Endometrial abnormalities occurring in young women on long-term sequential oral contraception.

Recently the occurrence of adenocarcinoma of the endometrium has been reported in young women exposed to sequential oral contraceptive agents for long periods of time. Twelve young women who had been using Oracon for periods of from 13 to 93 months were subjected to office endometrial aspirations. Tissue specimens showed endometrium which varied in diagnosis from proliferative endometrium to severe atypical adenomatous endometrial hyperplasia bordering on endometrial carcinoma in situ. Adenomatous endometrial hyperplasia is though by many investigators to be a precancerous condition. The progression of endometrial changes from benign proliferation to cystic hyperplasia and adenomatous hyperplasia accompanied by varying degrees of anaplasia in young women exposed to Oracon for long periods of time is significant. It is not surprising, therefore, that adenocarcinoma of the endometrium has been reported in these women at an age where this condition had been relatively uncommon prior to the use of sequential oral contraceptives.

Letter: Sequential oral contraceptives.

PIP: Lyon, Silverberg, and Makowski published papers showing that young women taking long-term sequential oral contraceptives, especially Oracon, may develop adenocarcinoma of the endometrium. Other reports have shown that sequentials may cause adenomatous hyperplasia accompanied by severe degrees of anaplasia. All patients studied were asymptomatic, and the majority were oligomenorrheic prior to using sequentials. Patients who choose to continue with these agents should be closely observed and subjected to office endometrial aspirations at 6-month intervals. If adenomatous hyperplasia is diagnosed, patients should be encouraged to use nonsteroid forms of contraception. Repeat aspiration should be performed in 3-6 months; the patients should keep basal body temperature records. If situation persists and the adenomatous hyperplasia persists for 3-6 months, oral or parenteral progesterone therapy is indicated. It is believed that progestins will reverse the adenomatous hyperplasia. If it does not revert to secretory endometrium and severe, atypical adenomatous hyperplasia is found, hysterectomy may be indicated.^ieng

An abortion perspective: legal considerations.

PIP: In 1955 the American Law Institute proposed in its Model Penal Code that physicians be given the legal right to terminate a pregnancy. In 1967 Colorado enacted the first legislation based on those proposals. In 1973 the Supreme Court of the United States passed a decision which effectively nullified the abortion laws in most states. In the first and second trimesters of pregnancy the decision to terminate is strictly between the women and her doctor. In the third trimester the state has the option of proscribing abortion except where necessary for the preservation of the life or health of the mother. In 1976 the Supreme Court affirmed its previous decision and further clarified the right of a pregnant woman to terminate a pregnancy without interference by the state, her husband, or the pregnant minor's parents. The Court also struck a ban on the use of intra-amniotically infused hyptertonic saline for terminating second trimester pregnancies. Recent data shows that the newer technique of dilatation and evacuation is the safest method of termination up to 20 weeks gestation. In 1980 the Court declared that federal funding of abortion is not a legal requirement of the constitution. States may not be required to fund abortion services. The only consent required to perform an abortion is that of the pregnant woman. No consent is needed from the man involved.^ieng

Choriocarcinoma presenting as a complication of elective first trimester abortion.

PIP: A case of metastatic gestational trophoblastic disease detected at a routine 2-week post-abortion examination is presented. The subject was an 18-year old unmarried white gravida 1, para 0 female. At the post-abortion examination, a right adnexal mass was fixed in the pelvis. The pregnancy test still yielded a positive result. Laparotomy was performed and revealed a malignant trophoblast on the serosal surface on the uterus at the site of a spontaneous perforation. Histologic examination of the original endometrial contents revealed a hydatiform mole with 1 area of myometrial invasion. The patient was put on triple chemotherapy and antibiotic therapy. She has since been asymptomatic and is currently taking oral contraceptive medication. The incidence of molar pregnancy is 1/1200 to 2000 pregnancies in the U.S. That of choriocarcinoma is even more rare. Choriocarcinoma follows as a malignant sequelae in nearly 3% of patients with hydatiform mole. It used to be the most uniformly and rapidly fatal malignancy in women. It is currently the one solid malignancy that can be cured with chemotherapy, and normal subsequent pregnancies have even been reported. All tissues removed during an elective abortion must be carefully examined. Pathologists must describe microscopic findings of tissue and not submit reports with gross diagnoses such as 'products of conception'. Villi of normal pregnancy must be identified if accurate diagnoses are to be made and tragedies avoided.^ieng

Ketamine sedation during the treatment of retinopathy of prematurity.

AIMS: To report the use of ketamine sedation as an alternative anaesthetic method for babies undergoing treatment for retinopathy of prematurity (ROP). METHODS: All babies who underwent treatment for ROP over a 2-year period were included in this study. The babies preoperative weight, medical condition, and ventilation status was recorded. Data were collected on their ventilation status pre-, intra-, and postprocedure. Any change in their cardiac or respiratory status during or in the subsequent 3 days following the treatment was noted. RESULTS: Eleven babies, 22 eyes, required treatment over this period. The procedure was well tolerated with only three babies having intraoperative complications, which all resolved spontaneously. Two babies had postoperative complications requiring additional ventilation. In no case was the procedure abandoned owing to anaesthetic complications. CONCLUSIONS: The use of ketamine sedation allows the laser to be performed in a ward setting and avoids the potential risk of general anaesthesia and inter- and intra-hospital transfer. It has been found to produce few intra- or postoperative complications for the infant, while providing satisfactory conditions for the treatment of ROP.

Encephalopathy with retinitis due to cat-scratch disease.

