Individual patient data meta-analysis of randomized evidence to assess the effectiveness of laparoscopic uterosacral nerve ablation in chronic pelvic pain

BACKGROUND

There have been conflicting results in randomized trials of the effects of laparoscopic uterosacral nerve ablation (LUNA) in chronic pelvic pain. Our objective was to perform a meta-analysis using individual patient data (IPD) to provide the most comprehensive and reliable assessment of the effectiveness of LUNA.

METHODS

Electronic searches were conducted in the Medline, Embase, PsycInfo and Cochrane Library databases from database inception to August 2009. The reference lists of known relevant papers were searched for any further articles. Randomized trials comparing LUNA with no additional intervention were selected and authors contacted for IPD. Raw data were available from 862 women randomized into five trials. Pain scores were calibrated to a 10-point scale and were analysed using a multilevel model allowing for repeated measures.

RESULTS

There was no significant difference between LUNA and No LUNA for the worst pain recorded over a 12 month time period (mean difference 0.25 points in favour of No LUNA on a 0-10 point scale, 95% confidence interval: -0.08 to 0.58; P = 0.1).

CONCLUSIONS

LUNA does not result in improved chronic pelvic pain.

Communication of adenomyosis with the endometrial cavity: visualization with saline contrast sonohysterography

We report four cases of a finding of communication between the endometrial cavity and adenomyotic lesions observed during saline contrast sonohysterography. In each case there was a saline-filled defect extending from the endometrial cavity into the myometrium in the region of previously suspected adenomyosis. We believe this finding represents the sonohysterographic correlate of endometrium invading the myometrium, as has been described histologically.

A six-month randomized controlled trial of exercise and pyridostigmine in the treatment of fibromyalgia

OBJECTIVE

A subset of fibromyalgia (FM) patients have a dysfunctional hypothalamic-pituitary-insulin-like growth factor 1 (IGF-1) axis, as evidenced by low serum levels of IGF-1 and a reduced growth hormone (GH) response to physiologic stimuli. There is evidence that pyridostigmine (PYD) improves the acute response of GH to exercise in FM patients. The purpose of this study was to evaluate the clinical effectiveness of 6 months of PYD and group exercise on FM symptoms.

METHODS

FM patients were randomized to 1 of the following 4 groups: PYD plus exercise, PYD plus diet recall but no exercise, placebo plus exercise, and placebo plus diet recall but no exercise. The primary outcome measures were the visual analog scale (VAS) score for pain, tender point count, and total myalgic score. Secondary outcome measures were the total score on the Fibromyalgia Impact Questionnaire (FIQ) and FIQ VAS scores for individual symptoms (fatigue, poor sleep, stiffness, and anxiety), as well as quality of life (QOL) and physical fitness (lower body strength/endurance, upper and lower body flexibility, balance, and time on the treadmill).

RESULTS

A total of 165 FM patients completed baseline measurements; 154 (93.3%) completed the study. The combination of PYD and exercise did not improve pain scores. PYD groups showed a significant improvement in sleep and anxiety in those who completed the study and in QOL in those who complied with the therapeutic regimen as compared with the placebo groups. Compared with the nonexercise groups, the 2 exercise groups demonstrated improvement in fatigue and fitness. PYD was generally well tolerated.

CONCLUSION

Neither the combination of PYD plus supervised exercise nor either treatment alone yielded improvement in most FM symptoms. However, PYD did improve anxiety and sleep, and exercise improved fatigue and fitness. We speculate that PYD may have improved vagal tone, thus benefiting sleep and anxiety; this notion warrants further study.

