The effect of pre-analytical variables on downstream application and data analysis of human endometrial biopsies

STUDY QUESTION

What are the effects of pre-analytical variables on the downstream analysis of patient-derived endometrial biopsies?

SUMMARY ANSWER

There are distinct differences in the protein levels of the master regulator of oxygen homeostasis, hypoxia-inducible factor-1-alpha (HIF1α), and the protein and mRNA levels of three related genes, carbonic anhydrase 9 (CA9), vascular endothelial growth factor A (VEGFA) and progesterone receptor (PR) in human endometrial biopsies, depending on the pre-analytical variables: disease status (cancer vs benign), timing of biopsy (pre- vs post-hysterectomy) and type of biopsy (pipelle vs full-thickness).

WHAT IS KNOWN ALREADY

Patient-derived biopsies are vital to endometrial research, but pre-analytical variables relating to their collection may affect downstream analysis, as is evident in other tissues.

STUDY DESIGN SIZE DURATION

A prospective observational study including patients undergoing hysterectomy for endometrial cancer (EC) or benign indications was conducted at a large tertiary gynaecological unit in the UK. Endometrial biopsies were obtained at different time points (pre- or post-hysterectomy) using either a pipelle endometrial sampler or as a full-thickness wedge biopsy.

PARTICIPANTS/MATERIALS SETTING METHODS

The changes in HIF1α, CA9, VEGFA and PR protein levels were measured by semi-quantitative analysis of immunostaining, and the expression levels of three genes (CA9, VEGFA and PR) were investigated by quantitative real-time PCR, in endometrial biopsies from 43 patients undergoing hysterectomy for EC (n = 22) or benign gynaecological indications (n = 21).

MAIN RESULTS AND THE ROLE OF CHANCE

An increase in HIF1α immunostaining was observed in EC versus benign endometrium (functionalis glands) obtained pre-hysterectomy (P < 0.001). An increase in CA9 immunostaining was observed in EC versus benign endometrial functionalis glands at both pre- and post-hysterectomy time points (P = 0.03 and P = 0.003, respectively). Compared with benign endometrial pipelle samples, EC samples demonstrated increased mRNA expression of CA9 (pre-hysterectomy P < 0.001, post-hysterectomy P = 0.008) and VEGFA (pre-hysterectomy P = 0.004, post-hysterectomy P = 0.002). In benign uteri, HIF1α immunoscores (functionalis glands, P = 0.03 and stroma, P = 0.009), VEGFA immunoscores (functionalis glands, P = 0.03 and stroma, P = 0.01) and VEGFA mRNA levels (P = 0.008) were increased in matched post-hysterectomy versus pre-hysterectomy samples. Similarly, in EC, an increase in VEGFA immunoscores (epithelial and stromal) and VEGFA mRNA expression was observed in the matched post-hysterectomy versus pre-hysterectomy biopsies (P = 0.008, P = 0.004 and P = 0.018, respectively). Full-thickness benign post-hysterectomy endometrial biopsies displayed increased VEGFA (P = 0.011) and PR (P = 0.006) mRNA expression compared with time-matched pipelle biopsies.

LARGE SCALE DATA

N/A.

LIMITATIONS REASONS FOR CAUTION

This descriptive study explores the effect of pre-analytical variables on the expression of four proteins and three hypoxia-related genes in a limited number of endometrial biopsies from patients with EC and benign controls. Due to the small number, it was not possible to investigate other potential variables such as menstrual cycle phase, region-specific differences within the endometrium, grade and stage of cancer, and surgical technicalities.

WIDER IMPLICATIONS OF THE FINDINGS

Careful consideration of the effects of these pre-analytical variables is essential when interpreting data relating to human endometrial biopsies. A standardized approach to endometrial tissue collection is essential to ensure accurate and clinically transferrable data.

STUDY FUNDING/COMPETING INTERESTS

The authors have no conflicts of interest to declare. The work included in this manuscript was funded by Wellbeing of Women project grants RG1073 and RG2137 (D.K.H.), Wellbeing of Women Entry-Level Scholarship ELS706 and Medical Research Council MR/V007238/1 (A.M./D.K.H.), Liverpool Women's Hospital Cancer Charity (M.A.) and University of Liverpool (L.B., L.R. and E.N.).

Chiari I malformation with craniosynostosis and persistent falcine sinus draining into the straight sinus

Owing to the interconnected nature of the brain, anatomical variations in one area often coincide with, or are caused by, abnormalities in another. During dissection of a specimen with both Chiari I malformation and craniosynostosis, a persistent falcine sinus was observed to drain into the straight sinus. Such a variant should be noted by physicians as it could alter treatment plans and require more detailed imaging procedures prior to surgical correction. Herein, we report the case and discuss the possible embryological origins and clinical significance of the variant.

Factors underlying metastatic breast cancer patients' perceptions of symptom importance: a qualitative analysis

The symptom literature in cancer has primarily examined symptom severity, frequency and distress. Assessing cancer patients' perceptions of symptom importance-how important it is for them to see improvement in a symptom following an intervention-and factors influencing these judgments would also inform patient-centred care, but this analysis has not been undertaken. This qualitative study aimed to identify factors underlying perceptions of symptom importance among 25 symptomatic metastatic breast cancer (MBC) patients. Participants were recruited from a cancer centre in the Midwestern USA. Semi-structured interviews focused on patients' rationale for considering common symptoms (i.e., anxiety, sadness, sleep problems, pain or fatigue) to be important. Thematic analyses revealed five interrelated factors underlying MBC patients' perceptions of symptom importance: activity restriction, concentration difficulties, exacerbation of other physical symptoms, symptom-related long-term health concerns and negative impact on their relationships with others. Patients most frequently stated that a physical or psychological symptom was important because of the resulting activity restriction. Additionally, some patients considered pain to be important because it signalled potential long-term health concerns, such as worsening metastatic disease. Findings suggest that clinicians should take into account MBC patients' perceptions of symptom importance and factors underlying these judgments when making shared treatment decisions.

