Best predictors of grayscale ultrasound combined with color Doppler in the diagnosis of retained products of conception.

OBJECTIVES: To determine the best predictors of the presence of retained products of conception (RPOC) on grayscale and color Doppler transvaginal sonographic examination. METHODS: This was a retrospective study of 91 consecutive patients who underwent transvaginal sonography (TVS) with color Doppler to evaluate for the presence of RPOC. The images of TVS studies were reviewed by two radiologists in consensus blinded to the final outcome. Data on a number of variables including endometrial measurable mass and focal increased color vascularity were collected as predictors of RPOC. The patients' ages ranged from 17 to 48 years (mean, 31.8 ± 6.8) and gestational age from 5 to 24 weeks (mean, 9.2 ± 3.8). Thirty-six were confirmed as RPOC by dilatation and curettage (D&C) and pathology. Fifty-five were considered negative, 9 based on D&C results and 46 on clinical grounds. RESULTS: Sensitivity, specificity, negative- and positive-predictive and accuracy values were 81% (CI: 68%-94%), 71% (CI: 59%-83%), 85% (CI: 74%-95%), 64% (CI: 50%-78%), and 75% (CI: 66%-84%) to detect RPOC when a mass was present. The corresponding numbers for the presence of focal color vascularity were 94% (CI: 87%-100%) (p = 0.07), 67% (CI: 55%-80%) (p > 0.05), 95% (CI: 88%-100%) (p = 0.1), 65% (CI: 52%-78%) (p > 0.05), and 78% (CI: 70%-87%) (p > 0.05). Of the patients with confirmed RPOC on pathology, five had focal increased vascularity and no massand none had a mass without focal increased vascularity. CONCLUSION: An area of focal increased vascularity with or without a mass is the best predictor of the presence of RPOC.

Image guided photothermal focal therapy for localized prostate cancer: phase I trial.

PURPOSE: We ascertained the feasibility and safety of image guided targeted photothermal focal therapy for localized prostate cancer. MATERIALS AND METHODS: Twelve patients with biopsy proven low risk prostate cancer underwent interstitial photothermal ablation of the cancer. The area of interest was confirmed and targeted using magnetic resonance imaging. Three-dimensional ultrasound was used to guide a laser to the magnetic resonance to ultrasound fused area of interest. Target ablation was monitored using thermal sensors and real-time Definity contrast enhanced ultrasound. Followup was performed with a combination of magnetic resonance imaging and prostate biopsy. Validated quality of life questionnaires were used to assess the effect on voiding symptoms and erectile function, and adverse events were solicited and recorded. RESULTS: Interstitial photothermal focal therapy was technically feasible to perform. Of the patients 75% were discharged home free from catheter the same day with the remainder discharged home the following day. The treatment created an identifiable hypovascular defect which coincided with the targeted prostatic lesion. There were no perioperative complications and minimal morbidity. All patients who were potent before the procedure maintained potency after the procedure. Continence levels were not compromised. Based on multicore total prostate biopsy at 6 months 67% of patients were free of tumor in the targeted area and 50% were free of disease. CONCLUSIONS: Image guided focal photothermal ablation of low risk and low volume prostate cancer is feasible. Early clinical, histological and magnetic resonance imaging responses suggest that the targeted region can be ablated with minimal adverse effects. It may represent an alternate treatment approach to observation or delayed standard therapy in carefully selected patients. Further trials are required to demonstrate the effectiveness of this treatment concept.

Renal athersosclerotic revascularization evaluation (RAVE study): study protocol of a randomized trial [NCT00127738].