The morphology of the koniocellular axon pathway in the macaque monkey

The key objective of this study was to determine the distribution and morphology of koniocellular (K) lateral geniculate nucleus (LGN) axons in primary visual cortex (V1) of the macaque monkey. In particular, we were interested in understanding whether subpopulations of K axons exist in this species and, if so, if these subpopulations arise from different K layers of the LGN. Restricted injections of the tracers, biotinilated dextran amine, or Phaseolus vulgaris leucoagglutinin were targeted to specific LGN K layers under electrophysiological guidance and immunocytochemistry was used to visualize labeled axons in cortex that were subsequently reconstructed through serial sections. A total of 36 complete axons and 166 axon segments were reconstructed. Our results identified at least 2 main subpopulations of K axons in macaque V1 based on branching patterns and bouton distribution. Axons that arise primarily from LGN layers K1 and K2 are morphologically simple and tend to branch in cortical layers 1 and 3A. These axons give rise to fewer boutons than seen in axons arising from the dorsal K LGN layers K3-K6. Axons that arise from LGN layers K3-K6 terminate as complex, focused arbors in the cytochrome oxidase (CO) blobs in layer 3Balpha, with only occasional simple projections to the more superficial layers of cortex. Combined with previous observations, our data suggest that there are at least 3 subclasses of K LGN axons in macaque monkey that are similar to K axons identified earlier in both nocturnal simian owl monkeys (Ding and Casagrande 1997) and in prosimian, bush babies (Lachica and Casagrande 1992) suggesting that the LGN K channels that terminate in the CO blobs and in layer 1 are not unique to macaque monkeys but are a common primate feature.

Genomic progression in mouse models for liver tumors

The principal cause of human liver cancer is infection with hepatitis viruses B and C, but tumor progression is fueled by ensuing perturbations that confer gain of function on proto-oncogenes or loss of function on tumor suppressor genes. Frequent among these perturbations is overexpression of the proto-oncogene MET. We have modeled the pathogenesis of liver tumors by expressing conditional transgenes of MET in the hepatocytes of inbred mice. The response to the MET transgene varied with both the magnitude and timing of its expression but included hyperplasia of hepatic progenitor cells, as well as benign and malignant tumors that display both phenotypic and genotypic resemblances to human counterparts. The results reveal MET to be a crucial switch in the development of the liver; dramatize how different cellular compartments within a developmental lineage can give rise to distinctive tumor stem cells; delineate rules of tumor progression; provide evidence that the experimental tumors in mice are authentic models for human tumors; and support a role for MET in the genesis of human liver tumors. The models should be useful in elucidating the mechanisms of tumorigenesis and in the preclinical testing of new therapeutics.

Obstipation as a paraneoplastic presentation of small cell lung cancer: case report and literature review

Paraneoplastic symptoms caused by abnormal gastrointestinal motility may be the initial manifestation of small cell lung cancer (SCLC). We report a case of a 63-year-old woman who presented with progressive constipation culminating in obstipation, and associated symptoms of more widespread dysmotility. A paraneoplastic syndrome was suspected. The only abnormality on chest computed tomography was a minimally enlarged paratracheal lymph node. Positron emission tomography demonstrated increased activity in the lymph node. The antinuclear neuronal antibody titer was elevated. Bronchoscopy with transtracheal biopsy confirmed the diagnosis of SCLC. One year after diagnosis, the patient had progressive symptoms of intestinal obstruction, and ultimately feculent vomiting. On abdominal radiography, colonic sitz markers ingested a year earlier were in virtually the same positions as after ingestion. Palliative colectomy with ileostomy was performed. The myenteric plexus in the terminal ileum and colon showed infiltration by a mixture of B-cell and T-cell lymphocytes and plasma cells, and no gross neuronal abnormalities. We review the clinical and pathologic features, clinical course, and management of paraneoplastic pseudoobstruction.

