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Background: Hope is a positive coping mechanism that is important at all stages of illness, more so for palliative care patients. Objective: To explore the experiences of hope of palliative care patients. Methods: A qualitative study was conducted at University of Malaya, Kuala Lumpur, Malaysia. Adult palliative care in-patients were recruited and interviewed with semi structured questions on hope. Transcripts from the interviews were thematically analyzed with qualitative data management software NVIVO. Results: 20 palliative care patients participated in the study. The themes generated from thematic analysis were (1) The notions of hope, (2) The sources and barriers of hope and (3) The contents of hope. Conclusion: Hope is an ever-present source of energy that gives people strength to carry on even in the most adverse situations. Understanding hope from the palliative care perspective may allow healthcare providers to develop strategies to better foster hope in the terminally ill.

Objective: To investigate the subcellular expression of mammary serine proteinase inhibitor (Maspin) in oral squamous cell carcinoma and its relationship to the clinicopathological features., Methods: The Maspin protein subcellular expression was detected in 45 patients with oral squamous cell carcinoma by immunohistochemical staining. The relationship between the Maspin protein subcellular expression and the clinicopathological parameters was analyzed., Results: The negative rate of nuclear maspin expression was 64% (29/45), and the weakly positive rate was 11% (5/45), and the strong positive rate was 24% (11/45). Nuclear maspin expression was negatively correlated with T stage (P = 0.019), lymph node metastasis (P = 0.038) and postoperative metastasis (P = 0.004), but positively correlated with the patients' survival rate (P = 0.014). The negative rate of cytoplasmatic maspin expression was 38% (17/45), and the weakly positive rate was 31% (14/45), and the strong positive rate was 31% (14/45). Cytoplasmatic maspin expression was negatively correlated with lymph node metastasis (P = 0.038) and postoperative metastasis (P = 0.004), but positively correlated with the patients' survival rate (P = 0.014)., Conclusions: Maspin expression may be a significant marker in predicting prognosis of oral squamous cell carcinoma.

Purpose: To determine whether continuous infiltration of local anaesthetic can reduce the pain score and morphine use over 48 hours after total knee arthroplasty (TKA)., Methods: 11 men and 43 women aged 50 to 82 years who underwent unilateral TKA for osteoarthritis were recruited. They were randomised into 3 groups. In group 1, 17 patients who acted as controls received patient-controlled analgesia (PCA) with intravenous morphine for 48 hours. In group 2, 16 patients received continuous infiltration of bupivacaine to the subcutaneous tissue and intra-articular space for 48 hours, in addition to PCA. In group 3, 21 patients received an intra-articular injection of local anaesthetic, followed by continuous infiltration of bupivacaine to the subcutaneous tissue and intraarticular space for 48 hours, in addition to PCA. For each patient, a visual analogue score (VAS) for pain was recorded postoperatively at 2, 4, 6, 12, 24, 36, and 48 hours. The total amount of morphine used was recorded at 24 and 48 hours., Results: Over 48 hours, the VAS for pain and morphine use was significantly higher in controls than patients in groups 2 and 3., Conclusion: Continuous infiltration of local anaesthetic into the intra-articular space and subcutaneous tissues, in addition to PCA with intravenous morphine, provides significantly more pain relief and reduces morphine use.

Objective: To compare the efficacy and safety of PEG-IFNalpha-2b (Peg-Intron) with IFNalpha-2b (Intron A) in treating HBeAg positive chronic hepatitis B patients., Methods: Two hundred thirty chronic hepatitis B (CHB) patients eligible to the following criteria were enrolled into this study: HBsAg and HBeAg(Abbott kit) positive for at least 6 months, serum HBV DNA > or =10(5) copies/ml (real time PCR, LLQ <10(3) copies/ml) and ALT > or =2 x ULN. After 1:1 randomization, the patients received PegIntron (group A: 1.0 microg/kg body weight, SC, once a week) or Intron A (group B: 3 MIU SC, three times a week) for 24 weeks, and followed up for 24 weeks., Results: (1) In groups A and B, respectively, 80.87% and 83.48% were males; their median ages were 31.0 and 32.0 years old; their median body weights were 65.6 and 65.5 kg; mean serum HBV DNA loads were 8.06 log10 and 7.99 log10; their mean ALT values were 4.17 x ULN and 3.77 x ULN. All of the above parameters between the two groups had no statistically significance differences. (2) At the end of treatment and after follow-up, compared to the Intron A group, the PegIntron group showed better response (including complete and partial response rate, HBV DNA undetectable rate, HBeAg seroconversion rate), but the differences of all of them had no statistical significance. The rate of HBeAg loss was higher in patients receiving PegIntron after follow-up (P = 0.0424). (Table 2) (3) PegIntron and Intron A reduced serum HBV DAN persistently during the therapy. Mean reduction at the end of the treatment was much higher in the PegIntron group than in the Intron group (2.22 log10 copies/ml vs 1.66 log10 copies/ml, P = 0.0283). (4) The overall incidence of adverse events (AEs) in the PegIntron group was similar to that of the Intron A group (94.78% vs 95.65%). The AEs associated with PegIntron administration were similar in nature to those with Interon A, such as influenza-like symptoms, fever, fatigue, headache, nausea, etc and the differences of their incidences had no statistical significance., Conclusions: The efficacy and safety of PEG-IFNalpha-2b treatment for CHB patients seems to be better than that of IFNalpha-2b; however, further studies are needed to confirm it.

