Analytical validation of a multi-cancer early detection test with cancer signal origin using a cell-free DNA-based targeted methylation assay

The analytical validation is reported for a targeted methylation-based cell-free DNA multi-cancer early detection test designed to detect cancer and predict the cancer signal origin (tissue of origin). A machine-learning classifier was used to analyze the methylation patterns of >105 genomic targets covering >1 million methylation sites. Analytical sensitivity (limit of detection [95% probability]) was characterized with respect to tumor content by expected variant allele frequency and was determined to be 0.07%-0.17% across five tumor cases and 0.51% for the lymphoid neoplasm case. Test specificity was 99.3% (95% confidence interval, 98.6-99.7%). In the reproducibility and repeatability study, results were consistent in 31/34 (91.2%) pairs with cancer and 17/17 (100%) pairs without cancer; between runs, results were concordant for 129/133 (97.0%) cancer and 37/37 (100%) non-cancer sample pairs. Across 3- to 100-ng input levels of cell-free DNA, cancer was detected in 157/182 (86.3%) cancer samples but not in any of the 62 non-cancer samples. In input titration tests, cancer signal origin was correctly predicted in all tumor samples detected as cancer. No cross-contamination events were observed. No potential interferent (hemoglobin, bilirubin, triglycerides, genomic DNA) affected performance. The results of this analytical validation study support continued clinical development of a targeted methylation cell-free DNA multi-cancer early detection test.

Feasibility of Patient-Reported Outcomes Measurement Information System (PROMIS®) computerized adaptive tests in systemic lupus erythematosus outpatients

Objective

The aims of this study were to assess the feasibility of administering Patient-Reported Outcomes Measurement Information System (PROMIS®) computerized adaptive tests (CATs) to outpatients with systemic lupus erythematosus (SLE).

Methods

Adults with SLE were recruited during routine outpatient visits at an SLE Center of Excellence. Participants completed 14 PROMIS CATs and provided feedback on their experience. Differences in socio-demographic and clinical characteristics between participants and non-participants were evaluated.

Results

A total of 204 (86%) of 238 socioeconomically and racially diverse SLE patients completed PROMIS CATs. There were no significant differences between participants and non-participants. Time constraints were cited most frequently as reasons for non-participation. More than 75% of individuals submitted positive comments, including approval of the content and format of questions, and the survey’s promotion of self-reflection. A minority of participants cited challenges, most often related to question phrasing (8%) and technical difficulties (6%).

Conclusions

The administration of PROMIS CATs was feasible and positively received in a diverse cohort of SLE outpatients. Neither socio-demographic nor disease characteristics were significant barriers to successful completion of PROMIS CATs. PROMIS CATs have great potential for efficiently measuring important patient-centered outcomes in routine clinical care of a wide range of SLE patients.

Selection-free genome editing of the sickle mutation in human adult hematopoietic stem/progenitor cells

Genetic diseases of blood cells are prime candidates for treatment through ex vivo gene editing of CD34+ hematopoietic stem/progenitor cells (HSPCs), and a variety of technologies have been proposed to treat these disorders. Sickle cell disease (SCD) is a recessive genetic disorder caused by a single-nucleotide polymorphism in the β-globin gene (HBB). Sickle hemoglobin damages erythrocytes, causing vasoocclusion, severe pain, progressive organ damage, and premature death. We optimize design and delivery parameters of a ribonucleoprotein (RNP) complex comprising Cas9 protein and unmodified single guide RNA, together with a single-stranded DNA oligonucleotide donor (ssODN), to enable efficient replacement of the SCD mutation in human HSPCs. Corrected HSPCs from SCD patients produced less sickle hemoglobin RNA and protein and correspondingly increased wild-type hemoglobin when differentiated into erythroblasts. When engrafted into immunocompromised mice, ex vivo treated human HSPCs maintain SCD gene edits throughout 16 weeks at a level likely to have clinical benefit. These results demonstrate that an accessible approach combining Cas9 RNP with an ssODN can mediate efficient HSPC genome editing, enables investigator-led exploration of gene editing reagents in primary hematopoietic stem cells, and suggests a path toward the development of new gene editing treatments for SCD and other hematopoietic diseases.

A Digital PCR-Based Method for Efficient and Highly Specific Screening of Genome Edited Cells

The rapid adoption of gene editing tools such as CRISPRs and TALENs for research and eventually therapeutics necessitates assays that can rapidly detect and quantitate the desired alterations. Currently, the most commonly used assay employs “mismatch nucleases” T7E1 or “Surveyor” that recognize and cleave heteroduplexed DNA amplicons containing mismatched base-pairs. However, this assay is prone to false positives due to cancer-associated mutations and/or SNPs and requires large amounts of starting material. Here we describe a powerful alternative wherein droplet digital PCR (ddPCR) can be used to decipher homozygous from heterozygous mutations with superior levels of both precision and sensitivity. We use this assay to detect knockout inducing alterations to stem cell associated proteins, NODAL and SFRP1, generated using either TALENs or an “all-in-one” CRISPR/Cas plasmid that we have modified for one-step cloning and blue/white screening of transformants. Moreover, we highlight how ddPCR can be used to assess the efficiency of varying TALEN-based strategies. Collectively, this work highlights how ddPCR-based screening can be paired with CRISPR and TALEN technologies to enable sensitive, specific, and streamlined approaches to gene editing and validation.

