An Assessment of Business of Medicine Knowledge in Obstetrics and Gynecology Fellows: A Pilot Study

STUDY OBJECTIVE

To identify knowledge gaps in business education among obstetrics and gynecology fellows METHODS: An online anonymous survey was distributed to obstetrics and gynecology subspecialty fellows, including pediatric and adolescent gynecology, minimally invasive gynecologic surgery, and reproductive endocrinology and infertility fellows.

RESULTS

Of the 483 fellows who received the questionnaire, 159 completed the surveys, resulting in a response rate of 32.9%. A total of 80 reproductive endocrinology and infertility fellows (50.3%), 47 minimally invasive gynecologic surgery fellows (29.6%), and 32 pediatric and adolescent gynecology (20.1%) fellows completed the survey. Over half reported debt from either undergraduate or medical school (52.2%). Over half (58.5%) reported 0 hours of finance education in their residency or fellowship training. In general, fellows reported relatively higher levels of confidence in nonmedical aspects of business, such as purchasing a home (63.9%), life and disability insurance (57.2%), and making financial plans for the future (57.9%). Conversely, a large portion of fellows reported feeling "not at all confident" in business topics related to the field of medicine, including contract negotiation (24.7%), non-competes (27.1%), relative value units system-based pay (32.0%), general office practice management (58.2%), legal aspects of business (71.8%), accounting and billing (54.4%), and marketing (55.7%).

CONCLUSION

Our survey demonstrates an unmet demand among obstetrics and gynecology fellows to learn topics related to the business of medicine. Knowledge of these topics is critical for those pursuing private practice or academic medicine. Future initiatives should evaluate other subspecialties and prioritize creating a standardized education tool to better prepare trainees entering medical practice.

Mindfulness training is associated with improved quality of life in female collegiate athletes

OBJECTIVE

To examine the effects of a mindfulness intervention on health-related quality of life in female Division I collegiate athletes.

PARTICIPANTS

135 female collegiate athletes, ages 18 - 23 years.

METHODS

Health related quality of life (HRQoL) was reported twice/year in approximately January and July from January 2017 to 2020 with the 12-question Veterans Rand survey (VR-12). Twenty-three of the participants received a 6-week, in-person, group mindfulness training in spring 2019, while 112 did not.

RESULTS

A significant interaction between time and mindfulness was identified with respect to the mental component score of the VR-12 of the VR-12 (MCS; β = 3.86 ± 1 .56, p = 0.012) but no significant relationships were identified with respect to time (pre-mindfulness: β = -2.36 ± 1.38, p = 0.074), mindfulness (yes: β = -2.26 ± 1.54, p = 0.14) or season (winter: β = -0.84 ± 0.57, p = 0.14). With respect to the physical component score (PCS), no significant relationships were identified with respect to time (pre-mindfulness: β = -1.09 ± 1.21, p = 0.37), mindfulness (yes: β = 1.30 ± 1.31, p = 0.32), season (winter: β = 0.50 ± 0.50, p = 0.32), or the interaction between time and mindfulness (β = 0.35 ± 1 .36, p = 0.80).

CONCLUSIONS

Among female collegiate athletes, mindfulness training is associated with significant improvements in mental HRQoL, but not physical HRQoL.

Home language and literacy environment and its relationship to socioeconomic status and white matter structure in infancy

The home language and literacy environment (HLLE) in infancy has been associated with subsequent pre-literacy skill development and HLLE at preschool-age has been shown to correlate with white matter organization in tracts that subserve pre-reading and reading skills. Furthermore, childhood socioeconomic status (SES) has been linked with both HLLE and white matter organization. It is important to understand whether the relationships between environmental factors such as HLLE and SES and white matter organization can be detected as early as infancy, as this period is characterized by rapid brain development that may make white matter pathways particularly susceptible to these early experiences. Here, we hypothesized that HLLE (1) relates to white matter organization in pre-reading and reading-related tracts in infants, and (2) mediates a link between SES and white matter organization. To test these hypotheses, infants (mean age: 8.6 ± 2.3 months, N = 38) underwent diffusion-weighted imaging MRI during natural sleep. Image processing was performed with an infant-specific pipeline and fractional anisotropy (FA) was estimated from the arcuate fasciculus (AF) and superior longitudinal fasciculus (SLF) bilaterally using the baby automated fiber quantification method. HLLE was measured with the Reading subscale of the StimQ (StimQ-Reading) and SES was measured with years of maternal education. Self-reported maternal reading ability was also quantified and applied to our statistical models as a proxy for confounding genetic effects. StimQ-Reading positively correlated with FA in left AF and to maternal education, but did not mediate the relationship between them. Taken together, these findings underscore the importance of considering HLLE from the start of life and may inform novel prevention and intervention strategies to support developing infants during a period of heightened brain plasticity.