BACKGROUND: It is uncertain whether patients with renal vascular disease will have renal or mortality benefit from re-establishing renal blood flow with renal revascularization procedures. The RAVE study will compare renal revascularization to medical management for people with atherosclerotic renal vascular disease (ARVD) and the indication for revascularization. Patients will be assessed for the standard nephrology research outcomes of progression to doubling of creatinine, need for dialysis, and death, as well as other cardiovascular outcomes. We will also establish whether the use of a new inexpensive, simple and available ultrasound test, the renal resistance index (RRI), can identify patients with renal vascular disease who will not benefit from renal revascularization procedures1. METHODS/DESIGN: This single center randomized, parallel group, pilot study comparing renal revascularization with medical therapy alone will help establish an infrastructure and test the feasibility of answering this important question in clinical nephrology. The main outcome will be a composite of death, dialysis and doubling of creatinine. Knowledge from this study will be used to better understand the natural history of patients diagnosed with renal vascular disease in anticipation of a Canadian multicenter trial. Data collected from this study will also inform the Canadian Hypertension Education Program (CHEP) Clinical Practice Guidelines for the management of Renal and Renal Vascular Disease. The expectation is that this program for ARVD, will enable community based programs to implement a comprehensive guidelines based diagnostic and treatment program, help create an evidence based approach for the management of patients with this condition, and possibly reduce or halt the progression of kidney disease in these patients. DISCUSSION: Results from this study will determine the feasibility of a multicentered study for the management of renovascular disease.

Effects of calcium binding on the structure and stability of human growth hormone.

Thermodynamic analysis of calcium ions binding to human growth hormone (hGH) was done at 27 degrees C in NaCl solution, 50 mM, using different techniques. The binding isotherm for hGH-Ca2+ was obtained by two techniques of ionmetry, using a Ca(2+)-selective membrane electrode, and isothermal titration calorimetry. Results obtained by two ionmetric and calorimetric methods are in good agreement. There is a set of three identical and non-interacting binding sites for calcium ions. The intrinsic dissociation equilibrium constant and the molar enthalpy of binding are 52 microM and -17.4 kJ/mol, respectively. Temperature scanning UV-vis spectroscopy was applied to elucidate the effect of Ca2+ binding on the protein stability, and circular dichroism (CD) spectroscopy was used to show the structural change of hGH due to the metal ion interaction. Calcium ions binding increase the protein thermal stability by increasing of the alpha helix content as well as decreasing of both beta and random coil structures.

Group B streptococcus endocarditis following second-trimester abortion.

An 18-year-old woman who underwent an elective second-trimester abortion developed Streptococcus agalactiae (group B streptococcus) endocarditis characterized by a large, pedunculated vegetation involving a previously normal tricuspid valve. Polyarthritic symptoms, as well as multiple pulmonary emboli, were experienced, and cure followed a course of treatment using intravenous penicillin G potassium combined with gentamicin sulfate. Endocarditis caused by this pathogen usually occurs among individuals compromised by underlying chronic disorders and, today, is a rare sequela of pregnancy and abortion. When planning therapy, consideration should be given to the possibility of tolerance among clinical isolates and the need for operative intervention in selected patients.

Treatment of ectopic pregnancy by transvaginal intratubal methotrexate administration.

Twelve women with tubal pregnancies were treated with intratubal transvaginal methotrexate injection (1 mg/kg body weight). Serum beta-hCG levels decreased in all patients, and the resolution time from injection to undetectable beta-hCG levels was 14-120 days. In spite of declining serum beta-hCG and unruptured tubal pregnancy, two patients subsequently requested definitive treatment for their ectopic pregnancies and underwent surgery. Four of six women found to have a living embryo in their gestational sacs required a repeat methotrexate injection; one of these also required a local potassium chloride injection. The tubal pregnancies resolved in nine patients treated with methotrexate alone. During resolution, we noted a gradually increasing resistance index of the blood flow in the region of the gestation, but the tube became distended to 4.4 +/- 0.4 cm before gradually decreasing in size. No complications or side effects were encountered. These findings suggest that intratubal transvaginal methotrexate administration can provide a safe alternative to surgical treatment for patients with early unruptured tubal ectopic pregnancy. However, the presence of a living embryo makes the ectopic pregnancy more resistant to methotrexate treatment.

Transvaginal intratubal methotrexate treatment of ectopic pregnancy.