An outcomes analysis of anterior epistaxis management in the emergency department

Background

Many treatment options exist for the management of anterior epistaxis. However, little is known about treatment outcomes. The objective was to identify the currently utilised methods of management and outcomes for patients with anterior epistaxis presenting to the emergency department (ED) at a Canadian tertiary care center.

Methods

A retrospective review of ED visits from January 2012-May 2014 for adult patients with a diagnosis of anterior epistaxis was performed. Patient demographic data, comorbidities, and treatment methods were documented. The effectiveness of different treatment modalities was determined.

Results

Three hundred fifty-three primary anterior epistaxis cases were included. Mean patient age was 70 years and 49 % of patients were female. Comorbidities included hypertension (56 %), diabetes (19 %), CAD (28 %), and atrial fibrillation (27 %). A large proportion of the cohort (61 %) was on at least one anticoagulant or antiplatelet therapy. The most common utilised treatment modalities were silver nitrate cauterization, Merocel®, petroleum gauze packing, nasal clip and 15 % were simply observed. Initial treatment success was achieved in 74 % of cases. Of patients receiving specific treatment modalities, silver nitrate cauterization had the highest success rate at 80 %. 26 % of patients returned to the ED for recurrence of epistaxis with highest rates occurring in the nasal clip (59 %), Merocel® (26 %), and petroleum gauze packing (42 %) groups.

Conclusions

The differences in recurrence rate among the different treatment modalities observed may be due to true differences in effectiveness or differences in treatment selection by the ED physicians based on severity of epistaxis. Cauterization with silver nitrate, however, offers the added benefit of no need for follow up. Further study is needed to elucidate the most efficacious treatment modality based on epistaxis severity.

Haemophilus influenzae serotype B (Hib) seroprevalence in England and Wales in 2009

A national seroprevalence study was performed to determine the prevalence of Haemophilus influenzae type b (Hib) antibodies in England and Wales in 2009, when Hib disease incidence was the lowest ever recorded. A total of 2,693 anonymised residual sera from routine diagnostic testing submitted by participating National Health Service hospital laboratories were tested for Hib anti-polyribosyl-ribitol phosphate (PRP) IgG antibodies using a fluorescent bead assay. Median anti-PRP IgG concentrations were highest in toddlers aged 1–4 years (2.65 μg/ml), followed by children aged 5–9 years (1.95 μg/ml). Antibody concentrations were significantly lower after this age, but were still significantly higher among 10–19 year-olds (0.54 μg/ml) compared with adults aged >20 years (0.16 μg/ ml; p<0.0001). Half of the adults (51%) did not have Hib antibody concentrations ≥0.15 μg/ml, the level considered to confer short-term protection. Thus, the current excellent Hib control appears to be the result of high anti-PRP antibody concentrations in children aged up to 10 years, achieved through the various childhood vaccination campaigns offering booster immunisation. The lack of seroprotection in adults emphasises the importance of maintaining control of the disease and, most probably carriage, in children, therefore raising the question as to whether long-term routine boosting of either pre-school children or adolescents may be required.

Progesterone vaginal gel for the reduction of recurrent preterm birth: primary results from a randomized, double-blind, placebo-controlled trial

OBJECTIVE

Preterm birth is the leading cause of perinatal morbidity and mortality worldwide. Treatment of preterm labor with tocolysis has not been successful in improving infant outcome. The administration of progesterone and related compounds has been proposed as a strategy to prevent preterm birth. The objective of this trial was to determine whether prophylactic administration of vaginal progesterone reduces the risk of preterm birth in women with a history of spontaneous preterm birth.

METHODS

This randomized, double-blind, placebo- controlled, multinational trial enrolled and randomized 659 pregnant women with a history of spontaneous preterm birth. Between 18 + 0 and 22 + 6 weeks of gestation, patients were assigned randomly to once-daily treatment with either progesterone vaginal gel or placebo until either delivery, 37 weeks' gestation or development of preterm rupture of membranes. The primary outcome was preterm birth at </= 32 weeks of gestation. The trial was analyzed using an intent-to-treat strategy.

RESULTS

Baseline characteristics were similar in the two treatment groups. Progesterone did not decrease the frequency of preterm birth at </= 32 weeks. There was no difference between the groups with respect to the mean gestational age at delivery, infant morbidity or mortality or other maternal or neonatal outcome measures. Adverse events during the course of treatment were similar for the two groups.

CONCLUSION

Prophylactic treatment with vaginal progesterone did not reduce the frequency of recurrent preterm birth (</= 32 weeks) in women with a history of spontaneous preterm birth. The effect of progesterone administration in patients at high risk for preterm delivery as determined by methods other than history alone (e.g. sonographic cervical length) requires further investigation.