Patterns of Neural Functional Connectivity in Infants at Familial Risk of Developmental Dyslexia

Importance

Developmental dyslexia is a heritable learning disability affecting 7% to 10% of the general population and can have detrimental impacts on mental health and vocational potential. Individuals with dyslexia show altered functional organization of the language and reading neural networks; however, it remains unknown how early in life these neural network alterations might emerge.

Objective

To determine whether the early emergence of large-scale neural functional connectivity (FC) underlying long-term language and reading development is altered in infants with a familial history of dyslexia (FHD).

Design, Setting, and Participants

This cohort study included infants recruited at Boston Children's Hospital between May 2011 and February 2019. Participants underwent structural and resting-state functional magnetic resonance imaging in the Department of Radiology at Boston Children's Hospital. Infants with FHD were matched with infants without FHD based on age and sex. Data were analyzed from April 2019 to June 2021.

Exposures

FHD was defined as having at least 1 first-degree relative with a dyslexia diagnosis or documented reading difficulties.

Main Outcomes and Measures

Whole-brain FC patterns associated with 20 predefined cerebral regions important for long-term language and reading development were computed for each infant. Multivariate pattern analyses were applied to identify specific FC patterns that differentiated between infants with vs without FHD. For classification performance estimates, 99% CIs were calculated as the classification accuracy minus chance level.

Results

A total of 98 infants (mean [SD] age, 8.5 [2.3] months; 51 [52.0%] girls) were analyzed, including 35 infants with FHD and 63 infants without FHD. Multivariate pattern analyses identified distinct FC patterns between infants with vs without FHD in the left fusiform gyrus (classification accuracy, 0.55 [99% CI, 0.046-0.062]; corrected P < .001; Cohen d = 0.76). Connections linking left fusiform gyrus to regions in the frontal and parietal language and attention networks were among the paths with the highest contributions to the classification performance.

Conclusions and Relevance

These findings suggest that on the group level, FHD was associated with an early onset of atypical FC of regions important for subsequent word form recognition during reading acquisition. Longitudinal studies linking the atypical functional network and school-age reading abilities will be essential to further elucidate the ontogenetic mechanisms underlying the development of dyslexia.

Functional Connectivity in Infancy and Toddlerhood Predicts Long-Term Language and Preliteracy Outcomes

Functional connectivity (FC) techniques can delineate brain organization as early as infancy, enabling the characterization of early brain characteristics associated with subsequent behavioral outcomes. Previous studies have identified specific functional networks in infant brains that underlie cognitive abilities and pathophysiology subsequently observed in toddlers and preschoolers. However, it is unknown whether and how functional networks emerging within the first 18 months of life contribute to the development of higher order, complex functions of language/literacy at school-age. This 5-year longitudinal imaging project starting in infancy, utilized resting-state functional magnetic resonance imaging and demonstrated prospective associations between FC in infants/toddlers and subsequent language and foundational literacy skills at 6.5 years old. These longitudinal associations were shown independently of key environmental influences and further present in a subsample of infant imaging data (≤12 months), suggesting early emerged functional networks specifically linked to high-order language and preliteracy skills. Moreover, emergent language skills in infancy and toddlerhood contributed to the prospective associations, implicating a role of early linguistic experiences in shaping the FC correlates of long-term oral language skills. The current results highlight the importance of functional organization established in infancy and toddlerhood as a neural scaffold underlying the learning process of complex cognitive functions.

White matter in infancy is prospectively associated with language outcomes in kindergarten

Language acquisition is of central importance to child development. Although this developmental trajectory is shaped by experience postnatally, the neural basis for language emerges prenatally. Thus, a fundamental question remains: do structural foundations for language in infancy predict long-term language abilities? Longitudinal investigation of 40 children from infancy to kindergarten reveals that white matter in infancy is prospectively associated with subsequent language abilities, specifically between: (i) left arcuate fasciculus and phonological awareness and vocabulary knowledge, (ii) left corticospinal tract and phonological awareness, and bilateral corticospinal tract with phonological memory; controlling for age, cognitive, and environmental factors. Findings link white matter in infancy with school-age language abilities, suggesting that white matter organization in infancy sets a foundation for long-term language development.

[Treatment of post-total knee replacement gonalgy by radiofrequency ablation of the genicular nerves]

Neurotomy of genicular nerves by radiofrequency is a technique efficient to reduce mecanic knee pain and pain after total knee replacement. In this article, we describe the case of a patient that has suffered from chronic knee pain after total knee replacement. The patient has successfully benefited of a neurotomy of genicular nerves by radiofrequency in the inferior right limb.

The need for business in reproductive medicine

The business of medicine continues to be an area of growing importance, particularly in reproductive medicine. We provide a synthesis of salient concepts within the spectrum of business in medicine. The topics we review include finances and accounting; business operations as related to human resources, information technology (telemedicine), organizational governance, and practice models; insurance billing and contract negotiations; and the impact of health care policy on reproductive medicine.