Screening for gestational diabetes: a retrospective audit

There are various indications for screening pregnant women for gestational diabetes. Screening is then often carried out by performing a timed random blood sugar (t-RBS). In this unit a raised t-RBS is an indication to perform a glucose tolerance test (GTT), and if this is abnormal, the patient is managed with dietary modification or insulin therapy. A t-RBS is considered abnormal if the fasting value (> 2 hours since last meal) is > 5.7 mmol/l, or the non-fasting value (<2 hours since last metal) is > 6.3 mmol/l. However, higher t-RBS values have been recommended by the Diabetic Pregnancy Study Group. This group considers a t-RBS abnormal if the fasting value is > 6.1 mmol/l, or the non-fasting value is > 7.0 mmol/l. A retrospective audit was carried out to determine if cases of gestational diabetes would have been missed if the new guidelines were adopted. There were 112 patients with a fasting t-RBS of 5.8 to 6.1 mmol/l, inclusive, and 196 patients with a non-fasting t-RBS of 6.4 to 7.0 mmol/l, inclusive; 45 patients did not have a GTT result. Therefore 263 patients were included in the study. The number of patients with a normal GTT result was 257 (97.7%), and 6 (2.30%) patients had an abnormal GTT result. Only 4 (1.52%) were labelled as gestational diabetics, and all these cases were managed with diet alone with no adverse obstetric outcome. A large number of GTTs are performed unnecessarily in our unit, and the values recommended by the Diabetic Pregnancy Study Group should be adopted.

Laser laparoscopy for endometriosis and endometriotic cysts

BACKGROUND

Endometriosis is a common and debilitating condition involving women during their reproductive years. It is characterized by the occurrence of endometrial glands and stroma outside the uterine cavity. Presenting symptoms include chronic nonmenstrual pelvic pain, dysmenorrhea, dyspareunia, and subfertility. The condition is diagnosed at laparoscopy, and operative laparoscopic surgery for endometriosis is also possible.

METHODS

This article critically evaluates the evidence for the laparoscopic management of endometriosis and endometriotic cysts. It focuses on laser laparoscopy and reviews the contribution made by the Minimal Access Therapy Training Unit, Guildford, UK, to the treatment of this condition.

RESULTS

Few randomized controlled trials have been undertaken to evaluate the surgical management of endometriosis. The studies that have been done show that laparoscopic surgery, including laser laparoscopy, is effective in the management of painful symptoms and subfertility and preventing cyst recurrence. Several of the landmark studies in this area have been carried out in Guildford.

CONCLUSION

Laparoscopic surgery is the treatment of choice for patients with endometriosis and endometriotic cysts.

Recurrence of chocolate cysts after laparoscopic ablation

STUDY OBJECTIVE

To estimate the recurrence rate of chocolate cysts 3 to 12 months after ablative laparoscopic surgery. The secondary outcome measure was the need for a repeat surgical procedure.

DESIGN

Prospective cohort study (Canadian Task Force classification II-2).

SETTING

Tertiary referral center for laparoscopic treatment of endometriosis.

PATIENTS

Seventy-three consecutive women with chocolate cysts larger than 2 cm.

INTERVENTION

Laparoscopy at which cyst capsules were vaporized or coagulated with the potassium-titanyl-phosphate (KTP) laser or Bicap bipolar diathermy.

MEASUREMENTS AND MAIN RESULTS

There were 96 cysts (23 bilateral) in 73 women (1 patient underwent a two-stage procedure). Their mean diameter was 4.79 cm (range 2-25 cm). The median r-AFS score was 56 (range 22-128), and 55 patients (75.3%) had stage 4 disease. The KTP laser was used in 50 women (68.5%) and bipolar diathermy in 23 (31.5%). At 12 months, 5 patients (6.9%) were lost to follow-up, and 12 had a recurrent cyst. Therefore, the cyst recurrence rate/patient was 16.4% (12/73) and the rate/cyst was 12.5% (12/96). Women who had recurrences were significantly more likely to have bilateral cysts, 7/12 (58.3%), than those with single cysts, 16/61 (26.2%, p =0.032). Bicap bipolar diathermy was associated with a recurrence rate of 20.8% (5/24). The rate in women who had KTP laser ablation was 14.3% (7/49, NS). Eighteen patients had repeat operations (including on recurrent cysts). Therefore the reoperation rate was 24.6% (18/73). No major surgical complications occurred. One woman had a postoperative wound infection after a second procedure to remove an ovary with a recurrent cyst.

