Polyarthritis in a child with Rosai-Dorfman disease.

A 5-year-old boy presented with fever, rash, lymphadenopathy and polyarthritis. Systemic onset juvenile idiopathic arthritis was initially considered in the differential diagnosis, but lymph node biopsy established the diagnosis of Rosai-Dorfman disease (RDD). The arthritis recurred twice. Both times it correlated with the severity of the other clinical and laboratory abnormalities of RDD and responded to treatment with dexamethasone and vinblastine. This report adds inflammatory arthritis to the extranodal manifestations of RDD in children and suggests that this disorder should be considered as a rare cause of fever with rash, lymphadenopathy and arthritis.

Why results of clinical trials and observational studies of antitumour necrosis factor (anti-TNF) therapy differ: methodological and interpretive issues.

OBJECTIVE: Results of randomised clinical trials (RCTs) appear to differ from results of observational studies. This paper explores differences in methodology, interpretation and presentation of results that elucidate these differences. METHOD: We identified patients who completed a survey questionnaire during the period January 1998 through December 1998 and also completed one between July 2003 and June 2004, an average span of 4.7 years. The mean time from study initiation to anti-TNF administration was 2.1 years, and the mean treatment time was 2.1 (SD 1.3) years at study closure. During this period 38.3% of patients received anti-TNF therapy. We compared the results of patients in this group with results from RCTs. RESULTS: RCTs utilise flare design, patient selection, control groups and regression to the mean. Observational studies, on the other hand, confound additional prior therapy and anti-TNF effect, do not employ control groups, and may have less regression to the mean. CONCLUSIONS: RCTs and observational studies assess and report efficacy and effectiveness in ways that are so different that they are often incommensurable. A key difference is whether results should represent changes from flare states or should, instead, consider chronic status prior to initiation of therapy. There is little evidence that the clinical state at the start of most anti-TNF RCTs represents a chronic state. Economic analyses that utilise the RCT starting point overestimate the cost effectiveness of anti-TNF therapy. The solution for these problems and a guide to understanding the real results of anti-TNF therapy lies in collecting preclinical trial data in all patients who will enter clinical trials. In addition, RCT results would more approximate those of observational studies if all reporting was done after subtracting the effect of the comparator group.

Comparison of transvaginal ultrasound, hysteroscopy, and dilatation and curettage in the diagnosis of abnormal vaginal bleeding and intrauterine pathology in perimenopausal and postmenopausal women.

STUDY OBJECTIVE: To compare transvaginal ultrasound, hysteroscopy, and dilation and curettage (D&C) in the evaluation of women with perimenopausal and postmenopausal bleeding. DESIGN: Descriptive study (Canadian Task Force classification II-1). SETTING: Seven outpatient clinics. PATIENTS: One thousand two hundred eighty-six women. INTERVENTION: Transvaginal ultrasound, hysteroscopy, and D&C. MEASUREMENTS AND MAIN RESULTS: Of our patient population, 29 (2.26%) had a histologic diagnosis of endometrial carcinoma; in 2 of them (7.14%) endometrial thickness was 5 mm or less. In 10 women (34.5%), endometrial carcinoma was missed by hysteroscopy (sensitivity 65.52%, specificity 99.92%). Complication rate of D&C was 1.4%. CONCLUSION: In women with perimenopausal and postmenopausal bleeding neither transvaginal ultrasound nor hysteroscopy as a single diagnostic tool is suitable to rule out endometrial cancer.

[Effectiveness and tolerance of depot leuprorelin acetate for preoperative endometrium flattening before endometrial ablation. German Leuprorelin Study Group]. / Wirksamkeit und Verträglichkeit von Leuprorelinacetat-Depot zur präoperativen Endometriumabflachung vor Endometriumablation. Deutsche Leuprorelinstudiengruppe.

OBJECTIVE: In order to assess the efficacy and tolerability of leuprorelin acetate depot in pre-operative flattening of the endometrium prior to hysteroscopic endometrial ablation, 94 patients from eight centres were included in the per protocol analysis. MATERIAL AND PATIENTS: The patients included were pre- or peri-menopausal, had completed their family planning and had intractable uterine bleeding. The primary target criterion was the reduction in maximum endometrial thickness after two injections of leuprorelin acetate depot with an interval of four weeks between injections. Surgery took place two weeks after the second injection. RESULTS: Sufficient pre-treatment was achieved in 91.5% of the patients with > 50% decrease and/or a type 1 endometrium according to sonographic and/or endometrial atrophy (Score 11) according to the central histological evaluation. The endometrium was flattened by a mean of 4.0 +/- 4.1 mm. In terms of clinical response, amenorrhoea, hypomenorrhoea or normal menstruation were achieved after endometrial ablation. Hence 91.5% of patients benefited from the overall treatment after six weeks and still 83% after six months. The trial medication was well tolerated overall. The most common side-effect described was hot flushes which could be attributed to the deliberate oestrogen withdrawal. CONCLUSION: In view of the good study results, hormone-suppressive pretreatment of the endometrium can be recommended prior to elective ablation. Surgery should take place during the oestrogen-suppressed phase.

Indications for Distal Salpingoscopy

Internal and external tubal pathology are the decisive factors for evaluating tubal function. Salpingoscopy is the most reliable method to determine the mucosal status as the correlation of external and internal pathology is low. We performed distal salpingoscopies according to the method and classification described by Brosens et al on 253 tubes in 159 women and compared external pathology with intratubal findings. In 126 tubes without external pathology, only 2 cases showed moderate mucosal damage (class III), whereas 124 tubes had an intact mucosa (119 class I) or minor pathology (5 class II). Of 127 tubes with external pathology, the mucosa was determined to be class I in 51 cases, class II in 17, class III in 30, class IV (severe damage) in 22, and class V (severe damage) in 7. The correlation of external and internal damage is low. For example, we found that from 10 thin-walled hydrosalpinges, that was formerly a strong indication for microsurgical intervention, 4 showed severely damaged mucosa and were sent for in vitro fertilization (IVF), 3 showed moderate damage (mucosa class III), and only 3 had minor damage (mucosa class II). For complications, we observed four cases with slight bleeding from the fimbriae, two with slight damage of the mucosa, and one incomplete perforation of the tubal wall. We conclude that salpingoscopy should be performed whenever external pathology is detected in an infertility workup. It leads to better evaluation for either microsurgery or IVF. Microsurgical intervention can be avoided in cases with a poor prognosis. If no external pathology of the tube is detected salpingoscopy is not necessary.