing a new technique and standardized tool for teaching, assessment, and simulator development.

Outcome measures for heavy menstrual bleeding

Heavy menstrual bleeding is one of the most commonly encountered gynecological problems. While accurate objective quantification of menstrual blood loss is of value in the research setting, it is the subjective assessment of blood loss that is of greater importance when assessing the severity of heavy menstrual bleeding and any subsequent response to treatment. In this review the various approaches to objective, subjective and semi-subjective assessment of menstrual blood loss will be discussed.

PeerWise provides significant academic benefits to biological science students across diverse learning tasks, but with minimal instructor intervention

We demonstrate that student engagement with PeerWise, an online tool that allows students to author and answer multiple-choice questions (MCQs), is associated with enhanced academic performance across diverse assessment types on a second year Genetics course. Benefits were consistent over three course deliveries, with differential benefits bestowed on groups of different prior ability. A rating scheme, to assess the educational quality of students' questions, is presented and demonstrates that our students are able intuitively to make such quality assessments, and that the process of authoring high quality questions alone does not explain the academic benefits. We further test the benefits of providing additional PeerWise support and conclude that PeerWise works efficiently with minimal intervention, and can be reliably assessed using automatically generated PeerWise scores.

Real-time visualisation and analysis of internal examinations--seeing the unseen

Internal examinations such as Digital Rectal Examination (DRE) and bimanual Vaginal Examination (BVE) are routinely performed for early diagnosis of cancer and other diseases. Although they are recognised as core skills to be taught on a medical curriculum, they are difficult to learn and teach due to their unsighted nature. We present a framework that combines a visualisation and analysis tool with position and pressure sensors to enable the study of internal examinations and provision of real-time feedback. This approach is novel as it allows for real-time continuous trajectory and pressure data to be obtained for the complete examination, which may be used for teaching and assessment. Experiments were conducted performing DRE and BVE on benchtop models, and BVE on Gynaecological Teaching Assistants (GTA). The results obtained suggest that the proposed methodology may provide an insight into what constitutes an adequate DRE or BVE, provide real-time feedback tools for learning and assessment, and inform haptics-based simulator design.

Estimating and comparing the reliability of a suite of workplace-based assessments: an obstetrics and gynaecology setting

This paper reports on a study that compares estimates of the reliability of a suite of workplace based assessment forms as employed to formatively assess the progress of trainee obstetricians and gynaecologists. The use of such forms of assessment is growing nationally and internationally in many specialties, but there is little research evidence on comparisons by procedure/competency and form-type across an entire specialty. Generalisability theory combined with a multilevel modelling approach is used to estimate variance components, G-coefficients and standard errors of measurement across 13 procedures and three form-types (mini-CEX, OSATS and CbD). The main finding is that there are wide variations in the estimates of reliability across the forms, and that therefore the guidance on assessment within the specialty does not always allow for enough forms per trainee to ensure that the levels of reliability of the process is adequate. There is, however, little evidence that reliability varies systematically by form-type. Methodologically, the problems of accurately estimating reliability in these contexts through the calculation of variance components and, crucially, their associated standard errors are considered. The importance of the use of appropriate methods in such calculations is emphasised, and the unavoidable limitations of research in naturalistic settings are discussed.

Gingipain-dependent degradation of mammalian target of rapamycin pathway proteins by the periodontal pathogen Porphyromonas gingivalis during invasion

Porphyromonas gingivalis and Tannerella forsythia are gram-negative pathogens strongly associated with periodontitis. Their abilities to interact, invade and persist within host cells are considered crucial to their pathogenicity, but the mechanisms by which they subvert host defences are not well understood. In this study, we set out to investigate whether P. gingivalis and T. forsythia directly target key signalling molecules that may modulate the host cell phenotype to favour invasion and persistence. Our data identify, for the first time, that P. gingivalis, but not T. forsythia, reduces levels of intracellular mammalian target of rapamycin (mTOR) in oral epithelial cells following invasion over a 4-h time course, via the action of gingipains. The ability of cytochalasin D to abrogate P. gingivalis-mediated mTOR degradation suggests that this effect is dependent upon cellular invasion. We also show that levels of several other proteins in the mTOR signalling pathway are modulated by gingipains, either directly or as a consequence of mTOR degradation including p-4E-BP1. Taken together, our data suggest that P. gingivalis manipulates the mTOR pathway, providing evidence for a potentially novel mechanism by which P. gingivalis mediates its effects on host cell responses to infection.

