Variation in Vaginal Hysterectomy Rates in an Integrated Healthcare System.

STUDY OBJECTIVE: To describe trends in minimally invasive hysterectomy (MIH) and assess patient, surgical, and provider characteristics associated with differences in vaginal versus laparoscopic rates within an integrated healthcare system. DESIGN: A retrospective cohort study. SETTING: Kaiser Permanente Northern California from 2008 to 2018. PATIENTS: Patients who underwent MIH for benign conditions excluding uterine prolapse and incontinence surgeries. INTERVENTIONS: Hysterectomies. MEASUREMENTS AND MAIN RESULTS: A total of 27518 hysterectomies were performed for benign indications. Of these, the proportion of MIH increased from 29.1% (2008) to 96.7% (2018) (p <.001). The proportion of vaginal hysterectomies (VHs) of all hysterectomies did not change significantly over the study period (p = .07); however, the proportion of VH among MIH cases decreased from a high of 50.6% in 2008 to 13.2% in 2018 (p <.001). VH rates were lower in obese and morbidly obese patients (p <.001 and p = .02, respectively) and in women with uterine weights >250 g (p <.001). The differences persisted after controlling for patient demographic, clinical, and surgery characteristics. Low surgical volume was inversely associated with VH (adjusted relative risk, 7.19; 95% confidence interval, 6.62-7.81; p <.001). VH rates ranged from 11.5% to 27.8% across service areas (hospitals). Service area remained a significant predictor of VH after controlling for patient (including body mass index and uterine weight) and surgery-related characteristics. Postoperative hospital stay decreased from 33.8 ± 16.4 hours (2008) to 6.1 ± 12.2 (2018) for VH. Operative time was shorter for VH than laparoscopic hysterectomies (LHs) (1.7 vs 2.5 hours; p <.001). Overall operative/perioperative complications were low and not significantly different (VH vs LH). CONCLUSION: As the proportion of MIH increased, LH became the preferred route despite similar rates of postoperative stay and intraoperative complications and shorter operative time for VH compared with LH. Service area and provider volume were independent predictors of MIH route, suggesting that training and evidence-based guidelines for route selection may help preserve VH rates.

Teens' perspectives on yoga as a treatment for stress and depression.

OBJECTIVE: To understand adolescents' experiences and attitudes toward yoga, with a particular focus on acceptability and feasibility of a yoga intervention for depressed adolescents. DESIGN: Qualitative analysis of data from three focus groups and eight individual interviews, for a total of 22 teen participants. SETTING: Outpatient setting in a psychiatric hospital in the U.S. MAIN OUTCOME MEASURES: Teens were asked about their own and their peers' attitudes toward, and experiences with, hatha yoga; reactions to a study-created yoga video; and opinions on class logistics. RESULTS: Teens had both positive and negative attitudes toward, and experiences with, hatha yoga. They commented on "who does yoga;" many responses suggested a limited group (e.g., moms; people with money and time). Participants agreed that yoga could be potentially beneficial for depressed or stressed teens. Self-consciousness while being in a yoga class was a major concern. Overall, teens reacted favorably to the study-created yoga video. Teens had varied opinions about class logistics including class duration and size. Teens cited barriers to class, such as transportation, as well as barriers to home yoga practice. CONCLUSIONS: Key points for developing a yoga class that might be appealing to depressed or stressed teens include: creating a class with variety that teens will find interesting; taking concrete steps to decrease teen self-consciousness; incorporating messages relevant for teens and consistent with yoga philosophy; and actively countering stereotypes about who practices yoga. Limitations of this study include the lack of data from male teens.

Evaluation of different bonded investments for dental titanium casting.

The properties of several different investments were investigated including phosphate bonded, magnesia bonded, and alumina cement investments. Measurements included the setting expansion, thermal expansion, and compressive strength of investments, as well as the tensile strength, elongation, Vickers hardness (VHN) and surface roughness of titanium castings. For phosphate bonded investment, the setting expansion after being mixed with its own mixing solution was 2.10%, which was larger than the other investments; the thermal expansion was -0.25% at 200 degrees C, the compressive strength 14 and 5 MPa after heating. For titanium cast in phosphate bonded investment, the hardness on its top surface was 655 Hv, the tensile strength was 379 MPa, the elongation was 19.4%, and the surface roughness was 2.29 microm. Athough the thermal expansion of phosphate bonded investment is small, the setting expansion is large enough to compensate for the shrinkage of titanium castings. As its thermal expansion at T >/= 600 degrees C was constant and its heating-cooling cycle was almost reversible, these two properties can reduce the thermal shock and thus avoid cracking of the investment.