OBJECTIVE: To evaluate the efficacy of transvaginal intratubal methotrexate (MTX) treatment of tubal ectopic pregnancy (EP). SETTING: Outpatient setting in University Hospital. PATIENTS: Forty women with early EP and rising serum beta-human chorionic gonadotropin (beta-hCG) levels. INTERVENTION: Transvaginal intratubal administration of MTX (1 mg/kg body weight). MAIN OUTCOME MEASURES: Success was defined as declining serum beta-hCG to undetectable levels, no tubal dilatation on ultrasound examination, and no further intervention was required. RESULTS: Treatment was associated with a 70% success rate. No difference was found in the success rate between women with an embryo (76.9%) and those with no embryo in their fallopian tubes (66.7%). The initial serum beta-hCG levels were also not different between patients who were successfully treated and those who failed to respond to the treatment. Despite declining serum beta-hCG levels, tubal rupture occurred in two patients. CONCLUSIONS: Treatment of EP by transvaginal MTX administration is associated with a 70% success rate. This is independent of the presence of an embryo or the initial serum beta-hCG levels. Rupture of EP can still occur despite low and declining serum beta-hCG levels.

Acute female pelvic pain: ultrasound evaluation.

Ultrasound has become a valuable primary imaging tool in the assessment of acute pelvic pain in women, both for diagnosis and for assessment of complications. Although ultrasound is an established imaging tool for gynecologic diseases, it is also a useful modality for assessing nongynecologic disorders that cause acute pelvic pain, such as diverticulitis and urinary tract calculi. These are important differential diagnoses in women with acute pelvic pain, and sonologists are not always expert in their diagnosis. This article reviews the gamut of conditions that can cause acute pelvic pain in women. The usual gynecologic causes are included, such as ectopic pregnancy, but also considered are conditions such as diverticulitis, appendicitis, and incarcerated hernia, which are important differential considerations.

Familial Mediterranean fever and primary antiphospholipid syndrome, a rare association. A case report.

The authors present the case of a twenty-one-year-old woman with familial Mediterranean fever who during her first pregnancy developed a primary antiphospholipid syndrome. This is an association not reported previously.

Laddering through pedigrees: family history of malignancies in primary breast cancer patients.

A family history (FH) of breast cancer (BC) is a long recognized risk factor for developing the disease. Also, there have been some reports of links between an FH and some other malignancies (mostly uterus, ovary, and prostate cancers), and an increased risk of developing BC. In this paper we present descriptive report of the occurrence pattern of malignancies in families of BC afflicted patients through 4 generations. Patients included 542 Iranian primary BC cases, presenting at an outpatient clinic for treatment and follow-up. Detailed pedigrees were drawn for each patient, and data for a total of 6220 relatives were gathered. Among the probands, 29.9% and 53.9% had a positive FH of BC and other malignancies (OM) respectively. Mean number of breast cancers was nearly double in maternal-lines versus paternal-line relatives. Also, occurrence of brain, uterus, and colorectal cancers was significantly higher in maternal-line relatives, but conversely, liver cancer showed a tendency toward paternal-line relatives (1st degree relatives excluded). The highest frequency of BC involvement was noted in 2nd degree/2nd generation, and 3rd degree/3rd generation relatives. For OMs, although gastric cancer was by far the most frequent OM across pedigrees, uterus cancer, and hematopoeitic system lesions (leukemia) predominated over gastric cancer through the 3rd and 4th generations respectively. We did not find any relation between having a positive FH of BC, and developing early-onset BC. The findings discussed in this paper were partially presented at the 18th UICC International Cancer Congress, Oslo-Norway, 30 June-5 July 2002.

The biomarker-based validity of a food frequency questionnaire to assess the intake status of folate, pyridoxine and cobalamin among Iranian primary breast cancer patients.