The putative window of embryo implantation in the human opens between days 19--24 of the menstrual cycle. During this period, the endometrium undergoes distinctive structural and functional changes orchestrated by steroid hormones, growth factors, and cytokines to attain a receptive phase in which it acquires the ability to implant the developing embryo. A major challenge in the study of human reproduction is to identify the molecular signals that participate in the establishment of this critical receptive phase in the context of the natural cycle. Toward this goal, we analyzed human endometrial biopsies at various days of the menstrual cycle by employing messenger RNA (mRNA) differential display technique. We isolated several complementary DNAs representing genes that are either up- or down-regulated within the putative window of implantation. We identified one of these genes as that encoding interferon (IFN)-inducible guanylate-binding protein 1 (or GBP1), which possesses GTPase activity. Analysis of endometrial biopsies by Northern blotting and RT-PCR demonstrated that GBP1 mRNA is specifically induced at the midsecretory phase of the menstrual cycle. In situ hybridization analysis revealed that GBP1 mRNA expression is localized in the glandular epithelial cells as well as in the stroma in the immediate vicinity of the glands. We observed that treatment of human endometrial adenocarcinoma cell, Ishikawa, with IFN-gamma or IFN-alpha markedly induced the expression of GBP1 mRNA. IFN-gamma was, however, a more potent inducer of GBP1 than IFN-alpha. Consistent with this finding, the temporal profile of GBP1 expression during the menstrual cycle resembled that of IFN-gamma mRNA more closely than that of IFN-alpha, predicting a regulatory role of IFN-gamma in GBP1 expression in midsecretory human endometrium. Although the precise function of GBP1 in the receptive human uterus remains unclear, its unique expression overlapping the putative window of implantation suggests that it might serve as a useful marker of uterine receptivity in the human.

Progesterone (P) and zona pellucida are known to induce acrosome reaction in human sperm by increasing cytosolic calcium. High concentrations of potassium ions (K+) improve the rate of acrosome reaction in human sperm in vitro. This article determined whether the effect of K+ on the acrosome in human sperm is mediated by increasing intracellular calcium ([Ca2+]i). The effect of K+ on [Ca2+]i was examined by using Fura 2 as the fluorescent indicator. The effect of K+ and P on [Ca2+]i in sperm and the involvement of ion channels was compared. Motile sperm were collected by the swim-up method from semen of healthy volunteers and capacitated overnight in BWW containing 0.5% BSA. Incubation of capacitated sperm with different concentrations of potassium chloride (1.25-20 mM) resulted in dose-dependent increase in [Ca2+]i similar to that observed with P. The increase in [Ca2+]i by K+ and P was blocked by the addition of EGTA, a Ca2+ chelator. K+-induced change in [Ca2+] was not altered by the addition of dihydropyridine derivatives. The combined treatment of K+ (20 mM) and P (0.75 microg/mL) caused an additive effect on the increase in [Ca2+]i. It would appear that human sperm plasma membrane possess different Ca2+ channels responsive to P and K+.