Topoisomerase 2alpha plays a pivotal role in the tumor biology of stage IV thymic neoplasia.

BACKGROUND: Microsatellite studies in histologic types B3 and C thymic neoplasia detected gains on chromosome 17q, which contains the Her-2/neu and its juxtaposed topoisomerase 2alpha (T2alpha) genes. The study aimed to evaluate their impact on tumor biology and survival of advanced thymic neoplasia patients. METHODS: From 1991 to 2005, 36 consecutive stage IV thymic carcinoma patients were treated, 18 men and 18 women, aged 11 to 84 years. There were 22 thymic carcinoma, 13 type B3, and 1 type B2 thymoma. Patients received treatment consisting of surgical resection, combination chemotherapy with the CAP (cyclophosphamide, Adriamycin, cisplatin) regimen, or radiation therapy potentiated by high-dose weekly 5-fluorouracil infusion. Permutations of these 3 treatment modalities were prescribed as necessary. RESULTS: T2alpha gene amplification was detected in 4 of 14 thymic carcinoma and 1 of 15 type B3 thymoma. Three thymic carcinoma patients had Her-2/neu coamplification and these 3 patients had rapidly growing tumor and extensive disease at initial diagnosis. CAP was prescribed in 28 patients and 20 patients responded (response rate, 71.4%, 95% confidence interval [CI]: 52.8% to 85%); all responders overexpressed (> or = 10% nuclei positive) the T2alpha protein, whereas 4 nonresponders had very low expression. T2alpha overexpression predicts CAP response, and its absence predicts resistance (P = .001). Overall survival was significantly prolonged if the tumor was resectable (P = .001), of type B3 histology (P = .0039), and had no Her-2 gene amplification (P = .0081). CONCLUSION: T2alpha and Her-2/neu genes play a pivotal role in the tumor biology, CAP response, and survival of advanced thymic neoplasia patients.

Evaluation of different bonded investments for dental titanium casting.

The properties of several different investments were investigated including phosphate bonded, magnesia bonded, and alumina cement investments. Measurements included the setting expansion, thermal expansion, and compressive strength of investments, as well as the tensile strength, elongation, Vickers hardness (VHN) and surface roughness of titanium castings. For phosphate bonded investment, the setting expansion after being mixed with its own mixing solution was 2.10%, which was larger than the other investments; the thermal expansion was -0.25% at 200 degrees C, the compressive strength 14 and 5 MPa after heating. For titanium cast in phosphate bonded investment, the hardness on its top surface was 655 Hv, the tensile strength was 379 MPa, the elongation was 19.4%, and the surface roughness was 2.29 microm. Although the thermal expansion of phosphate bonded investment is small, the setting expansion is large enough to compensate for the shrinkage of titanium castings. As its thermal expansion at T > or = 600 degrees C was constant and its heating-cooling cycle was almost reversible, these two properties can reduce the thermal shock and thus avoid cracking of the investment.

Demand for traditional medicine in Taiwan: a mixed Gaussian-Poisson model approach.

Hurdle count models are used to examine the participation and consumption decisions in Chinese medicine use. Motivated by a household production model, a second censoring mechanism is introduced into existing single-hurdle models, and the resulting specification accommodates conscientious abstainers, as well as economic non-consumers, and admits excessive zeros in the sample. In contrast to previous studies that found few predictors, empirical results based on a Taiwanese national sample suggest that Western medicine is a gross substitute to Chinese medicine, and both time price and money price play more important roles than income. Insurance, lifestyle and demographics also determine the use of Chinese medicine.

Electrolytic A12O3 coating on co-cr-mo implant alloys of hip prosthesis.