BACKGROUND/OBJECTIVES: Folate, pyridoxine and cobalamin are coenzymatically essential in one-carbon methyl metabolism, and their deficiencies could explain some alterations during breast carcinogenesis. We aimed to evaluate the validity of folate, pyridoxine and cobalamin estimates from a food frequency questionnaire (FFQ) on the basis of their corresponding fasting plasma biomarkers, in breast cancer (BC) patients. SUBJECTS/METHODS: In a prospective, consecutive case series, 149 women with primary BC aged between 30 and 69 years as a representative sample of Iranian women with BC were recruited. The 136-item FFQ was used for the validity assay. Fasting plasma folate and cobalamin were tested by automated electrochemiluminescence. The high-pressure liquid chromatography with fluorescence detection was used to determine the plasma levels of pyridoxal-5'-phosphate (PLP) and total homocysteine (tHcy). RESULTS: Area under the curve (AUC) for assessing the diagnostic accuracy of folate-related data through an FFQ was 0.74 (P<0.01) in the reference model (folate plasma level<5.9 ng/ml), with sensitivity and specificity of 68% and 63%, respectively. The positive and negative predictive values (PPV and NPV) were 96.9% and 96.8%, respectively. The AUC for cobalamin intake in the reference model (plasma cobalamin<260 pmol/l) was 0.64 (P<0.01), with 60% sensitivity and 61% specificity. Although tHcy ≥10.0 µmol/l was used as reference indicator, the folate intake (AUC=0.71, P<0.01) and cobalamin intake status (AUC=0.67, P<0.05) were also determined appropriately by FFQ. CONCLUSIONS: Dietary folate and cobalamin estimates from FFQ were significantly correlated with their fasting plasma concentrations. Our data supported the validity of new FFQ to rank individuals by dietary intake status of folate and cobalamin.

Novel evolutionary models and periodic charts in p- and q-individual chromosomes of auxiliary lymph node and buccal cells.

Signal copy number (SCN) and signal intensity (SI) of subtelomeres (ST) are investigated in auxiliary lymph node (ALN) and buccal (BUC) cells by fluorescence in situ hybridization. The extracted total cell of 38256 and 2309 was, respectively, analyzed from the benign ALN- and BUC-cells of an affected breast cancer patient. The Periodic model was based on ST behavior including normal-, down-, and upregulated clones with diverse SCN. The arm-p/q ratio based signature, as a subtelomeric array, reflects discordance and concordance of ST-behavior within individual chromosomes as a concept of "Individualization of Cells" rather than "Global Insight of Cells". The Periodic charts could be considered as a reliable and refreshable platform through which the cellular evolution could be patterned and characterized. Signature of ST-profile in the BUC and ALN cells and the nature of diverse SCN and SI as quantitative and qualitative value led to modeling the real personalized perspective of cellular evolution. Protein expression of Ki67, Cyclin D1, and Cyclin E was assayed, as a complementary panel. These targets could be applied as the predictive and preventive markers for an early detection at BUC and ALN levels to plan the required managements in the breast cancer patients.

Effect of compatible and noncompatible osmolytes on the enzymatic activity and thermal stability of bovine liver catalase.

Catalase is an important antioxidant enzyme that catalyzes the disproportionation of H2O2 into harmless water and molecular oxygen. Due to various applications of the enzyme in different sectors of industry as well as medicine, the enhancement of stability of the enzyme is important. Effect of various classes of compatible as well as noncompatible osmolytes on the enzymatic activity, disaggregation, and thermal stability of bovine liver catalase have been investigated. Compatible osmolytes, proline, xylitol, and valine destabilize the denatured form of the enzyme and, therefore, increase its disaggregation and thermal stability. The increase in the thermal stability is accompanied with a slight increase of activity in comparison to the native enzyme at 25 °C. On the other hand, histidine, a noncompatible osmolyte stabilizes the denatured form of the protein and hence causes an overall decrease in the thermal stability and enzymatic activity of the enzyme. Chemometric results have confirmed the experimental results and have provided insight into the distribution and number of mole fraction components for the intermediates. The increase in melting temperature (Tm) and enzymatic rate could be further amplified by the intrinsic effect of temperature enhancement on the enzymatic activity for the industrial purposes.

Renal cell carcinoma containing macroscopic fat on CT mimics an angiomyolipoma due to bone metaplasia without macroscopic calcification.