CONCLUSION

Laparoscopic cyst fenestration followed by capsule ablation is safe and effective treatment for preventing recurrence of chocolate cysts.

The ovarian endometrioma: why is it so poorly managed? Indicators from an anonymous survey

As a tertiary referral centre for women with severe endometriosis we see a large number of patients who have endometriotic cysts, and many of these patients have been operated on by gynaecologists elsewhere in the UK. We have been surprised by the variety of approaches to their management. In order to establish the current clinical practices of endometrioma management amongst gynaecologists in the UK, we have carried out an anonymous survey. There appears to be an equal preference for open versus endoscopic surgery, even though there is considerable evidence suggesting that endoscopic surgery is superior. However, the management of endometriomas varies significantly between the two groups. In this article, we have presented the results of our survey and used them as the basis for a debate on the management of endometriomas.

Long term outcome following laparoscopic supracervical hysterectomy

OBJECTIVES

To assess the long term outcome of laparoscopic supracervical hysterectomy.

DESIGN

Retrospective study.

SETTING

Minimal Access Surgical Unit, Department of Gynaecology, Royal Surrey County Hospital, Surrey.

METHODS

Analysis of patient case records.

POPULATION

Seventy consecutive women who had a laparoscopic supracervical hysterectomy. OUTCOME MEASURES Symptoms related to the cervical stump and the need for further surgery.

RESULTS

The mean time of patient follow up was 66 months (range 52-84). The mean time from initial procedure to second treatment was 14 months (range 3-53). Seventeen women (24.3%) reported symptoms related to the cervical stump, and all required further surgery. The cervical stump was removed in 16 (22.8%). One patient had laparoscopic adhesiolysis only and two had a laparotomy and trachelectomy because the bowel was adherent to the cervical stump. Nine had a laparoscopically assisted cervical trachelectomy as the sole procedure. Five had laser treatment to endometriotic deposits, and laparoscopically assisted cervical trachelectomy. Histological analysis showed normal cervical tissue in six (35.3%). Endometriosis was detected in four cervical stumps (23.5 %), residual endometrium in another four (23.5 %) cases, and chronic cervicitis, mild CIN and a mucocoele in a further three patients. Of the 17 women who reported cervical stump symptoms, 14 (82.3%) had been treated for endometriosis in the past, compared with 17/53 (32%) who did not have symptoms (P < 0.0002, chi2 test).

CONCLUSIONS

Symptoms related to the cervical stump requiring further surgery frequently occur following a laparoscopic supracervical hysterectomy.

Exercise for patients with fibromyalgia: risks versus benefits

Although exercise in the form of stretching, strength maintenance, and aerobic conditioning is generally considered beneficial to patients with fibromyalgia (FM), there is no reliable evidence to explain why exercise should help alleviate the primary symptom of FM, namely pain. Study results are varied and do not provide a uniform consensus that exercise is beneficial or what type, intensity, or duration of exercise is best. Patients who suffer from exercise-induced pain often do not follow through with recommendations. Evidence-based prescriptions are usually inadequate because most are based on methods designed for persons without FM and, therefore, lack individualization. A mismatch between exercise intensity and level of conditioning may trigger a classic neuroendocrine stress reaction. This review considers the adverse and beneficial effects of exercise. It also provides a patient guide to exercise that takes into account the risks and benefits of exercise for persons with FM.

Long-term follow-up of a controlled trial of laser laparoscopy for pelvic pain

BACKGROUND AND OBJECTIVES

The purpose of this study was to assess the long-term efficacy of laparoscopic laser surgery in the treatment of painful pelvic endometriosis.

METHODS

We conducted a long-term follow-up of 56 patients who had participated in a randomized, double-blind controlled study at a tertiary referral center for the laparoscopic treatment of endometriosis. The patients had pelvic pain, minimal-to-moderate endometriosis, and underwent laser laparoscopy. We asked patients whether they had now achieved satisfactory symptom relief or whether they had received any further medical intervention for their endometriosis. The main outcome measure was continued symptom relief after treatment and subsequent medical history.

