Does a "one-stop" gynecology screening clinic for women in hereditary nonpolyposis colorectal cancer families have an impact on their psychological morbidity and perception of health?

Screening programs can reduce the burden of disease, however, they can be associated with raised levels of anxiety. The risk of endometrial and ovarian cancer is increased in hereditary nonpolyposis colorectal cancer (HNPCC). There is no prospective evidence to support screening for gynecological disease in HNPCC, however, current recommendations include the use of ultrasound and endometrial biopsy. This study assesses the impact of screening for gynecological cancer on self-reported symptoms of anxiety, depression, and perceptions of health. Women from HNPCC families attending gynecological screening (n = 26) completed the Hospital Anxiety and Depression Scale and the ShortForm36v2 questionnaires prior to screening with transvaginal ultrasound, outpatient/office hysteroscopy, endometrial biopsy, and ovarian tumor marker assessment (CA125). The same questionnaires were completed at 3 and 6 months following screening (15/26). Women in HNPCC families attending for gynecological screening did not have excess symptoms of anxiety or depression at baseline in subjective comparison to other populations. The process of screening and false positive screening results had no significant impact on symptoms of anxiety and depression or perceptions of health. We conclude that within the limitations of analysis in this small study group, screening for gynecological disease in HNPCC does not appear to be associated with any psychological morbidity.

Exploring the potential chemopreventative effect of aspirin and rofecoxib on hereditary nonpolyposis colorectal cancer-like endometrial cancer cells in vitro through mechanisms involving apoptosis, the cell cycle, and mismatch repair gene expression.

Women in hereditary nonpolyposis colorectal cancer (HNPCC) families have up to a 71% lifetime risk for developing endometrial cancer (EC). This compares to the female lifetime risk for colorectal cancer (CRC) in HNPCC of 60%. The basis of HNPCC is an inherited mutation in a mismatch repair gene (MMR). Aspirin and COX2 inhibitors seem to have a chemoprotective effect on CRC in the general population and are the subject of prospective clinical studies in patients at high risk for CRC including HNPCC. There is no evidence that these agents have any protective effect against EC in the general population. This study investigated the effect of aspirin and a COX2 inhibitor (rofecoxib) on an HNPCC EC cell line model (Ishikawa) by assessing the effect on proliferation, apoptosis, the cell cycle, and MMR gene expression. Aspirin inhibits EC cell proliferation by inducing apoptosis and changes in the cell cycle. This effect is not mediated by changes in MMR gene (hMSH2) expression as assessed by quantitative reverse transcription-polymerase chain reaction. Rofecoxib inhibits EC cell proliferation; this did not appear to be mediated by induction of apoptosis, by alterations of the cell cycle, or by changes in MMR gene expression.

Perceptions of professionalism in medicine: a qualitative study.

PURPOSE: Current guidelines for medical undergraduate education require students to develop appropriate attitudes towards professionalism. As much of the literature defines professionalism in vague terms--altruism, humanism, excellence--few studies have operationalised medical professionalism. This study aims to describe the views and experiences individuals have about medical professionalism to provide a more comprehensive understanding of medical professionalism. METHODS: An interview study of medical educators, medical students, doctors, allied health professionals and lay professionals was employed to assess views and experiences of professionalism in medicine. Thematic content analysis was applied to the resulting transcripts; the data were managed by NUD*IST software. RESULTS: Twenty-three people participated. Two types of examples about professionalism were provided: conceptual (honest, trustworthy, competent); behavioural (communicating effectively, treating patients equally, working in teams). Seven themes were elicited from the data: compliance to values, patient access, doctor-patient relationship, demeanour, professional management, personal awareness and motivation. CONCLUSION: The study provided a description of views about medical professionalism. These data allowed for a more thorough conceptualisation which should be used to inform measures of medical professionalism in order to improve the validity of assessments of medical students' attitudes.

The detection of microsatellite instability in blind endometrial samples--a potential novel screening tool for endometrial cancer in women from hereditary nonpolyposis colorectal cancer families?

