Clinical aspects of pelvic inflammatory disease

Pelvic inflammatory disease (PID) is a common and poorly managed condition. Untreated or inadequately treated, it leads to tubal infertility, ectopic pregnancy and chronic pelvic pain. Diagnostic difficulties are compounded by the wide variety of clinical presentations and the insensitivity and poor specificity of laboratory tests. Better recognition of mild and atypical disease needs a high index of suspicion whenever young, sexually active women present with gynaecological symptoms. Laparoscopy supplemented by microbiological tests and fimbrial minibiopsy should be regarded as the diagnostic 'gold standard' for research studies; new studies are required to identify techniques which might reduce under- and over-diagnosis. Early treatment reduces the risk of an adverse effect on fertility. Any therapeutic regimen selected should be effective against the common aetiological agents Chlamydia trachomatis, Neisseria gonorrhoeae, genital mycoplasmas and aerobic and anaerobic bacteria. Since at least 60% of cases of PID can be attributed to infection with a sexually transmitted organism, partner notification forms an essential part of management.      

Chirurgie der differenzierten Schilddrüsenkarzinome

Die 5-Jahres-überlebensrate von differenzierten Schilddrüsenkarzinomen ist generell sehr gut und betr?gt 80 – 95%. Hierbei bestehen Abh?ngigkeiten zum Alter des Patienten [15], zum prim?ren Tumorstadium, zur histologischen Differenzierung und zum Ausma? der region?ren und Fernmetastasierung [6]. Patienten mit Tumorfreiheit haben ebenfalls eine bessere Prognose gegenüber denen mit einem Resttumor. Dies spricht für ein konsequentes Vorgehen beim Prim?reingriff mit Thyreoidektomie und Entfernung der Lymphknoten des zentralen Kompartments. Stadienadaptiert schlie?t sich eine Radiojodtherapie oder die Kombination mit einer externen Radiatio an. Bei der Reoperation differenzierter Schilddrüsenkarzinome mu? zwischen der individuellen Prognose des Patienten, dem Ziel der Operation und der postoperativen Morbidit?t/Mortalit?t entschieden werden. Aufgrund des hohen Risikos sollten diese Operationen in Zentren durchgeführt werden, so da? postoperative Komplikationen (permanente Recurrensparese/Hypoparathyreoidismus) vertretbar gering gehalten werden k?nnen (Tabelle 11). Dennoch sollte nicht au?er Acht gelassen werden, da? individuell bei differenzierten Schilddrüsenkarzinomen im Stadium pT1 auch ein eingeschr?nkt radikales Vorgehen (Hemithyreoidektomie) ohne Verschlechterung der Prognose m?glich scheint. Strenge Nachuntersuchungsergebnisse und Ergebnisse weiterer klinischer Studien müssen hierzu abgewartet werden.     

Ergebnisse des seletiven venösen Etagenkatheters (SVK) beim okkulten C-Zell-Karzinom der Schilddrüse

Background: Medullary thyroid carcinoma (MTC) can — even in recurrent cases — only be treated surgically. Therefore, preoperative localization of the tumor is essential.Methods: From April 1986 through April 1997, 137 patients with MTC were operated on at our clinic. In 22 patients with recurrent tumor which had not been radiologically localized, 28 selective venous catheterizations (SVC) with determination of calcitonin levels were carried out.Results: In 23 examinations a suspected tumor could be identified (nine cervical unilateral, seven mediastinal, four cervical unilateral and mediastinal, one cervical bilateral and mediastinal, one liver, one cervical unilateral and liver). In 18 cases surgery was performed for recurrence (nine cervical revisions, one mediastinal dissection, six cervicomediastinal dissections, two laparotomies). In 15 of 18 cases, tumor tissue was found in the previously suspected area. In ten cases serum calcitonin levels dropped postoperatively by 6%–75%. A normalization of the hormone level was achieved only once by yet another operation. During further follow-up, five of the reoperated patients died from their disease. The other 17 patients are being followed up, whereby calcitonin levels are elevated but there is no clinical or radiological evidence of tumor.Conclusions: Although in the patient cohort presented a normalization of serum calcitonin could be achieved only once, the authors consider SVC useful because it is the only means of localization of tumor tissue in cases of negative radiologic studies and therefore allows a planned approach to the operation procedure in these cases.     