Basics of practice management: managing many for the care of one

In today's changing health care landscape, it has become necessary that providers have a fundamental understanding of practice management as pertinent to the care they provide. The reproductive endocrinology and infertility (REI) practice is a uniquely complex setting with many component parts, necessitating frequent assessment and collaboration to provide safe, quality, and cost-effective care. In this review, we aim to describe the basics of medical practice management, divided into six sections: practice models; operations; patient safety; patient experience; employee recruitment; development, and satisfaction; and technology. These topics will be presented with a focus on the application of these principles to the REI practice.

Factors Affecting Daily Cochlear Implant Use in Children: Datalogging Evidence

Background: Children with profound hearing loss can gain access to sound through cochlear implants (CIs), but these devices must be worn consistently to promote auditory development. Although subjective parent reports have identified several factors limiting long-term CI use in children, it is also important to understand the day-to-day issues which may preclude consistent device use. In the present study, objective measures gathered through datalogging software were used to quantify the following in children: (1) number of hours of CI use per day, (2) practical concerns including repeated disconnections between the external transmission coil and the internal device (termed “coil-offs”), and (3) listening environments experienced during daily use.

Purpose: This study aimed to (1) objectively measure daily CI use and factors influencing consistent device use in children using one or two CIs and (2) evaluate the intensity levels and types of listening environments children are exposed to during daily CI use.

Research Design: Retrospective analysis.

Study Sample: Measures of daily CI use were obtained from 146 pediatric users of Cochlear Nucleus 6 speech processors. The sample included 5 unilateral, 40 bimodal, and 101 bilateral CI users (77 simultaneously and 24 sequentially implanted).

Data Collection and Analysis: Daily CI use, duration, and frequency of coil-offs per day, and the time spent in multiple intensity ranges and environment types were extracted from the datalog saved during clinic appointments. Multiple regression analyses were completed to predict daily CI use based on child-related demographic variables, and to evaluate the effects of age on coil-offs and environment acoustics.

Results: Children used their CIs for 9.86 ± 3.43 hr on average on a daily basis, with use exceeding 9 hr per day in ˜64% of the children. Daily CI use reduced significantly with increasing durations of coil-off (p = 0.027) and increased significantly with longer CI experience (p < 0.001) and pre-CI acoustic experience (p < 0.001), when controlled for the child’s age. Total time in sound (sum of CI and pre-CI experience) was positively correlated with CI use (r = 0.72, p < 0.001). Longer durations of coil-off were associated with higher frequency of coil-offs (p < 0.001). The frequency of coil-offs ranged from 0.99 to 594.10 times per day and decreased significantly with age (p < 0.001). Daily CI use and frequency of coil-offs did not vary significantly across known etiologies. Listening environments of all children typically ranged between 50 and 70 dBA. Children of all ages were exposed to speech in noisy environments. Environment classified as “music” was identified more often in younger children.

Conclusions: The majority of children use their CIs consistently, even during the first year of implantation. The frequency of coil-offs is a practical challenge in infants and young children, and demonstrates the need for improved coil retention methods for pediatric use. Longer hearing experience and shorter coil-off time facilitates consistent CI use. Children are listening to speech in noisy environments most often, thereby indicating a need for better access to binaural cues, signal processing, and stimulation strategies to aid listening. Study findings could be useful in parent counseling of young and/or new CI users.

Reintroducing Dyslexia: Early Identification and Implications for Pediatric Practice

Dyslexia is a common learning disorder that renders children susceptible to poor health outcomes and many elements of socioeconomic difficulty. It is commonly undiagnosed until a child has repeatedly failed to learn to read in elementary school; this late diagnosis not only places the child at an academic disadvantage but also can be a precursor to psychiatric comorbidities such as anxiety and depression. Genetic and neuroimaging research have revealed that dyslexia is heritable and that it is undergirded by brain differences that are present even before reading instruction begins. Cognitive-behavioral research has revealed that there are early literacy skill deficits that represent red flags for dyslexia risk and can be measured at a preschool age. Altogether, this evidence points to dyslexia as a disorder that can be flagged by a pediatrician before school entry, during a period of heightened brain plasticity when interventions are more likely to be effective. In this review, we discuss the clinical implications of the most recent advances in dyslexia research, which converge to indicate that early identification and screening are crucial to the prevention or mitigation of adverse secondary consequences of dyslexia. We further highlight evidence-based and practical strategies for the implementation of early risk identification in pediatric practice so that physicians can be empowered in their ability to treat, educate, and advocate for their patients and families with dyslexia.

Impact of Consistency in Daily Device Use on Speech Perception Abilities in Children with Cochlear Implants: Datalogging Evidence

Cochlear implants (CIs) give children with severe to profound hearing loss access to sound. There appears to be a dose effect of sound exposure on speech perception abilities as shown by the positive influence of early implantation and CI experience. The consistency in device use per day could also affect sound dose, potentially affecting perceptual abilities in children with CIs.