Systematic quantification of HDR and NHEJ reveals effects of locus, nuclease, and cell type on genome-editing

Precise genome-editing relies on the repair of sequence-specific nuclease-induced DNA nicking or double-strand breaks (DSBs) by homology-directed repair (HDR). However, nonhomologous end-joining (NHEJ), an error-prone repair, acts concurrently, reducing the rate of high-fidelity edits. The identification of genome-editing conditions that favor HDR over NHEJ has been hindered by the lack of a simple method to measure HDR and NHEJ directly and simultaneously at endogenous loci. To overcome this challenge, we developed a novel, rapid, digital PCR–based assay that can simultaneously detect one HDR or NHEJ event out of 1,000 copies of the genome. Using this assay, we systematically monitored genome-editing outcomes of CRISPR-associated protein 9 (Cas9), Cas9 nickases, catalytically dead Cas9 fused to FokI, and transcription activator–like effector nuclease at three disease-associated endogenous gene loci in HEK293T cells, HeLa cells, and human induced pluripotent stem cells. Although it is widely thought that NHEJ generally occurs more often than HDR, we found that more HDR than NHEJ was induced under multiple conditions. Surprisingly, the HDR/NHEJ ratios were highly dependent on gene locus, nuclease platform, and cell type. The new assay system, and our findings based on it, will enable mechanistic studies of genome-editing and help improve genome-editing technology.

Droplet Digital™ PCR: Multiplex Detection of KRAS Mutations in Formalin-Fixed, Paraffin-Embedded Colorectal Cancer Samples

Targeted therapies in many cancers have allowed unprecedented progress in the treatment of disease. However, routine implementation of genomic testing is constrained due to: 1) limited amounts of sample (pg–ng range) per biological specimen, 2) diagnostic turnaround time and workflow, 3) cost, and 4) difficulties in detection of mutational loads below 5%. KRAS is mutated in approximately 40% of colorectal cancers (CRCs). The majority of mutations affect codons 12, 13, and 61 and indicate a negative response to anti–epidermal growth factor receptor (EGFR) therapy. To optimize therapy strategies for personalized care, it is critical to rapidly screen patient samples for the presence of multiple KRAS mutations.

Droplet Digital™ PCR: Multiplex Detection of KRAS Mutations in Formalin-Fixed, Paraffin-Embedded Colorectal Cancer Samples

Targeted therapies in many cancers have allowed unprecedented progress in the treatment of disease. However, routine implementation of genomic testing is constrained due to: 1) limited amounts of sample (pg–ng range) per biological specimen, 2) diagnostic turnaround time and workflow, 3) cost, and 4) difficulties in detection of mutational loads below 5%. KRAS is mutated in approximately 40% of colorectal cancers (CRCs). The majority of mutations affect codons 12, 13, and 61 and indicate a negative response to anti–epidermal growth factor receptor (EGFR) therapy. To optimize therapy strategies for personalized care, it is critical to rapidly screen patient samples for the presence of multiple KRAS mutations.

The somatic reproductive tissues of C. elegans promote longevity through steroid hormone signaling

Removal of the germ cells of C. elegans extends lifespan in part because signals from the somatic reproductive tissues activate the nuclear hormone receptor DAF-12.

In Caenorhabditis elegans and Drosophila melanogaster, removing the germline precursor cells increases lifespan. In worms, and possibly also in flies, this lifespan extension requires the presence of somatic reproductive tissues. How the somatic gonad signals other tissues to increase lifespan is not known. The lifespan increase triggered by loss of the germ cells is known to require sterol hormone signaling, as reducing the activity of the nuclear hormone receptor DAF-12, or genes required for synthesis of the DAF-12 ligand dafachronic acid, prevents germline loss from extending lifespan. In addition to sterol signaling, the FOXO transcription factor DAF-16 is required to extend lifespan in animals that lack germ cells. DAF-12/NHR is known to assist with the nuclear accumulation of DAF-16/FOXO in these animals, yet we find that loss of DAF-12/NHR has little or no effect on the expression of at least some DAF-16/FOXO target genes. In this study, we show that the DAF-12-sterol signaling pathway has a second function to activate a distinct set of genes and extend lifespan in response to the somatic reproductive tissues. When germline-deficient animals lacking somatic reproductive tissues are given dafachronic acid, their expression of DAF-12/NHR-dependent target genes is restored and their lifespan is increased. Together, our findings indicate that in C. elegans lacking germ cells, the somatic reproductive tissues promote longevity via steroid hormone signaling to DAF-12.

