Quality of life in mucopolysaccharidoses: construction of a specific measure using the focus group technique

OBJECTIVE

To describe the perceptions of patients, their caregivers, and their healthcare providers to the development of a new specific instrument for assessment of the quality of life (QoL) in patients with mucopolysaccharidoses (MPS) using a qualitative focus group (FG) design. FGs were held in two Brazilian states (Rio Grande do Sul and Rio de Janeiro).

RESULTS

Three versions of the new instrument were developed, each for a different age group: children (age 8-12 years), adolescents (age 13-17), and adults (age ≥ 18). The FGs mostly confirmed the relevance of items. All FGs unanimously agreed on the facets: School, Happiness, Life Prospects, Religiosity, Pain, Continuity of Treatment, Trust in Treatment, Relationship with Family, Relationship with Healthcare Providers, Acceptance, and Meaning of Life. The overall concept of QoL (as proposed by the WHO-World Health Organization) and its facets apply to this patient population. However, other specific facets-particularly concerning clinical manifestations and the reality of the disease-were suggested, confirming the need for the development of a specific QoL instrument for MPS.

Effect of previous hormone replacement therapy on endometrial polyps during menopause

The aim of this study was to evaluate the effect of hormone replacement therapy (HRT) on the expression of Ki-67, bcl-2 and c-erb.B2 in endometrial polyps during menopause. Sixteen patients using HRT and 24 untreated controls with endometrial polyps were enrolled in this study. Polypectomy was carried out by hysteroscopy. The presence of c-erb.B2, bcl-2 and Ki-67 expression was determined by immunohistochemistry. HRT was found to decrease Ki-67 and bcl-2 expression in endometrial polyps without affecting the c-erb.B2 staining reaction. HRT may cause endometrial polyp involution by decreasing proliferation and stimulating apoptosis.

Proliferation kinetics in adenomyosis during the menstrual cycle and during oral contraceptive use

Our objective was to investigate the presence of focal p53 expression in relation to proliferation rates in adenomyotic lesions during the menstrual cycle and in women on oral contraception. Fifty-nine perimenopausal patients with menorrhagia and adenomyosis were submitted to endometrial resection. The procedure was carried out during menstruation (n = 14), during the proliferative phase (n = 15), during the luteal phase (n = 20) or following the use of oral contraceptives (n = 10). The number of Ki-67-positive cells was low during menstruation, during the luteal phase and following the use of progestins. In the proliferative phase, on the other hand, there was a significant increase in the percentage of Ki-67-positive cells. Focal p53 expression was detected mainly during the proliferative phase of the menstrual cycle when proliferation rates were high. PTEN expression was detected in all cases irrespective of the phase of the menstrual cycle or use of oral contraception. We conclude that proliferation rates in adenomyotic lesions undergo marked cyclic variations and this affects the percentage of cases showing focal p53 expression in the glandular epithelium.

Proliferation profile of endometrial polyps in post-menopausal women

OBJECTIVE

To determine whether or not the presence of c-erbB2 over-expression in endometrial polyps affects the percentage of cells positive for Ki-67 proliferation marker.

METHODS

Thirty-five patients with endometrial polyps were submitted to polypectomy by hysteroscopy. Ki-67 and c-erbB2 over-expression were investigated in the polyps by immunohistochemistry.

RESULTS

The presence of c-erbB2 over-expression by immunohistochemistry was observed in 80% of endometrial polyps and was associated with higher proliferation rates as determined by the number of positive Ki-67 cell nuclei. In c-erbB2-negative polyps, the proliferation rates were low.

CONCLUSION

Ki-67 and c-erbB2 over-expression are frequent in endometrial polyps in post-menopausal women.

Hysteroscopic and immunohistochemical findings in type I and type II endometrial carcinomas

STUDY OBJECTIVE

To determine whether types I and II endometrial carcinomas have different precursor lesions recognized at hysteroscopy and immunohistochemistry.

DESIGN

Single center case study (Canadian Task Force classification II-2).

SETTING

A private, university affiliated hospital.

PATIENTS

One hundred forty-six postmenopausal women with endometrial pathology diagnosed by hysteroscopy and biopsy.

INTERVENTION

Hysteroscopy and immunohistochemical determination of p53 overexpression.

MEASUREMENTS AND MAIN RESULTS

The number of cells showing p53 overexpression was low in endometrial polyps, hyperplasia, and G1 endometrioid carcinomas. A marked increase was seen only in high-grade G2-G3 endometrioid carcinomas and in cases of uterine papillary serous carcinoma. In the latter, strong p53 overexpression was detected in early forms still confined to endometrial polyps. Hysteroscopy could not differentiate between high- and low-grade endometrioid carcinomas.