Key challenges in simulated patient programs: an international comparative case study

BACKGROUND

The literature on simulated or standardized patient (SP) methodology is expanding. However, at the level of the program, there are several gaps in the literature. We seek to fill this gap through documenting experiences from four programs in Australia, Canada, Switzerland and the United Kingdom. We focused on challenges in SP methodology, faculty, organisational structure and quality assurance.

METHODS

We used a multiple case study method with cross-case synthesis. Over eighteen months during a series of informal and formal interactions (focused meetings and conference presentations) we documented key characteristics of programs and drew on secondary document sources.

RESULTS

Although programs shared challenges in SP methodology they also experienced differences. Key challenges common to programs included systematic quality assurance and the opportunity for research. There were differences in the terminology used to describe SPs, in their recruitment and training. Other differences reflected local conditions and demands in organisational structure, funding relationships with the host institution and national trends, especially in assessments.

CONCLUSION

This international case study reveals similarities and differences in SP methodology. Programs were highly contextualised and have emerged in response to local, institutional, profession/discipline and national conditions. Broader trends in healthcare education have also influenced development. Each of the programs experienced challenges in the same themes but the nature of the challenges often varied widely.

NADPH oxidase-derived reactive oxygen species mediate decidualization of human endometrial stromal cells in response to cyclic AMP signaling

Differentiation of human endometrial stromal cells into specialized decidual cells is critical for embryo implantation and survival of the conceptus. Initiation of this differentiation process is strictly dependent on elevated cAMP levels, but the signal intermediates that control the expression of decidual marker genes, such as prolactin (PRL) and IGFBP1, remain poorly characterized. Here we show that cAMP-dependent decidualization can be attenuated or enhanced upon treatment of primary cultures with a nicotinamide adenine dinucleotide phosphate (NADPH) oxidase inhibitor (diphenylen iodonium) or activator (apocynin), respectively. Time-course analysis demonstrated that cAMP enhances endogenous reactive oxygen species production, apparent after 12 h of stimulation, which coincides with a dramatic increase in decidual PRL and IGFBP1 expression. Knockdown of the Rho GTPase RAC1, which disables activation of the NADPH oxidase homologs NADPH oxidase (NOX)-1, NOX-2, and NOX-3, had no effect on PRL or IGFBP1 expression. In contrast, silencing of NOX-4, or its cofactor p22(PHOX), inhibited the expression of both decidual markers. Finally, we show that the NOX-4/p22(PHOX) complex regulates the DNA-binding activity of CCAAT/enhancer binding protein-β, a key regulator of human endometrial stromal cell differentiation. Thus, NOX-4 activation and reactive oxygen species signaling play an integral role in initiating the endometrial decidual response in preparation of pregnancy.

The poly(c)-binding protein-1 regulates expression of the androgen receptor

The androgen receptor (AR) is a ligand-dependent transcription factor, expressed in male and female reproductive organs, and essential for normal reproduction in both sexes. The levels of AR are tightly controlled in androgen-responsive cells in which it plays a central role in the regulation of target gene expression. The AR is abundantly expressed in human endometrial stromal cells (HESCs), but levels decline markedly after differentiation into decidual cells in vivo and in primary cultures. Decidualization profoundly down-regulated AR protein levels with no discernible effect on either AR mRNA or protein stability, suggesting that loss of the receptor was a consequence of translational inhibition. Here we show that HESCs express three RNA-binding proteins, Hu antigen R and the poly(C)-binding proteins PCBP1 and PCBP2, that reportedly target the 3'-untranslated region of AR transcripts. Only PCBP1 expression was enhanced in secretory endometrium in vivo and in decidualizing HESCs. Furthermore, knockdown of PCBP1 in decidualizing cells was sufficient to restore AR protein levels, indicating that loss of the AR protein is primarily the consequence of a translational block. PCBP1 also blocked AR translation in a cell-free system, although this did not require binding to the 3'-untranslated region of the receptor mRNA. Furthermore, knockdown of PCBP1 in the prostate cancer LNCaP cell line also increased AR protein. Therefore, PCBP1 plays a major role in the dynamic expression of AR in both male and female androgen-responsive cells.