Incidence and determinants of moderate COPD (GOLD II) in male smokers aged 40–65 years: 5-year follow up

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a major health problem with an estimated prevalence of 10-15% among smokers. The incidence of moderate COPD, as defined by the Global Initiative for Chronic Obstructive Lung Disease (GOLD), is largely unknown. AIM: To determine the cumulative incidence of moderate COPD (forced expiratory volume in 1 second/forced vital capacity ratio [FEV1/FVC] <0.7 and FEV1 <80% predicted) and its association with patient characteristics in a cohort of male smokers. DESIGN: Prospective cohort study. SETTING: The city of IJsselstein, a small town in the Netherlands. METHOD: Smokers aged 40-65 years who were registered with local GPs, participated in a study to identify undetected COPD. Baseline measurements were taken in 1998 of 399 smokers with normal spirometry (n = 292) or mild COPD (FEV1/FVC <0.7 and FEV1 >or=80% predicted, n = 107) and follow-up measurements were conducted in 2003. RESULTS: After a mean follow-up of 5.2 years, 33 participants developed moderate COPD (GOLD II). This showed an estimated cumulative incidence of 8.3% (95% CI = 5.8 to 11.4) and a mean annual incidence of 1.6%. No participant developed severe airflow obstruction. The risk of developing moderate COPD in smokers with baseline mild COPD (GOLD I) was five times higher than in those with baseline normal spirometry (one in five versus one in 25). CONCLUSIONS: In a cohort of middle-aged male smokers, the estimated cumulative incidence of moderate COPD (GOLD II) over 5 years was relatively high (8.3%). Age, childhood smoking, cough, and one or more GP contacts for lower respiratory tract problems were independently associated with incident moderate COPD.     

Chest radiography in general practice: indications, diagnostic yield and consequences for patient management

BACKGROUND: Chest radiography (CXR) is frequently performed in Western societies. There is insufficient knowledge of its diagnostic value in terms of changes in patient management decisions in primary care. AIM: To assess the influence of CXR on patient management in general practice. DESIGN OF STUDY: Prospective cohort study. SETTING: Seventy-eight GPs and three general hospitals in the Netherlands. METHOD: Patients (n = 792) aged > or =18 years referred by their GPs for CXR were included. The main outcome was change in patient management assessed by means of questionnaires filled in by GPs before and after CXR. RESULTS: Mean age of the patients was 57.3+/-16.2 years and 53% were male. Clinically relevant abnormalities were found in 24% of the CXRs. Patient management changed in 60% of the patients following CXR. Main changes included: fewer referrals to a medical specialist (from 26 to 12%); reduction in initiation or change in therapy (from 24 to 15%); and more frequent reassurance (from 25 to 46%). However, this reassurance was not perceived as such in a quarter of these patients. A change in patient management occurred significantly more frequently in patients with complaints of cough (67%), those who exhibited abnormalities during physical examination (69%), or those with a suspected diagnosis of pneumonia (68%). CONCLUSION: Patient management by the GP changed in 60% of patients following CXR. CXR substantially reduced the number of referrals and initiation or change in therapy, and more patients were reassured by their GP. Thus, CXR is an important diagnostic tool for GPs and seems a cost-effective diagnostic test.     

Diminished expression of the α5β1 integrin (fibronectin receptor) by invasive clones of a human follicular thyroid cancer cell line

Altered adhesion plaques have been observed in transformed cell lines and are associated with enhanced metastatic potential. The prototypical adhesion plaque is formed by 51 fibronectin receptors (FnRs) interacting with the cellular actin network. We have found differences in the actin networks of noninvasive (FTC-133) and invasive (FTC-236, FTC-238) clones of a human follicular thyroid cancer cell line. Furthermore, thyroid-stimulating hormone (TSH) induces stress fibers in FTC-133. In order to investigate differences in adhesion plaques, expression of fibronectin (FN) and its receptor by these cells was analyzed. For these studies FTC-133, FTC-236, and FTC-238 were cultured in serum-depleted DME-H21 medium for 24 hours before the addition of TSH 30 mU/ml. No quantitative differences were noted in FN expression on Western blot in either the conditioned medium or cellular extracts. Western blots and immunohistochemical studies indicated that TSH induced secretion of FN only in FTC-133. Flow cytometry with an 5 antibody demonstrated a 52% and 45% reduction (p<0.01) in expression of FnR by FTC-236 and FTC-238, respectively, compared to FTC-133; this finding was supported by immunohistochemistry results. TSH treatment did not alter FnR expression. From these studies, we conclude that invasive clones of FTC decrease their expression of FnRs without changing their expression of FN. Furthermore, TSH treatment may promote FN secretion by FTC-133, although it does not seem to affect FnR or absolute FN expression. The diminished expression of FnR adhesion plaques may enhance metastatic potential in some follicular thyroid cancers.