Vaginal progesterone is associated with a decrease in risk for early preterm birth and improved neonatal outcome in women with a short cervix: a secondary analysis from a randomized, double-blind, placebo-controlled trial

OBJECTIVE

To investigate the efficacy of vaginal progesterone to prevent early preterm birth in women with sonographic evidence of a short cervical length in the midtrimester.

METHODS

This was a planned, but modified, secondary analysis of our multinational, multicenter, randomized, placebo-controlled trial, in which women were randomized between 18 + 0 and 22 + 6 weeks of gestation to receive daily treatment with 90 mg of vaginal progesterone gel or placebo. Cervical length was measured with transvaginal ultrasound at enrollment and at 28 weeks of gestation. Treatment continued until either delivery, 37 weeks of gestation or development of preterm rupture of membranes. Maternal and neonatal outcomes were evaluated for the subset of all randomized women with cervical length < 28 mm at enrollment. The primary outcome was preterm birth at </= 32 weeks.

RESULTS

A cervical length < 28 mm was identified in 46 randomized women: 19 of 313 who received progesterone and 27 of 307 who received the placebo. Baseline characteristics of the two groups were similar. In women with a cervical length < 28 mm, the rate of preterm birth at </= 32 weeks was significantly lower for those receiving progesterone than it was for those receiving the placebo (0% vs. 29.6%, P = 0.014). With progesterone, there were fewer admissions into the neonatal intensive care unit (NICU; 15.8% vs. 51.9%, P = 0.016) and shorter NICU stays (1.1 vs. 16.5 days, P = 0.013). There was also a trend toward a decreased rate of neonatal respiratory distress syndrome (5.3% vs. 29.6%, P = 0.060).

CONCLUSION

Vaginal progesterone may reduce the rate of early preterm birth and improve neonatal outcome in women with a short sonographic cervical length.

In vivo protective performance of N95 respirator and surgical facemask

BACKGROUND

The SARS outbreak in 2003 has spawned a major controversy concerning protective performance facemasks for healthcare workers. This study reports a study on in-vivo protective performance of surgical masks and N95 respirators.

METHODS

Typical surgical masks and N95 respirators used in Hong Kong hospitals were tested in comparison with those treated with nano-functional materials (called nano-masks) on various physical properties and in-vivo wear filtration efficiency, as well as usability test in hospitals for surgical masks.

RESULTS

Tests on physical properties showed that N95 respirators had significantly lower air permeability and water vapor permeability than surgical masks. The in-vivo filtration tests illustrated that N95 respirators filtered out 97% of potassium chloride (KCl) solution, while surgical masks filtered out 95% of KCl solution. Nano-masks show stronger water repellency and antibacterial activities, but no difference in usability, comparing with normal N95 and surgical masks.

CONCLUSIONS

Surgical masks can provide in-vivo filtration protection of 95% filtration efficiency. N95 respirators provide higher in-vivo filtration efficiency of 97% with significant reduction of air permeability and water vapor permeability. Compared to normal surgical masks/respirators, the nano-masks can provide additional protective functions in stopping capillary diffusion and antibacterial activities.

Docetaxel and capecitabine for previously treated metastatic colorectal cancer

13579

Background: Docetaxel (D) induces human colon cancer cell lines to upregulate thymidine phosphorylase, an enzyme which activates capecitabine (C) to its cytotoxic form. This provided rationale for adding low dose D to C in patients with colorectal cancer (CRC). Although this combination has been established in metastatic breast cancer, it has not been evaluated in CRC. Because of concerns of toxicity in a pretreated population, we performed a phase I trial in patients with previously treated CRC. Methods: Eligibility: At least 1 prior treatment for metastatic disease; ECOG PS 0–1; adequate organ function. Design: Phase I, dose escalation. D, IV, days 1 & 8, and C, PO BID days 5–18, repeated q21days. Dose Level 1: D=15mg/m2, C=1000mg/m2; Level 2: D= 15 mg/m2, C= 1100 mg/m2; Level 3: D= 20 mg/m2, C= 1100 mg/m2; Level 4: D=20mg/m2, C=1250mg/m2. Results: 13 patients have thus far been treated. 11 are evaluable for toxicity and 10 for response (1 at dose level 4 was taken off study due to non-compliance before completion of cycle 1; another died of progressive cancer before completing cycle 1 at dose level 4; another is evaluable for toxicity but not yet for response). 9 with colon, 4 with rectal primary sites. Median follow-up= 5 mo (1–19 mo). Med age= 59 (30–75); #prior regimens for met disease 1–2, all of which were 5-FU based. Toxicities No dose limiting toxicities (DLT) until Dose Level 4. Dose Level 1: 1/3 developed grade 2 diarrhea and hand-foot syndrome and delayed grade 3 hand-foot; Dose Level 2: 2/3 developed grade 2 toxicities (hand-foot in one and diarrhea in the other); Dose Level 3: 1/3 developed delayed grade 2 hand-foot; Dose Level 4: 1 patient with delayed grade 2 hand-foot and grade 1 eye tearing; another developed DLT (grade 4 stomatitis/dehydration). Response 6/10 patients progressed after 2 cycles; 2 pts had stable disease, one lasting 4.6 mo; 2 patients had a partial response, one of which lasted 9 mo. The latter case had refractory disease to FOLFOX 4 but a 78% reduction in her liver metastases to D+C. Conclusions: The combination of low dose docetaxel, used as chemosensitizing agent, with capecitabine in this pretreated group of patients with metastatic CRC appears to be well tolerated, with no DLTs seen until Dose Level 4, and has modest activity. MTD determination awaits further accrual.