The human endometrium acquires the ability to implant the developing embryo within a specific time window that is thought to open between days 19-24 of the secretory phase of the menstrual cycle. During this period the endometrium undergoes pronounced structural and functional changes induced by the ovarian steroids, estrogen and progesterone, that prepare it to be receptive to invasion by the embryo. The identification of reliable biochemical markers to assess this critical receptive phase in the context of the natural cycle remains one of the major challenges in the study of human reproduction. Our previous studies in a rat model system demonstrated that the expression of calcitonin, a peptide hormone involved in calcium homeostasis, is transiently induced by progesterone in the glandular epithelium at the onset of implantation. Attenuation of calcitonin synthesis in the uterus during the preimplantation phase by administration of calcitonin antisense oligodeoxynucleotides severely impairs implantation of rat embryos, suggesting that this peptide hormone plays a critical role in uterine receptivity. To investigate whether calcitonin is also expressed in the human endometrium during implantation, we monitored the spatio-temporal expression of calcitonin on various days of the menstrual cycle. Our studies employing RT-PCR showed that calcitonin messenger ribonucleic acid is expressed in human endometrium during the postovulatory midsecretory phase (days 17-25) of the menstrual cycle, with maximal expression occurring between days 19-21. Very little calcitonin expression was detected in the endometrium in either the preovulatory proliferative (days 5-14) or the late secretory (days 26-28) phase. In situ hybridization and immunocytochemical analyses localized the calcitonin expression predominantly in the glandular epithelial cells of the endometrium. Our studies further showed that calcitonin expression in the human endometrium is under progesterone regulation. Treatment of women with an antiprogestin, mifepristone (RU-486), drastically reduced calcitonin expression in the endometrium. Collectively, these findings reveal that progesterone-induced expression of calcitonin in the secretory endometrium temporally coincides with the putative window of implantation in the human.

Objective: To compare the findings in infertility patients who underwent preoperative hysterosalpingography (HSG) followed by hysteroscopy and to determine the incidence of tubal ostial polyps, their HSG appearance and the results of hysteroscopic resection in our patient population., Study Design: Sixty-eight infertility patients were evaluated by HSG followed by hysteroscopy. HSG diagnoses were divided into groups: group 1, normal; group 2, bilateral tubal occlusion; group 3, unilateral tubal occlusion; group 4, filling defects; and group 5, abnormal cavity. HSG findings were compared to the hysteroscopy findings. For patients in whom tubal ostial polyps were found, the findings were described, including postsurgical interval to conception., Results: The agreement rates were 90%, 50%, 69%, 73% and 71% for groups 1-5, respectively. The positive predictive value of an abnormal HSG was 65%, and the negative predictive value of a normal HSG was 90%. Six of 68 patients (11.3%) had polyps at the fallopian tube ostium. Three of these patients (50%) had had the finding of proximal tubal occlusion on the ipsilateral side predicted by HSG; three had had normal HSGs. Four of the six conceived following polypectomy. The mean interval from surgery to conception was 4.5 months., Conclusion: HSG was a specific but not sensitive predictor of uterine pathology in our patient population. Tubal ostial polyps may occur in a significant proportion of infertility patients and can cause proximal tubal occlusion on HSG. Their possible contribution to infertility and clinical significance deserve further investigation.

Background: Hormone production is a characteristic associated with the presence of solid tumors in the ovary. We present a case of a solitary ovarian cyst producing large amounts of testosterone and presenting with rapid onset of hirsutism., Case: A woman presented approximately 6 months postpartum with irregular menses and rapid onset of hirsutism. Laboratory and radiologic evaluation indicated an ovarian cyst as the source. On removal, the cyst was found to have high amounts of testosterone in its fluid and the surrounding stroma had nests of luteinized cells., Conclusion: The chronic anovulation in the postpartum period may have prolonged the lifespan of the luteinized stromal cells, resulting in high levels of circulating testosterone and causing rapid progression of hirsutism.

Objective: To compare the survival rate of frozen-thawed embryos with perforated zonae from microsurgical fertilization (subzonal insemination) (SUZI) with that of embryos with intact zonae., Design: Thirty-eight embryos resulting from microsurgical fertilization by SUZI were cryopreserved in 16 patient cycles. Within the same period, 140 zonae-intact embryos from 46 patient cycles were cryopreserved. The survival rate of the SUZI embryos was compared with the zonae-intact embryos after thawing. Clinical pregnancies were compared after the transfer of the thawed embryos., Results: The total survival rates were 94.7% and 89.3% for thawed SUZI embryos and zonae-intact embryos, respectively. Within each type of embryo, total survival rates were similar irrespective of the age of the embryos at freezing. The blastomere loss per thawed embryo was the same for zonae-intact and SUZI embryos. One clinical pregnancy was obtained in patients who received thawed SUZI embryos and nine in patients who received embryos with intact zonae., Conclusions: It is concluded that SUZI embryos can be cryopreserved and thawed with the same degree of confidence as zonae-intact embryos. The low implantation rate of thawed SUZI embryos requires confirmation in a larger clinical series.