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Resumen Se han observado placas adhesivas alteradas en líneas celulares transformadas en asociación con un potencial metastásico incrementado. La prototípica placa adhesiva se forma por la interacción de receptores 5-1 con la trama celular de actina. Hemos encontrado diferencias en las tramas de actina en clones no invasivos (FTC-133) e invasivos (FTC-236, FTC-238) de una línea celular de cáncer folicular de tiroides.Además, la TSH induce líneas de estrés en FTC-133. Con el objeto de investigar las diferencias en las placas adhesivas, se hizo el análisis de la expresión de fibronectina (FN) y sus receptores en tales células.Para estos estudios se hizo el cultivo de FTC-133, FTC-236 y FTC-238, en sueros depletados de DME-H21 por 24 horas anteriores a la adición de 30 mU/ml TSH por 24 horas. No se observaron diferencias cuantitativas en la expresion de FN o en el Western blot ni en los medios condicionados ni en los extractos celulares. Los Western blots y los estudios inmunohistoquímicos indicaron que la TSH induce la secreción de FN sólo en FTC-133. La citometría de flujo con un anticuerpo 5 demostró una reducción de 52% y 45% (p<0.01) en la expresión de FnR por FTC-236 y FT-238, respectivamente, en comparación con FTC-133; este hallazgo fue verificado por inmuno-histoquímica. El tratamiento con TSH no alteró la expresón FnR. Con base en estos estudios, es nuestra conclusión que los clones invasivos de FTC disminuyen la expresión de FnR sin cambiar su expresión de FN. Además, el tratamiento con TSH puede promover la secreciòn de FN por FTC-133, aunque no parece afectar la expresión de FnR o la expresión absoluta de FN. Esta expresión disminuída de las placas adhesivas FnR puede incrementar el potencial metastásico en algunos cánceres foliculares de tiroides.

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Résumé On a observé des altérations des plaques d'adhésion dans certaines lignées cellulaires transformées, et celles-ci semblent être associées à un potentiel métastatique augmenté. La plaque d'adhésion prototypique est formée par des récepteurs 51 de fibronectine (FnR) qui agissent sur le réseau cellulaire d'actine. Nous avons trouvé une différence entre les réseaux d'actine des clones noninvasifs (FTC-133) et invasifs (FTC-236, FTC-238) des lignées cellulaires dans le cancer folliculaire de la thyroïde chez l'homme. La TSH induit des fibres de stress dans le FTC-133. Afin d'évaluer les différences dans les plaques d'adhésion, l'expression de la fibronectine (FN) et de son récepteur ont été analysées. Pour ces études, les clones FTC-133, FTC-236 et FTC-238 ont été mis en culture dans le milieu DME-H21 dépourvu en sérum pendant 24 heures avant l'addition de 30 mU/ml de TSH/24 heures. II n'y avait aucune différence quantitative dans l'expression FN sur Western blot que ce soit sur le milieu ainsi conditionné ou sur les extraits cellulaires. Les Western blots et les études immunohistochimiques ont indiqué que la TSH n'induisait la sécrétion de FN que dans la lignée FTC-133. La cytométrie de flux avec l'anticorps 5 a démontré une réduction respectivement de 52% et de 45% (p<0.01) dans l'expression de FnR par les clones FTC-236 et FTC-238, comparé au FTC-133. Cette donnée a été confirmée par l'immunohistochimie. A partir de ces études, nous concluons que les clones d'invasion de FTC diminuent leur expression en FnR sans changer leur expression de FN. De plus, un traitement par la TSH peut induire la sécrétion de FN par le clone FTC-133 alors qu'il ne semble pas influencer le FnR ou l'expression FN. L'expression diminuée des plaques d'adhésion FnR semble potentialiser les métastases dans certains cancers de la thyroïde.

     

The natural history of the double pylorus

A study of 11 patients with "double pylorus" revealed that a second channel between the gastric antrum and the duodenal bulb is the result of ulcer penetration. The fistula can be a sign of spontaneous recovery from ulcerative disease; the fistula occurred in conjunction with clinical improvement in the majority of the patients. The advantages of radiological vs. endoscopic diagnostic procedures are discussed.