No significant financial relationships to disclose.

Antimicrobial effect of surgical masks coated with nanoparticles

This study assessed the antimicrobial activity of nanoparticles (consisting of a mixture of silver nitrate and titanium dioxide) and nanoparticle-coated facemasks to protect against infectious agents. The minimum inhibitory concentrations of the nanoparticles against Escherichia coli and Staphylococcus aureus were 1/128 and 1/512, respectively. The antibacterial activity of nanoparticle-coated masks was quantified according to the procedures of AATCC 100-1999. A 100% reduction in viable E. coli and S. aureus was observed in the coated mask materials after 48 h of incubation. Skin irritation was not observed in any of the volunteers who wore the facemasks. Nanoparticles show promise when applied as a coating to the surface of protective clothing in reducing the risk of transmission of infectious agents.

Effects of wearing N95 and surgical facemasks on heart rate, thermal stress and subjective sensations

Aim: The study was aimed at investigating the effects of wearing N95 and surgical facemasks with and without nano-functional treatments on thermophysiological responses and the subjective perception of discomfort. Method: Five healthy male and five healthy female participants performed intermittent exercise on a treadmill while wearing the protective facemasks in a climate chamber controlled at an air temperature of 25°C and a relative humidity of 70%. Four types of facemasks, including N95 (3M 8210) and surgical facemasks, which were treated with nano-functional materials, were used in the study. Results: (1) The subjects had significantly lower average heart rates when wearing nano-treated and untreated surgical facemasks than when wearing nano-treated and untreated N95 facemasks. (2) The outer surface temperature of both surgical facemasks was significantly higher than that of both N95 facemasks. On the other hand, the microclimate and skin temperatures inside the facemask were significantly lower than those in both N95 facemasks. (3) Both surgical facemasks had significantly higher absolute humidity outside the surface than both N95 facemasks. The absolute humidity inside the surgical facemask was significantly lower than that inside both N95 facemasks. (4) Both surgical facemasks were rated significantly lower for perception of humidity, heat, breath resistance and overall discomfort than both N95 facemasks. The ratings for other sensations, including feeling unfit, tight, itchy, fatigued, odorous and salty, that were obtained while the subjects were wearing the surgical facemasks were significantly lower than when the subjects were wearing the N95 facemasks. (5) Subjective preference for the nano-treated surgical facemasks was the highest. There was significant differences in preference between the nano-treated and untreated surgical facemasks and between the surgical and N95 facemasks. Discussion: We discuss how N95 and surgical facemasks induce significantly different temperature and humidity in the microclimates of the facemasks, which have profound influences on heart rate and thermal stress and subjective perception of discomfort.

Effect on outcome of early intensive management of geriatric trauma patients

BACKGROUND

Despite significant injuries elderly patients (aged 70 years or more) often do not exhibit any of the standard physiological criteria for trauma team activation (TTA), i.e. hypotension, tachycardia or unresponsiveness to pain. As a result of these findings the authors' TTA criteria were modified to include age 70 years or more, and a protocol of early aggressive monitoring and resuscitation was introduced. The aim of the present study was to assess the effect of the new policy on outcome.

METHODS

This trauma registry study included patients aged 70 years or more with an Injury Severity Score (ISS) greater than 15 who were admitted over a period of 8 years and 8 months. The patients were divided into two groups: group 1 included patients admitted before age 70 years and above became a TTA criterion and group 2 included patients admitted during the period when age 70 years or more was a TTA criterion and the new management protocol was in place. The two groups were compared with regard to survival, functional status on discharge and hospital charges.

RESULTS

There were 336 trauma patients who met the criteria, 260 in group 1 and 76 in group 2. The two groups were similar with respect to mechanism of injury, age, gender, ISS and body area Abbreviated Injury Score. The mortality rate in group 1 was 53.8 per cent and that in group 2 was 34.2 per cent (P = 0.003) (relative risk (RR) 1.57 (95 per cent confidence interval 1.13 to 2.19)). The incidence of permanent disability in the two groups was 16.7 and 12.0 per cent respectively (P = 0.49) (RR 1.39 (0.59 to 3.25)). In subgroups of patients with an ISS of more than 20 the mortality rate was 68.4 and 46.9 per cent in groups 1 and 2 respectively (P = 0.01) (RR 1.46 (1.06 to 2.00)); 12 of 49 survivors in group 1 and two of 26 in group 2 suffered permanent disability (P = 0.12) (RR 3.18 (0.77 to 13.20)).

CONCLUSION

Activation of the trauma team and early intensive monitoring, evaluation and resuscitation of geriatric trauma patients improves survival.

Old age as a criterion for trauma team activation

BACKGROUND

Elderly trauma patients have been shown to have a worse prognosis than young patients. Age alone is not a criterion for trauma team activation (TTA). In the present study, we evaluated the role of age > or = 70 years as a criterion for TTA.

METHODS

The present study was a trauma registry study that included injured patients 70 years of age or older. Patients who died in hospital, were admitted to the intensive care unit (ICU) within 24 hours, or had a non-orthopedic operation were assumed to benefit from TTA.

