Test-positive rate at CT colonography is increased by rectal bleeding and/or unexplained weight loss, unlike other common gastrointestinal symptoms.

PURPOSE: We evaluated the rate of significant colonic and extra-colonic abnormalities at computed tomography colonography (CTC), according to symptoms and age. MATERIALS AND METHODS: We retrospectively evaluated 7361 consecutive average-risk subjects (3073 males, average age: 60.3 ± 13.9; range 18-96 years) for colorectal cancer (CRC) who underwent CTC. They were divided into three groups according to clinical symptoms: 1343 asymptomatic individuals (group A), 899 patients with at least one "alarm" symptom for CRC, including rectal bleeding and unexplained weight loss (group C), and 5119 subjects with other gastrointestinal symptoms (group B). Diagnostic and test-positive rates of CTC were established using optical colonoscopy (OC) and/or surgery as reference standard. In addition, clinically significant extra-colonic findings were noted. RESULTS: 903 out of 7361 (12%, 95% confidence interval (CI) 0.11-0.13) subjects had at least one clinically significant colonic finding at CTC. CTC true positive fraction and false positive fraction were respectively 637/642 (99.2%, 95%CI 0.98-0.99) and 55/692 (7.95%, 95%CI 0.05-0.09). The pooled test-positive rate in group C (138/689, 20.0%, 95%CI 0.17-0.23) was significantly higher than in both groups A (79/1343, 5.9%, 95%CI 0.04-0.07) and B (420/5329, 7.5%, 95%CI 0.07-0.08) (p < 0.001). Aging and male gender were associated to a higher test positive rate. The rate of clinically significant extra-colonic findings was significantly higher in group C (44/689, 6.4%, 95%CI 0.04-0.08) versus groups A (26/1343, 1.9%, 95%CI 0.01-0.02) and B (64/5329, 1.2%, 95%CI 0.01-0.02) (p < 0.001). CONCLUSION: Both test-positive and significant extra-colonic finding rates at CTC are significantly increased in the presence of "alarm" gastrointestinal symptoms especially in older patients.

Screening for colorectal cancer in asymptomatic average risk patients: role of imaging.

Early detection of colorectal cancer or advanced adenomas is a public health priority in many industrialized countries. There are various methods of screening average risk individuals for colorectal cancer, and their effectiveness may depend on subjective parameters like local expertise and patient's preferences. This paper reviews these tests with special emphasis regarding imaging techniques that aim to provide less-invasive alternatives to optical colonoscopy (OC) which is the standard of reference. Both Double-Contrast Barium Enema (DCBE) and Virtual Colonoscopy (VC) have >90% sensitivity compared to OC in the detection of clinically relevant colonic lesions. Nevertheless, VC may have an edge over DCBE for technical and reproductivity reasons, as well as greater learning opportunities. Imaging techniques criticisms regarding diminutive and flat lesions, cost, radiation exposure and effects on gastroenterological practice are addressed.

Analgesia and pulmonary function after lung surgery: is a single intercostal nerve block plus patient-controlled intravenous morphine as effective as patient-controlled epidural anaesthesia? A randomized non-inferiority clinical trial.

BACKGROUND: Thoracic epidural anaesthesia (EDA) is regarded as the 'gold standard' for postoperative pain control and restoration of pulmonary function after lung surgery. Easier, less time-consuming, and, perhaps, safer is intercostal nerve block performed under direct vision by the surgeon before closure of the thoracotomy combined with postoperative i.v. patient-controlled analgesia with morphine. We hypothesized that this technique is as effective as thoracic EDA. METHODS: The study was designed as a single-centre, open labelled, randomized non-inferiority trial. A total of 92 patients undergoing elective lung surgery were randomly assigned to the epidural (n=47) or intercostal group (n=45), and 83 patients completed the study. Pain scores, inspiratory vital capacity, forced vital capacity (FVC), forced expiratory volume in the first second (FEV1), and peak expiratory flow rate (PEFR) were assessed during the first four postoperative days. RESULTS: Median treatment differences regarding pain scores at rest failed to demonstrate non-inferiority of the intercostal nerve block at the first postoperative day. Patients of the intercostal group reported significantly higher pain scores on coughing during the first and second postoperative days. The epidural group had a significantly higher median FVC, FEV1, and PEFR values on the second postoperative day. No difference was found in pulmonary complications, length of hospital stay, or in-hospital deaths. CONCLUSIONS: In patients undergoing lung surgery, single intercostal nerve block plus i.v. patient-controlled analgesia with morphine is not as effective as patient-controlled EDA with respect to pain control and restoration of pulmonary function.