Reproductive tissues are known to generate important intercellular signals. For example, in mammals, the reproductive tissues produce steroid hormones such as estrogen and testosterone that have profound effects on development and physiology. Studies of the nematode C. elegans and other organisms have shown that the reproductive system can also affect the rate at which an animal ages. Removal of C. elegans' germ cells extends lifespan but this effect is not simply due to sterility, as removal of both the somatic reproductive tissues and the germ cells does not extend lifespan. Instead, loss of the germ cells extends lifespan by activating a pathway that requires input from the somatic gonad. In this study, we demonstrate that the somatic reproductive tissues promote longevity by controlling the activity of a steroid signaling pathway that regulates the DAF-12 nuclear hormone receptor.

Characterization of two melanin-concentrating hormone genes in zebrafish reveals evolutionary and physiological links with the mammalian MCH system

Melanin-concentrating hormone (MCH) regulates feeding and complex behaviors in mammals and pigmentation in fish. The relationship between fish and mammalian MCH systems is not well understood. Here, we identify and characterize two MCH genes in zebrafish, Pmch1 and Pmch2. Whereas Pmch1 and its corresponding MCH1 peptide resemble MCH found in other fish, the zebrafish Pmch2 gene and MCH2 peptide share genomic structure, synteny, and high peptide sequence homology with mammalian MCH. Zebrafish Pmch genes are expressed in closely associated but non-overlapping neurons within the hypothalamus, and MCH2 neurons send numerous projections to multiple MCH receptor-rich targets with presumed roles in sensory perception, learning and memory, arousal, and homeostatic regulation. Preliminary functional analysis showed that whereas changes in zebrafish Pmch1 expression correlate with pigmentation changes, the number of MCH2-expressing neurons increases in response to chronic food deprivation. These findings demonstrate that zebrafish MCH2 is the putative structural and functional ortholog of mammalian MCH and help elucidate the nature of MCH evolution among vertebrates.

Germ-cell loss extends C. elegans life span through regulation of DAF-16 by kri-1 and lipophilic-hormone signaling

In C. elegans, removing the germ cells extends life span by triggering the nuclear localization and activation of the DAF-16/FOXO transcription factor in the intestine. In this study, we identify and analyze genes required for germline removal to extend life span. We find that the reproductive system communicates with the intestine through lipophilic-hormone signaling and that a gene called kri-1 is likely to act in the intestine to promote DAF-16 nuclear localization in response to this signal. This lipophilic-signaling pathway and kri-1 are not required for DAF-16's nuclear localization and life-span extension in animals with decreased insulin/IGF-1 signaling. Thus, this pathway specifically enables the integration of cues from the reproductive system with central DAF-16-activation pathways to influence the aging of the animal.

Physiology of female sexual function and dysfunction

Female sexual dysfunction is age-related, progressive, and highly prevalent, affecting 30-50% of American women. While there are emotional and relational elements to female sexual function and response, female sexual dysfunction can occur secondary to medical problems and have an organic basis. This paper addresses anatomy and physiology of normal female sexual function as well as the pathophysiology of female sexual dysfunction. Although the female sexual response is inherently difficult to evaluate in the clinical setting, a variety of instruments have been developed for assessing subjective measures of sexual arousal and function. Objective measurements used in conjunction with the subjective assessment help diagnose potential physiologic/organic abnormalities. Therapeutic options for the treatment of female sexual dysfunction, including hormonal, and pharmacological, are also addressed.

The role of androgens in hormone replacement therapy

In recent years, increased attention to women's sexual health has propelled basic scientific research and clinical trials investigating treatment paradigms for improving sexual well-being. As the prevalence of female sexual dysfunction has become manifest, knowledge of the intricate pathophysiological role of androgens in maintaining sexual function has fostered a clearer understanding of the effect of age on androgen status, the role of androgens in the postmenopausal ovary, and aetiological mechanisms of androgen insufficiency in premenopausal and postmenopausal women. Understanding the long-term safety and efficacy of physiological androgen replacement and the development of sensitive testosterone assays for specific use in women will better characterise women who are most likely to respond to androgen therapy and, thereby, optimise their quality of life.

Tissue-specific activities of C. elegans DAF-16 in the regulation of lifespan

In C. elegans, the transcription factor DAF-16 promotes longevity in response to reduced insulin/IGF-1 signaling or germline ablation. In this study, we have asked how different tissues interact to specify the lifespan of the animal. We find that several tissues act as signaling centers. In particular, DAF-16 activity in the intestine, which is also the animal's adipose tissue, completely restores the longevity of daf-16(-) germline-deficient animals, and increases the lifespans of daf-16(-) insulin/IGF-1-pathway mutants substantially. Our findings indicate that DAF-16 may control two types of downstream signals: DAF-16 activity in signaling cells upregulates DAF-16 in specific responding tissues, possibly via regulation of insulin-like peptides, and also evokes DAF-16-independent responses. We suggest that this network of tissue interactions and feedback regulation allows the tissues to equilibrate and fine-tune their expression of downstream genes, which, in turn, coordinates their rates of aging within the animal.