Objectives: The objectives were to determine (1) if sera from women with histories of spontaneous abortions were teratogenic to cultured embryos more often than were sera of nonaborters, (2) if the teratogenicity could be corrected by adding nutrients to the sera, and (3) if these findings were relevant to reproductive outcomes., Study Design: Rat embryos were cultured for 48 hours on sera from 102 subjects who had experienced spontaneous abortions. Samples from 48 were retested with nutrients added and 10 took dietary supplements, were again tested with embryo cultures, and reported on their pregnancy outcomes., Results: The frequencies of teratogenic sera increased with numbers of spontaneous abortions (0 to > or = 5) in a manner that did not deviate from linearity (27% to 89%) (chi 2 p > 0.957). Nutrient supplements were added to 48 samples, and 40 were corrected and 10 subjects were given dietary supplement. Sera from six showed improved embryo cultures, and these women completed their pregnancies., Conclusions: Rat embryo cultures may provide unique insights into the causes and treatment of spontaneous abortions.

Traditional therapies for abnormal cervical mucus, other than timed intrauterine insemination, are noteworthy for being ineffectual. Patients (n = 27) with documented abnormal Insler scores in repetitive cycles and failure to conceive with traditional treatments were screened with conjugated equine estrogens (CEE) for estrogen responsiveness of the cervix. Only 5 patients were found unresponsive. Seventeen patients with CEE-responsive cervices then were treated with human gonadotropins (hMG), initially 1 ampule days 5 to 11. If the mucus failed to improve, the hMG was increased to standard doses. Eight patients responded to 1 ampule hMG with improved mucus and conception. The remainder required 2 ampules hMG. In patient cycles with corrected cervical mucus, the viable fecundibility (fv) was 0.35. This is significantly higher than predicted for this population (fv = 0.09; P less than 0.01). In all, 14 of 17 patients conceived viable pregnancies during hMG treatment. It is concluded that graduated hMG is efficacious in treating patients with abnormal cervical mucus responsive to CEE. It is preferable to either in vitro fertilization or gamete intrafallopian transfer, based on both cost and efficacy for most patients.

In a study to assess real-time ultrasonography (US) as an alternative to hysterosalpingography (HSG) in the evaluation of uterine abnormalities and tubal patency, 61 women underwent US immediately before hysteroscopy/laparoscopy. Saline was instilled into the uterus to provide contrast during US. The findings were compared with surgical and preoperative HSG findings. With surgical findings as the standard, US was as accurate (sensitivity 98%, specificity 100%) as HSG (sensitivity 98%, specificity 92%) in demonstrating uterine abnormalities and provided a more complete assessment of the abnormality. US was as accurate (sensitivity 100%, specificity 91%) as HSG (sensitivity 96%, specificity 94%) in demonstrating the presence of tubal patency but less accurate in establishing which tubes were patent. Thus real-time US with fluid instillation provides an accurate alternative to HSG in screening for uterine abnormalities and tubal patency.

Immunoreactive prolactin is produced by late secretory human endometrium in vitro. Human myometrium in explant culture also produces prolactin. A primate model with the use of the cynomolgus monkey is described that allowed repeated samplings of uterine secretions in vivo. The uterine secretory prolactin thus measured appears immunoreactively similar to human serum prolactin, and the pattern of secretions reflects the previously described pattern of endometrial prolactin production in vitro.

Ultrasound can be used to monitor the growth and rupture of the dominant follicle. Thirty-three patients with unexplained infertility underwent serial sonography (mean, 3.2 scans/cycle) for luteinized unruptured follicle syndrome (LUFS). The incidence of LUFS was 9% (three patients) in the initial scan cycle. Three patients (9%) demonstrated rupture of a follicle significantly smaller than the mean (22.1 mm) (z less than 0.01) in the initial scan cycle. At standard radiology fees ($7000 +/ diagnosed LUFS) the cost/benefit ratio of this method of diagnosis will be controversial. It is suggested that scanning at reduced fees in the gynecologist's office, particularly in conjunction with postcoital tests, would decrease cost and increase the potential benefit.