Silencing of the JNK pathway maintains progesterone receptor activity in decidualizing human endometrial stromal cells exposed to oxidative stress signals

Survival of the conceptus is dependent on continuous progesterone signaling in the maternal decidua but how this is achieved under conditions of oxidative stress that characterize early pregnancy is unknown. Using primary cultures, we show that modest levels of reactive oxygen species (ROS) increase sumoylation in human endometrial stromal cells (HESCs), leading to enhanced modification and transcriptional inhibition of the progesterone receptor (PR). The ability of ROS to induce a sustained hypersumoylation response, or interfere with PR activity, was lost upon differentiation of HESCs into decidual cells. Hypersumoylation in response to modest levels of ROS requires activation of the JNK pathway. Although ROS-dependent JNK signaling is disabled on decidualization, the cells continue to mount a transcriptional response, albeit distinct from that observed in undifferentiated HESCs. We further show that attenuated JNK signaling in decidual cells is a direct consequence of altered expression of key pathway modulators, including induction of MAP kinase phosphatase 1 (MKP1). Overexpression of MKP1 dampens JNK signaling, prevents hypersumoylation, and maintains PR activity in undifferentiated HESCs exposed to ROS. Thus, JNK silencing uncouples ROS signaling from the SUMO conjugation pathway and maintains progesterone responses and cellular homeostasis in decidual cells under oxidative stress conditions imposed by pregnancy.—Leitao, B., Jones, M. C., Fusi, L., Higham, J., Lee, Y. Takano, M., Goto, T., Christian, M., Lam, E. W.-F., Brosens, J. J. Silencing of the Jnk pathway maintains progesterone receptor activity in decidualizing human endometrial stromal cells exposed to oxidative stress signals.

Proteomic analysis of endometrium from fertile and infertile patients suggests a role for apolipoprotein A-I in embryo implantation failure and endometriosis

Pregnancy is dependent upon the endometrium acquiring a receptive phenotype that facilitates apposition, adhesion and invasion of a developmentally competent embryo. Surface-enhanced laser desorption/ionization time-of-flight mass spectrometry of mid-secretory endometrial biopsies revealed a 28 kDa protein peak that discriminated highly between samples obtained from women with recurrent implantation failure and fertile controls. Subsequent tandem mass spectroscopy unambiguously identified this peak as apolipoprotein A-I (apoA-I), a potent anti-inflammatory molecule. Total endometrial apoA-I levels were, however, comparable between the study and control group. Moreover, endometrial apoA-I mRNA expression was not cycle-dependent although there was partial loss of apoA-I immunoreactivity in luminal and glandular epithelium in mid-secretory compared with proliferative endometrial samples. Because of its putative anti-implantation properties, we examined whether endometrial apoA-I expression is regulated by embryonic signals. Human chorionic gonadotrophin (hCG) strongly inhibited apoA-I expression in differentiating explant cultures but not when established from eutopic endometrium from patients with endometriosis. Pelvic endometriosis was associated with elevated apoA-I mRNA levels, increased secretion by differentiating eutopic endometrial explant cultures and lack of hCG-dependent down-regulation. To corroborate these observations, we examined endometrial apoA-I expression and its regulation by hCG in a non-human primate model of endometriosis. As in humans, hCG strongly inhibited endometrial apoA-I mRNA expression in disease-free baboons, but this response was entirely lost upon induction of pelvic endometriosis. Together, these observations indicate that perturbations in endometrial apoA-I expression, modification or regulation by paracrine embryonic signals play a major role in implantation failure and infertility.