Sexual Dysfunction in the Older Woman

Sexuality is one of the most important quality of life issues for both men and women. Sexual dysfunction is a highly prevalent, age-related and progressive problem. The various physiological and psychological changes that occur with aging can have a significant impact on sexual function. The complexity of female sexual dysfunction remains distinct from that of a man. Thus, we cannot approach female patients or their sexual function problems in a similar fashion to that of male patients. A woman's motivation and ability to find and respond to sexual stimuli is largely influenced by her emotional intimacy with her partner. Frequently, the emotional and relationship well-being a woman experiences contributes more to her sexual enjoyment than does her physiological response. However, it is imperative to assess for possible physiological barriers a woman may have which impede a healthy and satisfying sexual life. Therefore, a comprehensive approach, addressing both the physiological and psychological factors is instrumental to the evaluation of female patients with sexual complaints. After years of ardent research and recent therapeutic advances in male sexual dysfunction, researchers have begun addressing the intricacy of female sexual complaints. Studies involving both pre- and postmenopausal women have reported that most women do experience some type of sexual dysfunction during their lifetime. The sexual complaints women experience in their younger years may follow them into older adulthood, but often times change considerably because of various age-related changes. In an effort to assist researchers and clinicians in designing studies and implementing appropriate evaluation and treatment options for women with sexual complaints, a classification system for female sexual dysfunction has been designed. The four categories of female dysfunction include: hypoactive sexual desire disorder, sexual arousal disorder, orgasmic disorder and sexual pain disorders. Evaluation of women with sexual complaints should include a detailed psychological, social and medical history and thorough physical examination including a hormonal profile. Current treatment options are dependent on the diagnosis and include physical therapy, psychological counselling, hormonal supplements, medication changes and sexual devices. There has also been a burgeoning interest in investigational medications for female sexual dysfunction, from centrally acting (e.g. serotonin agonists) to peripheral, localised treatment (e.g. vasodilating creams). The area of female sexuality and sexual dysfunction has been undergoing important critical changes within the last 10 years. Researchers and clinicians are continuing to recognise the need to try and understand both the psychological and physiological aspects of the female sexual experience and how they influence one another.

Safety and Efficacy of Sildenafil Citrate for the Treatment of Female Sexual Arousal Disorder: A Double-Blind, Placebo Controlled Study

PURPOSE

We evaluated the efficacy and safety of sildenafil citrate in spontaneously or surgically postmenopausal women with female sexual arousal disorder (FSAD).

MATERIALS AND METHODS

Sildenafil (a 50 mg dose adjustable to 100 or 25 mg) was evaluated in a 12-week, double-blind, placebo controlled study in 202 postmenopausal women with FSAD who had protocol specified estradiol and free testosterone concentrations, and/or were receiving estrogen and/or androgen replacement therapy. Patients were excluded if emotional, relationship or historical abuse issues contributed significantly to sexual dysfunction. Primary end points were questions 2 (increased genital sensation during intercourse or stimulation) and 4 (increased satisfaction with intercourse and/or foreplay) from the Female Intervention Efficacy Index (FIEI). Secondary end points were the remaining questions from this index, the Sexual Function Questionnaire and sexual activity event log questions.

RESULTS

Significant improvements in FIEI questions 2 (p = 0.017) and 4 (p = 0.015) were noted with sildenafil compared with placebo. For women with FSAD without concomitant hypoactive sexual desire disorder (HSDD) sildenafil was associated with significantly greater improvement in 5 of 6 FIEI items compared with placebo (p <0.02). No significant improvements were shown for women with concomitant HSDD. Most adverse events were mild to moderate with headache, flushing, rhinitis, nausea and visual symptoms reported most frequently.

CONCLUSIONS

Sildenafil was effective and well tolerated in postmenopausal women with FSAD without concomitant HSDD or contributory emotional, relationship or historical abuse issues. All patients had protocol specified estradiol and free testosterone concentrations or were receiving estrogen and/or androgen replacement therapy.

Correlation of androgen receptors, aromatase, and 5-alpha reductase in the human vagina with menopausal status

OBJECTIVE

To determine whether aromatase and 5alpha-reductase mRNAs are expressed in human vagina and to evaluate the presence of androgen receptors in human vaginal tissue based on age and menopausal status.

DESIGN

Prospective study.

SETTING

Specimens obtained from clinical renal urology practice.

PATIENT(S)

Premenopausal and postmenopausal women undergoing surgery for prolapse or incontinence.

MAIN OUTCOME MEASURE(S)

Expression of aromatase and 5alpha-reductase type 1 and 2 mRNAs was evidenced by reverse transcriptase-polymerase chain reaction (RT-PCR), and the density of androgen receptors was measured by semiquantitative immunohistochemistry.