CONCLUSION

The p53-driven pathway plays an important role in the origin of papillary serous carcinoma but not in G1 endometrioid cancer that evolves from estrogen-stimulated endometrium. However, this pathway is important for progression of low-grade endometrioid carcinomas to higher-grade tumors.

Detection of testosterone and estrogen receptors in the postmenopausal endometrium

OBJECTIVE

To detect the presence of testosterone and estrogen receptors in the stroma and glandular epithelium in the malignant and non-malignant endometrium.

METHODS

One hundred and forty-five consecutively-enrolled peri- or postmenopausal patients were submitted to diagnostic or operative hysteroscopy. These patients either had a history of abnormal uterine bleeding or they were asymptomatic with an endometrial echo greater than 4 mm. The presence of estrogen and testosterone receptors was determined in endometrial samples by immunohistochemistry, using monoclonal antibodies and a streptavidin-biotin peroxidase complex system with diamino benzidine as the chromogen.

RESULTS

Testosterone receptors were detected mainly in the stroma in the non-malignant endometrial lesions and in the atypical glandular epithelium in cases of estrogen-positive endometrial carcinomas.

CONCLUSIONS

The presence of testosterone receptors in estrogen receptor positive endometrial carcinomas may be involved in the mechanism of cell proliferation in these tumors. The strong staining reaction for testosterone receptors in the endometrial glands can be considered one of the features of invasive malignancy.

Polypectomy and endometrial resection in postmenopausal patients

STUDY OBJECTIVE

To evaluate the therapeutic efficacy of polypectomy associated with endometrial resection for the treatment of polyps in postmenopausal women.

DESIGN

Prospective study (Canadian Task Force classification II-2).

SETTING

Private urban hospital with facilities for endoscopic surgery.

PATIENTS

Sixty-six women with endometrial polyps.

INTERVENTIONS

Sixty-four of the 66 patients underwent polypectomy followed by endometrial resection. One patient had hysterectomy because endometrial biopsy showed serous papillary carcinoma.

MEASUREMENTS AND MAIN RESULTS

No major complications were associated with the procedure. Histopathology showed hyperplasia in most polyps. One patient had a papillary uterine carcinoma in the polyp that was not detected by preoperative endometrial biopsy. The women were followed with transvaginal sonography for 1 year after surgery.

CONCLUSION

Polypectomy followed by endometrial resection is a very low-risk procedure for postmenopausal patients. There was no recurrence after the first year in women who completed follow-up.

Administration of medroxyprogesterone acetate after endomyometrial resection

STUDY OBJECTIVE

To assess the efficacy of endometrial resection for treatment of menorrhagia in women to whom no preoperative agent was given to prepare the endometrium.

DESIGN

Retrospective analysis of patients' records for all endometrial resections in which medroxyprogesterone acetate was used postoperatively.

SETTING

Hospital day surgery unit.

PATIENTS

Seventy patients with menorrhagia.

INTERVENTIONS

The women underwent transvaginal sonography, followed by hysteroscopy and endometrial biopsy. The endometrium was removed using the 27F resectoscope followed by coagulation with the rollerball. Medroxy-progesterone acetate was prescribed for 2 months after surgery.

MEASUREMENTS AND MAIN RESULTS

All women achieved a reduction in menstrual flow and 50% reported amenorrhea after endometrial resection. In only two was hysterectomy necessary due to recurrence of menorrhagia.

CONCLUSION

Preoperative endometrial preparation was unnecessary when endometrial resection was carried out for treatment of menorrhagia. However, the patients received medroxyprogesterone acetate postoperatively.

Hysteroscopy and transvaginal sonography in menopausal women receiving hormone replacement therapy

STUDY OBJECTIVE

To evaluate the endometrial cavity of menopausal women with irregular bleeding while receiving hormone replacement therapy.

DESIGN

Comparative evaluation of hysteroscopic and biopsy findings.

SETTING

A center for reproductive studies.

PATIENTS

Forty-one patients receiving different regimens of hormone replacement therapy.

INTERVENTIONS

Hysteroscopy, endometrial biopsy, and transvaginal sonography were performed in all 41 women. In 10 patients, endometrial polyps were removed with the resectoscope.

MEASUREMENTS AND MAIN RESULTS

Irregular bleeding during hormone replacement therapy was associated with atrophic endometrium whenever transvaginal sonography showed endometrial thickness to be less than 4 mm. In patients who developed increased endometrial thickness after hormone replacement therapy, hysteroscopy revealed the presence of endometrial polyps in the uterine cavity. Histopathologic examination of excised polyps revealed cystic or adenomatous hyperplasia confined to these lesions.

CONCLUSIONS

Endometrial polyps can appear in menopausal women receiving hormone replacement therapy despite the presence of progestins to oppose the action of estrogens.