Microsatellite instability (MSI) is the phenotypic molecular characteristic of the majority of tumors associated with the hereditary nonpolyposis colorectal cancer syndrome (HNPCC). Women in this group have an increased risk of endometrial cancer (EC). This study aimed to determine whether MSI could be demonstrated in blind endometrial samples from women with EC, HNPCC kindreds undergoing screening for EC, and women with normal endometrium. Twenty-four women with EC, 20 women from HNPCC kindreds, and 20 women undergoing gynecological surgery for benign indications underwent blind sampling. MSI analysis was performed by conventional polymerase chain reaction using fluorescent-labeled primers and automated analysis. Twelve microsatellites were studied with MSI defined as evident when novel alleles were seen in endometrial biopsy samples compared to genomic DNA. Of the 24 EC samples obtained, sufficient DNA for analysis was extracted in 17 cases. Three cases had evidence of MSI in at least 7/12 loci. None of the endometrium from the two other study groups revealed evidence of MSI. This is the first demonstration of MSI in blind endometrial biopsies. The ability to demonstrate MSI in heterogeneous endometrial samples suggests potential for the development of a novel EC screening tool for women in HNPCC kindreds.

A randomised controlled trial comparing outpatient versus daycase endometrial polypectomy.

OBJECTIVE: To evaluate outpatient versus daycase endometrial polypectomy by comparing success rate, complications, patient tolerance, pain score, analgesia requirement and recovery. DESIGN: A randomised controlled trial. SETTING: A large UK Teaching hospital. POPULATION: Forty consecutive women diagnosed with an endometrial polyp at outpatient hysteroscopy were randomly assigned in equal proportions to outpatient or daycase polyp removal. METHODS: The outpatient cohort underwent endometrial polypectomy either using grasping forceps or a bipolar electrode (Versapoint; Gynecare Inc., Menlo Park, CA, USA) introduced down the operating channel of a rigid hysteroscope (Versascope; Gynecare Inc.). The daycase cohort underwent traditional endometrial polyp resection using a hysteroscopic, monopolar, electrosurgical resecting loop, performed under general anaesthetic. MAIN OUTCOME MEASURES: The main outcome measures were as follows: success rates and intra or postoperative complications, time away from home, analgesia requirements, pain scores on the day of and one day after endometrial polypectomy, return to work and preoperative fitness and preference for the location of a future endometrial polypectomy. RESULTS: The majority of women from both cohorts were premenopausal (62.5%), parous (85%) and in paid employment (62.5%). One woman allocated to outpatient polypectomy had cervical stenosis and dilatation was unsuccessful in the outpatient setting. There were no other intra or postoperative complications in either arm of the study. The mean intraoperative visual analogue style (0-100 mm) pain score during outpatient polypectomy was 23.7 mm (1-62). A proportion of women (20%) described no intraoperative discomfort; however, the majority (75%) described mild or moderate intraoperative discomfort. More women in the outpatient cohort (58%) described themselves as pain free for the remainder of the day than in the daycase cohort (28%) (P= 0.09). The day after the procedure, all women from the outpatient group described slight or no discomfort compared with only 41% of women from the daycase group (P= 0.02). All women undergoing outpatient polypectomy had a significantly shorter mean time away from home (3.24 [1.5-5] hours) than women undergoing daycase polypectomy (7.42 [6-10.5] hours), P < 0.0005. Similarly, women from the outpatient cohort had a significantly faster mean return to preoperative fitness (1 [0-4] day versus 3.2 [1-13] days; P= 0.001) and required less postoperative analgesia than the daycase cohort. Ninety-five percent of women from the outpatient cohort and 82% of women from the daycase cohort stated they would prefer to undergo an endometrial polypectomy in the outpatient setting should they require a further polyp removal. CONCLUSION: Endometrial polypectomy can be successfully performed in the outpatient setting with minimal intraoperative discomfort, a significantly shorter time away from home and faster recovery and is preferred by women when compared with daycase polypectomy. Resources need to be made rapidly available to undertake larger scale research and develop this service across the UK.

Does tamoxifen therapy affect the hormone receptor expression and cell proliferation indices of endometrial polyps? An immunohistochemical comparison of endometrial polyps from postmenopausal women exposed and not exposed to tamoxifen.

OBJECTIVE: This study set out to test the null hypothesis that tamoxifen therapy would not affect the hormone receptor expression (oestrogen and progesterone receptors-ER and PR) or markers of cell proliferation/apoptosis (Ki67 and Bcl-2) of endometrial polyps from postmenopausal women exposed and not exposed to tamoxifen. METHODS: Endometrial polyps were prospectively obtained from women presenting with abnormal bleeding attending an out-patient hysteroscopy clinic who subsequently underwent endometrial polypectomy (16 from postmenopausal women not exposed to tamoxifen, 9 from women exposed to tamoxifen). Immunohistochemical staining for ER, PR, Ki67 and Bcl-2 was performed on polyps from both groups of women. Non-parametric statistical analysis was used (Mann-Whitney and Spearmans rank correlation). RESULTS: Endometrial polyps from tamoxifen users had significantly lower oestrogen receptor but increased progesterone receptor and Bcl-2 expression. There were no significant differences for proliferation markers (Ki67) between postmenopausal endometrial polyps exposed and not exposed to tamoxifen. CONCLUSIONS: Tamoxifen has a significant affect on hormone receptor expression and markers of apoptosis in endometrial polyps. The results support the hypothesis that tamoxifen promotes polyp growth by inhibiting apoptosis. The mechanism for this does not appear to be oestrogen receptor mediated.