RESULT(S)

The mRNAs for aromatase and 5alpha-reductase isotypes 1 and 2 were detected in vaginal specimens. Androgen receptors were present in vaginal mucosa, submucosa, stroma, smooth muscle, and vascular endothelium. Expression was significantly greater in vaginal submucosa. A negative correlation existed between age and androgen receptor density.

CONCLUSION(S)

Expression of genes encoding for enzymes involved in testosterone metabolism in the human vagina, as well as androgen receptor location, density, and changes with menopausal status, suggests that androgens may play a role in regulating vaginal smooth muscle and vaginal blood flow.

Sexual side effects of SSRI medications: potential treatment strategies for SSRI-induced female sexual dysfunction

Depression often coexists with sexual dysfunction, and the medical treatment of depression can further worsen sexual symptoms or cause de novo sexual dysfunction in a person who did not experience it prior to treatment. There are many drugs that can adversely affect sexual response. Among antidepressants, this effect is commonly observed with selective serotonin-reuptake inhibitors (SSRI). Various strategies for the treatment of SSRI-related sexual dysfunction have been studied, including: awaiting spontaneous remission of sexual dysfunction; reducing the dose of medication; taking a "drug holiday"; adding another drug to help reverse sexual symptoms; changing antidepressants; or initially starting with a different antidepressant that is known to have fewer or no sexual side effects. Overall, it is important to address sexual health when caring for a patient--to improve drug compliance and the patient's well being.

Impact of pelvic floor disorders and prolapse on female sexual function and response

Pelvic floor disorders and FSD are prevalent and challenging problems. These disorders include prolapse of the uterus, cervix, vagina, bladder, and rectum and incontinence. These diseases likely affect women's sexual well-being through physical and emotional effects. Women with pelvic floor disorders often have co-existing urologic and sexual complaints. Patients who present with these urologic problems should be questioned about their sexual function. Surgical treatment in these patients may be curative of their sexual disorders (e.g., by repairing incontinence) but may also have undesired effects on sensation, blood flow, and the anatomy. These effects can affect sexual arousal and orgasm or cause dyspareunia. It is hoped that a better understanding of the anatomy of this area will guide us in a more targeted approach to management of these conditions.

Safety and efficacy of topical nitroglycerin for treatment of vulvar pain in women with vulvodynia: a pilot study

OBJECTIVE

To evaluate the safety and efficacy of topical nitroglycerin cream for the treatment of vulvar pain in women with vulvodynia.

METHODS

A total of 34 women diagnosed with vulvodynia were included in this study. Patients were treated with 0.2% nitroglycerin cream in the clinic. The cream was applied directly to the skin at the genital/vulvar area where the pain was located. Patients who did not experience any adverse side effects were instructed to use the cream at home at least three times per week, 5-10 minutes prior to sexual relations. Patients completed a pretreatment pain scale at baseline and a posttreatment pain scale questionnaire 4-6 weeks later.

RESULTS

Twenty-one patients completed both the pre- and posttreatment pain scale questionnaires, and 13 patients completed only the posttreatment pain questionnaire. Thirty-one patients (91.5%) stated that "overall" their pain had improved. Analysis of the pre- and posttreatment questionnaires revealed a significant decrease in pain intensity on a scale of 0 (no pain) to 5 (excruciating pain; 3.95-2.57; P < .000). There was also a significant decrease in the frequency of overall painful episodes on a scale of 0 (never) to 4 (always; 3.25-2.15, P < .006). All 21 patients reported "improvement" of pain during sexual activity (3.65-2.15; P < .005).

CONCLUSION

Topical nitroglycerin is safe and effective in providing temporary relief of introital dyspareunia and vulvar pain in women with vulvodynia. Women who completed this study experienced significant improvement in their overall pain and pain with sexual activity after nitroglycerin use. A larger placebo-controlled study is necessary to establish the optimum dosage level and to minimize the side effects.

Physiology and pathophysiology of female sexual function and dysfunction

Female sexual dysfunction is age-related, progressive, and highly prevalent, affecting 30%-50% of American women. While there are emotional and relational elements to female sexual function and response, female sexual dysfunction can occur secondary to medical problems and have an organic basis. This paper addresses the anatomy and physiology of normal female sexual function as well as the pathophysiology of female sexual dysfunction. Although the female sexual response is inherently difficult to evaluate in the clinical setting, a variety of instruments have been developed to assess subjective measures of sexual arousal and function. Objective measurements, used in conjunction with the subjective assessment, help diagnose potential physiologic/organic abnormalities. Therapeutic options for the treatment of female sexual dysfunction, including hormonal, and pharmacological, are also addressed.