The ceramic films over metallic implant surfaces have the potential to improve implant performance with respect to implant fixation, wear, or corrosion. In this study, the electrolytic Al2O3 coatings on F-1537 Co-Cr-Mo alloy were conducted in an aqueous solution of Al(NO3)3. Through the cycle polarization test in Hank's solution, it was found that the corrosion potential and protection potential of the alumina-coated were higher than that of the uncoated, and the corrosion current density was lower. The phase transformation of A12O3 film on Co-Cr-Mo alloy annealed at 800 K revealed todlite (5Al2O3 . H2O) and thetaAl2O3 (113) preferred orientation for 20 min, and thetaAl2O3 (200) preferred orientation with eta phase for 80 min. Scanning electron microscopy/energy dispersive spectroscopy observations after the scratch tests showed that the adhesion of the alumina films on Co-Cr-Mo alloy can load a stress over the yield strength (450 MPa) of Co-Cr-Mo alloy. The wear loss of ultra-high molecular-weight polyethylene to the Al2O3-coated specimen was eight times less than that to the uncoated. It is concluded that such Al2O3-coated films on Co-Cr-Mo implant alloy exhibit excellent quality in corrosion, adhesion, and wear for the application of hip prosthesis.

Sensitization of a tumor, but not normal tissue, to the cytotoxic effect of ionizing radiation using Panax notoginseng extract.

The aim of the present study was to investigate any sensitization effect of the Panax notoginseng extract (PNE) and the purified Saponin (Rb1) on the radiation response of an experimental tumor (KHT sarcoma) in mice, in comparison with any effects on a normal tissue (bone marrow). PNE at a concentration of 0.1-100 mg/kg produced an increase in tumor radiosensitivity. The sensitization effect was maximal at 10 mg/kg and at 30 minutes after injection. Higher doses were toxic to the bone marrow stem cells. Similarly Rb1 at a concentration 0.001 to 1 mg/kg also produced an increase in tumor radiosensitivity, with maximum effect at 1 mg/kg. Higher doses were not toxic to the bone marrow stem cells in this case. Radiosensitization factors were calculated as ratios of D0 (the radiosensitivity parameter), and these were highly significant for the tumor and very similar for both compounds at the doses used, namely 1.18-1.19. There was no significant effect for bone marrow stem cells (sensitization factors of 0.99 +/- 0.01 for both compounds). The differential effect on tumor, and the magnitude of the radiosensitization, suggest that further purified or synthetic versions of this extract may be useful not only in vascular-related diseases but also in cancer therapy.

Effects of chromium picolinate supplementation on insulin sensitivity, serum lipids, and body composition in healthy, nonobese, older men and women.

BACKGROUND: Chromium is an essential nutrient required for carbohydrate and lipid metabolism. Chromium supplementation in humans has been reported to improve glucose metabolism and improve serum lipid parameters and to reduce body fat; parameters that worsen with aging. As a result, chromium picolinate has been widely promoted as a health aid for the general population. The purpose of the study was to examine the effects of chromium supplementation on insulin sensitivity, serum lipids, and body composition in nonobese, healthy men and women of advanced age. METHODS: A randomized, double-blind, placebo-controlled study with 19 subjects (9 men and 10 women), aged 63-77, were given either chromium picolinate, 1,000 microg/d, or a placebo for 8 weeks. Serum lipids were measured at baseline and 8 weeks. Insulin sensitivity and body composition were measured with the minimal-model intravenous glucose tolerance test and dual-energy x-ray absorptiometry scan, respectively, at baseline and after 8 weeks of chromium or placebo supplementation. RESULTS: No significant change in serum lipids, insulin sensitivity, or body composition was observed in the chromium group compared with the placebo group. CONCLUSIONS: Chromium picolinate supplementation alone does not appear to improve insulin sensitivity, serum lipids, or change body composition in nonobese, healthy men and women of advanced age.

FTDP-17 tau mutations decrease the susceptibility of tau to calpain I digestion.

Frontal temporal dementia and Parkinsonism linked to chromosome 17 (FTDP-17) is caused by splice site and missense mutations in the tau gene, and characterized by the accumulation of filamentous tau in cerebral neurons and glia. The missense mutations reduce the ability of tau to promote microtubule assembly and increase the ability of tau to form filaments. In this report we demonstrate that mutants V337M and R406W are less susceptible than mutant P301L or corresponding wild type tau to degradation by calpain I. The differences were at least in part due to changes in accessibility of a cleavage site located about 100 amino acids off the carboxy-terminus. The results suggest that the pathogenesis of some forms of FTDP-17 may involve tau accumulation due to decreased proteolytic degradation.