Exploring the underperformance of male and minority ethnic medical students in first year clinical examinations

Evidence shows that medical students from Minority Ethnic (ME) backgrounds and male medical students underperform in undergraduate examinations. Our study confirmed these findings in first year clinical (year 3) medical students, and further explored this disparity in performance. We conducted a series of meta-analyses to measure the effects of sex and ethnic group on the written examination and Objective Structured Clinical Examination (OSCE) scores of three groups of year 3 medical students at two London UK medical schools (n = 1,051; 46.0% male; 48.7% White). Male and ME students scored lower on written and OSCE assessments. Both assessments were statistically significantly correlated (mean r = 0.45) and therefore the effects of sex and ethnic group were measured on each exam after being adjusted for the effect of the other. Although sex and ethnic differences remained on the OSCE when adjusted for written performance, these differences disappeared on the written when it was adjusted for OSCE performance. These findings may reflect a relative deficit in practical clinical knowledge in male and ME year 3 students. Results were unlikely to be due to examiner bias, as the machine-marked unadjusted written exam results showed significant sex and ethnic differences.

Progestogens versus oestrogens and progestogens for irregular uterine bleeding associated with anovulation

BACKGROUND

Dysfunctional uterine bleeding (DUB) is excessively heavy, prolonged or frequent bleeding of uterine origin which is not due to pregnancy or to recognisable pelvic or systemic disease. Anovulation may be inferred from a number of observations but, in the normal clinical situation, anovulation is often assumed when a woman presents with heavy, prolonged or frequent bleeding, particularly in those who are at the extremes of reproductive life and in women known to have polycystic ovarian syndrome. Menstrual bleeding that is irregular or excessive is poorly tolerated by the majority of women. Changes in the length of the menstrual cycle generally imply disturbances of the hypothalamo-pituitary-ovarian (HPO) axis. In anovulatory DUB with acyclic (irregular) oestrogen production there will be no progesterone withdrawal from oestrogen primed endometrium and so cycles are irregular. Prolonged oestrogen stimulation may cause a build up of endometrium with erratic bleeding as it breaks down and is expelled. This is the rationale for using cyclical progestogens during the second half of the menstrual cycle, in order to provoke a regular withdrawal bleed. Continuous progestogen is intended to induce endometrial atrophy and hence to prevent oestrogen-stimulated endometrial proliferation. Progestogens, and oestrogens and progestogens in combination are already widely used in the management of irregular or excessive bleeding due to DUB but the regime, dose and type of progestogen used varies widely, with little consensus about the optimum treatment approach.

OBJECTIVES

To determine the effectiveness and acceptability of progestogens alone and oestrogens and progestogens in combination in the management of irregular bleeding associated with anovulation.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Group Trials Register (searched 4 May 2007), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, Issue 2), MEDLINE (1966 to May 2007), EMBASE (1985 to May 2007), CINAHL (1982 to May 2007), Biological Abstracts (1969 to May 2007), Current Contents (1980 to 2007) and reference lists of articles.

SELECTION CRITERIA

All randomised controlled trials of progestogens (via any route) alone or in combination with oestrogens in the treatment of irregular bleeding associated with anovulation.

DATA COLLECTION AND ANALYSIS

Study quality assessment and data extraction were carried out independently by two review authors. Both authors were experts in the content matter.

MAIN RESULTS

No randomised trials were identified which compared progestogens with oestrogens and progestogens or with placebo in the management of irregular bleeding associated with anovulation. Only one small, non-randomised study compared two progestogen regimes in the management of heavy and irregular bleeding in women with confirmed anovulation. One randomised study compared the effects of two progestogens on endometrial histology in women with a variety of menstrual symptoms, half of whom had cystic glandular hyperplasia.

AUTHORS' CONCLUSIONS

There is a paucity of randomised studies relating to the use of progestogens and of oestrogens and progestogens in combination in the treatment of irregular bleeding associated with anovulation. Further research is needed to establish the role of these treatments in the management of this common gynaecological problem.