The use of the Female Intervention Efficacy Index (FIEI) as an immediate outcome measure of medical intervention to treat female sexual dysfunction

Many medications used in the treatment of male erectile dysfunction are still in the experimental phases for use in women. Numerous pharmacological options for women presently under testing include the EROS-CTD clitoral therapy device (Berman et al., 1999b; Billups et al., 2001). In addition to the new medical developments for treating female sexual dysfunction, methods for evaluating sexual responses and efficacy of intervention are evolving as well.

Effect of sildenafil on subjective and physiologic parameters of the female sexual response in women with sexual arousal disorder

Sexual dysfunction is a complaint of 30-50% of American women. Aside from hormone replacement therapy, there are no current FDA-approved medical treatments for female sexual complaints. The goal of this pilot study was to determine safety and efficacy of sildenafil for use in women with sexual arousal disorder (SAD). Evaluations were completed on 48 women with complaints of SAD. Physiologic measurements, including genital blood flow, vaginal lubrication, intravaginal pressure-volume changes, and genital sensation were recorded pre- and postsexual stimulation at baseline and following 100 mg sildenafil. Subjective sexual function was assessed using a validated sexual function inventory at baseline and following 6 weeks of home use of sildenafil. At termination of the study patients also completed an intervention efficacy index (FIEI). Following sildenafil, poststimulation physiologic measurements improved significantly compared to baseline. Baseline subjective sexual function complaints, including low arousal, low desire, low sexual satisfaction, difficulty achieving orgasm, decreased vaginal lubrication, and dyspareunia also improved significantly following 6 weeks home use of sildenafil. Sildenafil appears to significantly improve both subjective and physiologic parameters of the female sexual response. Double-blind, placebo-controlled studies are currently in progress to further determine efficacy of this medication for treatment of female sexual dysfunction complaints in different populations of women.

Female neurogenic sexual dysfunction secondary to clitoral neuropathy

We herein present several cases of female sexual dysfunction related in part to organic neurologic pathophysiology. These cases emphasize the role of the central and peripheral nervous systems in female sexual function.

Pharmacotherapy or psychotherapy?: effective treatment for FSD related to unresolved childhood sexual abuse

Childhood sexual abuse (CSA) is the form of sexual victimization most correlated with sexual dysfunction in adulthood (Atkeson, Calhoun, Resick, & Ellis, 1994; Sarwer & Durlak, 1996; Laumann, Paik, & Rosen, 1999). The goal of this study was to address the sexual ramifications of unresolved CSA and consider the effectiveness of vasoactive pharmacotherapy, specifically sildenafil, for the treatment of women with unresolved CSA. The sample included 35 women (mean age, 45 years) who presented to a sexual health clinic and who were not of childbearing potential. Of the sample 7 women (23%) had a history of unresolved CSA. Following a psychosexual history and medical evaluation, all women were treated with 100 mg of sildenafil, to be used over a 6-week period at home. When home doses were complete, participants filled out the FIEI, a valid and reliable 5-item questionnaire asking about sexual response post sildenafil. Parameters of sexual response included vaginal lubrication, amount and quality of sensation, satisfaction with intercourse, and ability to reach orgasm. Trends were calculated comparing women with and without unresolved CSA history. A minority of women with CSA responded positively to sildenafil.

Female sexual dysfunction

The ideal approach to female sexual dysfunction would be a collaborative effort between therapists and physicians and would include a complete medical and psychosocial evaluation, and inclusion of the partner spouse in the evaluation and treatment process. Despite significant anatomic and embryologic parallels between men and women, the multifaceted nature of female sexual dysfunction clearly is distinct from that of the man. The clinician cannot approach female patients or their sexual function problems in the same fashion as in male patients. The context in which a woman experiences her sexuality is equally if not more important than the physiologic outcome she experiences, and these issues should be determined before beginning medical therapy or determining treatment efficacies.

Novel approaches to female sexual dysfunction

Female sexual dysfunction is age-related, progressive and highly prevalent, affecting 30 - 50% of American women. While there are emotional and relational elements to sexual function, it has become increasingly evident that female sexual dysfunction can occur secondary to medical problems and has an organic basis. A plethora of different female sexual dysfunctions exist and in order to obtain a greater understanding of the possible treatments for these problems, it is essential to have a strong knowledge base of female pelvic anatomy, the neurogenic mediators of female sexual response, the impact of hormones on female sexual function and the aetiologies of female sexual dysfunction. Currently, there are potential therapeutic options for the treatment of female sexual dysfunction and these options include both hormonal and pharmacological therapy. However, therapeutic agents may not prove to be enough and the ideal approach to female sexual dysfunction is thus a collaborative effort between therapists and physicians, which should include a complete medical and psychosocial evaluation, as well as inclusion of the partner or spouse in the evaluation and treatment process.