The insulin-like growth factor system in the GT1-7 GnRH neuronal cell line.

Evidence suggests that insulin-like growth factors (IGFs; IGF-I and IGF-II) are involved in the regulation of reproductive function including the development of the gonadotropin-releasing hormone (GnRH) neuronal system and the modulation of GnRH secretory activities. To further characterize the regulatory role of the IGF system on GnRH neuronal function, we have examined the gene expression of IGF-I, IGF-II, IGF-I receptor (IGF-IR), and IGF-binding proteins (IGFBPs) in a GnRH neuronal cell line (GT1-7 cells). The relative effects of IGFs and insulin on GnRH secretion by these cells was also investigated. RT-PCR analysis demonstrated IGF-I, IGF-II and IGF-IR mRNAs in GT1-7 cells. The mRNAs for IGFBP-2, -3, -4, -5 and -6 but not IGFBP-1 were also detected. Immunoreactive protein bands for IGFBP-2, -4 and -5 but not for other IGFBPs were demonstrated by Western blot with IGFBP-5 appearing to be the most abundant IGFBP secreted by GT1-7 cells. IGFBP-5 production by GT1-7 cells was stimulated by both IGF-I and IGF-II in a dose-dependent manner with approximately equal potency, whereas insulin caused no significant effect. GnRH secretion by GT1-7 cells treated with IGF-I or IGF-II but not insulin showed an increase (80-100%) at 2 h of treatment followed by a decrease (46%) at 6 h that continued up to 24 h. We conclude that the expression of IGFs, IGF-IR and IGFBPs and their interactions in the regulation of GnRH secretion by GT1-7 cells as demonstrated by our study provide a basis for an autocrine regulatory role for the IGF system in GnRH neuronal secretory activities.

Progesterone advances the diurnal rhythm of tuberoinfundibular dopaminergic neuronal activity and the prolactin surge in ovariectomized, estrogen-primed rats and in intact proestrous rats.

A diurnal change of tuberoinfundibular dopaminergic (TIDA) neuronal activity exists in female rats, which is prerequisite for the estrogen-induced afternoon PRL surge. Because progesterone (P4) administered in the morning can advance and amplify the PRL surge, it is of interest to learn whether its action involves the TIDA neuron. In adult ovariectomized and estrogen-primed Sprague-Dawley rats, P4 (2 mg/kg, s.c.), given at 0800 h, exhibited a significant effect in advancing and amplifying the afternoon PRL surge, as determined by both chronic catheterization and decapitation methods of blood sampling. The afternoon decrease of TIDA neuronal activity, as determined by 3,4-dihydroxyphenylacetic acid concentration in the median eminence, was also advanced from 1400 to 1300 h. These effects of P4 on PRL surge and TIDA neuronal activity were shown to be dose- (from 0.5-4 mg/kg) and estrogen-dependent. To determine whether the effect of P4 was indeed acting via specific P4 receptor (PR), we used a PR antagonist, RU486, an antisense oligodeoxynucleotide (ODN) for PR messenger RNA (mRNA), and an antibody against PR in this study, to answer this question. Treatments of RU486 (5 mg x 3, s.c.) for 1-2 days before, and on the sampling day, were effective in antagonizing the effects of P4 on TIDA neuronal activity and on PRL secretion. Intracerebroventricular injection of an antisense ODN (4 nM) for PR mRNA or of an antibody (1:1 and 1:5) against PR for 2 days (24 and 48 h before decapitation) also were effective. Treatments of RU486 on the sampling day only, of sense ODN for PR mRNA, or of diluted PR antibody (1:10) were without significant effect. The involvement of P4 or PR on modulating the TIDA neuronal rhythm and the PRL surge also was shown in proestrous rats. In conclusion, P4 may play a significant modulatory role on rhythmic changes of the TIDA neuronal activity and the PRL surge in the female rats.

Effects of lifestyle and body composition on the ovary.