RESULTS

During a 7.5-year period, 883 elderly (> or = 70 years) trauma patients meeting trauma center criteria were admitted to our center. Overall, 223 patients (25%) met at least one of the standard TTA criteria. The mortality in this group was 50%, the ICU admission rate was 39%, and a non-orthopedic operation was required in 35%. The remaining 660 patients (75%) did not meet standard TTA criteria. The mortality was 16%, the need for ICU admission was 24%, and non-orthopedic operations were required in 19%. Sixty-three percent of patients with severe injuries (Injury Severity Score > 15) and 25% of patients with critical injuries (Injury Severity Score > 30) did not have any of the standard hemodynamic criteria for TTA.

CONCLUSION

Elderly trauma patients have a high mortality, even with fairly minor or moderately severe injuries. A significant number of elderly patients with severe injuries do not meet the standard criteria for TTA. It is suggested that age > or = 70 years alone should be a criterion for TTA.

The presentation of tetanus in an emergency department

Traditionally, the literature has described a certain population as at risk for tetanus infection. We reviewed the demographics, clinical presentation, laboratory findings, management, and outcome of all patients who presented to our emergency department (ED) with tetanus in the last 10 years and compared our experience with this classic literature. We performed a retrospective case series review at a large, inner-city medical center; 11 cases of tetanus were identified from 1986 to 1997. Nine male and two female patients were identified with an average age of 45 years. All had an acute injury to the skin, and most (82%) reported having no history of recent immunization. The most common recorded symptoms were trismus and rigidity in the abdomen, neck, back, or extremities. There was only one misdiagnosis in the ED. Three patients died in the hospital, while the other eight were discharged either home or to a rehabilitation facility. In contrast to the classic literature, we found that tetanus in our inner city ED presented in recent immigrants, particularly younger men, over half of whom had received no childhood immunization. Laboratory results and cultures are of little diagnostic value, so timely recognition of the clinical presentation is important.

Randomized comparison of ampicillin-sulbactam to cefoxitin and doxycycline or clindamycin and gentamicin in the treatment of pelvic inflammatory disease or endometritis

OBJECTIVE

To evaluate the efficacy and safety of ampicillin-sulbactam (3 g every 6 hours) in patients with pelvic inflammatory disease or postpartum endometritis using a randomized, comparative, multicenter study of parallel design.

METHODS

Eligible patients with pelvic inflammatory disease were randomized to receive either ampicillin-sulbactam or cefoxitin (2 g every 6 hours) plus doxycycline (100 mg every 12 hours). Those with endometritis were randomized to ampicillin-sulbactam or clindamycin (900 mg every 8 hours) plus gentamicin (1.5 mg/kg every 8 hours). In the ampicillin-sulbactam group, chlamydia-positive patients also received oral doxycycline.

RESULTS

For pelvic inflammatory disease, the clinical response rates (cure or improvement) were 85.5% (47 of 55) and 89.6% (43 of 48) in the ampicillin-sulbactam and cefoxitin and doxycycline groups, respectively (chi 2 = 0.10, P = .76). For endometritis, the clinical response rates were 88.7% (141 of 159) and 90.8% (139 of 153) in the ampicillin-sulbactam and clindamycin and gentamicin groups, respectively (chi 2 = 0.15, P = .70). The percentages of patients with pelvic inflammatory disease who had adverse experiences were not significantly different in the cefoxitin and doxycycline group (47% [29 of 62]) than in those receiving ampicillin-sulbactam (33% [22 of 66]) (P = .12). These adverse effects were mostly mild or moderate. In the endometritis subjects, the incidence of adverse experiences in the ampicillin-sulbactam group (11% [20 of 179]) was comparable to that during treatment with clindamycin and gentamicin (12% [22 of 180]). These adverse experiences were also mostly mild to moderate.

CONCLUSION

Ampicillin-sulbactam is as effective and well tolerated as combination regimens using cefoxitin plus doxycycline and clindamycin plus-gentamicin for the treatment of pelvic inflammatory disease or endometritis, respectively.

Radiographic diagnosis of ankle fractures: are three views necessary?

One hundred and twenty-three sets of emergency room ankle x-rays (anteroposterior lateral and mortise) were retrospectively reviewed to determine whether all three views were necessary to diagnose the presence of an ankle fracture. Four physicians (two orthopaedic surgeons, one musculoskeletal radiologist, and one emergency room physician) reviewed all randomly ordered sets of films twice--once with all three views and once with only the lateral and mortise views. The overall accuracy of two views was within the 95% expected threshold of accuracy using three views. The lateral and mortise views alone appear sufficient for ankle fracture diagnosis, and imply a substantial decrease in radiation and cost savings to the patient.

Bacterial vaginosis: efficacy and safety of intravaginal metronidazole treatment

OBJECTIVE

We evaluated the effectiveness and safety of intravaginal metronidazole in the treatment of bacterial vaginosis. Demographic data, Gram stain score, and individual clinical diagnostic criteria for bacterial vaginosis were evaluated for association with therapeutic outcome.

METHODS

According to accepted diagnostic criteria and blinded Gram stain scoring for quality control, a multicenter, prospective, double-blinded trial of patients randomized to either 0.75% metronidazole gel 5 gm twice daily for 5 days or placebo was undertaken. Therapeutic response after completion of treatment was evaluated by examination at 4 to 16 days and again at 28 to 32 days for patients initially cured.