RESULTS

Of the original 56 patients, we were able to contact 38 (67.9%). The mean (range) time since operation was 73 months. Painful symptoms had recurred in 28/38 (73.7%) patients at some point since their operation. The median (range) time for recurrence was 19.7 (5-60) months. At the time of follow-up, satisfactory symptom relief was reported in 21/38 (55.3%) patients. The remaining 17/38 (44.7%) patients continued to experience painful symptoms, and eight eventually had a hysterectomy.

CONCLUSIONS

This study suggests that operative laparoscopy can have long-term benefits for the majority of women with pelvic pain due to endometriosis, but because of the small numbers, this study lacks the power to demonstrate this conclusively.

Laparoscopic management of ovarian endometriomas: a critical review of current practice

Endometriomas are a common cause of gynaecological morbidity, but their aetiology and management remain controversial This review focuses on identifying the evidence from published literature for the laparoscopic management of ovarian endometriomas. A critical appraisal shows that laparoscopic surgery is equivalent to laparotomy. There is no evidence to suggest that one minimal access surgical technique is clearly superior to another. However, this may be related to the inconsistencies in study design. In view of this we describe and justify our own management strategy for dealing with endometriomas.

Kaposi's sarcoma-associated herpesvirus-encoded interleukin-6

Since the discovery of the virus in 1994, the rapid pace with which Karposi's sarcoma-associated herpesvirus (KSHV) research has progressed has quickly led to a broad understanding of the structure of the virus and its biology and pathology in humans. Molecular piracy of potentially useful cellular genes has emerged as a characteristic feature of this virus. The viral homolog of human IL-6, vIL-6 is an example in kind. Studies in vitro and in vivo have shown that vIL-6 can stimulate the growth of KSHV-infected primary infusion lymphoma (PEL) cells, can promote hematopoiesis, and act as an angiogenic factor through the induction of vascular endothelial growth factor (VEGF). It is not difficult to envision how vIL-6, through these properties and perhaps others yet to be identified, can contribute to KSHV survival and spread in the human population.

The importance of hemoglobin levels during radiotherapy for carcinoma of the cervix

BACKGROUND

It is unclear whether blood transfusion can overcome the negative impact of anemia before or during radiotherapy (RT) in patients with carcinoma of the cervix. The objective of this retrospective study was to examine the impact of anemia and blood transfusion on 605 patients with carcinoma of the cervix treated with radical RT at 7 centers across Canada in 1989, 1990, and 1992.

METHODS

The data collected included hemoglobin (Hgb) levels from the time of diagnosis to the end of therapy; blood transfusions administered; and identifiable patient-, tumor-, and treatment-related factors. Survival, disease free survival, and pelvic control analyses were evaluated by univariate and multivariate analysis.

RESULTS

The median follow-up was 41 months (range, 0-92 months). Presenting Hgb level, average weekly nadir Hgb (AWNH) during RT, and blood transfusion were correlated significantly with local control, disease free survival, and overall survival on univariate analysis. However, the AWNH remained significant on multivariate analysis, whereas Hgb at presentation and blood transfusion did not. The 5-year survival was 74% for patients with an AWNH >/= 120 g/L, 52% for patients with AWNH levels 110-119 g/L inclusive, and 45% for patients with AWNH levels < 110 g/L (P < 0.0001). At each Hgb level, patients who were transfused and maintained a specific Hgb level had a survival rate that was not significantly different from patients who were at that level spontaneously. There was a significant reduction in both pelvic and distant recurrence (P < 0.0001 and P < 0.0006, respectively) in patients whose AWNH level during RT was >/= 120 g/L compared with < 120 g/L. A reduction in the rate of distant recurrence was observed in patients with and without pelvic recurrence.