Cat-scratch disease is one of several diseases known to be caused by Bartonella species. Some infections due to Bartonella resolve spontaneously without treatment with antibiotics, but in other cases the disease can be fatal without treatment. This case study reports a 7-year-old male who presented with an unexplained encephalopathy and unusual retinal findings associated with evidence supporting infection by B. henselae. The 7-year-old male presented with a 2-week history of general malaise and cervical lymphadenopathy progressing onto fever, headache, vomiting, and confusion associated with meningism. Lumbar puncture revealed a raised cerebrospinal fluid protein, low glucose, and raised white cell count. Abnormal retinal findings and raised antibodies titres to B. quintana indicated a diagnosis of cat-scratch disease. He was treated with azithromycin orally for 3 weeks and made a complete recovery.

Bovine pericardium (Tutopatch) wrap for hydroxyapatite implants.

PURPOSE: To evaluate bovine pericardium (Tutopatch) as a wrapping material for hydroxyapatite implants in patients undergoing enucleation for uveal melanoma. METHOD: Prospective cohort study of patients who had enucleation for uveal melanoma between January 2003 and August 2003 were included in the study. Any patient with less than 3 months follow-up was excluded. Enucleation was performed under general anaesthesia followed by insertion of hydroxyapatite implants wrapped in bovine pericardium (Tutopatch). The recti muscles were sutured directly to the wrap. The tenon's capsule and conjunctiva were closed in two layers. A conformer was inserted at 1 week and artificial eye at 2-3 months. The patients were followed up regularly and were assessed for cosmetic result, exposure of implant, and the need for any further surgical procedures. RESULTS: A total of 19 patients (seven male and 12 female) were included in the study. Median age at diagnosis was 63 years (range 38-80 years). Median follow-up was 26 months (range 22-30 months). No patient developed postoperative complications of wound dehiscence. The overall cosmetic result was excellent in all the patients. The rate of postoperative complications compared favourably with published data using other wrapping materials/implants. CONCLUSION: Tutopatch is a safe wrapping material for hydroxyapatite orbital implants in patients undergoing enucleation for uveal melanoma.

The development of adenocarcinoma of the endometrium in young women receiving long-term sequential oral contraception.

PIP: 4 cases of adenocarcinoma of the endometrium were reported in young women. All were using and had used for periods of 4-12 years a sequential oral contraceptive, Oracon, manufactured by Mead Johnson Laboratories. Ethinyl estradiol and mestranol, the 3 methyl ether of ethinyl estradiol, are 25 times more potent than diethylstilbestrol, which has recently been implicated in the development of vaginal adenocarcinoma in female offspring of women treated during pregnancy with it. A study is now in progress to determine whether long-term use of Oracon produces premalignant changes in the endometrium. Doctors with patients on similar sequential contraceptives should watch for abnormal vaginal bleeding.^ieng

Chemical and enzymatic variation in the cell walls of pathogenic Candida species.

Cell walls, isolated from seven pathogenic species of Candida, were lipid extracted and fractionated by treatment with ethylenediamine or enzymatically hydrolyzed using chitinase and laminarinase. Two different chitinase preparations were used, one from Streptomyces sp. which had some beta-1,3-glucanase activity, and another from Serratia marcescens which did not have glucanase activity. Laminarinase was a commercial preparation. The monosaccharide constituents of whole cell walls and the fractions derived from them were determined qualitatively and quantitatively by gas-liquid chromatography of the products of a mild acid hydrolysis and by the phenol - sulfuric acid assay of the products of a stronger acid hydrolysis. The monomeric constituents of the enzymatic hydrolyses were analyzed using gas-liquid chromatography. Approximately 50% of all walls was soluble in ethylenediamine. Glucose and mannose were the only monosaccharides found in all of the fractions derived from ethylenediamine extraction examined. Similarities among the strains, based upon relative amounts of glucose and mannose, were more apparent than differences, but statistical analyses of the data revealed a general trend of decreasing similarity in the following order, C. albicans and C. stellatoidea, C. tropicalis and C. parapsilosis, and C. pseudotropicalis, C. guilliermondii, and C. krusei. In the enzymatic assays, mannose and glucose were released by laminarinase, whereas glucose and N-acetyl-D-glucosamine or N-acetyl-D-glucosamine alone were released by the chitinases. These assays supported the trend in relationships cited above, with the data being somewhat more definitive.

Adjuvant activity of Escherichia coli heat-labile enterotoxin and effect on the induction of oral tolerance in mice to unrelated protein antigens.

The ability of Escherichia coli heat-labile enterotoxin (LT) to influence the induction and maintenance of tolerance was examined in animals primed orally with a soluble protein antigen, ovalbumin (OVA), or in animals primed orally with two unrelated protein antigens administered simultaneously, OVA and bovine serum albumin (BSA). LT is immunologically and structurally related to the cholera enterotoxin (CT), which has been shown to be capable of abrogating oral tolerance to protein antigens when delivered simultaneously with the antigens. In this study, simultaneous administration of LT with OVA was shown to prevent the induction of tolerance to OVA and to increase the serum anti-OVA IgG response 30- to 90-fold over OVA-primed and PBS-primed animals, respectively. This effect was determined to be a function of the enzymatically active A subunit of the toxin since the B (binding) subunit alone was unable to influence tolerance induction. Animals fed LT with OVA after the initial OVA prime developed a significantly lower serum IgG and mucosal IgA anti-OVA response than those fed LT with OVA in the initial immunization, indicating that prior exposure to the antigen reduces the effectiveness of LT to influence tolerance and its ability to act as an adjuvant. LT was not able to abrogate tolerance once it had been established. Serum IgG and mucosal IgA responses in animals receiving LT on only a single occasion, that being upon first exposure to antigen, were equivalent to responses after three OVA/LT primes, indicating that commitment to responsiveness occurs early and upon first exposure to antigen.(ABSTRACT TRUNCATED AT 250 WORDS)