The objectives of the present study were to identify the impact of consistency in device use on: (1) speech perception abilities and (2) asymmetry in speech perception abilities between bilateral CIs.

Retrospective analysis.

To achieve the first objective, data from 65 children (age range at speech test: 1.91–18.05 yrs) with one (unilaterally implanted or bimodal) or two CIs (sequentially or simultaneously implanted) were included. A subset of data from 40 children with bilateral CIs was included to achieve the second objective. Of the 40 children with two CIs, 15 received their CIs sequentially.

Device use information was extracted from datalogs stored in personal speech processors using custom software. Speech perception scores per CI collected in quiet were also evaluated. Multiple regression was used to assess the impact of daily CI use, while controlling for factors previously identified to affect speech perception: age at speech test, length of pre-CI (acoustic) hearing experience, length of CI hearing experience, and order of CI for the first objective, and CI category (simultaneous/sequential implantation), interimplant delay, and length of CI experience for the second objective.

On average, children wore their CIs for 11.59 ± 2.86 hours/day and, with one CI, exhibited 65.07 ± 22.64% accuracy on speech perception tests. Higher monaural speech perception scores were associated with longer everyday CI use and CI experience (p < 0.05). Among children with bilateral CIs, those with simultaneously implanted CIs and similar bilateral hearing experience demonstrated a small but significant right ear advantage with higher speech perception scores when using the right rather than left CI (mean difference = 4.55 ± 9.83%). The asymmetry in speech perception between CIs was larger and more variable in children who received their CIs sequentially (mean difference CI1-CI2 = 27.48 ± 24.87%). These asymmetries decreased with longer/consistent everyday use of the newer CI (p < 0.05). Yet, despite consistent everyday device use of the second CI (>12 hours/day), only a small proportion of children implanted sequentially (one out of seven children) achieved symmetrical function similar to children with simultaneously received bilateral CIs.

Consistent everyday CI use contributes to higher speech perception scores. Although consistent CI use can help reduce the asymmetry in speech perception abilities of children with sequentially implanted CIs subsequent to interimplant delay, residual asymmetry often persists.

The relationship between biological and psychosocial risk factors and resting-state functional connectivity in 2-month-old Bangladeshi infants: A feasibility and pilot study

Childhood poverty has been associated with structural and functional alterations in the developing brain. However, poverty does not alter brain development directly, but acts through associated biological or psychosocial risk factors (e.g. malnutrition, family conflict). Yet few studies have investigated risk factors in the context of infant neurodevelopment, and none have done so in low‐resource settings such as Bangladesh, where children are exposed to multiple, severe biological and psychosocial hazards. In this feasibility and pilot study, usable resting‐state fMRI data were acquired in infants from extremely poor (n = 16) and (relatively) more affluent (n = 16) families in Dhaka, Bangladesh. Whole‐brain intrinsic functional connectivity (iFC) was estimated using bilateral seeds in the amygdala, where iFC has shown susceptibility to early life stress, and in sensory areas, which have exhibited less susceptibility to early life hazards. Biological and psychosocial risk factors were examined for associations with iFC. Three resting‐state networks were identified in within‐group brain maps: medial temporal/striatal, visual, and auditory networks. Infants from extremely poor families compared with those from more affluent families exhibited greater (i.e. less negative) iFC in precuneus for amygdala seeds; however, no group differences in iFC were observed for sensory area seeds. Height‐for‐age, a proxy for malnutrition/infection, was not associated with amygdala/precuneus iFC, whereas prenatal family conflict was positively correlated. Findings suggest that it is feasible to conduct infant fMRI studies in low‐resource settings. Challenges and practical steps for successful implementations are discussed.

In-season changes in heart rate recovery are inversely related to time to exhaustion but not aerobic capacity in rowers

To determine if in-season changes in heart rate recovery (HRR) are related to aerobic fitness and performance in collegiate rowers. Twenty-two female collegiate rowers completed testing before and after their competitive season. Body fat percentage (BF%) was determined by dual-energy X-ray absorptiometry. Maximal aerobic capacity (VO_2max ) and time to exhaustion (T_max ) were determined during maximal rowing ergometer testing followed by 1 minute of recovery. HRR was expressed absolutely and as a percentage of maximal HR (HRR%_1 min ). Variables were compared using paired Wilcoxon tests. Multivariable regression models were used to predict in-season changes in HRR using changes in VO_2max and T_max , while accounting for changes in BF%. From preseason to post-season, VO_2max and BF% decreased (3.98±0.42 vs 3.78±0.35 L/min, P=.002 and 23.8±3.4 vs 21.3±3.9%, P<.001, respectively), while T_max increased (11.7±1.3 vs 12.6±1.3 min, P=.002), and HRR%_1 min increased (11.1±2.7 vs 13.8±3.8, P=.001). In-season changes in VO_2max were not associated with HRR%_1 min (P>.05). In-season changes in T_max were related to changes in HRR%_1 min (β=-1.67, P=.006). In-season changes in BF% were not related to changes in HRR (P>.05 for all). HRR_1 min and HRR%_1 min were faster preseason to post-season, although the changes were unrelated to VO_2max . Faster HRR%_1 min post-season was inversely related to changes in T_max . This suggests that HRR should not be used as a measure of aerobic capacity in collegiate rowers, but is a promising measure of training status in this population.

