Diagnosis and management of ectopic pregnancy.

Ectopic pregnancy affects 1% to 2% of all pregnancies and is responsible for 9% of pregnancy-related deaths in the United States. When a pregnant patient presents with first-trimester bleeding or abdominal pain, physicians should consider ectopic pregnancy as a possible cause. The patient history, physical examination, and imaging with transvaginal ultrasonography can usually confirm the diagnosis. When ultrasonography does not clearly identify the pregnancy location, the physician must determine whether the pregnancy is intrauterine (either viable or failing) or ectopic. Use of the beta subunit of human chorionic gonadotropin (ß-hCG) discriminatory level, the ß-hCG value above which an intrauterine pregnancy should be visualized by transvaginal ultrasonography, may be helpful. Failure to visualize an intrauterine pregnancy when ß-hCG is above the discriminatory level suggests ectopic pregnancy. In addition to single measurements of ß-hCG levels, serial levels can be monitored to detect changes. ß-hCG values in approximately 99% of viable intrauterine pregnancies increase by about 50% in 48 hours. The remaining 1% of patients have a slower rate of increase; these patients may have pregnancies that are misdiagnosed as nonviable intrauterine or ectopic. After an ectopic pregnancy has been confirmed, treatment options include medical, surgical, or expectant management. For patients who are medically unstable or experiencing life-threatening hemorrhage, a surgical approach is indicated. For others, management should be based on patient preference after discussion of the risks, benefits, and monitoring requirements of all approaches.

Adult vaccination.

Immunization has effectively decreased the burden of disease on society. Nevertheless, over 50,000 deaths occur annually in the United States from vaccine-preventable disease, and nearly all of these occur in adults. It is essential for primary care physicians to be knowledgeable about the unique immunization-related needs of adults and to be aware of the factors that determine the need for vaccination.

Endometrial cancer.

Endometrial cancer is the leading cause of gynecologic cancer in the United States. Etiologically, endometrial carcinoma usually results from unopposed estrogen stimulation of the endometrium, although non-estrogen-related forms occur as well. The most common presentation of endometrial cancer is postmenopausal bleeding. A variety of diagnostic modalities are available to aid in the detection of the disease, each with its own strengths and limitations. These modalities include endometrial biopsy, ultrasonography, saline infusion sonography, and hysteroscopy. A definitive diagnosis requires pathologic confirmation via endometrial biopsy or dilatation and curettage. Surgical staging of endometrial cancer will dictate how physicians manage the condition. For most women, staging and initial treatment are accomplished with total hysterectomy, bilateral salpingo-oophorectomy, and peritoneal washings. Surgery, radiation, and chemotherapy play a role in treatment, depending on tumor stage and grade. At present, there are no recommendations for screening the general population.

Screening and prevention: cervical cancer.

Cervical cancer is the leading cause of cancer death in women in developing countries and significant disparities in cervical cancer mortality rates persist in the United States. Improved recognition of the role of human papilloma virus (HPV) in cervical cancer pathogenesis has recently revolutionized screening and prevention strategies. Improved understanding and implementation of these advances will allow primary care physicians to significantly impact the cervical cancer mortality burden. This article reviews the basic physiology of the transformation zone, current understanding of cervical cancer pathogenesis, the history and evolution of cervical cancer screening in general and in specific populations of women, and an overview of the development and current use of the HPV vaccine.

Interview with the retinoblastoma family members: do they help each other?

The ultimate destiny of a cell to undergo division, differentiation, survival, and death results from an intricate balance between multiple regulators including oncogenes, tumor suppressor genes, and cell cycle associated proteins. Deregulation of the cell cycle machinery switches the phenotype from a normal cell to a cancerous cell. Fundamental alterations of tumor suppressor genes may result in an unregulated cell cycle with the accumulation of mutations and eventual neoplastic transformation. As such, one may define cancer as a genetic disease of the cell cycle. In this review, we will emphasize our current understanding of how the cell cycle machinery maintains cellular homeostasis by studying the consequences of its deregulation.