Gender-related differences in patients with carcinoid syndrome: new insights from an Italian multicenter cohort study.

BACKGROUND: The incidence of neuroendocrine neoplasm (NEN) and related carcinoid syndrome (CaS) has increased markedly in recent decades, and women appear to be more at risk than men. As per other tumors, gender may be relevant in influencing the clinical and prognostic characteristics of NEN-associated CS. However, specific data on carcinoid syndrome (CaS) are still lacking. PURPOSE: To evaluate gender differences in clinical presentation and outcome of CaS. METHODS: Retrospective analysis of 144 CaS patients from 20 Italian high-volume centers was conducted. Clinical presentation, tumor characteristics, therapies, and outcomes (progression-free survival, PFS, overall survival, OS) were correlated to gender. RESULTS: Ninety (62.5%) CaS patients were male. There was no gender difference in the site of primary tumor, tumor grade and clinical stage, as well as in treatments. Men were more frequently smokers (37.2%) and alcohol drinkers (17.8%) than women (9.5%, p = 0.002, and 3.7%, p = 0.004, respectively). Concerning clinical presentation, women showed higher median number of symptoms (p = 0.0007), more frequent abdominal pain, tachycardia, and psychiatric disorders than men (53.3% vs 70.4%, p = 0.044; 6.7% vs 31.5%, p = 0.001; 50.9% vs. 26.7%, p = 0.003, respectively). Lymph node metastases at diagnosis were more frequent in men than in women (80% vs 64.8%; p = 0.04), but no differences in terms of PFS (p = 0.51) and OS (p = 0.64) were found between gender. CONCLUSIONS: In this Italian cohort, CaS was slightly more frequent in males than females. Gender-related differences emerged in the clinical presentation of CaS, as well as gender-specific risk factors for CaS development. A gender-driven clinical management of these patients should be advisable.

Diagnostic yield and safety of transbronchial lung cryobiopsy for diffuse parenchymal lung diseases diagnosis: Comparison between 1.7-mm and 1.9-mm probes.

PURPOSE OF THE RESEARCH: transbronchial lung cryobiopsy has been recently accepted as a valid and less invasive alternative to surgical lung biopsy. The purpose of this randomized controlled study was to evaluate, for the first time, the quality and safety of biopsy specimens obtained by using the new disposable 1.7-mm cryoprobe compared with the standard re-usable 1.9 mm cryoprobe in the diagnosis of diffuse parenchymal lung diseases. METHODS: 60 consecutive patients were prospectively enrolled and randomly assigned to two different groups: 1.9 mm (group A) and 1.7 mm (group B); primary endpoints were pathological and multidisciplinary diagnostic yield, sample size and complication rate. PRINCIPAL RESULTS: the pathological diagnostic yield of cryobiopsy was 100% in group A and 93.3% in group B (p = 0.718); cryobiopsy median diameter was 6.8 mm in group A and 6.7 mm in group B (p = 0,5241). Pneumothorax occurred in 9 patients in group A and 10 in group B (p = 0.951); mild-to-moderate bleeding in 7 cases and 9 cases in group A and B respectively (p = 0.559). No death or severe adverse events were observed. CONCLUSIONS: there was no statistically significant difference between the two groups, regarding diagnostic yield, adverse events and sampling adequacy.

Pathophysiology of light phenotype SARS-CoV-2 interstitial pneumonia: from histopathological features to clinical presentations.

Little is known about the light phenotype of SARS-CoV-2 pneumonia, which behaves in an unusual way, unlike other known respiratory diseases. We believe that the histopathological features of early COVID-19 could be considered the pathophysiological hallmark of this disease. Lung cryobiopsies show almost pristine alveoli, enlarged/hyperplasic alveolar capillaries along with dilatation of the post capillary pulmonary venules. Hypoxemia could therefore be explained by a reduction of the normal V/Q ratio, due to blood overflow around well ventilated alveoli. This could clarify typical manifestations of type L COVID-19, such as happy hypoxemia, response to awake prone positioning, response to PEEP/CPAP and platypnea orthodeoxia.

Intensive care of patients requiring open abdomen treatment: a case-series analysis.