CONCLUSIONS

AWNH is highly predictive of outcome for patients treated with RT for carcinoma of the cervix. Blood transfusion appears to overcome the negative prognostic effects of low presenting Hgb levels and AWNH levels.

Involvement of interleukin-10 (IL-10) and viral IL-6 in the spontaneous growth of Kaposi's sarcoma herpesvirus-associated infected primary effusion lymphoma cells

Primary effusion lymphoma (PEL) is a distinct type of lymphoma associated with Kaposi's sarcoma-associated herpesvirus (KSHV) infection. To determine the factors responsible for the unrestrained proliferation of PEL, we have studied the growth factor requirements of the PEL-derived BCBL-1 and BC-1 cell lines. Both cell lines were found to be autocrine growth factor dependent and to release human interleukin-6 (IL-6), viral IL-6 (vIL-6), and human IL-10 in the culture supernatant. To establish whether these cytokines contribute to autocrine growth, neutralizing antibodies against human IL-6, vIL-6, human IL-10, and soluble IL-10 receptor were used. These experiments showed that human IL-10 and, to a lesser degree, vIL-6 serve as autocrine growth factors for BCBL-1 and BC-1 cells. Thus, human IL-10 and vIL-6 are growth factors released and used by PEL cells for autonomous proliferation and may be critical to the development and progression of PEL.

Calreticulin and calreticulin fragments are endothelial cell inhibitors that suppress tumor growth

Several angiogenesis inhibitors are fragments of larger proteins that are themselves not active as angiogenesis inhibitors. Vasostatin, the N-terminal domain of calreticulin inclusive of amino acids 1-180, is an angiogenesis inhibitor that exerts antitumor effects in vivo. In the present study, we examined whether the full-length calreticulin molecule shares the antiangiogenic and antitumor activities of vasostatin. Similar to vasostatin, calreticulin selectively inhibited endothelial cell proliferation in vitro, but not cells of other lineages, and suppressed angiogenesis in vivo. When inoculated into athymic mice, calreticulin inhibited Burkitt tumor growth comparably with vasostatin. Calreticulin lacking the N-terminal 1-120 amino acids inhibited endothelial cell proliferation in vitro and Burkitt tumor growth in vivo comparably with vasostatin. An internal calreticulin fragment encompassing amino acids 120-180 also inhibited endothelial cell proliferation in vitro and angiogenesis in vivo comparably with calreticulin and vasostatin. These results suggest that the antiangiogenic activities of vasostatin reside in a domain that is accessible from the full-length calreticulin molecule and localize to calreticulin N-terminal amino acids 120-180. Thus, calreticulin and calreticulin fragments are inhibitors of angiogenesis that directly target endothelial cells, inhibit angiogenesis, and suppress tumor growth. This information may be critical in designing targeted inhibitors of pathological angiogenesis that underlies cancer and other diseases.

Selecting doctoral programs in nursing: resources for students and faculty

Sixty-nine doctoral programs in nursing are currently offered at 75 universities in the United States. Resources to assist prospective doctoral students in making decisions concerning successfully pursuing doctoral education are collected and organized by a variety of nursing organizations. Nurses in academic settings access these lists and specialty publications through their deans' offices and professional affiliations. Prospective students, on the other hand, are largely employed in clinical settings and are often unaware of the existence of this information, which could assist them in their decisions. The purpose of this article is to provide prospective doctoral students and the faculty that may advise them with a current information to use in selecting a doctoral program in nursing.