We report a case of renal cell carcinoma (RCC) containing foci of macroscopic fat, which were pathologically proven to be areas of osseous metaplasia. The macroscopic fat was not associated with calcification on the pre-operative CT scan. To our knowledge, there are no reported cases of RCC that contain osseous metaplasia without evidence of macroscopic calcification on CT. The finding is significant because standard imaging practice is to classify a renal mass containing intratumoral macroscopic fat that is not associated with calcification, ossification or invasion of perirenal or hilar fat as an angiomyolipoma.

Ultrasound-guided thrombin injection of iatrogenic groin pseudoaneurysm: Doppler features and technical tips.

The practice of angiographic procedures is increasing and, concomitantly, there has been an increase in the incidence of iatrogenic femoral pseudoaneurysms (PA). Ultrasound-guided thrombin injection is becoming the accepted gold standard in the treatment of PA. It is a cost-effective, safe and efficacious treatment that requires a short learning curve. The aim of this pictorial review is to demonstrate the Doppler and ultrasound features used to diagnose PA and those that help differentiate it from alternative diagnoses, and to describe the procedure of thrombin injection, highlighting technical tips and ways to avoid potential complications.

CT assessment of anastomotic bowel leak.

AIM: To evaluate the predictors of clinically important gastrointestinal anastomotic leaks using multidetector computed tomography (CT). SUBJECTS AND METHODS: Ninety-nine patients, 73 with clinical suspicion of anastomotic bowel leak and 26 non-bowel surgery controls underwent CT to investigate postoperative sepsis. Fifty patients had undergone large bowel and 23 small bowel anastomoses. The time interval from surgery was 3-30 days (mean 10+/-5.9 SD) for the anastomotic group and 3-40 days (mean 14+/-11 SD) for the control group (p=0.3). Two radiologists blinded to the final results reviewed the CT examinations in consensus and recorded the presence of peri-anastomotic air, fluid or combination of the two; distant loculated fluid or combination of fluid and air; free air or fluid; and intestinal contrast leak. Final diagnosis of clinically important anastomotic leak (CIAL) was confirmed at surgery or by chart review of predetermined clinical and laboratory criteria. RESULTS: The prevalence of CIAL in the group undergoing CT was 31.5% (23/73). The CT examinations with documented leak were performed 5-28 (mean; 11.4+/-6 SD) days after surgery. Nine patients required repeat operation, 10 percutaneous abscess drainage, two percutaneous drainage followed by surgery, and two prolonged antibiotic treatment and total parenteral nutrition (TPN). Of the CT features examined, only peri-anastomotic loculated fluid containing air was more frequently seen in the CIAL group as opposed to the no leak group (p=0.04). There was no intestinal contrast leakage in this cohort. Free air was present up to 9 days and loculated air up to 26 days without CIAL. CONCLUSION: Most postoperative CT features overlap between patients with and without CIAL. The only feature seen statistically more frequently with CIAL is peri-anastomotic loculated fluid containing air.

A thermodynamic study on the interaction between magnesium ion and human growth hormone.

A thermodynamic study on the interaction between magnesium ion and human growth hormone (hGH) was studied at 27 degrees C in NaCl solution (50 mM) using different techniques. Two techniques of ionmetry using a Mg2+selective membrane electrode and isothermal titration calorimetry were applied to obtain the binding isotherm for hGHMg2+; results obtained by both techniques were found to be in good agreement. There is a set of three identical and noninteracting binding sites for magnesium ions. The intrinsic dissociation equilibrium constant and the molar enthalpy of binding are 46 microM and -17.7 kJ/mol, respectively. Temperature scanning UV-visible spectroscopy was applied to elucidate the effect of Mg2+ binding on the protein stability, and circular dichroism (CD) spectroscopy was used to show the structural change of hGH due to the metal ion interaction. Magnesium ion binding increased the protein thermal stability by increasing the alpha-helix content as well as decreasing both beta and random coil structures. However, the secondary structural change of the protein returns to its native form, including a small change in the tertiary structure, in high concentrations of magnesium ion.