Metformin increases the ovulatory rate and pregnancy rate from clomiphene citrate in patients with polycystic ovary syndrome who are resistant to clomiphene citrate alone.

OBJECTIVE: To determine whether metformin treatment increases the ovulation and pregnancy rates in response to clomiphene citrate (CC) in women who are resistant to CC alone. DESIGN: Randomized, double-blind, placebo-controlled trial. SETTING: Multicenter environment. PATIENT(S): Anovulatory women with the polycystic ovary syndrome (PCOS) who were resistant to CC. INTERVENTION(S): Participants received placebo or metformin, 500 mg three times daily, for 7 weeks. Information on reproductive steroids, gonadotropins, and oral glucose tolerance testing was obtained at baseline and after treatment. Metformin or placebo was continued and CC treatment was begun at 50 mg daily for 5 days. Serum P level > or =4 ng/mL was considered to indicate ovulation. With ovulation, the daily CC dose was not changed, but with anovulation it was increased by 50 mg for the next cycle. Patients completed the study when they had had six ovulatory cycles, became pregnant, or experienced anovulation while receiving 150 mg of CC. MAIN OUTCOME MEASURE(S): Ovulation and pregnancy rates. RESULT(S): In the metformin and placebo groups, 9 of 12 participants (75%) and 4 of 15 participants (27%) ovulated, and 6 of 11 participants (55%) and 1 of 14 participants (7%) conceived, respectively. Comparisons between the groups were significant. CONCLUSION(S): In anovulatory women with PCOS who are resistant to CC, metformin use significantly increased the ovulation rate and pregnancy rate from CC treatment.

Measuring the success of electronic medical record implementation using electronic and survey data.

Computerization of physician practices is increasing. Stakeholders are demanding demonstrated value for their Electronic Medical Record (EMR) implementations. We developed survey tools to measure medical office processes, including administrative and physician tasks pre- and post-EMR implementation. We included variables that were expected to improve with EMR implementation and those that were not expected to improve, as controls. We measured the same processes pre-EMR, at six months and 18 months post-EMR. Time required for most administrative tasks decreased within six months of EMR implementation. Staff time spent on charting increased with time, in keeping with our anecdotal observations that nurses were given more responsibility for charting in many offices. Physician time to chart increased initially by 50%, but went down to original levels by 18 months. However, this may be due to the drop-out of those physicians who had a difficult time charting electronically.

Hepatocyte growth factor (HGF) induces invasion of endometrial carcinoma cell lines in vitro.

OBJECTIVES: The overall goal of this study was to investigate the role of the hepatocyte growth factor (HGF)/Met pathway in the pathophysiology of invasive endometrial carcinoma. Our objectives were (1) to examine expression of HGF and Met in surgical endometrial carcinoma specimens and endometrial carcinoma cell lines, and (2) to determine if HGF would stimulate invasion of endometrial carcinoma cell lines in vitro. METHODS: Using RT-PCR and Western immunoblotting, endometrial carcinoma specimens and the endometrial carcinoma cell lines KLE, HEC-1A, HEC-1B, and RL-95 were examined for expression of HGF and Met. A Boyden chamber invasion assay using collagen type I coated 8-microm porous membranes was then used to determine if HGF would stimulate cell invasion. Last, we assessed the capacity of endometrial stromal cells, isolated from normal human endometrium, to produce HGF as determined by an enzyme-linked immunosorbent assay and to stimulate invasion of the KLE cell line. RESULTS: All of the endometrial carcinoma tissue samples were found to express Met mRNA, and two of four samples expressed HGF mRNA. However, the endometrial carcinoma cell lines expressed only Met and not HGF mRNA. Both the endometrial carcinoma tissue specimens and the endometrial carcinoma cell lines expressed the 140-kDa Met protein. HGF induced the invasion of the KLE and HEC-1A cells through the collagen-coated membranes in a dose-dependent fashion. The optimal concentration of HGF was between 10 and 100 ng/ml. HGF (10 ng/ml) stimulated KLE invasion 1.8-fold (P < 0.05) and HEC-1A invasion 6.5-fold (P < 0.05). During exposure to endometrial stromal cell conditioned medium containing HGF as determined by ELISA, invasion of the KLE cell line was stimulated 2.5-fold (P < 0.05). CONCLUSION: These results demonstrate that HGF stimulates the invasion of endometrial carcinoma cells in vitro. Since endometrial adenocarcinoma specimens express Met, these findings suggest that the HGF/Met pathway may play a role in the invasive progression of endometrial carcinoma.

Human endometrial interleukin-6 (IL-6): in vivo messenger ribonucleic acid expression, in vitro protein production, and stimulation thereof by IL-1 beta.