RESULTS

After metronidazole treatment, 38 (78%) of 49 patients were cured initially, compared with 11 (27%) of 41 placebo recipients (p < 0.001). One month after treatment 31 (91%) of 34 in the group initially cured by metronidazole remained cured. Side effects were uncommon and mild. Significant intercenter differences were noted for vaginal discharge assessment but not for other diagnostic criteria. Among patients cured initially with metronidazole, mean Gram stain score was 0.58 among those in whom cure was maintained versus 2.33 for those in whom recurrent bacterial vaginosis developed 1 month after treatment (p = 0.03). Curative metronidazole treatment was found initially in 4 (100%) of 4 patients with sperm present on gram stain compared with 34 (76%) of 45 with sperm absent (p = 0.56) and in 6 (100%) of 6 and 25 (89%) of 28, respectively, at the final visit (p = 1.0).

CONCLUSIONS

Intravaginal metronidazole is effective, safe, well-tolerated, durable therapy for bacterial vaginosis. Characterization of vaginal discharge appears to be the most variable among the diagnostic criteria for bacterial vaginosis. Gram stain score may be able to identify patients cured early after therapy who are at risk for later recurrence. Exposure to semen does not appear to affect efficacy of intravaginal metronidazole.

Reference accuracy in the emergency medicine literature

STUDY OBJECTIVE

To determine the incidence and nature of errors in the citation and quotation of references contained in the emergency medicine literature.

DESIGN

A retrospective analysis of a random sample of articles and references found in the three major emergency medicine journals.

SETTING

A university/county hospital.

METHODS

We examined single issues of three emergency medicine journals: Annals of Emergency Medicine, Journal of Emergency Medicine, and American Journal of Emergency Medicine.

INTERVENTIONS

None.

MEASUREMENTS

Four independent reviewers assessed 145 references from 46 referring authors for citational and quotational accuracy.

MAIN RESULTS

Major and minor citation errors were found in 10.3% and 17.2% of reference listings, respectively. Qualitative quotational errors were found in 35.2% of references. Eighty-two percent of these errors were considered to be major. Quantitative quotational errors were found in 47% of references reviewed. Secondary rather than primary reference sources were used in 41.4% of references reviewed.

CONCLUSION

This study demonstrates a substantial error rate in the citation and quotation of reference sources in the emergency medicine literature. In addition, verification of primary source material was not done by a large percentage of the authors reviewed. Recommendations for improving the accuracy of the emergency medicine literature are offered.

Successful conversion of unstable supraventricular tachycardia to sinus rhythm with adenosine

STUDY PURPOSE

To evaluate the efficacy of adenosine in the treatment of emergency department patients with unstable paroxysmal supraventricular tachycardia (PSVT).

DESIGN

A retrospective chart review conducted over two years.

SETTING

A university-affiliated hospital ED.

PARTICIPANTS

Patients with unstable PSVT (systolic blood pressure of less than 90 mm Hg, chest pain, pulmonary edema, and/or altered mental status) who were treated with adenosine.

INTERVENTIONS

Patients' preadenosine and postadenosine heart rates, symptoms, and blood pressure were recorded, as were complications and recurrence of PSVT. PSVT was diagnosed by surface ECG.

RESULTS

Twelve patients were identified (three men and nine women with a mean age of 47.6 years). Nine patients presented with hypotension (mean systolic blood pressure, 79 mm Hg), ten with chest pain, and six with both chest pain and hypotension. There were no patients with altered mental status or pulmonary edema. Eight patients converted to sinus rhythm with a single 6-mg bolus of adenosine; the remaining four required an additional 12-mg bolus. In all cases, chest pain and hypotension resolved within minutes of conversion to sinus rhythm. There were no clinically significant adverse effects or recurrence of PSVT during ED observation (mean, 1.8 hours). All patients responded to adenosine; none required electrical cardioversion.

CONCLUSION

In the unstable patient with PSVT, adenosine appears to be a safe and effective alternative to current advanced cardiac life support-recommended immediate electrical cardioversion.

Evaluation and management of acute uvular edema

Acute uvular edema is a potentially life-threatening condition with a variety of causes. Other upper airway structures, most notably the epiglottis, may also become involved, and complete or partial airway obstruction may ensue rapidly. An accurate diagnosis may be essential in establishing effective treatment.

The vagina of women infected with Trichomonas vaginalis has numerous proteinases and antibody to trichomonad proteinases

BACKGROUND

Patients with trichomoniasis have serum antibody to numerous T. vaginalis cysteine proteinases, indicating that the proteinases are expressed in vivo. It was important, therefore, to examine for the presence of soluble trichomonad proteinases and/or antibody to the proteinases in the vagina of infected women.

METHODS

Vaginal washes (VWs) from 20 women were examined for the presence of proteinases by electrophoresis using acrylamide co-polymerised with gelatin as the indicator system. Antibody to proteinases in VWs was detected by an immunoprecipitation assay involving protein A-bearing Staphylococcus aureus first coated with anti-human immunoglobulin G (IgG) antibody, which was then added to VWs. For VWs having soluble proteinases, the bacteria were used to determine whether immune complexes between antibody and proteinases were present. VWs without soluble proteinases were incubated with the anti-human IgG treated bacteria before adding to detergent extracts of T. vaginalis. Individual isolates from the patients examined in this study were also analysed by one- and two-dimensional electrophoresis for their proteinase content. Finally, VWs were from patients without any history of other sexually transmitted diseases (STDs) as well as from individuals having numerous other STDs, including yeast, group B streptococcus, chlamydia, and syphilis.