Current methods for the management of endometriosis in adolescent patients

Endometriosis is increasingly recognized as a challenging problem of both diagnosis and management in adolescent gynecology. Areas covered: This special report summarizes the current practices in the evaluation and management of endometriosis in adolescent patients. Expert commentary: We recommend prompt recognition and treatment of endometriosis whenever possible. Management should begin with empiric treatment with NSAIDS and hormonal therapy if complaints of pain interfering with daily activities are elicited. If a patient fails medical therapy after three to six months, surgical intervention is warranted by a clinician experienced in operating in this age range and familiar with the appearance of endometriosis in this age range.

A Role for Histone H2B Variants in Endocrine-Resistant Breast Cancer

Acquired resistance to aromatase inhibitors (AIs) remains a major clinical problem in the treatment of estrogen receptor-positive (ER+) breast cancer. We and others have previously reported widespread changes in DNA methylation using breast cancer cell line models of endocrine resistance. Here, we show that the histone variant HIST1H2BE is hypomethylated in estrogen deprivation-resistant C4-12 and long-term estrogen-deprived (LTED) cells compared with parental MCF-7 cells. As expected, this hypomethylation associates with increased expression of HIST1H2BE in C4-12 and LTED cells. Both overexpression and downregulation of HIST1H2BE caused decreased proliferation in breast cancer cell lines suggesting the need for tightly controlled expression of this histone variant. Gene expression analysis showed varied expression of HIST1H2BE in a large panel of breast cancer cell lines, without restriction to specific molecular subtypes. Analysis of HIST1H2BE messenger RNA (mRNA) expression in ER+ AI-treated breast tumors showed significantly higher expression in resistant (n = 19) compared with sensitive (n = 37) tumors (p = 0.01). Using nanostring analysis, we measured expression of all 61 histone variants in endocrine-resistant and endocrine-sensitive tumors. We found significant overexpression of 22 variant histone genes in tumors resistant to AI therapy. In silico The Cancer Genome Atlas (TCGA) analysis showed frequent amplification of the HIST1 locus. In summary, our studies show, for the first time, that overexpression of histone variants might be important in endocrine response in ER+ breast cancer, and that overexpression is at least in part mediated via epigenetic mechanisms and amplifications. Future studies addressing endocrine response should include a potential role of these currently understudied histone variants.

X-linked TEX11 mutations, meiotic arrest, and azoospermia in infertile men

BACKGROUND

The genetic basis of nonobstructive azoospermia is unknown in the majority of infertile men.

METHODS

We performed array comparative genomic hybridization testing in blood samples obtained from 15 patients with azoospermia, and we performed mutation screening by means of direct Sanger sequencing of the testis-expressed 11 gene (TEX11) open reading frame in blood and semen samples obtained from 289 patients with azoospermia and 384 controls.

RESULTS

We identified a 99-kb hemizygous loss on chromosome Xq13.2 that involved three TEX11 exons. This loss, which was identical in 2 patients with azoospermia, predicts a deletion of 79 amino acids within the meiosis-specific sporulation domain SPO22. Our subsequent mutation screening showed five novel TEX11 mutations: three splicing mutations and two missense mutations. These mutations, which occurred in 7 of 289 men with azoospermia (2.4%), were absent in 384 controls with normal sperm concentrations (P=0.003). Notably, five of those TEX11 mutations were detected in 33 patients (15%) with azoospermia who received a diagnosis of azoospermia with meiotic arrest. Meiotic arrest in these patients resembled the phenotype of Tex11-deficient male mice. Immunohistochemical analysis showed specific cytoplasmic TEX11 expression in late spermatocytes, as well as in round and elongated spermatids, in normal human testes. In contrast, testes of patients who had azoospermia with TEX11 mutations had meiotic arrest and lacked TEX11 expression.

CONCLUSIONS

In our study, hemizygous TEX11 mutations were a common cause of meiotic arrest and azoospermia in infertile men. (Funded by the National Institutes of Health and others.).

Oocyte cryopreservation in a patient with sickle cell disease prior to hematopoietic stem cell transplantation: first report

PURPOSE

To report the first occurrence of successful ovarian stimulation, oocyte retrieval and oocyte cryopreservation for fertility preservation in an adolescent with severe sickle cell disease scheduled to undergo a hematopoietic stem cell transplant

METHODS

Case report.

RESULTS

A 19 year old female with severe sickle cell disease presented for fertility preservation counseling prior to hematopoietic stem cell transplantation. She ultimately underwent ovarian stimulation using a minimal stimulation GnRH antagonist protocol resulting in the successful banking of oocytes prior to transplant. The unique hazards associated with ovarian stimulation in patients with sickle cell disease, such as thrombosis and vaso-occlusive events, are discussed and the methods undertaken to minimize these risks are described.