OBJECTIVE: To investigate human endometrial interleukin-6 (IL-6) expression and effects thereon by IL-1 beta. DESIGN: Prospective. SETTING: Academic medical center. PATIENT(S): Endometrial biopsy specimens from normal volunteers (n = 20) at four specific menstrual stages were used for in vivo study. Endometrial specimens for in vitro study were obtained from patients (n = 19) undergoing gynecologic surgery. INTERVENTION(S): Time and dose-response treatment of endometria with IL-1 beta in tissue culture. MAIN OUTCOME MEASURE(S): In vivo IL-6 messenger RNA expression by Northern analysis and in vitro endometrial IL-6 protein production by assay of the conditioned media. RESULT(S): Midsecretory and late secretory phase endometria expressed more IL-6 messenger RNA than late proliferative phase endometria in vivo. Similarly in vitro, in pg/mg endometrium per hour secretory endometria IL-6 protein production, 25.7 +/- 7.1 (mean +/- SEM), exceeded that of proliferative endometria, 4.7 +/- 1.0. With IL-1 beta treatment, secretory endometria IL-6 protein production exceeded that of proliferative endometria. Interleukin-1 beta stimulated endometrial IL-6 protein production in time- and dose-dependent manners. CONCLUSION(S): Human endometrial IL-6 expression varies with the menstrual cycle, occurs more highly in secretory endometria, and in vitro is stimulated by interleukin-1 beta. Human endometrial IL-6 may therefore mediate some actions of IL-1 beta involving the endometrium and trophoblast.

Human endometrial expression of granulocyte colony-stimulating factor (G-CSF) and its receptor, stimulation of endometrial G-CSF production by interleukin-1 beta, and G-CSF inhibition of choriocarcinoma cell proliferation.

PROBLEM: To investigate the expression, regulation thereof, and actions of human endometrial granulocyte colony-stimulating factor (G-CSF). METHODS: Endometrial expression of messenger ribonucleic acids for G-CSF and its receptor were studied using reverse transcriptase-polymerase chain reaction. In tissue culture, endometrial G-CSF protein production, baseline and in response to interleukin-1 beta, was determined by enzyme-linked immunosorbant assay of the conditioned media. G-CSF effects on proliferation of three choriocarcinoma cell lines were determined. RESULTS: In vivo, human endometrium expressed messenger ribonucleic acids for G-CSF and its receptor throughout the menstrual cycle, and endometrium expressed G-CSF protein in vitro. Interleukin-1 beta stimulated endometrial G-CSF protein production in time and dose dependent manners. G-CSF inhibited proliferation of two choriocarcinoma cell lines. CONCLUSIONS: These results suggest that 1) G-CSF may have physiologic roles in the endometrium throughout the menstrual cycle; 2) endometrial G-CSF protein production is stimulated by interleukin-1 beta; and 3) that G-CSF may, in part, mediate local actions of interleukin-1 beta and modulate trophoblast proliferation.

Interleukin-1 beta and tumor necrosis factor-alpha stimulate granulocyte colony-stimulating factor production by placental villous core mesenchymal cells.

OBJECTIVE: To test the hypothesis that interleukin-1 beta (IL-1 beta) and tumor necrosis factor-alpha (TNF-alpha) regulate granulocyte colony-stimulating factor (G-CSF) production by human placental villous core mesenchymal cells. METHODS: Villous core mesenchymal cells were isolated from placentas at 14-20 weeks' gestation and cultured in vitro. Cells were treated with IL-1 beta or TNF-alpha in dose-response and time-course studies. We measured G-CSF mRNA expression by Northern blot analysis and G-CSF protein production by enzyme-linked immunosorbent assay of the conditioned media. RESULTS: Unstimulated mesenchymal cells expressed negligible G-CSF. Steady-state G-CSF mRNA expression was maximal 3-6 hours after IL-1 beta treatment and 6-18 hours after TNF-alpha treatment. Each cytokine induced G-CSF protein production in dose-and time-dependent manners, with IL-1 beta more potent than TNF-alpha. The G-CSF mRNA expression and G-CSF protein production induced by the combination of both cytokines exceeded that induced by either cytokine alone. CONCLUSIONS: Interleukin-1 beta and TNF-alpha stimulate G-CSF production by placental villous core mesenchymal cells in vitro. These results identify a potential mechanism by which villous core mesenchymal cells mediate, in part, the placental response to these two cytokines.

Serum creatine kinase does not predict ectopic pregnancy.

OBJECTIVE: To evaluate the discriminatory ability of maternal serum creatine kinase (SCK) as a test for ectopic pregnancy (EP). DESIGN: Serum creatine kinase concentrations were obtained prospectively from symptomatic patients being evaluated for early abnormal pregnancy. Serum creatine kinase concentrations from all patients and from a subset of these patients with maternal serum beta-hCG concentrations < 6,500 mIU/mL (conversion factor to SI unit, 1.00) were analyzed with descriptive statistics, receiver operator characteristic (ROC) curve analysis, and calculations of predictive values. SETTING: A university hospital emergency room. PATIENTS: Fifty-six patients with intrauterine gestations (25 with beta-hCG concentrations < 6,500 mIU/mL) and 23 patients with EP (20 with beta-hCG concentrations < 6,500 mIU/mL) were studied. RESULTS: For all patients and the subgroup with beta-hCG concentrations < 6,500 mIU/mL, mean SCK levels were not significantly different between ectopic and intrauterine gestations. For all patients and the subgroup with beta-hCG concentrations < 6,500 mIU/mL, the areas under the ROC curves did not demonstrate discriminatory ability of the SCK test. The highest positive predictive value of an elevated SCK for EP was 52% using the SCK concentration of 70 U/L, and this was seen in the subgroup of patients with beta-hCG values < 6,500 mIU/mL. CONCLUSIONS: Maternal SCK concentrations do not reliably predict EP.