Cybernetic model of the growth dynamics of Saccharomyces cerevisiae in batch and continuous cultures

Growth of Saccharomyces cerevisiae on glucose in aerobic batch culture follows the well-documented diauxic pattern of completely fermenting glucose to ethanol during the first exponential growth phase, followed by an intermediate lag phase and a second exponential growth phase consuming ethanol. In continuous cultures over a range of intermediate dilution rates, the yeast bioreactor exhibits sustained oscillations in all the measured concentrations, such as cell mass, glucose, ethanol, and dissolved oxygen, the amounts of intracellular storage carbohydrates, such as glycogen and trehalose, the fraction of budded cells as well as the culture pH. We present here a structured, unsegregated model for the yeast growth dynamics developed from the 'cybernetic' modeling framework, to simulate the dynamic competition between all the available metabolic pathways. This cybernetic model accurately predicts all the key experimentally observed aspects: (i) in batch cultures, duration of the intermediate lag phase, sequential production and consumption of ethanol, and the dynamics of the gaseous exchange rates of oxygen and carbon dioxide; and (ii) in continuous cultures, the spontaneous generation of oscillations as well as the variations in period and amplitude of oscillations when the dilution rate or agitatin rate are changed.

Vasostatin, a calreticulin fragment, inhibits angiogenesis and suppresses tumor growth

An endothelial cell inhibitor was purified from supernatant of an Epstein-Barr virus-immortalized cell line and identified as fragments of calreticulin. The purified recombinant NH2-terminal domain of calreticulin (amino acids 1-180) inhibited the proliferation of endothelial cells, but not cells of other lineages, and suppressed angiogenesis in vivo. We have named this NH2-terminal domain of calreticulin vasostatin. When inoculated into athymic mice, vasostatin significantly reduced growth of human Burkitt lymphoma and human colon carcinoma. Compared with other inhibitors of angiogenesis, vasostatin is a small, soluble, and stable molecule that is easy to produce and deliver. As an angiogenesis inhibitor that specifically targets proliferating endothelial cells, vasostatin has a unique potential for cancer treatment.

Interpretation of biopsy findings in the transplant liver

With several thousand liver transplants being performed each year and many patients being managed in their local medical centers, much of the interpretation of transplant liver biopsy specimens has moved from the transplant hospital to the community setting. This article discusses both typical and more peculiar changes that occur in the transplant liver biopsy specimen. Accurate interpretation requires clear knowledge of these possible changes as well as knowledge of clinical data, such as time elapsed since transplantation and the patient's primary disease.

Soft tissue problems associated with rheumatic disease

Rheumatic disease and associated soft tissue problems encompass a large number of syndromes and account for a high percentage of visits to primary care practitioners. This article describes the symptoms, causes, and treatments for five of the problems most commonly encountered: bursitis, tendinitis, carpal tunnel syndrome, myofascial pain syndrome, and fibromyalgia. Effective management requires a structured history, physical examination, and definitive diagnosis that distinguishes the soft tissue problem from a joint problem and an inflammatory syndrome from a noninflammatory syndrome. The overriding principle is self-management of treatments that focuses on relief of pain, maintenance of function, and avoidance of factors that cause recurrence or exacerbation of the problem. Medications, physical therapies, biomechanical aids, and exercise strategies, along with cognitive-behavioral techniques for the more chronic problems, are all known to decrease symptoms and to assist patients in returning to normal functioning.

Expanding the praxis debate: contributions to clinical inquiry

Nursing science continues to debate the adequacy of various philosophic paradigms for their ability to forward the discipline. Nursing must embrace multiple paradigms, methodologies, and their philosophic assumptions to adequately address the complex and multifaceted human phenomena that is the focus of clinical inquiry in nursing. This article examines the differences in interpretive and critical approaches to clinical inquiry relative to praxis, expanding how praxis can be used to inform nursing practice. Differences in the nature of knowledge, goals of inquiry, and claims to praxis between the interpretive and critical traditions are discussed. Praxis, realized through clinical inquiry in both the interpretive and the critical paradigms, may contribute important pieces of the puzzle to improve the human condition. Expanding the praxis debate challenges nurses to consider the emancipatory possibilities of clinical inquiry within both interpretive and clinical paradigms.

Dyspareunia: three case reports

Dyspareunia, a symptom rather than a diagnosis, is defined as pain experienced by a woman during intercourse. This article discusses how to elicit an accurate sexual history and lists 12 common causes of dyspareunia. Three case reports from the authors' practices will be used to describe the diagnosis and treatment of women with vulvar vestibulitis, hymenal strands, and vaginismus.