Are endometrial polyps from pre-menopausal women similar to post-menopausal women? An immunohistochemical comparison of endometrial polyps from pre- and post-menopausal women.

OBJECTIVE: Do endometrial polyps from pre- and post-menopausal women have similar immunohistochemical expression of oestrogen and progesterone receptors (ER, PR) and markers of cellular proliferation/apoptosis (Ki67 and Bcl-2). DESIGN: Prospective cohort study. Non-parametric statistical analysis was used. SETTING: Polyps recruited from women attending an out-patient hysteroscopy clinic in a UK district general hospital. PATIENTS: Fourteen pre-menopausal and 16 post-menopausal women who presented with abnormal bleeding with endometrial polyps. INTERVENTIONS: Immunohistochemical staining was performed on endometrial polyps. MAIN OUTCOME MEASURES: Significant differences or correlations between hormone receptor expression (oestrogen and progesterone) and cell growth indices (Ki67 and Bcl-2). RESULTS: Endometrial polyps from pre- and post-menopausal women had significant differences in their expression of hormone receptors and Ki67. However, polyps from both groups of women had similarly increased levels of Bcl-2, an inhibitor of apoptosis. CONCLUSIONS: Pre- and post-menopausal polyps exhibit differing hormone receptor and proliferation markers, presumably a result of their hormonal milieu. However, both groups appear to have lost the usual control mechanisms for apoptotic regulation, this appears to be responsible for their growth.

An immunohistochemical comparison of endometrial polyps from postmenopausal women exposed and not exposed to HRT.

OBJECTIVE: Our study set out to test the null hypothesis that oestrogen containing continuous combined hormone replacement therapy (HRT) would not affect the hormone receptor expression (oestrogen and progesterone receptors-ER, PR) or markers of cell proliferation/apoptosis (Ki67 and Bcl-2) in endometrial polyps from postmenopausal women exposed and not exposed to HRT. DESIGN: Immunohistochemical staining for ER, PR, Ki67 and Bcl-2 was performed on polyps obtained from two groups of postmenopausal women. SETTING: Polyps were obtained from postmenopausal women attending an outpatient hysteroscopy clinic in a district general hospital (Bradford Royal Infirmary, UK). POPULATION: Twenty-five postmenopausal women presenting with abnormal bleeding subsequently diagnosed with endometrial polyps (16 from women not exposed to HRT, 9 from women exposed to HRT). METHODS: Semiquantitative immunohistochemistry was performed. MAIN OUTCOME MEASURES: Significant differences or correlations in either hormone receptor expression or markers of cell proliferation/apoptosis between the two groups of polyps. RESULTS: There were no significant differences for hormone receptor expression (ER and PR) between endometrial polyps exposed and not exposed to HRT. Bcl-2 expression was higher than Ki67 in both groups, but polyps from HRT users had increased levels reflecting decreased apoptosis in these polyps. CONCLUSIONS: HRT has no demonstrable effect on polyp ER and PR expression. However, HRT does appear to inhibit apoptosis and cell proliferation in endometrial polyps, which may affect polyp growth.

Increase in peripheral blood mononuclear cell (PBMC)- and CD56+ cell-mediated killing of endometrial stromal cells by mycobacteria; a possible role in endometriosis immunotherapy?

BACKGROUND: Immunological therapies have shown promising results in the treatment of endometriosis. Mycobacteria are one of the most common immune therapies used in other diseases. We have assessed the effects of mycobacteria in altering the ability of peripheral blood mononuclear cells (PBMCs) and natural killer (NK) cells to kill endometrial stromal cells using an in vitro model. This may have implications in the immunotherapy of endometriosis. METHODS: Primary cultures of endometrial stromal cells were grown from female patients and PBMCs were extracted from healthy female volunteers. Effector cells (PBMCs or NK cells) were exposed to varying concentrations of mycobacteria before their ability to kill cultured endometrial cells was tested using a 51Cr-release assay. RESULTS: Treatment of effector cells with the Connaught Substrain Bacillus of Calmette and Guérin (BCG) led to increased killing of target cells by PBMCs and NK cells. The optimal concentration for treatment of effector cells with Connaught BCG was approximately 0.1 multiplicities of infection (m.o.i.). There was a trend towards increased killing after treatment with Pasteur BCG. CD56+ (NK) cells treated with BCG at 0.1 m.o.i. showed increased killing of target cells compared with untreated effector cells. CONCLUSIONS: Endometrial stromal cells are susceptible to killer cells activated by mycobacteria. This in vitro work suggests a possible role for mycobacteria in the immunotherapy of endometriosis.