Anatomy and physiology of female sexual function and dysfunction: classification, evaluation and treatment options

Female sexual dysfunction is a significant age-related, progressive and highly prevalent problem that affects a substantial number of women in the United States. The female sexual response cycle is initiated by neurotransmitter-mediated vascular and nonvascular smooth muscle relaxation resulting in increased pelvic blood flow, vaginal lubrication, and clitoral and labial engorgement. These mechanisms are mediated by a combination of neuromuscular and vasocongestive events. Physiological impairments that interfere with the normal female sexual response bring about complaints associated with diminished sexual arousal, libido, vaginal lubrication, genital sensation, and ability to achieve orgasm. Therapy aimed at restoring hormone levels as well as genital blood flow will be discussed.

Female sexual dysfunction: anatomy, physiology, evaluation and treatment options

It has been estimated that up to 76% of women, depending upon their age, have complaints of sexual dysfunction, including decreased libido, vaginal dryness, pain with intercourse, decreased genital sensation and difficulty or inability to achieve orgasm. Female sexual dysfunction is a significant problem that affects the quality of life of many women. This review addresses the etiologies and incidence of female sexual complaints, as well as new findings in the evaluation and treatment of female sexual dysfunction.

Clinical evaluation of female sexual function: effects of age and estrogen status on subjective and physiologic sexual responses

INTRODUCTION

30-50% of American women complain of sexual dysfunction. Aging, menopause, and a decline in circulating estrogen levels significantly increase the incidence of sexual complaints. Evaluation of physiologic components of the female sexual response has, in the past, been technically challenging and difficult to standardize. We describe methodology for evaluating physiologic and subjective components of the female sexual response in the clinical setting and determine the effects of age and estrogen status on them.

METHODS

48 women with complaints of sexual dysfunction were evaluated. Physiologic measurements include genital blood peak systolic velocity, vaginal pH, intravaginal pressure-volume changes (compliance), and genital vibratory perception thresholds. Measurements were recorded at baseline and following sexual stimulation. Baseline subjective sexual function was assessed using a Female Sexual Function Inventory. Age was then correlated with both physiologic and subjective sexual responses.

RESULTS

Sexual stimulation resulted in increased mean genital blood peak systolic velocity, vaginal pressure-volume, and vaginal pH measurements (P < 0.05) in all women. Older women (ages 55-71 y) and menopausal women not on hormone replacement therapy had significantly lower physiologic response sexual complaints. Baseline subjective sexual function complaints included low arousal (67%), low desire (21%), difficulty achieving orgasm (92%), and pain or discomfort during and/or following intercourse (67%).

CONCLUSIONS

Clinical evaluation of physiologic and subjective components of the female sexual response are possible using this comprehensive approach. Physiologic measurements were reproducible and easy to perform, and incidence and types of sexual complaints were assessed with the sexual function questionnaire. A comprehensive approach is necessary when evaluating female sexual dysfunction due to the significant emotional and relational factors that can contribute to the problem. This combined subjective/physiologic assessment may also prove useful when evaluating efficacy of pharmacotherapy in the future.

Vasculogenic female sexual dysfunction: vaginal engorgement and clitoral erectile insufficiency syndromes

The first phase of the female sexual response, associated with neurotransmitter-mediated vascular smooth muscle relaxation, results in increased vaginal lubrication, wall engorgement and luminal diameter as well as increased clitoral length and diameter. Specific physiologic impairments of vasculogenic female sexual dysfunction include vaginal engorgement and clitoral erectile insufficiency syndromes. These syndromes exist when during sexual stimulation abnormal arterial circulation into the vagina or clitoris, usually from atherosclerotic vascular disease, interferes with normal vascular physiologic processes. Clinical symptoms may include delayed vaginal engorgement, diminished vaginal lubrication, pain or discomfort with intercourse, diminished vaginal sensation, diminished vaginal orgasm, diminished clitoral sensation or diminished clitoral orgasm. An animal model of this syndrome, with significant physiologic responses between the control and the atherosclerotic pelvic nerve stimulated hemodynamic responses, is discussed. Non-atherosclerotic, traumatic vascular disease of the ilio-hypogastric-pudendal arterial bed from pelvic fractures or blunt perineal trauma may also result in diminished vaginal/clitoral arterial blood flow following sexual stimulation. Diagnostic studies assessing the hemodynamic integrity of the ilio-hypogastric-pudendal arterial bed to the vagina and clitoris and new oral/topical pharmacologic strategies for enhancing vaginal/clitoral blood flow in patients with vasculogenic female sexual dysfunction are discussed. There is a growing body of evidence that women with sexual dysfunction will commonly have physiologic abnormalities, such as vasculogenic female sexual dysfunction, contributing to their overall sexual health problems.

Effect of estrogen withdrawal on nitric oxide synthase expression and apoptosis in the rat vagina

OBJECTIVES

The physiology of the female sexual response and its molecular mediators remain poorly understood. Nitric oxide (NO) is synthesized in neurons and is a potent relaxor of vascular and nonvascular smooth muscle. In this study, we hypothesize that vaginal atrophy and declining sexual function during menopause may be NO dependent. Using the rat as an experimental model, we examined the expression and topologic localization of vaginal NO synthase (NOS) and the concomitant induction of apoptosis under normal and estrogen-depleted conditions.