BACKGROUND: This retrospective overview examines the management of patients with temporary open abdomen (OA). METHODS: The clinical characteristics and intensive care treatment of 34 consecutive patients with OA (1996-2012) were reviewed. RESULTS: Average age was 61 years, SAPS II score 43, SOFA 8. Two patients had non-contaminated abdomen; 12 had intact gut (only 8 later during stay); 7 repaired gut (only later 4); 13 cutaneous stoma (later 14), and 2 entero-atmospheric fistula (later 8+1 entero-enteral). The median ICU stay was 48 [36-94] days. One quarter of the 2376 ICU-days were classified as severe sepsis/septic shock (antibiotics were given for two thirds of the stay); three quarters were with ventilation; in 95% of days sedatives were given (mainly enterally). Continuous cavity lavage was done in three quarters of days; in 3% of days patients were fasted whereas >20 kcal/kg was given for 74% of days; we fed the gut in 95% of fed-days, in half of them combined with parenteral nutrition. Complications are discussed; mortality was 32.4%, limited to the ICU stay. CONCLUSION: The intensive care of patients with OA is challenging but can achieve better outcomes than expected. Continuous abdominal lavage improves the evacuation of contaminated fluid or debris and, coupled with antiseptics and low antibiotic pressure, reinforces the control of infection. The gut can be used for nutrition (even without gastrointestinal continuity), and long-term light sedation (mainly enteral) with minimal impact on perfusion, ventilation and gut motility.

Clinical analysis of multiple primary malignancies in the elderly.

BACKGROUND: Cancer incidence raises progressively during life span; it is estimated that by the year 2030 almost 70% of all neoplasms will occur in people over 65 years old. As carcinogenesis is a multistep, time-requiring process, it is expected that as people live longer they are more likely to develop cancer, and therefore, the prevalence of multiple primary malignancies (MPM) is destined to increase with age. PATIENTS AND METHODS: Records of all consecutive cancer patients referred to our center from January 2004 to January 2007 were reviewed. We chose the definition of MPM proposed by Warren and Gates. Multiple malignancies were assessed for elderly (>or=70 years old) and younger patients. t-Test and Mc Nemar test were used; subgroup analysis was also performed according to age stratification. RESULTS: A total of 1,503 consecutive patients were considered; 566 were 70 years old or more (mean age 76.5 years, range 70-96 years) and 878 were younger (mean age 57 years, range 18-69 years). The prevalence of multiple malignancies in the elderly people versus younger ones was 15% and 6%, respectively (P = 0.001). As far as the elderly population is concerned, 21% (56/271) of males compared with 14% (42/295) of females had developed MPM; no significant difference was found between the subgroups with MPM or not as far as age (P = 0.16), comorbidities (P = 0.79), medications (P = 0.76), CIRS-G score and index (P = 0.47, P = 0.54), and PS (P = 0.93) are concerned. Most frequent associations among cancer types were prostate with lung (10/87, 11%), prostate with colorectal cancer (10/87, 11%), and smoking-related cancer, namely lung and head and neck cancer (X/Y, 6%). CONCLUSIONS: Elderly patients are more likely to develop MPM compared to younger ones. Significant cancer association according to field cancerogenesis concept was the one of smoking-related cancer; other MPM patterns were apparently a random phenomenon.

[Pathophysiology and prevention of contrast-induced acute renal failure]. / Fisiopatologia e prevenzione della insufficienza renale acuta da mezzo di contrasto.

Although the infusion of iodinated contrast media in diagnostic and interventional procedures may cause acute renal failure (ARF) especially in older or diabetic patients with preexisting nephropathy, these procedures are often unavoidable. Contrast medium-induced ARF is defined as an increase in serum creatinine of 0.5 mg/dL or a 25% or greater relative increase from baseline within 72 hours of iodinated contrast medium infusion. Because it is often very difficult to employ alternative diagnostic procedures, it is mandatory to adopt prophylactic protocols to prevent radiocontrast nephropathy. Renal hemodynamic lesions leading to medullary hypoxia, oxygen free radicals inducing tubular cell alterations, and parenchymal vasoconstriction are the main factors in the pathogenesis of contrast-induced ARF. Among the many proposed protocols to prevent contrast-induced renal toxicity, the most effective procedure is hydration with 1 mL/kg/h of isotonic saline solution in the 12 hours before and after contrast medium infusion. Promising results in terms of cardiac and renal protection have been reported in a recent trial with the use of high-dose N-acetylcysteine acting as an oxygen free radical scavenger: an intravenous bolus of 1200 mg N-acetylcysteine was given before coronary angiography followed by 1200 mg orally twice a day for 48 hours after the procedure. The protective effect seemed to involve not only the kidney: the drug was found to induce a significant reduction of the necrotic area in myocardial infarction.