Reduction of metabolic fuel availability below the critical level by food restriction or increased expenditure is appropriately accompanied by activations of multiple neuroendocrine-metabolic changes resulting in anovulation and amenorrhea, an important device for endogenous hypothalamic contraception. This reproductive strategy in women is required because of the enormous nutritional demand for reproductive success.

Melatonin enhances cortisol levels in aged women: reversible by estrogens.

The administration of melatonin increases cortisol levels in postmenopausal women. Aging and hypoestrogenism are believed to impair the regulation of the hypothalamo-pituitary-adrenal axis and may participate in the determination of this altered response. In this study the implications of hypoestrogenism were tested. Seven postmenopausal women were studied. At 08.00 hr for 2 consecutive days, each woman received randomly and in a double blind fashion a pill of placebo or melatonin (100 mg). Serum melatonin and cortisol levels were evaluated at 20 min intervals, for 48 hr. Measurements were performed in the same subjects both during no estrogen supplementation and at least two cycles of conjugated estrogens administration (0.625 mg/day). During estrogen supplementation, postmenopausal women showed slightly lower cortisol levels at lunch and early night (20.00-01.00 hr). The onset of the nocturnal melatonin rise was not modified, but that of cortisol was delayed of about 60 min (P < 0.02). The administration of melatonin elicited a marked increase in daytime cortisol levels in postmenopausal women (P < 0.02), but this stimulus completely disappeared during estrogen administration. Mean nighttime (20.00-08.00 hr) cortisol levels were not modified by daytime administration of melatonin. The present data reveal that in aged postmenopausal women, reversal of hypoestrogenism, resulting from supplemental estrogens, may improve the regulation of the hypothalamopituitary-adrenal axis.

Female hypogonadotropic hypogonadism. Hypothalamic amenorrhea syndrome.

The neuroendocrine-metabolic repertoire governing the reproductive cyclicity in women can be interrupted by a variety of social, environmental, nutritional, and psychological aberrations. Clinical conditions including exercise-related and psychogenic amenorrhea, and desynchronization of biological rhythms in the development of hypothalamic gonadotropin-releasing hormone dysfunction are discussed. Clinical and laboratory evaluations and modes of management are presented.

Acceleration of luteinizing hormone pulse frequency in functional hypothalamic amenorrhea by dopaminergic blockade.

A constellation of neuroendocrine secretory aberrations, including reduced LH pulse frequency and PRL concentrations, has been documented in women with functional hypothalamic amenorrhea (FHA). As pituitary function was preserved, these aberrations were attributed to an alteration in hypothalamic neuromodulation. To investigate the participation of the dopaminergic system in the genesis of the reduced LH pulse frequency and suppressed PRL levels in FHA, we studied six women with FHA and six cyclic women in the early follicular phase by obtaining blood samples at 15-min intervals for 48 h during sequential 24-h infusions of saline and a dopamine receptor blocker, metoclopramide (MCP). A hypothalamic vs. pituitary site of action was inferred from the pulsatility characteristics. MCP consistently elicited an increase in the LH pulse frequency in the women with FHA [7.3 +/- 1.2 (+/- SE) to 10.5 +/- 1.3 pulses/24 h; P less than 0.005]. In contrast, the eumenorrheic women did not show a significant change in LH pulse frequency in response to MCP (15.2 +/- 1.0 to 14.3 +/- 0.9 pulses/24 h). While the PRL concentrations were significantly lower in the FHA group during the infusion of saline (P less than 0.001) and MCP (P less than 0.005), the relative increases in PRL during MCP were similar in both groups. The acceleration of LH pulse frequency by blockade of dopamine receptors implies that there is increased hypothalamic dopaminergic inhibition of GnRH pulse frequency in women with FHA.

Altered waveform of plasma nocturnal melatonin secretion in premenstrual depression.