RESULTS

Approximately one-third of patients had soluble proteinases in the VWs; the remaining two-thirds (70%) of patients and normal women had no detectable proteinases in VWs. Half of the patients without soluble proteinases had IgG which, when bound to S. aureus, immunoprecipitated many proteinases from a detergent extract of T. vaginalis. All soluble proteinases and those precipitated from trichomonal extracts were inhibited by inhibitors of cysteine proteinases. Finally, patients having trichomoniasis in addition to numerous other STD agents, including yeast, group B streptococcus, chlamydia, and syphilis did not have soluble proteinases in VWs. Equally noteworthy, some patients with soluble proteinases in VWs did not have other detectable STD agents.

CONCLUSIONS

Proteinases were detected in the vagina of some patients with trichomoniasis, and in most cases the proteinases were complexed with IgG, which was precipitated by S. aureus. Patients without soluble proteinases in VWs also had antibody specifically to trichomonad proteinases, again demonstrating both the expression and immunogenic nature of the proteinases in vivo. The absence of soluble proteinases in normal women and in patients having other STD agents as well as the presence of proteinases in VWs of patients without other detectable STD pathogens reinforced the idea that the proteinases were of T. vaginalis parasite origin. The findings of this study indicate that proteinases may be important to the T. vaginalis-host interrelationship.

Antibody in sera of patients infected with Trichomonas vaginalis is to trichomonad proteinases

BACKGROUND

A recent report demonstrated the immunogenic character of the cysteine proteinases of Trichomonas vaginalis. It was of interest, therefore, to examine for the presence of serum anti-proteinase antibody among patients with trichomoniasis.

METHODS

An immunoprecipitation assay was used involving protein A-bearing Staphylococcus aureus first coated with the IgG fraction of goat anti-human Ig and then mixed with individual sera of patients to bind human antibody. These antibody-coated bacteria were then added to detergent extracts of T vaginalis. Bound immune complexes on S aureus were washed and solubilised for electrophoretic analysis on acrylamide copolymerised with gelatin for detection of proteinase activity.

RESULTS

Sera from patients (50/50), but none from sera of normal, uninfected women, possessed IgG to numerous trichomonad cysteine proteinases. The presence of this serum anti-proteinase antibody disappeared after drug treatment and cure of patients of the T vaginalis infection.

CONCLUSIONS

The commonality of the anti-proteinase antibody in the sera of patients with trichomoniasis provided evidence for the expression of the same repertoire of parasite proteinases during infection. These observations have important implications for the in vivo relevance of the proteinases and indicate that strategies to use a specific serum antibody response for diagnosis of this infection may be possible.

Vaginal antibody of patients with trichomoniasis is to a prominent surface immunogen of Trichomonas vaginalis

Twenty vaginal washes (VWs) and ten vaginal mucus (VM) samples from patients with trichomoniasis were examined for the presence of antibody to surface protein immunogens of Trichomonas vaginalis. Fourteen of 20 VWs (70%) and 8 of 10 VM (80%) had immunoglobulin G (IgG) antibody (Ab) that reacted in an immunoprecipitation (IP) assay with one iodinated Trichomonas vaginalis surface protein immunogen with a relative molecular mass of 230,000 daltons (230-kDa) (P230). No similar IP of any iodinated protein was observed when detergent extract was first depleted of P230 with monoclonal antibody (MAb), indicating a highly specific VW IgG response of patients to P230. VWs were also obtained from 10 patients from one to four weeks after treatment. These VWs had the same, or in one case a greater, level of IgG to P230. Under no circumstances was Ab to P230 or any other trichomonad protein detected in VWs or VM from normal, uninfected women. Flow cytofluorometry with VW Ab yielded heterogeneous fluorescent and non-fluorescent populations of trichomonads, reaffirming the restricted Ab response to one or a few epitopes on P230 in the vagina of patients. Under identical conditions, the MAb gave totally fluorescent parasite populations of some isolates, and the MAb again demonstrated variable epitope accessibility to Ab binding (Infect Immun 1987;55:1037). Finally, the MAb or VW Ab was never cytolytic for immunoreactive (fluorescent) parasites, even in the presence of complement. This study identifies the most important trichomonad surface immunogen on the basis of the vaginal Ab response, and data underscore the significance of immune evasion strategies of this sexually transmitted disease agent.

Molecular cloning of cDNA encoding a 55-kDa multifunctional thyroid hormone binding protein of skeletal muscle sarcoplasmic reticulum

A cDNA clone encoding 55-kDa multifunctional, thyroid hormone binding protein of rabbit skeletal muscle sarcoplasmic reticulum was isolated and sequenced. The cDNA encoded a protein of 509 amino acids, and a comparison of the deduced amino acid sequence with the NH2-terminal amino acid sequence of the purified protein indicates that an 18-residue NH2-terminal signal sequence was removed during synthesis. The deduced amino acid sequence of the rabbit muscle clone suggested that this protein is related to human liver thyroid hormone binding protein, rat liver protein disulfide isomerase, human hepatoma beta-subunit of prolyl 4-hydroxylase and hen oviduct glycosylation site binding protein. The protein contains two repeated sequences Trp-Cys-Gly-His-Cys-Lys proposed to be in the active sites of protein disulfide isomerase. Northern blot analysis showed that the mRNA encoding rabbit skeletal muscle form of the protein is present in liver, kidney, brain, fast- and slow-twitch skeletal muscle, and in the myocardium. In all tissues the cDNA reacts with mRNA of 2.7 kilobases in length. The 55-kDa multifunctional thyroid hormone binding protein was identified in isolated sarcoplasmic reticulum vesicles using a monoclonal antibody specific to the 55-kDa thyroid hormone binding protein from rat liver endoplasmic reticulum. The mature protein of Mr 56,681 contains 95 acidic and 61 basic amino acids. The COOH-terminal amino acid sequence of the protein is highly enriched in acidic residues with 17 of the last 29 amino acids being negatively charged. Analysis of hydropathy of the mature protein suggests that there are no potential transmembrane segments. The COOH-terminal sequence of the protein, Arg-Asp-Glu-Leu (RDEL), is similar to but different from that proposed to be an endoplasmic reticulum retention signal; Lys-Asp-Glu-Leu (KDEL) (Munro, S., and Pelham, H.R.B. (1987) Cell 48, 899-907). This variant of the retention signal may function in a similar manner to the KDEL sequence, to localize the protein to the sarcoplasmic or endoplasmic reticulum. The positively charged amino acids Lys and Arg may thus interchange in this retention signal.