Role and regulation of the serum- and glucocorticoid-regulated kinase 1 in fertile and infertile human endometrium

Using cDNA microarray analysis, we identified SGK1 (serum- and glucocorticoid-regulated kinase 1) as a gene aberrantly expressed in midsecretory endometrium of women with unexplained infertility. SGK1 is a serine/threonine kinase involved primarily in epithelial ion transport and cell survival responses. Real-time quantitative PCR analysis of a larger, independent sample set timed to coincide with the period of uterine receptivity confirmed increased expression of SGK1 transcripts in infertile women compared with fertile controls. We further demonstrate that SGK1 expression is regulated by progesterone in human endometrium in vivo as well as in explant cultures. During the midsecretory phase of the cycle, SGK1 mRNA and protein were predominantly but not exclusively expressed in the luminal epithelium, and expression in this cellular compartment was higher in infertile women. In the stromal compartment, SGK1 expression was largely confined to decidualizing cells adjacent to the luminal epithelium. In primary culture, SGK1 was induced and phosphorylated upon decidualization of endometrial stromal cells in response to 8-bromo-cAMP and progestin treatment. Moreover, overexpression of SGK1 in decidualizing cells enhanced phosphorylation and cytoplasmic translocation of the forkhead transcription factor FOXO1 and inhibited the expression of PRL, a major decidual marker gene. Conversely, knockdown of endogenous SGK1 by small interfering RNA increased nuclear FOXO1 levels and enhanced PRL expression. The observation that SGK1 targets FOXO1 in differentiating human endometrium, together with its distinct temporal and spatial expression pattern and increased expression in infertile patients, suggest a major role for this kinase in early pregnancy events.

Transcriptional cross talk between the forkhead transcription factor forkhead box O1A and the progesterone receptor coordinates cell cycle regulation and differentiation in human endometrial stromal cells

Differentiation of human endometrial stromal cells (HESCs) into decidual cells is associated with induction of the forkhead transcription factor forkhead box O1A (FOXO1). We performed a genomic screen to identify decidua-specific genes under FOXO1 control. Primary HESCs were transfected with small interfering RNA targeting FOXO1 or with nontargeting control small interfering RNA before treatment with a cAMP analogue and the progestin, medroxyprogesterone acetate for 72 h. Total RNA was processed for whole genome analysis using high-density oligonucleotide arrays. We identified 3405 significantly regulated genes upon decidualization of HESCs, 507 (15.3%) of which were aberrantly expressed upon FOXO1 knockdown. Among the most up-regulated FOXO1-dependent transcriptional targets were WNT signaling-related genes (WNT4, WNT16 ), the insulin receptor (INSR), differentiation markers (PRL, IGFBP1, and LEFTY2), and the cyclin-dependent kinase inhibitor p57(Kip2) (CDKN1C). Analysis of FOXO1-dependent down-regulated genes uncovered several factors involved in cell cycle regulation, including CCNB1, CCNB2, MCM5, CDC2 and NEK2. Cell viability assay and cell cycle analysis demonstrated that FOXO1 silencing promotes proliferation of differentiating HESCs. Using a glutathione-S-transferase pull-down assay, we confirmed that FOXO1 interacts with progesterone receptor, irrespectively of the presence of ligand. In agreement, knockdown of PR disrupted the regulation of FOXO1 target genes involved in differentiation (IGFBP1, PRL, and WNT4) and cell cycle regulation (CDKN1, CCNB2 and CDC2) in HESCs treated with either cAMP plus medroxyprogesterone acetate or with cAMP alone. Together, the data demonstrate that FOXO1 engages in transcriptional cross talk with progesterone receptor to coordinate cell cycle regulation and differentiation of HESCs.

Commentary: How can we make our medical students enthusiastic about a future in obstetrics and gynaecology?

Falling recruitment to obstetrics and gynaecology (O&G) among UK-trained undergraduates is a pressing concern. The reasons for this are multifactorial and include the previous restriction on the number of postgraduate training places. Undergraduate placements are a key time to encourage potential recruits into the specialty. A recent survey demonstrated various changes within medical school attachments over the past 15 years that are having a mixed influence on the undergraduate O&G experience. These are explored in relation to their potential impact on recruitment.

Effect of ethnicity and gender on performance in undergraduate medical examinations

OBJECTIVE

To assess the effect of ethnicity and gender on medical student examination performance.

DESIGN

Cohort study of Year 3 medical students in 2002 and 2003.

SETTING

Royal Free and University College Medical School, Imperial College School of Medicine.

SUBJECTS

A total of 1216 Year 3 medical students, of whom 528 were male and 688 female, and 737 were white European and 479 Asian.