[Sepsis, acute renal failure and multiple organ dysfunction syndrome]. / Sepsi, insufficienza renale acuta e "multiple organ dysfunction syndrome".

The so-called systemic inflammatory response syndrome (SIRS ) represents the cellular inflammatory and neuroendocrine systemic reaction in response to many adverse events. epsis is defined as IR induced by bacterial, mycotic or viral toxins. The circulating toxins deriving from the bacterial wall can activate the septic cascade that induces many systemic reactions involving the activation of the cellular immunity, complement and coagulation system. The endothelial cell is the target of the systemic phlogistic reaction; its stimulation is followed by the production of many vasoactive paracrine and systemic agents. In this context, local and systemic cytokine production plays a major role in inducing the septic cascade, which although meant to be a phlogistic defense reaction, can often become an uncontrolled and dangerous inflammatory reaction. The sepsis-derived lesions can involve many organs and apparatus leading to the picture of sepsis syndrome. Sepsis syndrome often induces severe pulmonary lesions with a picture of acute respiratory distress syndrome (ARDS ). The combination of acute renal failure and sepsis is associated with a high mortality rate, namely in patients with a nitric oxide-induced systemic reduction in peripheral vascular resistances and septic shock. The toxinemia can also induce myocardial damage with a reduction in cardiac performance. Therefore, septic patients who have a combination of pulmonary, cardio-vascular, renal and cerebral lesions present with the picture of multiple organ dysfunction syndrome, that can increase mor-tality to > 0%.

Do elderly cancer patients achieve an adequate dose intensity in common clinical practice?

BACKGROUND: Elderly patients rarely receive adequate dose intensity (DI) using conventional regimens. Possible causes are improper patient assessment, the chemotherapy (CT) regimen chosen, the number and severity of comorbidities, patient compliance and physician experience. To explore this issue, DI was retrospectively analyzed in elderly patients treated with conventional CT regimens for advanced solid cancer. PATIENTS AND METHODS: Patients > or =69 years were evaluated. All patients had metastatic solid tumors. Comorbidities, performance status (PS), toxicities, number of CT cycles, dose reduction and discontinuation of treatment were recorded. Relative DI (RDI) was calculated and regressed against these parameters. RESULTS: 108 patients were eligible. The most frequent diagnoses were: lung, head-and-neck and colorectal cancer. In 48 patients (44%), their initially scheduled treatment was modified. Mean RDI was 79% (range 19-100%, SD 20.6). Grade 3/4 non-hematological and hematological toxicity occurred in 27 (35/130) and 8% of patients (11/130), respectively. In regression analysis, RDI was significantly associated with hematological toxicity. RDI affected response rate but not overall survival. CONCLUSIONS: RDI is significantly affected by toxicity. These data suggest the importance of the treatment schedule and patient selection as predictorsof adequate treatment. Some non-ratable variables, however, might also play a role regarding the dose intensity delivered.

Randomized comparison of vaporizing electrode and cutting loop for endometrial ablation.