CONCLUSIONS

Controlled ovarian hyperstimulation and oocyte banking for fertility preservation is feasible in young women with sickle cell disease requiring hematopoietic stem cell transplant and deserves further investigation. Given the elevated risk of thrombosis and predisposition to painful vaso-occlusive events, controlled ovarian hyperstimulation in patients with sickle cell disease is not straightforward and requires a multi-disciplinary team approach to adequately address and minimize the risks in this unique patient population.

Adolescent endometriosis: diagnosis and treatment approaches

OBJECTIVES

To review the etiologies, diagnosis, and treatment options of adolescent endometriosis.

METHODS

Review of publications relating to adolescent endometriosis.

RESULTS

Endometriosis occurs in adolescents as young as 8 years of age; furthermore, there have been documented cases of endometriosis occurring prior to menarche. Adolescents presenting with pelvic pain are treated with cyclic combination oral contraceptive pills and nonsteroidal anti-inflammatory agents. If the pain does not respond to these therapies, then in adolescents as in adults, an operative laparoscopy is recommended for the diagnosis and surgical management of endometriosis. The operating gynecologist should be familiar with the appearance of the complete spectrum of various morphologies of endometriosis, as adolescents tend to have clear, red, white, and/or yellow-brown lesions more frequently than black or blue lesions. Subtle clear lesions of endometriosis may be better visualized by filling the pelvis with irrigation fluid so that the clear lesions can be appreciated in a three-dimensional appearance. Young women who are found to have endometriosis by laparoscopy may present with acyclic, cyclic, and constant pelvic pain. Adolescents with pelvic pain not responding to conventional medical therapy have approximately a 70% prevalence of endometriosis. It is known that endometriosis is a progressive disease and since there is no cure, adolescents with endometriosis require long-term medical management until the time in their lives when they have completed childbearing. Psychosocial support is extremely important for this population of young women with endometriosis.

CONCLUSIONS

Endometriosis occurs in adolescents, and presenting symptoms may vary from those seen in adult women with the disease. All health care providers must be aware of the existence of adolescent endometriosis. They should also be aware of the presenting symptoms so that the adolescent can be appropriately referred to a gynecologist comfortable with medical and surgical treatment options in this patient population. If laparoscopy is to be undertaken, the gynecologist must be prepared not only to diagnose but to surgically manage endometriosis. In addition, the subtle laparoscopic findings of endometriosis in adolescents must be recognized for an appropriate diagnosis. Long-term medical therapy will hopefully decrease pain and the progression of the disease, thus decreasing the risk of advanced-stage disease and infertility.

A randomized, controlled pilot study of the safety and efficacy of 4% icodextrin solution in the reduction of adhesions following laparoscopic gynaecological surgery

BACKGROUND

Adhesion-related readmissions are frequent sequelae to gynaecological surgery. Attempts to prevent adhesions by separating healing peritoneal surfaces include site-specific barriers and hydroflotation by instilled solutions. Rapid absorption limits the effectiveness of solutions such as Ringer's lactated saline (RLS). This pilot study assessed the safety, tolerability and preliminary effectiveness of a non-viscous, iso-osmolar solution of 4% icodextrin, an alpha-1,4 glucose polymer with prolonged intraperitoneal residence, in reducing adhesions after laparoscopic gynaecological surgery.

METHODS

Women aged > or = 18 years, requiring laparoscopic adnexal surgery (n = 62), were entered into a randomized, open-label, assessor-blinded, multicentre study to compare 4% icodextrin with RLS. Treatments were coded in blocks of four with equal randomization to each group, and pre-allocated to consecutively numbered patients. At least 100 ml per 30 min was used for intra-operative lavage, with 1 l instilled post-operatively. Per protocol analysis included all eligible patients (n = 53); reformation analysis required one or more baseline adhesion (n = 42). Incidence, extent and severity of post-operative adhesions were assessed at second-look laparoscopy after 6-12 weeks. Procedures were video-taped for third party, blinded assessment.

RESULTS

Safety and tolerability (laboratory variables, adverse events, clinical follow-up) were good with no difference between treatments. A shift analysis of incidence-ranked adhesions (n = 53) showed apparent improvements in more patients with icodextrin than RLS (37 versus 15%; not significant). Adhesion score reduction (n = 42) was more frequent in icodextrin- than RLS-treated patients: incidence (52 versus 32%), extent (52 versus 47%), and severity (65 versus 37%). Despite greater baseline adhesions, median reformation was less after icodextrin (24%) than RLS (60%). The pilot study group sizes were not powered for statistical significance.

CONCLUSIONS

In this preliminary study, 4% icodextrin lavage plus instillation was well tolerated and reduced adhesion formation and reformation following laparoscopic gynaecological surgery. A Phase III pivotal study is currently in progress.