OUTCOME MEASURE

Performance in summative written and objective structured clinical examinations (OSCEs) in July 2002 and 2003.

RESULTS

White females performed best in all OSCEs and in 3 out of 4 written examinations. Mean scores for each OSCE and 2 out of 4 written examinations were higher for white students than for Asian students. The overall size of the effect is relatively small, being around 1-2%.

CONCLUSION

Students of Asian origin, of both genders, educated in the UK, using English as their first language, continue to perform less well in OSCEs and written assessments than their white European peers.

Aromatase P450 messenger RNA expression in eutopic endometrium is not a specific marker for pelvic endometriosis

OBJECTIVE

To determine whether expression of aromatase P450 mRNA in eutopic endometrium is predictive of the presence of pelvic endometriosis.

DESIGN

A prospective, multicenter, observational study.

SETTING

Four tertiary centers for reproductive medicine.

PATIENT(S)

Sixty subjects of reproductive age undergoing laparoscopy for subfertility exploration, pain assessment, or sterilization.

INTERVENTION(S)

Endometrial biopsy at time of laparoscopy.

MAIN OUTCOME MEASURE(S)

The expression of aromatase P450 mRNA in endometrial specimens was determined by single-tube reverse transcription-polymerase chain reaction (RT-PCR). Glyceraldehyde-3-phosphate dehydrogenase (GAPDH) mRNA was amplified in parallel to exclude amplification failure.

RESULT(S)

The RT-PCR amplification was successful in 56 of the 60 biopsies (93%). Pelvic endometriosis was diagnosed in 34 patients (61%) and was strongly associated with aromatase P450 mRNA expression in eutopic endometrium. As a diagnostic marker for endometriosis, aromatase P450 mRNA expression yielded a sensitivity of 82%, a specificity of 59%, a positive predictive value of 76%, and a negative predictive value of 67%. If additional uterine pathology was taken in account, the sensitivity increased to 84%, the specificity to 72%, the positive predictive value to 87%, but the negative predictive value remained unchanged (67%).

CONCLUSION(S)

Although endometrial aromatase P450 gene expression is highly predictive of the presence of pelvic disease, the relative high incidence of false-negative results and lack of specificity is likely to impair clinical application.

Peptic ulceration in general practice in England and Wales 1994-98: period prevalence and drug management

BACKGROUND

Little is known about the burden of peptic ulcer in the community.

AIMS

To examine recent time trends in the period prevalence of peptic ulceration and its drug management, in England and Wales.

METHODS

For each year between 1994 and 1998, information on patients with a diagnosis of peptic ulceration was extracted from the General Practice Research Database.

RESULTS

The annual age-standardized period prevalence of peptic ulceration decreased from 3.3/1000 in 1994 to 1.5/1000 in 1998 for men, and from 1.8/1000 to 0.9/1000 for women. This decline was more evident among younger people, and among males registered with practices located in the most deprived electoral wards compared to those located in the least deprived. The proportion of patients receiving H2 receptor antagonists declined from 68% in 1994 to 41% in 1998. In contrast, the proportion prescribed proton pump inhibitors rose from 46% to 66%.

CONCLUSIONS

Over a 5-year period, the period prevalence of peptic ulceration has decreased markedly, especially among younger people and those from more deprived areas.

Recent trends in admissions and mortality due to peptic ulcer in England: increasing frequency of haemorrhage among older subjects

BACKGROUND

Although overall admission rates for peptic ulcer in England declined from the 1950s up until the mid 1980s, perforations among older women increased, possibly due to increasing use of non-steroidal anti-inflammatory drugs (NSAID). Since then, proton pump inhibitors, antibiotic treatment for Helicobacter pylori, low dose aspirin, and selective serotonin reuptake inhibitors (SSRI) have been introduced Aims: To determine time trends for hospital admissions for peptic ulcer from 1989 to 1999 (England), mortality from 1958 to 1998 (England and Wales), and prescriptions for ulcer healing drugs, aspirin, NSAID, oral anticoagulants, and SSRI from 1990 to 1999 (England).

METHODS

Hospital episode statistics for admissions and mortality were obtained from the Office of National Statistics: community prescription data from Statistics Division 1E of the Department of Health.