Coexistence of rocksalt and wurtzite structure in nanosized CoO films.

Cobalt oxide (CoO) films epitaxially grown on Ir(100) in (111) orientation were investigated by means of quantitative low-energy electron diffraction and scanning tunneling microscopy. We find with high crystallographic precision that in the bulk of the films the rocksalt structure prevails while near the surface there is a switch towards the wurtzite structure. As a consequence, nanosized CoO cannot be considered as a single structural phase. The film surfaces prove to be metallic, apparently connected with polarity compensation.

[Virtual colonoscopy: a new hope for colorectal cancer screening]. / La colonoscopie virtuelle: un espoir dans le dépistage du cancer du côlon.

Colon cancer is the second most common cause of cancer death and the first one in non-smoking persons. None of the current colorectal caner screening options is ideal. As for mammography in breast cancer screening, virtual colonoscopy, although still in clinical evaluation, promises to become a primary screening method as it is performant, quick, non-invasive and cheaper than conventional colonoscopy.

Contribution of diminished ovarian reserve to hypofertility associated with endometriosis.

OBJECTIVE: To determine if ovarian reserve, as measured by day 3 levels of E2 and FSH, was different in patients with endometriosis as compared to controls. STUDY DESIGN: Case-control study of 75 women with laparoscopically staged endometriosis and 75 age-matched controls undergoing in vitro fertilization/embryo transfer for male factor infertility. RESULTS: In women with stage III/IV endometriosis (revised American Fertility Society staging), day 3 E2 and FSH levels were significantly higher than control levels (51.9 pg/mL and 12.6 mIU/mL versus 34.7 pg/mL and 9.7 mIU/mL, P < .03). In contrast, women with stage I/II endometriosis did not differ significantly when compared to controls (36.8 pg/mL and 10.4 mIU/mL versus 34.0 pg/mL and 10.2 mIU/mL). The total group showed significantly higher E2 levels (41.8 pg/mL versus 34.1 pg/mL, P < .03), but no significant differences in FSH levels were observed. CONCLUSION: These data show that women with stage III/IV endometriosis have relatively diminished ovarian reserve, while this situation is not noted in women with stage I/II endometriosis. This observation is consistent with progressive loss of ovarian reserve in women with increasing stages of endometriosis independent of age.

[Value of MRCP for detection of choledocholithiasis in symptomatic patients: one-year experience with a standardized high resolution breath-hold technique]. / Efficacité d'une technique standardisée de MRCP pour la détection de cholédocholithiase: expérience d'un an chez des sujets symptomatiques.

In our institution, MRCP is actually replacing diagnostic ERCP. This study is addressing its accuracy in the diagnosis of symptomatic choledocholithiasis. 137 MRCP were performed in patients with upper abdominal pain and biological anomalies (n = 48), pain with cholelithiasis at sonography (n = 69) or non-alcoholic acute pancreatitis (n = 20) on a 1.5 T system with high gradients using a standardized combination of breath-hold HASTE and RARE sequences. We included in our study 74 patients who underwent as second test ERCP (n = 36), peroperative cholangiography (n = 13), or extensive follow-up with laboratory tests and/or sonography (n = 25). All examinations were judged as diagnostic, discrepancies between direct cholangiography and MRCP being noted in 4 patients (5.4%). Lithiasis was misinterpreted on MRCP as bubbles in 2 patients after sphincterotomy or surgery. We had two false positive diagnoses on MRCP: in one patient peroperative cholangiography was negative and in the other one ERCP was negative. With a sensitivity and PPV of 92%, a specificity and NPV of 96% MRCP in our experience is shown as an accurate diagnostic tool for the detection of stone in the common bile duct replacing ERCP.