Dicavitary uteri with twin gestation: a case following clomiphene citrate therapy and review of obstetric outcomes.

We report the first case of dicavitary twin pregnancy, following clomiphene citrate therapy, in a patient with uterus bicornis bicollis and anovulation. A review of the literature is presented, and obstetric outcomes and management of these rare pregnancies are discussed.

Receiver-operator characteristic, efficiency analysis, and predictive value of serum progesterone concentration as a test for abnormal gestations.

OBJECTIVE: Our objective was to determine if a discriminatory progesterone concentration could be established that confidently predicted abnormal early gestations. STUDY DESIGN: We analyzed differences in progesterone concentrations between normal (n = 40) and abnormal (n = 34) pregnancies during the first 49 days of gestation. The receiver-operator characteristic curve, test efficiency, and predictive value of serum progesterone to discriminate between an abnormal and normal first-trimester gestation were calculated for progesterone concentrations between 5 and 25 ng/ml. RESULTS: Receiver-operator characteristic curve analysis indicated that the best discriminatory progesterone concentration was 10 ng/ml. Test efficiency was maximum between serum progesterone concentration of 9 to 14 ng/ml (80%). When progesterone was less than 10 ng/ml, the predictive value of the abnormal test result was greater than 90%. CONCLUSION: Receiver-operator characteristic analysis, test efficiency, and the predictive value of an abnormal test result suggest that the best progesterone cut off point that predicts abnormal early pregnancies is 10 ng/ml.

Differences in affinity of cardiac beta-adrenergic receptors for [3H]dihydroalprenolol.

We performed quantitative light microscopic autoradiography of [3H]dihydroalprenolol (DHA) binding to frozen sections of canine myocardium to test the hypothesis that there are differences in the density or affinity of beta-adrenergic receptors on various tissue compartments. In one study, with concentrations of [3H]DHA from 0.34 to 5.1 nM, specific binding to cardiac myocytes was saturable, whereas nonspecific binding was linear with ligand concentration. Arterioles had more specific grain counts than muscle cells (P less than 0.0001), and Scatchard analysis showed that the arterioles had a much higher affinity for [3H]DHA than myocytes. In a second study with lower concentrations of [3H]DHA (0.19-1.98 nM), binding to the arterioles saturated, whereas binding to the cardiac myocytes did not. Specific binding to arterioles was significantly higher (P less than 0.0001) than binding to myocytes at all concentrations of [3H]DHA. The dissociation constants for the subendocardial and subepicardial myocytes were 1.57 and 1.71 nM, respectively, while the dissociation constant for the arterioles was 0.26 nM. The maximum number of binding sites was 911 grains/0.9 X 10(-2) mm2 for subepicardial myocytes, 936 for subendocardial myocytes, and 986 for arterioles. The large nerves accompanying an epicardial artery also demonstrated specific [3H]DHA binding. Thus this study has demonstrated major differences in the distribution and affinity of beta-adrenergic receptors, which may help to explain various physiological responses to beta-adrenergic stimulation.

Quantification of beta-adrenergic receptors in canine cardiac myocytes using autoradiography and an internal standard.

The type and amount of adrenergic receptors in different tissues are important determinants of their response to adrenergic stimulation in normal and pathologic states. Autoradiographic analysis of receptor binding has the advantage that receptor sites can be localized over different tissue compartments. However, quantitative assessment of receptor sites through autoradiography can only be made by using radioactive standards. The purpose of this study was to investigate the use of an internal standard method for quantitative autoradiographic receptor studies by analyzing the binding of the beta-receptor antagonist, [3H]dihydroalprenolol, to canine cardiac tissue. Sections from dog heart were incubated in [3H]dihydroalprenolol to label the beta-adrenergic receptors in the absence of (total binding) and in the presence of (nonspecific binding), 10(-5) M (+/-) propranolol. Specific binding was calculated as total minus nonspecific binding. Half of the sections were scraped off of the slides and assayed by scintillation spectrometry, and half of the sections were set up for light microscopic autoradiography. The autoradiograms were exposed, developed and stained, and grain density was quantified by using an automated image analyzer. By plotting grain density per tissue section against cpm per tissue section for total, nonspecific and specific binding, curves for efficiency of the autoradiographs were obtained. There were no significant differences among the slopes of the three lines. Also, there were no significant differences among the efficiencies of the total, nonspecific and specific binding at different concentrations of [3H]dihydroalprenolol using a two way analysis of variance. Thus, grain counts from the autoradiographs can be used to estimate the concentration of beta-adrenergic receptors in cardiac myocytes. By using these methods it was calculated that canine cardiac myocytes have 5.12 X 10(9) receptor sites/mm3.