METHODS

Thirty rats were categorized into six groups on the basis of phase of the estrous cycle or estrogen status after oophorectomy. The expression and cellular localization of NOS was examined in frozen sections using specific antibodies against neuronal (N-NOS) and endothelial NOS (E-NOS). Apoptotic cells were identified in situ using the terminal transferase technique (TUNEL). Trichome staining was performed in all specimens to determine smooth muscle/collagen ratios.

RESULTS

N-NOS immunoreactivity was localized to nerve fibers supplying vaginal smooth muscle, perivascular nerve plexuses, and lamina propria. E-NOS was localized to vascular endothelium and perivascular smooth muscle fibers. Both E-NOS and N-NOS expression in intact cycling animals was highest during proestrous and lowest during metestrous. After oophorectomy, levels of both N-NOS and E-NOS declined substantially compared with those of intact animals, and there was a parallel induction of apoptosis. Estrogen withdrawal also resulted in increased vaginal atrophy, intramural collagen accumulation, and perivascular wall thickening, as identified by trichome staining. Estrogen replacement resulted in a significant increase in E-NOS and N-NOS expression, as well as diminished apoptosis and vaginal atrophy.

CONCLUSIONS

This cellular distribution of NOS in the rat vagina suggests that NO may modulate both vaginal blood supply and vaginal smooth musculature. Estrogen appears to play a critical role in concomitantly regulating vaginal NOS expression and apoptosis in nerves, smooth muscle, vascular endothelium, and epithelium of the rat vagina. These findings may have significant clinical implications for the pathophysiology of postmenopausal female sexual dysfunction.

Sigmoid colon carcinoma metastatic to prostate

Although primary prostatic carcinoma is very common, prostatic metastasis is unusual. We describe a unique example of prostatic metastasis from noncontiguous colon cancer, after presumed curative resection of the primary tumor. Potential mechanisms of metastasis are examined in the context of clinical and histopathologic evidence. A possible role is proposed for early transrectal ultrasound examination in diagnosis of patients with unexplained urologic symptoms after resection of colorectal cancer.

Pharmacy-based antimicrobial-monitoring service

A pharmacy-based antimicrobial-monitoring service at a university teaching hospital is described. The service was developed and implemented by the pharmacy department in 1987. Antimicrobial drugs that can be misused, that are expensive, or for which bacterial resistance is a concern were targeted. When a pharmacist receives an order for a targeted antimicrobial, an antimicrobial-monitoring card is completed. Monitored drugs meeting approved criteria are dispensed as ordered. When the antimicrobial does not meet the criteria, the pharmacist contacts the physician and suggests an alternative. If the alternative is not accepted, the infectious diseases service is contacted and then informs the pharmacy department about the status of the drug. The agent is dispensed if no response is received within two hours. Qualified staff pharmacists rotate through the position of antimicrobial pharmacist, whose responsibilities include reviewing antimicrobial use throughout the hospital, checking relevant laboratory test results, and recommending adjustments to regimens. From July 1989 to June 1990, 3546 orders for monitored antimicrobials were reviewed; of these, 86% met the criteria, 9% did not meet the criteria but were approved, 2% were for drugs that were replaced by alternative therapies, 1% were for agents that were dispensed because the pharmacist was not contacted, and 2% represented medical staff overrides or drugs dispensed inappropriately. Pharmacist and physician compliance with the monitoring policy has been high. A positive, constructive, and educational relationship exists between pharmacists and physicians vis-à-vis the service. A pharmacy-based antimicrobial-monitoring service has been accepted by pharmacists and physicians and appears to be having a positive impact on prescribing habits.

Vancomycin pharmacokinetics in burn patients and intravenous drug abusers

The pharmacokinetics of vancomycin were evaluated in 34 patients (10 burn patients, 14 intravenous drug abusers [IVDA], and 10 controls). Multiple serum samples were drawn following a 1-h vancomycin infusion at steady state over an 8- to 12-h dosing interval. Pharmacokinetic parameters were derived by noncompartmental analysis. There were no significant differences among the groups with respect to age, weight, serum creatinine, volume of distribution, or protein binding. Burn patients had a significantly higher creatinine clearance than did IVDA or controls. Vancomycin clearances averaged 142.8, 98.0, and 67.7 ml/min in burn patients, IVDA, and controls, respectively. The renal clearance of vancomycin was also higher in burn patients than in the other groups. IVDA tended to have a higher vancomycin clearance (31% higher) than did controls, but the difference was not statistically significant. Vancomycin clearance was much higher in burn patients requiring dosage individualization and close monitoring. A considerable amount of vancomycin was eliminated through renal tubular secretion, making dosage predictions based on creatinine clearance more difficult. Further work with IVDA will be needed to determine if they represent a group requiring aggressive vancomycin dosages.