OBJECTIVE: To compare endometrial ablation using a vaporizing electrode with resection using a standard cutting loop, evaluating distension fluid absorption, operating time, and ease of procedure. METHODS: Premenopausal menorrhagic women with normal hysteroscopic and endometrial biopsy findings were allocated randomly to endometrial vaporization (n = 47) or resection (n = 44). Distension medium deficit, operating time, and degree of difficulty of the procedure were determined at surgery. Menstrual pattern of women in both groups was also assessed after 1-year follow-up. RESULTS: Mean +/- standard deviation (SD) distension fluid deficit was 109+/-126 mL in the vaporization and 367+/-257 mL in the resection group (mean difference 258 mL; 95% confidence interval 175, 341 mL; P < .001, unpaired t test). Mean +/- SD operating time was, respectively, 9.2+/-3.1 minutes versus 10.7+/-2.5 minutes. The surgeon classified intraoperative difficulties as none in 32, minimal in 11, moderate in four, and severe in none in the vaporization group, and 17, 14, seven, and six in the resection group. Menstrual pattern at 1 year in the former group was amenorrhea in 17 (36%) cases, hypomenorrhea or spotting in 20 (43%), normal flows in 10 (21%), and menorrhagia in none compared with, respectively, 21 (48%), 14 (32%), seven (16%), and two (5%) in the latter group. CONCLUSION: Endometrial ablation with the vaporizing electrode limited fluid absorption compared with resection by the standard cutting loop. Long-term effects on uterine bleeding were similar.

Preoperative CEA, NSE, SCC, TPA and CYFRA 21.1 serum levels as prognostic indicators in resected non-small cell lung cancer.

In 62 patients affected by resectable non-small cell lung cancer (NSCLC) submitted to radical surgery we evaluated the prognostic significance of CEA, NSE, SCC, TPA, and CYFRA 21.1 serum levels at diagnosis, as well as the predictive ability of these tumor markers with respect to histological type and pathological stage. The group was composed of 56 male and 6 female patients; the median age was 62 years (range 29-73 years). Thirty-four patients had a histological diagnosis of adenocarcinoma and 28 of squamous cell carcinoma; with regard to pathological stage, 32 patients had stage 1, 4 patients stage II and 23 patients stage IIIA disease. A good predictive ability with respect to histological type was obtained with SCC serum levels; as for pathological stage, TPA and CYFRA 21.1 were found to have moderate predictive ability. In this series of patients, at a median follow-up of 55 months after surgery, we found that both TPA and CYFRA 21.1 serum levels at diagnosis were reliable predictors of overall survival, high values of these markers being associated with a worse prognosis.

Endometrial ablation with a vaporizing electrode. I. Evaluation of in vivo effects.

BACKGROUND: To evaluate histologically and histochemically the physical and thermal effects of a vaporizing electrode as compared with a standard cutting loop in the performance of endometrial ablation. METHODS: Operative hysteroscopy was performed on 20 menorrhagic patients immediately before hysterectomy. Part of the posterior uterine wall was treated with a cylindrical, grooved, vaporizing electrode and undamped current set at 200 watts, and part with a standard cutting loop and undamped current set at 100 watts. A mucosal strip of about 1 cm width was left intact between the two treatment areas. Specimens underwent histologic examination after hematoxylin and eosin staining and histochemical assessment of thermal injury was based on detection of the respiratory enzyme dihydronicotinamide adenine dinucleotide diaphorase. RESULTS: The mean (standard deviation) endometrial thickness as determined on the untreated area of the posterior uterine wall was 1.08 (0.36) mm. The mean depth of furrows was 3.10 (0.90) mm with the use of the vaporizing electrode and 3.41 (1.11) mm after passage of the cutting loop. Corresponding values when thermal necrosis beneath the ablated area was assessed by the dihydronicotinamide adenine dinucleotide diaphorase technique were, respectively, 1.80 (0.40) mm and 0.41 (0.20) mm (mean difference, 1.39 mm; 95% confidence interval, 1.19 to 1.59: p<0.001, Mann-Whitney U test). CONCLUSIONS: A vaporizing electrode and a standard cutting loop obtained a similar degree of endomyometrial ablation. However, the depth of the thermal effect of the former electrode was significantly greater. Clinical studies are warranted, also considering the potential limitation of fluid absorption and menorrhagia recurrence when a vaporizing electrode is used.

Endometrial ablation with a vaporizing electrode. II. Clinical outcome of a pilot study.