RESULTS

Between 1989/90 and 1998/99, there was a marked rise in admissions for haemorrhage in older patients, particularly from duodenal ulcer. Perforations from gastric ulcer declined but perforations from duodenal ulcer increased among men at older ages. Since the mid 1980s mortality has declined in all age groups except for older women with duodenal ulcer. The number of prescriptions for histamine H(2) receptor antagonists remained constant but those for proton pump inhibitors increased by 5000%, aspirin 75mg by 460%, oral anticoagulants by 200%, and NSAID by 13% between 1990 and 1999. Since the introduction of SSRI in 1991, prescriptions have increased 15-fold.

CONCLUSIONS

Admission rates for gastric and duodenal ulcer haemorrhage and duodenal ulcer, but not gastric ulcer perforation, increased among older subjects, over a time when prescriptions for proton pump inhibitors, low dose aspirin, oral anticoagulants, and SSRI increased.

Endometrial bleeding in hormone replacement therapy users: preliminary findings regarding the role of matrix metalloproteinase 9 (MMP-9) and tissue inhibitors of MMPs

OBJECTIVE

To establish the effect of hormone replacement therapy (HRT) on the expression of matrix metalloproteinase 9 (MMP-9) and the tissue inhibitor of MMPs, TIMP-1, in the endometrium of postmenopausal and perimenopausal women.

DESIGN

Prospective observational study.

SETTING

United Kingdom teaching hospital.

PATIENT(S)

Thirty-one perimenopausal and postmenopausal HRT recipients, with a control group of eight postmenopausal women not undergoing HRT.

INTERVENTION(S)

Prospective record of bleeding patterns and endometrial biopsy.

MAIN OUTCOME MEASURE(S)

Endometrial histology, bleeding patterns, MMP-9, and TIMP-1 expression.

RESULT(S)

MMP-9 and TIMP-1 are expressed in benign postmenopausal endometrium. Expression of both molecules is reduced in HRT recipients compared with non-HRT recipients.

CONCLUSION(S)

Exposure to HRT appears to alter endometrial expression of MMP-9 and TIMP-1 and also the local balance between these molecules. This alteration may promote breakdown of the endometrial extracellular matrix and blood vessels and hence bleeding.

Folic acid supplements are more effective than increased dietary folate intake in elevating serum folate levels

In 1992, recommendations were disseminated aimed at reducing the incidence of neural tube defects. Women were advised to increase consumption of folic acid supplements and dietary folates during the periconceptional period and a major integrated national campaign was launched to help achieve this. In this study we found that only one-quarter of the women with an uncomplicated obstetric history and 51% with a complicated obstetric history took supplements for the recommended time period. Dietary modification was extremely unusual. Serum analysis demonstrated that intake of folic acid supplements provides a greater elevation in serum folate levels than dietary food intake, suggesting dietary manipulation is an ineffective strategy and that efforts would be better focused on increasing supplement intake at a clinically important time. More effective education strategies are required, and since approximately one-third of pregnancies are unplanned, fortification of foods with folic acid is warranted.

Progestogens versus oestrogens and progestogens for irregular uterine bleeding associated with anovulation

BACKGROUND

Dysfunctional uterine bleeding (DUB) is "excessively heavy, prolonged or frequent bleeding of uterine origin which is not due to pregnancy or to recognizable pelvic or systemic disease". Anovulation may be inferred from a number of observations but in the normal clinical situation, anovulation is often assumed when a woman presents with heavy, prolonged or frequent bleeding, particularly in those at the extremes of reproductive life and in women known to have the polycystic ovarian syndrome. Menstrual bleeding that is irregular or excessive is usually poorly tolerated by the majority of women. Changes in the length of the menstrual cycle generally imply disturbances of the hypothalamo-pituitary-ovarian (HPO) axis. In anovulatory DUB with acyclic (irregular) oestrogen production there will be no progesterone withdrawal from oestrogen primed endometrium and so cycles are irregular. Prolonged oestrogen stimulation may cause a build up of endometrium with erratic bleeding as it breaks down and is expelled. This is the rationale for using cyclical progestogens during the second half of the menstrual cycle in order to provoke a regular withdrawal bleed. Continuous progestogen is intended to induce endometrial atrophy and hence to prevent oestrogen-stimulated endometrial proliferation. Progestogens, and oestrogens and progestogens in combination are already widely used in the management of irregular or excessive bleeding due to DUB, but the regime, dose and type of progestogen used varies widely with little consensus about the optimum treatment approach.