Lovastatin induces growth inhibition and apoptosis in human malignant glioma cells

The competitive HMG-CoA reductase inhibitor lovastatin has been shown to suppress growth and induce morphological changes in a variety of non-glioma tumor cell lines. This study assesses the effects of this agent on the growth and survival of the human malignant glioma cell lines A172 and U87-MG. The response to the drug was investigated using a cell proliferation assay which revealed significant dose-dependent growth inhibition. Treatment with as little as 100 nM lovastatin over a period of 72 hours led to DNA degradation into nucleosome-sized fragments characteristic of apoptosis. Our data suggest that HMG-CoA reductase inhibitors such as lovastatin merit further investigation as potential therapeutic agents for the treatment of malignant gliomas.

Vulvodynia: diagnostic techniques and treatment modalities

Vulvodynia is a chronic vulvar discomfort often characterized by the patient's complaint of burning, stinging, irritation, or rawness. Vulvodynia has been recorded for centuries. Successful diagnostic techniques and treatment modalities, however, have come about only in the last decade. An accurate diagnosis is based on an exhaustive history and detailed physical examination. Highly technical and costly diagnostics provide little supplemental information. Differential diagnosis, previously called subsets of vulvodynia, includes infections (Candida, human papillomavirus, and herpes simplex virus), dermatoses (lichen sclerosus and inflammatory dermatoses), vulvar vestibulitis, iatrogenic causes, and dysesthesias (pudendal neuralgia and reflex sympathetic dystrophy). Primary care providers are fully capable of accurately diagnosing and managing vulvodynia patients, relying on subspecialty referral only for surgical intervention in selected cases.

Regression of experimental Burkitt's lymphoma induced by Epstein-Barr virus-immortalized human B cells

Epstein-Barr virus (EBV)-immortalized human B cells survive only transiently when injected subcutaneously into athymic mice, whereas Burkitt's lymphoma cells give rise to progressively growing subcutaneous tumors. In this study, we tested whether these Burkitt's tumors could be induced to regress via a bystander effect induced by EBV-immortalized B cells. Simultaneous inoculation of EBV-immortalized B cells and Burkitt's lymphoma cells in the same subcutaneous site resulted in tumors that regressed with necrosis and scarring. Similarly, simultaneous inoculation of EBV-immortalized B cells and Burkitt's lymphoma cells in separate subcutaneous sites resulted in regression of a proportion of the Burkitt's tumors. Furthermore, most of the established human Burkitt's tumors regressed with necrosis and scarring after intratumor inoculations with EBV-immortalized B cells. The EBV-immortalized B cells continued to exert this antitumor effect even when killed with irradiation. The experimental approach to Burkitt's lymphoma treatment described here exploits the ability of athymic mice to reject EBV-immortalized B cells to target an effective antitumor response to malignant cells normally incapable of eliciting it.

Performance model for optical extraction from a Q-switched chemical oxygen-iodine laser

A comprehensive time-dependent model for optical extraction from a Q-switched supersonic oxygen-iodine laser is described. Gas flow is treated by using an unsteady, premixed, quasi-one-dimensional model that accounts for gas motion and expansion as well as heat release in the cavity. The model uses a simplified, temperature-dependent, chemical kinetics package that consists of several reactions among the (3)Sigma, (1)Delta, and (1)Sigma states of oxygen, atomic and molecular iodine, water, and helium. Hyperfine relaxation effects on the gain and optical extraction from the 3 ? 4 line are treated by using a simple four-level laser model. An efficient algorithm for solving the coupled medium and optical extraction equations is described. This gain model, in conjunction with a geometric model of an unstable confocal resonator, is used to examine optical extraction from the medium as a function of pulse repetition rate, duty cycle, and optical mode width. It is shown that the output power may exhibit flow-induced relaxation oscillat ons, and the conditions under which these oscillations occur are discussed.