BACKGROUND: As a vaporizing electrode has been successfully used to treat submucous myomas, we evaluated its safety and efficacy in performing endometrial ablation. METHODS: Forty consecutive women with established menorrhagia with (n=26) and without (n=14) submucous myomas were enrolled in a prospective, noncomparative, pilot study. Hysteroscopic endometrial vaporization was performed with pure cutting current set at 200 watts. RESULTS: All procedures were completed without complications. Median (interquartile range, IQR) fluid deficit was 90 (0-200) ml and median (IQR) operating time 10 (7-12.5) min. A significant correlation was observed between operating time and fluid absorption (Spearman's test by ranks, r=0.47; p=0.002). The degree of difficulty of the operation was classified as none on 28 (70%) occasions, mild on 11 (27.5%) and moderate on one (2.5%). After a mean+/-s.d. follow-up of 20.3+/-2.4 months, amenorrhea or spotting were reported by 23 (57.5%) subjects, hypomenorrhea by 10 (25%), normal flows by six (15%), and menorrhagia by one (2.5%). The median (IQR) menstrual score calculated according to a pictorial blood loss assessment chart dropped from 282.5 (199-383) to 0 (0-15) (p<0.0001). Six (15%) subjects were very satisfied with the effect of surgery, 30 (75%) satisfied, two (5%) uncertain, one (2.5%) dissatisfied and one (2.5%) very dissatisfied. CONCLUSIONS: The vaporizing electrode seems to combine the benefits of the cutting loop (speed, efficacy and possibility of removing myomas) and the roller-ball electrode (safety and limited fluid absorption) while avoiding their respective disadvantages, and may be considered an interesting alternative in the hysteroscopic treatment of menorrhagia.

Levonorgestrel-releasing intrauterine device versus hysteroscopic endometrial resection in the treatment of dysfunctional uterine bleeding.

OBJECTIVE: To compare the effect of a levonorgestrel-releasing intrauterine device with that of endometrial resection on menstrual bleeding, patient satisfaction, and quality of life in menorrhagic women during 12 months of follow-up. METHODS: Seventy premenopausal women with dysfunctional uterine bleeding were enrolled in a prospective, open, parallel-group, controlled trial. They were randomized to either insertion of an intrauterine system releasing 20 micrograms/day of levonorgestrel (n = 35) or endometrial resection (n = 35). The women were evaluated at baseline, and thereafter, uterine bleeding was assessed monthly with a pictorial blood loss assessment chart. Clinical gynecologic examination was performed bimonthly, and the hematologic variables were measured at 6 and 12 months. On the latter occasion, the women were requested to rate the degree of satisfaction with the effect of their treatment and to complete the Short Form 36 General Health Survey questionnaire. RESULTS: Recurrent menorrhagia was observed at 12 months in four women in the intrauterine device group (including two with partial expulsion of the device) and in three women in the resection group. Compared with baseline values, at 1 year, the pictorial blood loss assessment chart score was reduced by 79% in the former group and by 89% in the latter. Amenorrhea or hypomenorrhea at 12 months was reported by 65% of the women with an intrauterine device compared with 71% who underwent endometrial resection. The degree of satisfaction with treatment was high in both groups, with 29 of 34 (85%) women being satisfied or very satisfied in the intrauterine device group versus 33 of 35 (94%) in the resection group. Health-related quality of life perception was not significantly different in the two treatment groups. CONCLUSION: Somewhat less satisfactory results were obtained with a levonorgestrel-releasing intrauterine system compared with endometrial resection for dysfunctional uterine bleeding at 1 year of follow-up.

The role of transvaginal ultrasonography and outpatient diagnostic hysteroscopy in the evaluation of patients with menorrhagia.