Guidelines for the diagnosis and treatment of hyperprolactinemia

Hyperprolactinemia is the most common endocrine disorder of the hypothalamic-pituitary axis. While it can occur in men, it occurs more commonly in women. The prevalence of hyperprolactinemia ranges from 0.4% in an unselected normal adult population to as high as 9-17% in women with reproductive disorders. There are many possible causes of hyperprolactinemia, falling into three general categories: physiologic, pharmacologic and pathologic. When specific treatable underlying causes have been eliminated and in cases of severe hyperprolactinemia, the most likely cause is a prolactin (PRL)-secreting pituitary adenoma. Microadenomas should be treated medically, with a dopamine agonist, if there is an indication for therapy (such as amenorrhea, infertility or bothersome galactorrhea). If there is no indication for therapy, microadenomas may be followed conservatively, as growth is uncommon. Macroadenomas may grow larger; medical therapy is recommended initially, with neurosurgical evaluation reserved for specific clinical situations, such as failure of medical therapy and evidence of mass effect despite medical therapy. In the United States, the dopamine agonists indicated for treatment of hyperprolactinemia are bromocriptine and cabergoline. Bromocriptine is usually given once or twice daily, while cabergoline has a long duration of action and is given once or twice weekly. Results of comparative studies indicate that cabergoline is clearly superior to bromocriptine in efficacy (PRL suppression, restoration of gonadal function) and tolerability.

Luteinizing hormone and human chorionic gonadotropin decrease type 2 5 alpha-reductase and androgen receptor protein levels in women's skin

The present study tested the hypothesis that LH/hCG may regulate the type 2 5 alpha-reductase and androgen receptor protein levels in skin. The skin samples obtained from women undergoing abdominal laparotomy or abdominoplasty were incubated in the presence or absence of hCG. Western blotting was then performed to determine the response of type 2 5 alpha-reductase and androgen receptors. The results demonstrated that treatment with hCG resulted in a significant time- and dose-dependent, although modest, decrease in 5 alpha-reductase and androgen receptor levels compared to the controls. These effects were mimicked by LH, but not by other hormones in the glycoprotein hormone family, including alpha- and beta-subunits of hCG. Although the biological and clinical importance of this regulation remains to be determined, these findings reaffirm that human skin is among the nongonadal tissues that respond to LH and hCG treatment.

Looking down the prospectoscope: obstetrics/gynecology in the year 2000 and beyond

It should be emphasized that the American College of Obstetricians and Gynecologists is advocating that those Obstetrician/Gynecologists who wish to be included under this new designation primary care physician "provide only ambulatory primary care," states the Executive Director, Dr. Ralph W. Hale. Thus, we enter a new era and must understand the lexicons, including HMO, independent provider organization, PPO, managed care organization, exclusive provider organization, IPA, hospital-physician organization, health plan provider data and information set, physician-hospital organization and utilization management--all these have become words with increased meaning for all clinicians. It is a rare physician lounge without physicians preoccupied by discussions regarding managed care, "Have you heard the latest reimbursement schedule?" or "It's less than Medicaid," and the discussions continue indefinitely. There has been a continued effort to have physicians be cost-efficient in their approach to all aspects of obstetrical and gynecological care. Capitation has proven to be the virtually exclusive method of reimbursement. Continued care with respect to clinical outcome, resource utilization, patient satisfaction, and quality care restructuring of practice/personnel/patient approach is based on the quarterly patient surveys, which have been evaluated and carefully reviewed. Patient satisfaction with a sincere effort to provide quality of care remains the underlying theme with respect to obstetrical and gynecological patient care. These are basic tenets. What is the future of obstetrics/gynecology with respect to managed health care? It does make sense to have a planned and well-coordinated approach to delivery of obstetrical as well as gynecological care with the goal of "quality" delivered at a "lower cost" having an overall positive impact on OB/GYN health care delivery. Currently, there are a number of states which have specific legislation enabling a patient to proceed to secure gynecological without going through a "gatekeeper." As we approach the year 2000 and beyond, clearly the prediction is that this will be an ever-increasing goal and objective of state medical societies to provide easy access for women's health care. Thus, we have awakened into a new era that is hallmarked by efficient, quality medical care provided by a physician who initially trained to be a subspecialist and now is an ambulatory primary care physician.

[Fortunes and misfortunes of a metal]

The history of amalgam (which essentially consists of mercury and silver) is briefly reviewed, from its origin through different civilizations. The various ways by which silver was extracted during colonial times are mentioned; credit for invention of the method, however, still remains unknown. Finally, the study lists the purposes for which the amalgam was originally used, mainly for the benefit of the mining industry, and only much later introduced into medicine and hence onto odontology.