The nocturnal secretion of plasma melatonin was determined under dim to dark conditions in eight patients with prospectively confirmed premenstrual syndrome and in eight age- and menstrual cycle phase-matched normal control subjects. Plasma samples for melatonin were collected every 30 minutes from 6 PM to 9 AM during the early follicular, late follicular, midluteal and late luteal phases of the menstrual cycle. Compared with normal controls, patients with premenstrual syndrome had an earlier (phase-advanced) offset of melatonin secretion, which contributed to a shorter secretion duration and a decreased area under the curve. No statistically significant differences were found between women with premenstrual syndrome and normal controls for melatonin onset or peak concentration, or for estradiol or progesterone levels. The data demonstrate that women with premenstrual syndrome have chronobiological abnormalities of melatonin secretion. The fact that these patients respond to treatments that affect circadian physiology, such as sleep deprivation and phototherapy, suggests that circadian abnormalities may contribute to the pathogenesis of premenstrual syndrome.

Pituitary function in isolated gonadotrophin deficiency.

Hypothalamic-pituitary function was assessed in 24 individuals with isolated gonadotrophin deficiency (IGD). Thirteen had normal olfaction (Group I) while 11 (Group II) had anosmia (Kallmann's syndrome). In response to a 10 micrograms intravenous (i.v.) bolus of GnRH, the minimal dose required to evoke a consistent gonadotrophin response in normal subjects, the patients responded with significant LH and FSH increases over baseline (P less than 0.01). In Group II patients, large doses (150 micrograms) of GnRH, which elicit maximal release of gonadotrophin in normal subjects did not increase gonadotrophin release beyond that produced by a 10 micrograms bolus. In response to two 10 micrograms GnRH doses, at times 0 and 120 min, the IGD patients responded with similar LH increases to both boluses (both P less than 0.01 compared to baseline). The maximal PRL responses to arginine infusion and to TRH in the male patients were similar to those of normal males. However, in the IGD females, the PRL response to TRH was less than in normal females. The TSH responses to TRH in IGD males and females were similar to each other and similar to normal. The IGD male GH response to arginine infusion was comparable to that in normal males. We conclude that (1) IGD patients appear to retain minimal endogenous GnRH secretion so that the IGD pituitary responds to a minimal dose of GnRH without priming; (2) IGD is a heterogeneous syndrome in which affected individuals with and without normal olfaction represent parts of the spectrum of the same disease; and (3) except for the PRL response in females, the PRL, TSH and GH responses demonstrate that the IGD pituitaries are largely intact.

Alterations of the adrenocorticotropin-cortisol axis in normal weight bulimic women: evidence for a central mechanism.

We studied pituitary-adrenal function in eight women with normal weight bulimia and seven normal women by measuring plasma ACTH and serum cortisol levels at 20-min intervals for 24 h and the responses to human CRH (hCRH) and to a noon meal. The bulimic women had increased 24-h transverse mean plasma ACTH [1.09 +/- 0.06 (+/- SE) vs. 0.75 +/- 0.14 pmol/L; P less than 0.05] and serum cortisol (235 +/- 21 vs. 152 +/- 9 nmol/L; P less than 0.005) concentrations. While the 24-h ACTH and cortisol pulse frequencies were unaltered, the bulimic women had higher (P less than 0.05) mean peak ACTH (1.46 +/- 0.09 vs. 1.03 +/- 0.15 pmol/L) and cortisol values (331 +/- 33 vs. 239 +/- 17 nmol/L). Despite having higher mean and peak plasma ACTH and serum cortisol values, the bulimic women had a blunted response of both ACTH (P less than 0.001) and cortisol (P less than 0.005) to hCRH, which included a lower mean maximal plasma ACTH response, decreased (P less than 0.05) integrated area under the ACTH response curve (161 +/- 12 vs. 231 +/- 23 pmol/min.L), a lower (P less than 0.05) maximum cortisol response (284 +/- 35 vs. 413 +/- 19 nmol/L), and decreased (P less than 0.05) area under the cortisol curve (11.1 +/- 1.9 vs. 15.9 +/- 1.3 X 10(3) nmol/min.L). The circadian variations of both ACTH and cortisol were maintained in the bulimic women; the nadir and acrophase times were similar to those of the normal women. However, the rise in serum cortisol that occurred within 1 h after the lunch meal in the normal women (104 +/- 35 nmol) did not occur in the bulimic women (P less than 0.05). These data demonstrate that marked changes in hypothalamic-pituitary-adrenal function occur in bulimia in the absence of weight disturbance and suggest central activation of CRH and/or synergistic factors as well as alterations in signals from gut to brain in this syndrome.