To verify the reliability of transvaginal ultrasonography in diagnosing intrauterine disease and in evaluating the operability of submucous myomas and to determine the feasibility, acceptability and validity of hysteroscopy for menorrhagia, we performed a prospective 5 year study on 793 women of mean age +/- SD of 41.5 +/- 7.8 years. All the patients referred for excessive menstrual bleeding with uterine volume <12 week pregnancy who underwent complete physical examination, transvaginal ultrasonography and outpatient hysteroscopy with endometrial biopsy were included in the study. Outpatient hysteroscopy was not completed due to intolerance or was unsatisfactory due to excessive bleeding in 23 cases (2.9%). Only 28 women (3.5%) declared they would have refused the procedure had they imagined the pain involved. One case of pelvic infection was observed. Compared with hysteroscopy, transvaginal ultrasonography had 96% sensitivity, 86% specificity, 91% positive predictive value and 94% negative predictive value in the diagnosis of intrauterine abnormality. The sensitivity, specificity, positive and negative predictive values of ultrasonography in identifying submucous myomas operable hysteroscopically (intramural extension <50%) were respectively 80, 69, 83 and 65% with a k index of agreement between ultrasonography and hysteroscopy of 0.48. Thus, considering the good specificity and high negative predictive value, transvaginal ultrasonography may be suggested as the initial investigation in menorrhagic patients, limiting hysteroscopy to cases with positive or doubtful sonographic findings.

Risk factors for adenomyosis.

In order to analyse risk factors for adenomyosis, 707 consecutive women who underwent hysterectomy between January 1993 and June 1994 at the Clinica Luigi Mangiagalli, Milan, Italy, were interviewed before surgery by trained physicians. Information on the presence of adenomyosis was obtained from pathologic records. Out of the 707 women, adenomyosis was identified in 150 subjects (21.2%). Women who smoked tended to be at decreased risk of the condition: in comparison with women who had never smoked, the risk for current smokers was 0.7 (0.3-1.3) and the risk decreased with number of cigarettes smoked per day, the odds ratios being 0.8 and 0.6 respectively in women reporting fewer than 10 and more than 10 cigarette smoked per day (chi2 trend 3.57, P = 0.06). The frequency of adenomyosis was higher in parous women: in comparison with nulliparae, the odds ratio of the disease were 1.8 [95% confidence interval (CI) 0.9-3.4] and 3.1 (95% CI 1.7-5.5) respectively in women reporting one and two or more births (chi2 trend 20.71, P < 0.01). Likewise, women reporting one or more spontaneous abortions had an odds ratio of 1.7 (95% CI 1.1-2.6) for adenomyosis, in comparison with those reporting no spontaneous abortion.

Leuprolide in a 3-monthly versus a monthly depot formulation for the treatment of symptomatic endometriosis: a pilot study.

An open-label randomized pilot study was conducted to evaluate the efficacy and acceptability of 6 months treatment with leuprolide in a 3-monthly versus a monthly i.m. depot injection for the relief of chronic pelvic pain in women with endometriosis. A total of 30 women aged 18-38 years were allocated to the 3-monthly depot arm (n = 15) or to the monthly depot arm (n = 15) after laparoscopic diagnosis of pelvic endometriosis. Mean (SD) deep dyspareunia scores according to a 0-3 point verbal rating scale decreased from 1.8 (0.9) at baseline to 1.3 (0.7) at the end of treatment in the 3-monthly depot group and from 2.1 (1.2) to 1.3 (0.7) in the monthly depot group. Corresponding values in non-menstrual pain scores fell from 2.1 (0.6) to 1.1 (0.3), and from 2.1 (0.8) to 1.2 (0.4) respectively, without statistically significant differences between the groups. Serum luteinizing hormone (LH) and 17 beta-oestradiol concentrations were significantly suppressed at 12 and 24 weeks compared with baseline values, without differences between the groups. The monthly depot caused a slightly more marked inhibition of serum follicle stimulating hormone (FSH) levels with respect to the 3-monthly preparation. Mean (SD) endometriosis scores at baseline and at 6-month follow-up laparoscopy were respectively 32.8 (25.1) and 12.2 (9.3) in the 3-monthly depot group and 29.0 (22.7) and 13.1 (15.3) in the monthly depot group (paired t-test, P < 0.05). Mean percentage decrease in lumbar spine bone mineral density was 5.2% in the former and 4.9% in the latter subjects. In the 3-monthly depot group, 13 women graded the tolerability of their treatment schedule as "good' compared with seven in the monthly depot group (chi 2 = 5.40, P = 0.02).

Depot medroxyprogesterone acetate versus an oral contraceptive combined with very-low-dose danazol for long-term treatment of pelvic pain associated with endometriosis.