New treatments of hyperandrogenism and hirsutism.

Approximately 5% to 8% of the female population demonstrates some form of hirsutism, the presence of prominent facial and body hair caused by excessive androgen effect. Treatment methods are classified into three categories: (1) hormonal suppression consisting of medical therapy to decrease androgen production, (2) the administration of antiandrogens to block the androgen effect at the hair follicle, and (3) physical methods of hair removal. Most patients require a combination of medical and physical therapy.

[State of the art of pancreatic cancer imaging]. / Actualités en imagerie du cancer du pancréas.

Ultrasonography and CT-scanner remain the first choice nowadays concerning detection and preoperative work-up of pancreatic cancer. MRI offers interesting options for the detection of liver metastases, and high quality of ductal and vascular examination. Actually, while we await a larger diffusion of MR systems and radiological expertise this technique is preferentially indicated as a third-step procedure when ultrasonography and CT-scanner are normal despite a real suspicion. Otherwise, MRI permits with a single non-invasive examination a complete work-up useful to prepare palliative therapy in case of unresectable tumor.

The use of propofol, nitrous oxide, or isoflurane does not affect the reproductive success rate following gamete intrafallopian transfer (GIFT): a multicenter pilot trial/survey.

BACKGROUND: Whether anesthetic agents administered during gamete intrafallopian transfer (GIFT) affect reproductive outcome is controversial. This multicenter pilot trial and survey had two purposes: to evaluate the effect of propofol, nitrous oxide, midazolam, and isoflurane on pregnancy outcome after GIFT, and to determine if a larger prospective, randomized study is warranted. METHODS: A written invitation was mailed to all 50 fertility programs in the United States that are members of the Society for Assisted Reproductive Technology and perform more than 30 GIFT procedures per year. They were invited to contribute information from the medical records of women who underwent GIFT during the calendar years 1993 and 1994. They were asked to document whether propofol, nitrous oxide, midazolam, a potent inhaled anesthetic agent was used during the GIFT procedure; if the woman became pregnant; and if she delivered at least one live neonate. RESULTS: Seven medical centers participated and contributed data from 455 women. The clinical pregnancy rate (number of pregnancies/total number of GIFT procedures) and the delivery rate (number of women who delivered at least one live baby/total number of GIFT procedures) were 35% and 32%, respectively. A statistically significant difference could not be found in the clinical pregnancy or delivery rates between those women who received propofol, nitrous oxide, midazolam, or isoflurane during GIFT and those who did not. CONCLUSIONS: No agent-related differences in pregnancy rates were found when propofol, nitrous oxide, isoflurane, or midazolam was used as part of the anesthetic technique for GIFT. Therefore, a more extensive prospective trial does not appear to be warranted.

Production of sequence specific polyclonal antibodies to human parathyroid hormone 1-37 by immunization with multiple antigenic peptides.

To generate site-specific antibodies to the N-terminal bioactive fragment of the parathyroid hormone hPTH 1-37, multiple antigenic peptide systems (MAP) for immunization were used. Two 10 residue fragments and a 14 residue fragment derived from knowledge of the secondary structure of hPTH 1-37 were selected to be synthesized as MAPs. Each peptide (hPTH 1-10, hPTH 9-18, and hPTH 24-37) was synthesized directly onto a branching heptalysine core matrix by automated solid phase synthesis. The hPTH 1-10 and the hPTH 24-37 MAP were highly immunogenic in rabbits. Ten polyclonal antisera obtained from rabbits were characterized by epitope mapping. Antigenic determinants were found as follows: 1) Sera K1-K3 raised to MAP 1-10 showed a predominant binding sequence at hPTH 1-5. 2) Sera K4-K6 raised to MAP 8-18 preferentially bound to residues 9-14. 3) Immunizing with hPTH 24-37 MAP led to antisera characterized as follows: serum K7 recognized residues 24-37, the sequence used for immunization, sera K8, K9 and K10 bound to residues 24-37 and 26-34. In summary, the favoured regions as deduced from the secondary structure of hPTH 1-37 were covered by the produced antibodies.