OBJECTIVES

To determine the effectiveness and acceptability of progestogens alone, and oestrogens and progestogens in combination in the management of irregular bleeding associated with anovulation.

SEARCH STRATEGY

The search strategy of the Menstrual Disorders Group was used to identify all randomised trials of progestogens alone or in combination with oestrogens in the management of irregular menstrual bleeding associated with anovulation. In addition a search of the Cochrane Controlled Trials Register was undertaken.

SELECTION CRITERIA

All randomised controlled trials of progestogens (via any route) alone or in combination with oestrogens in the treatment of irregular bleeding associated with anovulation.

DATA COLLECTION AND ANALYSIS

Study quality assessment and data extraction were carried out independently by two reviewers. Both reviewers were experts in the content matter.

MAIN RESULTS

No randomised trials were identified which compared progestogens with oestrogens and progestogens in the management of irregular bleeding associated with anovulation. Only one small, non-randomised study compared two progestogen regimes in the management of heavy and irregular bleeding in subjects with confirmed anovulation. One randomised study compared the effects of two progestogens on endometrial histology in subjects with a variety of menstrual symptoms, half of whom had cystic glandular hyperplasia. No studies were found which compared progestogens with oestrogens and progestogens in combination or with placebo in the management of irregular bleeding associated with anovulation.

REVIEWER'S CONCLUSIONS

There is a paucity of randomised studies relating to the use of progestogens and of oestrogens and progestogens in combination in the treatment of irregular bleeding associated with anovulation. Further research is needed to establish the role of these treatments in the management of this common gynaecological problem.

Asthma and thunderstorms: description of an epidemic in general practice in Britain using data from a doctors' deputising service in the UK

OBJECTIVE

To describe the areas affected and the scale of an epidemic of thunderstorm associated asthma on the night of 24/25 June 1994 and to explore the spatial and temporal relationship between the thunderstorm and the associated epidemic.

SETTING

The 29 offices of a deputising service for general practitioners' (GP) out of hours calls (Healthcall). At the time of the storm the deputising service provided out of hours cover for about 8500 out of about 30000 GPs in England, Scotland, and Wales.

METHODS

Patients who phoned the Healthcall offices to request a home visit were categorised as "asthma" or "other causes" based on their presenting complaint. The number of calls on the night of 24/25 June 1994 was compared in areas affected by thunderstorms and areas not affected by thunderstorms and with the night of 17/18 June 1994, when there were no thunderstorms.

RESULTS

A large area of the south and east of England was affected by an epidemic of asthma closely related both temporally and spatially with the thunderstorms on 24/25 June 1994. The pooled Mantel-Haenszel estimate for the risk of asthma in thunderstorm affected areas compared with the control night was 6.36 (95% confidence interval 4.97, 8.32) compared with a value of 1.01 (0.80, 1.27) for those not exposed. Extrapolation suggests about 1500 extra patients were likely to have requested a visit from a GP that night because of epidemic asthma.

CONCLUSIONS

Under certain circumstances thunderstorms are associated with asthma and can affect many patients. Deputising services are a useful source of data for the investigation of epidemics in primary care.

A preliminary investigation of what happens to women complaining of menorrhagia but whose complaint is not substantiated

This observational follow-up study determined the outcome, after a minimum of 3 years' follow up, in women complaining of excessively heavy menses, whose measured blood loss was within the normal range. Of the 81.7% of women followed up, 26% were happy with their periods, 19% were menopausal or taking hormone replacement therapy, 18% were taking a variety of other medical therapies and 28% had undergone surgery. The remainder were pregnant, lactating, or attempting conception. The decision to treat is not solely based on measured blood volume. Some women are intent upon an end to menstruation or have additional indications for surgical intervention. Others are happy with the reassuring knowledge that their menstrual blood loss is normal.