Anti-proliferative effect of mycobacteria, IFN-gamma and TNF-alpha on primary cultures derived from endometrial stroma: possible relevance to endometriosis?

PROBLEM: To assess the effects of mycobacteria and inflammatory cytokines on proliferation of endometrial stromal cells. An effect on endometrial stromal cell proliferation in vitro may suggest a similar effect on endometriotic cells in vivo. METHOD OF STUDY: Primary cultures of endometrial stromal cells were grown from female volunteers. Proliferation of cells was assessed by cell counting and incorporation of tritiated thymidine after exposure to mycobacteria or inflammatory cytokines. RESULTS: When assessed by cell counting, stromal cell growth was reduced following treatment with Connaught Bacillus of Calmette and Guérin (BCG) and Pasteur BCG: Mycobacterium smegmatis demonstrated a cytotoxic effect. Addition of the cytokines interferon (IFN)-gamma or tumour necrosis factor (TNF)-alpha at high concentrations led to a reduction in cell growth by 24 hr in two of three cell lines. A reduction in proliferation was also found when assessed by tritiated thymidine incorporation, which was statistically significant for Connaught BCG and M. smegmatis. CONCLUSIONS: Endometrial stromal cells are susceptible to the anti-proliferative effects of mycobacteria. The BCG and other mycobacteria are known immunomodulators in other disease conditions. Further work is required to assess whether these in vitro effects might translate into a useful therapy for endometriosis.

The carriage of pro-inflammatory cytokine gene polymorphisms in recurrent pregnancy loss.

PROBLEM: Recurrent pregnancy loss (RPL) affects 2-4% of couples, and remains largely unexplained. Recent studies have examined the role of cytokines in the maintenance of normal pregnancy, which is linked with an increased expression of Th2 cytokines. Overexpression of Th1 cytokines is associated with RPL. Knowing that functional polymorphisms exist for certain cytokines, it has therefore been suggested that women with RPL may have a genetic predisposition to overexpress Th1 cytokines. METHOD OF STUDY: The genes for interleukin-1 beta (IL-1beta) and tumor necrosis factor alpha (TNF-alpha) carry functional gene polymorphisms. In both cases these are biallelic polymorphisms that can be detected by polymerase chain reaction followed by restriction fragment length polymorphism. The aim of this pilot study was to assess whether carriage of the rarer alleles (TNF*2 and IL-1B*2) could act as independent risk factors in recurrent miscarriage. RESULTS: We found an increased incidence in the carriage of TNF*2, more pronounced in those women with two or more miscarriages. Carriage of the IL-1B*2 either alone or in association with TNF*2 was not associated with recurrent miscarriage. CONCLUSION: There may be a role for these cytokine gene polymorphisms in RPL.

A double-blind randomised trial of leuprorelin acetate prior to hysterectomy for dysfunctional uterine bleeding.

OBJECTIVE: To evaluate the use of pre-operative leuprorelin acetate for reducing the morbidity from hysterectomy for nonfibroid menorrhagia. DESIGN: A double-blind, randomised, placebo-controlled trial. SETTING: Gynaecology department in a large university teaching hospital. SAMPLE: Fifty-one women without uterine fibroids awaiting abdominal or vaginal hysterectomy for dysfunctional uterine bleeding. METHODS: Participants received leuprorelin acetate or placebo for eight weeks prior to hysterectomy. MAIN OUTCOME MEASURES: Operative blood loss, operative difficulty, first day morphine use, speed of return to 'normal health'. RESULTS: The study and control groups were similar as regards prognostic factors. Two women in the study group withdrew because of side-effects. Although a 34% reduction in uterine volume was seen in those treated with leuprorelin, there were no significant differences in operative blood loss (183 mL in the study group vs 285 mL in controls, P = 0.27), operation time (39 vs 49 min, P = 0.64) or operative difficulty (visual analogue scale 3.0 vs 4.0, P = 0.09). Furthermore, there was no difference between the groups in post-operative morbidity or rate of recovery. CONCLUSIONS: Treating women with leuprorelin acetate for 8 weeks prior to surgery for nonfibroid menorrhagia has no significant operative or post-operative benefits.