The need to step up the gonadotropin dosage in the stimulation phase of IVF treatment predicts a poor outcome.

PURPOSE: It is a common practice to increase the gonadotropin dose during ovarian stimulation when the estradiol (E2) rise is found to be inadequate. The prognostic impact of the use of this step-up regimen on the outcome of the affected in vitro fertilization (IVF) cycle is the subject of this study. METHODS: This is a retrospective analysis of IVF cycles in a series of consecutive patients who required an increase in the gonadotropin dosage during the stimulation phase because of inadequate E2 rise. Controls consisted of patients in whom the dose was not increased. After 4 days of stimulation, the gonadotropin dosage was increased if E2 levels failed to rise by 70% every 2 days. Outcome was defined in terms of maximum E2 level, number of follicles at aspiration, number of oocytes obtained, fertility rate, and pregnancy rate and was compared in study and control patients. Pregnancy was defined by sonographic demonstration of cardiovascular activity. RESULTS: One hundred forty-five patients were analyzed. A step-up regimen was used in 35 patients (24.1%). Patients who required the step-up dosing had significantly lower peak E2 levels (1373 vs 1828 pg/ml; P < 0.005), fewer follicles measuring greater than 16 mm (7.2 vs 9.7; P < 0.003), and fewer oocytes recovered (8.3 vs 11.2; P < 0.009). The fertilization rate (67.6 vs 64.2%) was not significantly different. The pregnancy rate (8.5 vs 32.7%; P < 0.004) was significantly lower in the group requiring the step-up regimen. CONCLUSIONS: The utilization of a step-up regimen during an IVF treatment cycle is a predictor of a poor outcome for the specific IVF cycle. As this information is available before retrieval, consideration of cycle cancellation may be appropriate.

A new immunoenzymometric assay for bioactive N-terminal human parathyroid hormone fragments and its application in pharmacokinetic studies in dogs.

Advances in the treatment of clinical disorders of mineral in homeostatis and metabolic bone disease with intact parathyroid hormone 1-84 or one of the biologically active N-terminal fragments require a precise and sensitive measurement in serum. Therefore, a two-site immunoenzymometric assay for the quantitative determination of bioactive hPTH-1-37 (human parathyroid hormone) at picomolar concentrations was developed. Monoclonal antibodies (mAB) against hPTH-1-37 were raised by hybridoma cells in serum-free cell culture. Furthermore, sequence-specific polyclonal antibodies were obtained by immunisation of rabbits using multiple antigenic peptides (MAP) representing the conspicuous regions of the primary structure of hPTH-1-37. The polyclonal and monoclonal antibodies were characterised by epitope mapping. The combination of a monoclonal antibody (13C63/5) recognising hPTH fragment 16-24 with a polyclonal antibody (k2) showing a predominant binding sequence at hPTH-1-5 led to a sandwich assay specific for N-terminally intact and therefore biologically active hPTH. The validated assay ranging from 4 to 1000 pmol/l was applied to pharmacokinetic studies of hPTH-1-37. After s.c. administration of 30 mu g/kg in 5 beagles, the maximum serum concentrations of hPTH-1-37 ranging at 2139 +/- 857 pmol/l were observed 45 min after the injection. Clearance of the peptide calculated from the exponential disappearance curve was 32.0 +/- 9.1 ml/min/kg with a mean t1/2 of 37 +/- 10 min.

Leukocytosis in response to exogenous gonadotrophin stimulation.