[Preliminary results of a project about the ecology of Phlebotomus vectors of cutaneous leishmaniasis in the state of Bahia]

Preliminary data of a project about the ecology of the Phlebotominae (sandflies) in a tegumentary leishmaniasis area of coconut plantation in the south of the State of Bahia, Brazil are presented. There are 60 dwellings far of one another, where existed 31 dogs and 229 inhabitants. Among them 41.5% were Montenegro positive; 37.5% from these had scars of healed ulcers and 8.8% had active ulcers. 53% of the house had dogs from which 22% were seropositive; from the 7 dogs with ulcers only 3 were seropositive. 14% of the inspected house harboured sandflies inside them. During two years of observations 72 sentinels hamsters were maintened at houses of patients with leishmaniasis ulcers, but they did not get the infection. During two years of observation, monthly collectings of sandflies were made inside house, chicken pen, curral, tree trunks and open field around a house with a patient with leishmaniasis. The following results were already obtained about the vectors: 5,614 specimens were identified as belonging to fourteen different species of sandflies. Among them Lutzomyia whitmani (92%) and Lutzomyia intermedia (4.8%) were the most abundant species. They are very anthropophilic and can be found inside houses and at peridomestic sites. Probably they are the principal vectors of the disease at domestic places. The other twelve species were less frequent and more found at sylvatic places in inspite they also bite the man. Generally the biting activity of most of the species of the area begins at 5 p.m. in the dusk and reaches its peak at 0 hour a.m., when begins declining until disapear at 7 a.m. L. whitmani was similarly collected with the same density in all lunar phases while L. intermedia was more abundant during the new moon phase. Most of the hundreds sandflies collected during the second year of observations, remains preserved in liquid nitrogen, watching for the adjustment of PCR molecular techniques to be processed for determination of the vector natural infection rates with leishmanias. Final results on all the project will be published as soon as the examination of such material has been processed.

Evaluation of the endometrial cavity during menopause

OBJECTIVE

To compare transvaginal sonography (TVS), hysteroscopy and suction curettage in the evaluation of uterine bleeding during the menopause.

METHODS

Forty-seven patients who presented with either postmenopausal bleeding (31 cases) or sonographic endometrial abnormalities at menopause (16 cases) were evaluated using TVS, hysteroscopy, and curettage with a Karman curette.

RESULTS

When endometrial thickness measured by TVS was < 4 mm, there was no endometrial pathology. However TVS could not differentiate accurately between hyperplasia, polyps or endometrial carcinoma. In these cases, endometrial thickness was invariably greater than 5 mm.

CONCLUSIONS

Hysteroscopy proved superior to curettage in the diagnosis of endometrial polyps.

Induction of ovulation with clomiphene citrate followed by LH-RH in women

Luteinizing hormone-releasing hormone (LH-RH) was used to induce ovulation following clomiphene priming to stimulate follicular growth. Ovulation was assumed to have occurred following LH-RH injection when progesterone levels started to rise within 48 h following treatment and LH pretreatment levels were below 8 mIU/ml. Ovulation occurred in eight of 10 patients following the administration of LH-RH and six pregnancies were achieved in the first 4 months of treatment.

Induction of ovulation with epimestrol and luteinizing hormone-releasing hormone (LH-RH)

Luteinizing hormone-releasing hormone (LH-RH) was used to induce LH surge and ovulation in 20 patients in whom follicular maturation was provoked by epimestrol, used in a dose of 5 mg/day from the fifth to 14th day of the cycle. Patients with elevated prolactin levels and galactorrhea were not included in the study. Complete follicular maturation, as inferred by estradiol levels above 200 pg/ml, were observed in 13 of 20 patients following epimestrol treatment. LH-RH induced ovulation in 90% of these patients following a three-day course of treatment. Normal corpus luteum function with progesterone levels above 8 ng/ml was observed in most cases. Five pregnancies occurred in the first two cycles of treatment. In patients with low estradiol levels, following epimestrol priming, the administration of LH-RH did not result in ovulation.

Effect of prostaglandin F2 alpha on oviduct contractility in marmoset monkeys

Prostaglandin F2 alpha (PGF2 alpha) increased oviductal contractility under different hormonal conditions. Changes in the response of the oviduct to PGF2 alpha were observed during the reproductive cycle. The response to PGF2 alpha was reduced during the follicular phase, but it increased markedly following both spontaneous and human chorionic gonadotropin-induced ovulation. During the luteal phase the effect of PGF2 alpha on the oviduct was significantly greater than during the follicular phase. The spontaneous motility of the oviduct also increased significantly following ovulation. This increase in motility occurred when progesterone blood levels reached values higher than 1.5 ng/ml, and it was not suppressed by indomethacin, a potent inhibitor of prostaglandin synthesis.