Immunocytochemical localization of relaxin in human corpora lutea: cellular and subcellular distribution and dependence on reproductive state

Relaxin is one of the hormones present during pregnancy and it is synthesized primarily by corpora lutea (CL). Other reproductive tissues including CL of the menstrual cycle may also synthesize this hormone. Very little is known, however, about the cellular and subcellular distribution of relaxin in human CL and dependence of luteal relaxin on the reproductive state. The light and electron microscope immunocytochemical studies described here were undertaken to obtain this information using antisera to porcine and human relaxin. Immunostaining was found in large luteal cells (17-30 microns) but not in small luteal cells (7-16 microns) or in nonluteal cells in any of the reproductive states or in human hepatocytes. Luteal immunostaining was low in early luteal phase; it increased progressively, reaching the highest level in late luteal phase, and then decreased greatly in corpora albicantia. Term pregnancy CL contained similar immunostaining as early luteal phase CL. Mid luteal phase CL contained more immunostained cells than late luteal phase CL, but the late luteal phase CL contained a greater amount of immunostaining per cell than mid luteal phase CL. The immunogold particles due to relaxin were primarily present in secretory granules and to a small extent in rough endoplasmic reticulum. Quantitation revealed that secretory granules contained a much higher number of gold particles than did rough endoplasmic reticulum. These two organelles from late luteal phase CL contained greater numbers of gold particles than those from mid luteal phase.(ABSTRACT TRUNCATED AT 250 WORDS)

[Esthetic dentistry in the prehispanic world]

The dental practices found by Spaniards in the new world in the sixteenth century were totally different from the ones done in Europe at that time. They were of two types, ornamental and curative. This paper displays the diverse types of ornamental dental practices performed in pre-Hispanic America, which have nothing to do with the concept of Odontology, as the object of these practices was to impart a type of dental aesthetics different from the classical concept of beauty. Outstanding among such practices were inlays, filing and polishing of teeth, and their pigmentation.

Binding of 125I-epidermal growth factor in human uterus

Quantitative light-microscopic autoradiography was used on five human uteri at two different phases of the menstrual cycle to ascertain the cell types with binding sites for epidermal growth factor (EGF). The results revealed that stromal cells, glandular epithelium of endometrium, elongated and circular muscle cells of myometrium, smooth muscle and endothelial cells of arterioles in the basal endometrium and myometrium contained numerous silver grains following incubation with 125I-EGF. Coincubation with 100-fold excess unlabeled EGF resulted in a complete disappearance of silver grains from all cell types. Quantitative grain analysis indicated that stromal cells contained the highest number of EGF-binding sites (P less than 0.05) with no significant differences among the others (P greater than 0.05). There was no cyclic variation of EGF-binding to any of the uterine cell types. The present data demonstrate that all the cell types of human uterus, including arterioles, contain EGF-binding sites. This suggests that all the cells in human uterus subserving different functions are targets of EGF action.

Prostaglandin binding to different cell types of human uterus: quantitative light microscope autoradiographic study

Five human uteri of the menstrual cycle were analyzed by quantitative light microscope autoradiography to determine which uterine cell types contain prostaglandin (PG) binding sites. The results showed that stromal cells, glandular epithelium, elongated and circular smooth muscles, arterioles and erythrocytes in lumen of arterioles contained numerous PGE and very few or no detectable PGF2 alpha binding sites. The grains which were present when incubated with [3H]PGE2 alone completely disappeared following coincubation with excess unlabeled PGE2 but not with excess unlabeled PGA1. Analysis of grain count data revealed that PGE binding sites in arterioles were lower than those in other uterine cell types and PGE binding sites in endometrial cells of proliferative phase uteri were higher than those in secretory phase uteri (P less than 0.05). Thus the present results demonstrate that all the cell types, including arterioles of human uterus of the menstrual cycle, contain PGE and minimal PGF2 alpha binding sites. This suggests that PGE binding sites in different cell types of human uterus subserve diverse effects of PGEs.

The presence of gonadotropin binding sites in the intracellular organelles of human ovaries

The nuclei (N), plasma membranes (PM), mitochondria-lysosomes, rough endoplasmic reticulum, and combined (light, medium, and heavy) Golgi (G) fractions were isolated from human ovaries. The purities of these fractions were evaluated by assays of appropriate marker enzymes, which revealed that some fractions were very pure but that others had minor contamination. When tested, all of the fractions exhibited 125I-labeled human chorionic gonadotropin (125I-hCG)-specific binding. This intracellular 125I-hCG binding was not due to PM contamination because: (1) N, which had no detectable 5'-nucleotidase (5'-NE) activity, a marker for PM, exhibited 125I-hCG-specific binding; (2) the G, which had only a fraction of the 5'-NE activity of PM, exhibited as much binding as PM; and (3) the ratios between specific 125I-hCG binding and 5'-NE activity in other fractions were not the same as for PM. They should have been the same if PM contamination was responsible for the 125I-hCG binding observed in other organelles. In conclusion, our results demonstrate that gonadotropin-binding sites are present in various intracellular organelles as well as in PM of human ovaries.