Intraamniotic infection in low-birth-weight infants

Intraamniotic infection (IAI) complicating births of low-birth-weight infants (less than 2500 g) was compared with IAI in births of infants weighing greater than or equal to 2500 g for differences in neonatal and maternal infectious morbidity and mortality, as well as differences in microbiological isolates in amniotic fluid. Four hundred four cases of clinically diagnosed IAI were prospectively evaluated. Thirty-seven patients (9.2%) delivered neonates less than 2500 g, and 367 patients (90.8%) delivered neonates greater than or equal to 2500 g. The low-birth-weight group had a significant increase in the incidence of sepsis (16.2% vs. 4.1%, P = .005) and death from sepsis (10.8% vs. 0%, P less than .001). Additional intrapartum conditions that might further predispose the low-birth-weight group to an increased risk of sepsis were not evident. Evaluation of the amniotic fluid did not demonstrate any increase in prevalence of group B streptococci, Escherichia coli, or enterococci in the low-birth-weight group. The presence of gram-negative anaerobes was significantly increased, however, in low-birth-weight pregnancies with IAI (59.5% vs. 31.6%, P = .001).

Antimicrobial activity of amniotic fluid against Chlamydia trachomatis, Mycoplasma hominis, and Ureaplasma urealyticum

Amniotic fluids obtained by amniocentesis at 16 weeks to term were examined for the presence of Chlamydia trachomatis, Mycoplasma hominis, and Ureaplasma urealyticum. Of 140 fluids tested, none harbored chlamydiae, and only one harbored mycoplasma, M. hominis. A number of amniotic fluids were subsequently tested for their ability to inhibit the growth of these microorganisms. Amniotic fluids and chlamydial suspensions in a 2:1 ratio were incubated 30 to 90 minutes before their inoculation in McCoy cells. Procedures were followed for chlamydial isolation. Genital mycoplasmas were incubated with amniotic fluid samples for 24 or 48 hours at 35 degrees C. Growth in amniotic fluid specimens was compared with growth in pseudoamniotic fluid and broth controls. Fourteen amniotic fluid specimens collected from gestations of 16 to 40 weeks, were found to be inhibitory to the formation of inclusions of C. trachomatis in McCoy cells. Ten amniotic fluid specimens (16 to 39 weeks, gestation) demonstrated various degrees of inhibition against M. hominis, and three fluids were inhibitory to the growth of Ureaplasma. The inhibitor was heat and protease resistant and activity was proportional to concentration. The molecular weight of the inhibitor was probably greater than 10,000 daltons, and pH, although perhaps a contributing factor, was not the cause of the inhibition.

Positive correlation between mature amniotic fluid optical density readings and the absence of neonatal hyaline membrane disease

Fetal pulmonary maturity is generally determined by analyzing amniotic fluid for surfactants. This task is accomplished by lipid extraction of the fluid and resolution, identification and quantitation of the isolated lipids with thin-layer chromatography. These methods are lengthy, cumbersome and often not available on demand. A quick, simple, reliable and economical test therefore would be highly desirable. We have been able to correlate an optical density (OD) reading of amniotic fluid at 650 nm greater than or equal to 0.15 with the absence of hyaline membrane disease (HMD). For 428 fluids in which an OD reading of greater than or equal to 0.15 was found and delivery occurred within 48 hours, HMD was present in only two infants. The accuracy of the test was 99.53% , with a false-positive rate of 0.47%. With the use of this simple and accurate test one can satisfy the requirement of an on-demand test to determine fetal pulmonary maturity.

Infection and phagocytosis as possible mechanisms of rupture in premature rupture of the membranes

The concept that premature rupture of the membranes is due to an infectious process is well accepted. However, no definitive data implicating a particular microorganism or a mechanism of action have been advanced. By the use of our recently developed experimental in vitro amnion-chorion reaction vessel model we have studied the effect of the peroxidase-hydrogen peroxide-halide antimicrobial system on these membranes. We have noted that amnion, chorion, decidua, and placental macrophages all possess peroxidase activity. Tissues collected from deliveries following labor (vaginal) are significantly higher in activity than those collected from deliveries with no labor (cesarean section). A mobilization of enzyme from macrophages to amnion appears to occur in the laboring patient. Increased protein hydrolysis is noted in membranes collected from patients without labor subjected to the peroxidase-hydrogen peroxide-halide cytotoxic system when compared with membranes from laboring patients. Bursting pressures of membranes collected from patients without labor are shown to be decreased when the membranes were incubated in the presence of lysolecithin or in the presence of amniotic fluid and phospholipase A2.