Inhibition of ovulation in marmoset monkeys by indomethacin

The effect of indomethacin on human menopausal gonadotropin/human chorionic gonadotropin-induced ovulation was studied in marmoset monkeys. Indomethacin was effective in preventing follicular rupture and ovum extrusion when administered simultaneously with gonadotropin. The production of progesterone and luteinization of the granulosa cells were not affected by indomethacin treatment. Histologic examination of corpora lutea from indomethacin-treated animals revealed the presence of entrapped oocytes surrounded by luteal cells. These results suggest that prostaglandin synthesis is required for ovulation in this species, but not for luteinization and progesterone production.

Pharmacologic modification of the time course of ovum transport in guinea pigs

Various agents were examined for their effects on ovum transport in the guinea pig. Estrogen significantly accelerated ovum transport in this species. The experiments further demonstrated that estrogen did not act by inducing prostaglandin synthesis, nor by altering plasma progesterone levels. The estrogen-induced acceleration was significantly antagonized by tamoxifen, an antiestrogen that acts by interfering with estrogen receptor synthesis. Cycloheximide also antagonized the effects of estrogen on ovum transport. These data suggest that the modification of ovum transport by estrogen is due to the entrance of estrogen into the nuclei of target cells, and subsequent protein synthesis. Although we assume that this action occurs at the level of the oviduct, our experiments do not prove this assumption.

Time course of ovum transport in guinea pigs

The time course of ovum transport was determined in cycling guinea pigs. The occurrence of ovulation was determined in assessing changes in vaginal cytology. The day of the postovulatory leukocyte influx was considered day 1 of the cycle. Ovum transport in guinea pigs is characterized by a relatively long sojourn in the ampulla, followed by rapid transport through the isthmus. This pattern is similar to that seen in women and subhuman primates and different from the pattern in rabbits.

Effect of ovulation and hormonal treatment on the in vitro response of rabbit oviducts to prostaglandins E1 and F2alpha

Rabbit oviductal circular muscle isometric contractile response was measured in relation to treatment with prostaglandin E1 (PGE1) and prostaglandin F2alpha (PGF2alpha). PGE1 (1 mug/ml) inhibition of the contractile response of the rabbit oviduct to field stimulation was increased in the proximal isthmus after ovulation. Estrogen and progesteron, in doses known to alter ovum transport, did not affect the response of the oviduct to PGE1. In comparison to the response of estrous tissues, the stimulatory effect of PGF2alpha on the isthmus was decreased 24 hours after administration of human chorionic gonadotropin (HCG). Treatment with estrogen and progesterone did not affect these postovulatory changes. The response of the ampullary-isthmic junction to PGF2alpha was significantly reduced 72 hours after administration of HCG. Neither ovulation nor steroid treatment affected the response of the ampulla to PGF2alpha. Changes in the sensitivity of the oviduct to prostaglandins after ovulation may be necessary for successful ovum transport.

The response of the human Fallopian tube to ergonovine and methyl-ergonovine in vivo

Ergonovine maleate (EM) is a powerful stimulant of human tubal motility. It has been therefore thought that EM could interfere with normal ovum transport and serve as a contraceptive. The tube activating effects of EM and methyl EM were evaluated in 14 women and results confirmed that both are powerful stimulants of the human Fallopian tube. EM immediately post coitus significantly reduces the conception rate.

Effect of prostaglandin E2 on oviductal adenosine 3':5'-monophosphate levels during estrus and pseudopregnancy

The basal levels of adenosine 3':5'-monophosphate (cyclic AMP) in the oviductal isthmus were lower during pseudopregnancy than during estrus. No differences were observed in the ampulla. Prostaglandin E2(PGE2) significantly increased cyclic AMP levels in the isthmus during pseudopregnancy but not during estrus. In contrast, in the ampulla, PGE2 did not alter cyclic AMP levels in either hormonal condition. Theophylline increased cyclic AMP levels in the isthmus and in the ampulla during pseudopregnancy. These results show that PGE2 causes a specific increase in cyclic AMP levels in the isthmus after ovulation.

Contractility of the fallopian tube

Recordings of intratubal pressure in women reveal a complex pattern of tubal contractions. Overall activity of the fallopian tube is increased during ovulation. During the luteal phase of the menstrual cycle, activity is depressed but never suppressed. The fallopian tube remains active during gestation in contrast with the uterus which is quiescent. The early puerperal tube displays a pattern of activity similar to that recorded during the late luteal phase of the menstrual cycle. Activation occurs during suckling and in response to exogenous oxytocin, prostaglandins, nor-adrenergic compounds, and ergot derivatives. It is concluded that contractility of the fallopian tube is less influenced by ovarian steroids than that of the uterus.