Leukocytosis may develop in women undergoing ovulation induction. The production of blood leukocytes and their numbers in circulation are regulated by complex interactions involving endogenous haematopoietic cytokines, such as granulocyte-colony stimulating factor (G-CSF), monocyte-colony stimulating factor (M-CSF), and interleukins. The purpose of this prospective study was to explore the presence of leukocytosis in women who receive urinary menotrophins, and to determine whether haematopoietic cytokines are changed in the stimulation process. Controls were volunteers of the same age range, not taking any medication, who received daily saline injections. Subjects underwent phlebotomy at defined points for determination of complete blood counts, G-CSF, M-CSF, and interleukin-6 concentrations. Baseline white blood cell (WBC) counts were similar in patients and controls. In menotrophin-treated patients the WBC counts rose significantly (4.19 +/- 0.28 to 6.37 +/- 0.71) during the stimulation and peaked in the luteal phase (P = 0.037). In contrast, WBC counts decreased in controls. Other leukocytic lineages were not affected. In treated patients G-CSF concentrations rose significantly (P = 0.028 versus controls), while changes in M-CSF and interleukin-6 were not significant.

Sonographic assessment of endometrial pattern and thickness in patients treated with clomiphene citrate, human menopausal gonadotropins, and intrauterine insemination.

OBJECTIVE: To analyze the endometrium sonographically in patients undergoing controlled ovarian stimulation with clomiphene citrate (CC) in addition to menotropins to determine the significance of endometrial pattern and thickness on pregnancy rate (PR). DESIGN: A prospective study analyzing patients receiving sequential CC and hMG followed by hCG and IUI. Patients who exhibited homogeneous endometrial patterns were compared with those who had trilaminar patterns visualized by transvaginal sonography at the end of the follicular phase. Endometrial thickness was emphasized in this group of patients. SETTING: Tertiary infertility center. PATIENT(S): All patients receiving sequential CC and hMG therapy at a tertiary infertility center. INTERVENTION(S): All patients received individualized dosing of hMG after 5 days of CC. Transvaginal sonography was performed 15 hours before hCG administration. Intrauterine insemination was performed 36 hours after hCG injection. MAIN OUTCOME MEASURE(S): Occurrence of pregnancy as determined by serially rising beta-hCG titers and sonographic confirmation. RESULT(S): During the study period, 223 patients were analyzed. Fifty patients had a homogeneous endometrium, whereas 173 patients had a trilaminar pattern. In the homogeneous group, the PR was 8%, and in the trilaminar group it was 21%. There was no significant difference in age, parity, diagnosis, peak E2 level, and mature follicle number between the two groups. Although homogeneous patterns were associated with thinner endometrium, no difference in PRs could be discerned within the trilaminar group on the basis of endometrial thickness. CONCLUSION(S): In patients receiving sequential CC and hMG ovarian stimulation, a homogeneous endometrial pattern on the day of hCG administration predicts a significantly decreased PR compared with a trilaminar pattern.

Isolation and characterization of the bioactive circulating human parathyroid hormone, hPTH-1-37.

The occurrence of hPTH-1-37 as the native bioactive circulating form of PTH-1-84 has now been obtained using a specific purification procedure for circulating parathyroid hormone, which involves a newly developed immunoenzymetric assay for N-terminally intact hPTH. In combination with two different methods of mass spectrometry, the molecular weight of the isolated immunoreactive peptide was shown to be 4401 Da, which corresponds to hPTH-1-37. Synthetic hPTH-1-37 material was tested in the chick bioassay and produced a clearcut increase in serum calcium concentration. We conclude that hPTH-1-37 is the native bioactive fragment of hPTH-1-84 in circulation.

Is the endometrial suction curette useful in the detection of chorionic villi during the first trimester?

OBJECTIVE: Early diagnosis of ectopic pregnancy is important for its medical management. Algorithms used for the diagnosis of ectopic pregnancy recommend obtaining a tissue diagnosis to rule out an intrauterine pregnancy when it is clear that a pregnancy is abnormal, but a stage of sonographic visualization has not been attained. The ability of an endometrial suction curette to identify products of conception early in pregnancy has not been documented. The purpose of this study was to determine the efficacy of an endometrial suction curette in detecting products of conception during the first trimester. METHODS: Twenty patients scheduled for termination of pregnancy via D&C agreed to endometrial sampling prior to dilatation of the cervix. All patients had transvaginal sonography which verified the gestational age. The specimen was evaluated microscopically after staining. RESULTS: Chorionic villi were identified in 14 of 20 (70 per cent) specimens as seen with light microscopy. CONCLUSION: An endometrial suction curette identifies chorionic villi from an intrauterine gestation in the first trimester with a sensitivity of 70 per cent. While most patients with an intrauterine gestation can be identified using an endometrial suction curette to obtain trophoblastic tissue, the absence of this tissue does not definitively identify an ectopic pregnancy. Therefore, the routine use of the endometrial biopsy in the algorithms for the diagnosis and treatment of ectopic pregnancy should be approached with caution.

