Long-term risk of endometrial cancer following postmenopausal bleeding and reassuring endometrial biopsy.

INTRODUCTION: Women with postmenopausal bleeding and endometrial thickness >4 mm undergo endometrial sampling to exclude endometrial cancer. The aim of this study is to investigate the relative risk of developing endometrial cancer in a prospective cohort after initial work-up for postmenopausal bleeding showing reassuring histology or insufficient sampling. MATERIAL AND METHODS: All women presenting with postmenopausal bleeding were prospectively included from January 2009 to April 2011. Follow-up data were collected from patient charts and PALGA (Dutch Pathology Registry). Hazard ratios for endometrial cancer were determined by calculating standardized incidence ratios. RESULTS: A total of 668 women were included and 568 women were available for follow-up [median follow-up time 47 (range 7-63) months]. Women who presented with postmenopausal bleeding, endometrial thickness >4 mm and hyperplasia without atypia on biopsy at the first presentation showed a significantly increased risk (standardized incidence ratio 17.15, 95% confidence interval 1.96-61.93) of being diagnosed with endometrial cancer during the first four years of follow up compared with the age-specific population. All women that developed endometrial cancer after initial reassuring histology presented with recurrent postmenopausal bleeding. None of the women with endometrial thickness >4 mm and no or insufficient sample for histology at the first presentation developed endometrial cancer during the follow up. CONCLUSIONS: Although in general, women with endometrial hyperplasia without atypia are considered to have a low risk for cancer, we observed a significant long-term risk of endometrial cancer after postmenopausal bleeding. Whether additional diagnostics or a more stringent follow-up regimen would be cost-effective, needs to be studied.

Respiratory herpes simplex virus type 1 infection/colonisation in the critically ill: marker or mediator?

BACKGROUND: The clinical significance and pulmonary pathogenicity of herpes simplex virus type 1 (HSV-1) in mechanically ventilated, critically ill patients are unclear. OBJECTIVE: To determine the clinical features and course of respiratory HSV-1 infections/colonisations in the critically ill, in order to evaluate the contribution to outcome. DESIGN: A retrospective cohort study in the intensive care unit of an university hospital, involving 22 patients with a HSV-1 isolated from bronchoalveolar lavage (BAL) fluid, divided into survivors (n = 13) and non-survivors (n = 9). All patients except for one survivor had been intubated and were mechanically ventilated. RESULTS: Non-survivors had acquired HSV-1 sooner on mechanical ventilation than survivors. Prior chronic heart disease was more prevalent in non-survivors than in survivors and, at the time of HSV-1 isolation, the mean creatinine level was higher (P < 0.05) in the former. Survivors had a somewhat greater fall in body temperature after a 10-day course of antiviral therapy than non-survivors, but the lung radiographic abnormalities prior to and after the course did not differ. There were no major differences in cardiorespiratory variables between outcome groups and causes of death and were judged not to relate, in general, to HSV-1. CONCLUSIONS: Critically ill patients in whom HSV-1 from BAL is isolated, have about 40% chance of dying, mainly because of severe underlying disease and comorbidity, which may predispose to endogenous reactivation of the virus. There is no clinical evidence for direct cardiorespiratory pathogenicity and beneficial effects of antiviral therapy. HSV-1 isolated from lung secretions may thus be a marker rather than a mediator of severe illness.