Decreasing estrogen in nonpregnant women lowers uterine myometrial type I nitric oxide synthase protein expression.

OBJECTIVE: Our purpose was to study the effect of estrogen on myometrial nitric oxide synthase. STUDY DESIGN: Twenty-four women were randomly assigned to treatment with gonadotropin-releasing hormone agonist or placebo for 8 weeks before hysterectomy, at which time samples of myometrium were collected and the serum levels of estrogen, nitrate, and nitrite measured. Myometrial nitric oxide synthase was measured with the arginine-citrulline assay. The levels of endothelial nitric oxide synthase and neuronal nitric oxide synthase were determined by Western blot analysis. RESULTS: Myometrial nitric oxide synthase was 88% calcium dependent but only partially calmodulin dependent. Women treated with gonadotropin-releasing hormone agonist had postmenopausal levels of estradiol and had significantly lower levels of myometrial neuronal nitric oxide synthase than those in the control group. Total, endothelial, and inducible nitric oxide synthase levels in the myometrium were unchanged, as were serum nitrite and nitrate levels. CONCLUSION: Neuronal nitric oxide synthase is regulated in the myometrium by estrogen. Myometrial nitric oxide synthase is not all calmodulin dependent; this may represent the activity of a novel nitric oxide synthase isoform.

Uterine ultrasonographic changes with gonadotropin-releasing hormone agonists.

OBJECTIVES: Our purpose was to assess the changes in uterine volume and uterine artery pulsatility index in response to gonadotropin-releasing hormone agonist treatment in women undergoing hysterectomy for nonfibroid-related uterine bleeding. STUDY DESIGN: A double-blind, placebo-controlled randomized trial of 51 women awaiting hysterectomy in a gynecology outpatient clinic was conducted. The women were treated for 8 weeks with either leuprolide acetate depot or placebo. Vaginal ultrasonographic examinations were performed before and after treatment. The paired t test was used for statistical analysis. RESULTS: In those allocated to therapy with gonadotropin-releasing hormone agonist the mean uterine volume decreased by 34% and the uterine artery pulsatility index increased from 2.25 to 2.7. No significant changes were seen in the placebo group. The intersonographer variability was low and there was a high correlation between uterine size as measured by ultrasonography before hysterectomy and that measured postoperatively. CONCLUSIONS: Treatment with gonadotropin-releasing hormone agonists leads to uterine shrinkage and an increase in the uterine artery pulsatility index even in the absence of uterine fibroids.

Menopausal changes in the myometrium: an investigation using a GnRH agonist model.

Thirty-four premenopausal women were randomized to receive 3.75 mg of leuprorelin acetate depot or placebo for 8 weeks before hysterectomy. Postoperatively, the myometrium was examined by two independent pathologists and the pathologic features were graded. Computer analysis was used to assess myometrial cellularity and arterial wall structure (on hematoxylin and eosin-stained sections) and vascularity (on sections immunostained for Factor VIII-related antigen). The cellularity of the gonadotrophin-releasing hormone agonist-treated myometrium was higher than the controls with less stromal edema. Focal myometrial hyalinization was present in a minority of cases, all in the gonadotrophin-releasing hormone agonist-treated cases. The arteries in the gonadotrophin-releasing hormone agonist-treated uteri underwent atrophy of the tunica media and had significantly more perivascular fibrosis. The number of vessels per 100 myocytes also was decreased. Hypoestrinism secondary to leuprorelin treatment leads to myocyte atrophy, decreased stromal edema, atrophy of the arcuate arteries, and decreased myometrial vascularity.

Surgical glove perforation.

In a study to investigate the incidence and significance of surgical glove perforation, bacterial contamination of surgeons' hands and gloves before and after operation was measured and the gloves tested for damage. Perforations were found in 74 of 582 gloves (12.7 per cent) and occurred in 34.5 per cent of operations. Glove perforation did not influence bacterial counts on the surgeons' hands or on the outside of their gloves. A separate clinical study of 100 adult hernia repairs gave no evidence that perforation increased wound sepsis. After standard pre-operative hand preparation, glove perforations are of no clinical significance to the patient, but their high incidence should alert surgeons to the need for protection against pathogens transmissible during surgery, such as hepatitis B and the human immunodeficiency virus. Protection of the surgeon is the main indication for preoperative change of damaged gloves.