Sonographic assessment of endometrial pattern and thickness in patients treated with human menopausal gonadotropins.

OBJECTIVE: To analyze sonographically the endometrium in patients undergoing controlled ovarian stimulation with menotropins in order to determine the significance of endometrial pattern and thickness on pregnancy rate. DESIGN: This is a prospective, nonrandomized study comparing pregnancy rates in patients with hyperechoic homogeneous patterns with those in patients with isoechoic or hypoechoic trilaminar patterns. SETTING: Tertiary infertility center. PATIENTS: All patients receiving menotropin therapy at a tertiary infertility center. INTERVENTIONS: All patients received individualized dosing of hMG starting on cycle day 3. Transvaginal sonography was performed 15 hours before hCG administration and the endometrium was assessed. MAIN OUTCOME MEASURE: Occurrence of pregnancy as determined by serially rising beta-hCG titers and sonographic confirmation. RESULTS: During the study period, 175 patients were evaluated. Thirty-four (19%) patients had a homogeneous endometrium, whereas 141 (81%) patients had a trilaminar pattern. There was 1 pregnancy (2.9%) among women with a homogeneous endometrial pattern and 33 pregnancies (23%) among those with a trilaminar pattern. No significant differences were found in mean E2 level, follicle numbers, parity, and diagnosis between the two groups. CONCLUSION: In patients receiving menotropins, a homogeneous pattern is a bad prognostic sign, regardless of endometrial thickness.

Secretion of a urodilatin-like immunoreactive (URO-like-IR) substance from a human kidney cell line (HEK-293).

The aim of this study was to explore whether sodium chloride is involved in the release of urodilatin from epithelial human embryonic kidney cells (HEK-293). Using a highly specific urodilatin radioimmunoassay combined with HPLC, gel chromatography, and a cyclic GMP generating bioassay, we demonstrate that HEK-293 cells release a biologically active 3.5 kD, urodilatin-like immunoreactive substance. To show the effect of sodium on urodilatin release, HEK-293 cells were incubated with cell culture buffer containing 120, 130, 140, and 150 mmol/l sodium, respectively. Urodilatin secretion from HEK-293 cells is increased to 176% when extracellular sodium is raised to 150 mmol/l (control: 120 mmol/l = 100%). There was no significant difference when exposing the cells to 140 mmol/l or 150 mmol/l sodium. It is suggested, that beside the known extrarenal factors influencing urodilatin secretion, high cephalic sodium and cardiac volume load, urodilatin secretion might also be regulated by an intrarenal sodium sensitive mechanism.

Isolation of human uteroglobin from blood filtrate.

The purpose of this study was to assess the possibility of isolating biologically active peptides from human blood using large volumes of blood filtrate, which are available from patients undergoing extracorporeal ultrafiltration because of renal insufficiency. This filtrate was submitted to six chromatographic separation steps, yielding one purified peptide which was completely analysed in its primary structure. It was found to be strikingly similar to proteins, described initially as rabbit uteroglobin (or blastokinin) and, more recently, from human bronchial lavage as the '10 kDa Clare cell protein', as well as from human urine as 'protein-1'. The natural molecule contains two chains of identical amino acid sequences of 70 residues which are arranged as an antiparallel dimer due to the disulphide bonds between two cysteines at positions 3 and 69. Mass analysis of the molecular forms yielded molecular weights from 15827 Da (non-oxidized form) to 15859 Da (bi-oxidized form). We conclude that this peptide isolated from the filtrate represents the human uteroglobin, and we demonstrate for the first time that this peptide may be involved as a humoral factor in reproductive or other physiological functions.