OBJECTIVE: Our purpose was to evaluate the efficacy and safety of depot medroxyprogesterone acetate versus an oral contraceptive combined with very-low-dose danazol in the long-term treatment of pelvic pain in women with endometriosis. STUDY DESIGN: Eighty patients with endometriosis and moderate or severe pelvic pain were randomized to treatment for 1 year with intramuscular depot medroxyprogesterone acetate 150 mg every 3 months or a cyclic monophasic oral contraceptive (ethinyl estradiol 0.02 mg, desogestrel 0.15 mg) combined with oral danazol 50 mg a day for 21 days of each 28-day cycle. The women were asked to grade the degree of their satisfaction at the end of therapy. Variations in severity of symptoms during treatment were determined by a 10 cm visual analog and a 0- to 3-point verbal rating scale. RESULTS: Twenty nine of 40 subjects (72.5%) in the depot medroxyprogesterone acetate group were satisfied after 1 year of therapy compared with 23 of 40 (57.5%) in the oral contraceptive plus danazol group (chi 2(1) = 1.37, p = 0.24, odds ratio 1.95, 95% confidence interval 0.76 to 4.97). A significant decrease was observed in all symptom scores in both study groups. At 1-year assessment dysmenorrhea was significantly greater in women allocated to oral contraceptive plus danazol. CONCLUSION: Depot medroxyprogesterone acetate seems to be an effective, safe, and convenient low-cost treatment for pelvic pain associated with endometriosis. However, women should be carefully counseled regarding menstrual changes and the potential prolonged delay in the return of ovulation.

PIP: The tolerability and effectiveness of depot medroxyprogesterone acetate (DMPA), compared with an oral contraceptive (OC) combined with low-dose danazol, in the long-term treatment of pelvic pain in women with endometriosis were evaluated in a randomized clinical trial. 40 women were allocated to each treatment regimen. At the 1-year assessment, a significant decrease was observed in all symptom scores of the visual analog and the verbal rating scale in both study groups. Only pain at menstruation was significantly greater in women in the OC group (because of the absence of regular flow in subjects in the DMPA group). In the DMPA group, 1 woman (2.5%) was very satisfied with her treatment, 28 (70%) were satisfied, 2 (5%) were uncertain, and 1 (2.5%) was very dissatisfied. Corresponding figures for the OC-danazol group were 6 (15%), 17 (42.5%), 4 (10%), 12 (30%), and 1 (2.5%). Overall, 72.5% of women in the DMPA group compared with 57.5% of those in the OC group were pleased after 1 year of treatment. It was concluded that, in selected women with highly symptomatic endometriosis, DMPA offers good analgesic results with tolerable side effects.

Endometrial Ablation with a Vaporizing Electrode in Women with Regular Uterine Cavity or Submucous Leiomyomas

To verify the technical feasibility and safety of endometrial ablation with a vaporizing electrode (Vaportrode), we performed operative hysteroscopy in a consecutive series of 40 women (mean ± SD age 45.3 ± 4.7 yrs) with established menorrhagia and uterine volume less than 12 weeks' gestation. The results in 26 women with a regular uterine cavity were compared with those in 14 patients who had submucous myomas with less than 50% intramural extension. Surgery was undertaken after 2-month treatment with a depot gonadotropin-releasing hormone agonist. Pure cutting current was set at 200 W. Mean ± SD operating time was 8.6 ± 2.4 minutes in women with a regular cavity and 14.4 ± 5.2 in those with submucous myomas (mean difference 5.8 minutes, 95% CI 3.4-8.3). Corresponding values for distention fluid absorption were, respectively, 76 ± 103 and 227 ± 138 ml (mean difference 151 ml, 95% CI 73-229). A significant correlation was observed between operating time and distention fluid deficit (Spearman r = 0.47, p = 0.002). No complications occurred and all the procedures were performed as day surgery. After a mean follow-up of 4 months, no recurrence of menorrhagia was reported. Endometrial ablation with the Vaportrode is rapid, effective, and safe. Fluid deficit, although significantly greater in women with submucous myomas than in those with regular cavities, always remained within safety limits and below the usual values observed after resection with the wire loop.