This prospective study includes 31 women with a prolactin (PRL) level greater than 20 ng/ml (upper limits of normal in our laboratory) on at least three different occasions and chemically euthyroid. Each woman received bromocriptine mesylate (BRC) 1.25 mg (1/2 tablet)/day for 2 weeks, at which time a repeat PRL level was obtained. If needed, the dose was increased in a stepwise fashion until the PRL level was in the normal range. Results show that 12 of 15 patients with an initial PRL greater than 20 but less than 50 ng/ml required 2.5 mg or less of BRC daily. Of 9 patients with a PRL greater than 50 but less than 100 ng/ml, 5 required 2.5 mg daily with the remaining 4 needing 5.0 mg. Five of 7 patients with a PRL greater than 100 ng/ml required 5.0 mg or more, while one responded to 1.25 mg. These findings confirm that a lower than manufacturer-recommended dose of BRC is usually effective in normalizing PRL levels, especially when the initial PRL is less than 100 ng/ml.

The production of prolactin by explants of late secretory endometrium has been correlated with the extent of decidual differentiation. This correlation is strengthened by the observation that luteal phase defective endometrium produces less prolactin than normal control endometrium in a 24-hour in vitro culture system. In the present study the prolactin production by explants of normal, luteal phase defective, progesterone-corrected luteal phase defective, and clomiphene- or follicle-stimulating hormone/luteinizing hormone-corrected luteal phase defective late secretory endometrium was measured over 96 hours at 24-hour intervals. Progesterone in physiologic concentrations was added to the culture medium to maintain tissue integrity and prolactin synthesis. The prolactin production of normal late secretory endometrium rose over 96 hours under progesterone stimulation. The luteal phase defective endometrium produced significantly less prolactin under the same conditions. Histologically proven corrected luteal phase defective endometrium, regardless of treatment method, produced prolactin not different from the normal controls of the same dates. From these results it is concluded that histologic correction of luteal phase defective endometrium is associated with a corresponding biochemical correction with use of prolactin as a metabolic marker. The findings also strongly support timed endometrial biopsy as the method of diagnosis and evaluation of treatment of luteal phase defect.

In the evaluation of 39 patients with untreated and treated luteal phase defect (LPD), serial ultrasonographic monitoring of follicular development identified three morphologically distinct growth patterns: normal-sized follicles, small follicles, and luteinized-unruptured follicles. All three patterns were observed in both untreated (46% had normal-sized follicles, 39% had small follicles, 15% had luteinized-unruptured follicles) and treated patients. A small follicle was observed uncommonly in histologically corrected LPD patients (6%). However, a luteinized-unruptured follicle (38%) may persist or be induced in situations where clomiphene citrate has been used to correct LPD or induce ovulation. Ultrasonographic evaluations of follicular growth in luteal phase defect support the theory that luteal phase defect represents a spectrum of normal and abnormal ovarian cycle events.

We have shown that a smaller dose of bromocriptine is effective in lowering the PRL level to the normal range in some hyperprolactinemic women. Based on these findings, we recommend that when treating hyperprolactinemic women who desire conception, the dose of bromocriptine should be titrated according to the response of circulating PRL levels. This will minimize the dose, reduce cost, probably reduce side effects, and possibly avoid undesirable functional effects such as corpus luteum dysfunction.

To test the hypothesis that an abnormal luteal phase is associated with significant symptoms of premenstrual syndrome, psychologic and somatic premenstrual syndrome symptoms were evaluated in a group of 83 infertile patients undergoing timed endometrial biopsy for the assessment of luteal phase adequacy. The severity of psychologic and somatic symptoms was evaluated separately. It was found that luteal phase defect, defined by endometrial biopsy, was associated with less severe psychologic and no more severe somatic symptoms of premenstrual syndrome in comparison with normal luteal phase controls. The data suggest that the hormonal milieu associated with luteal phase defects does not correlate with premenstrual syndrome symptoms and do not support the hypothesis that suboptimal ovarian function causes premenstrual syndrome.

Recurrent abortion associated with both a chromosomal abnormality and a müllerian anomaly has been reported previously only once. A 31-year-old woman was referred for secondary habitual abortion and found to have sex chromosome mosaicism, subseptate uterus and chronic endometritis. Following hysteroscopic resection of the subseptum and antibiotic therapy for the endometritis, a term pregnancy ensued. Complete evaluation and treatment of all correctable etiologies of recurrent pregnancy loss are essential in such cases.

Cervical dilatation in preparation for first-trimester abortion using acupuncture at loci SP6 and LI4 was studied in 20 patients, who were compared to a control group in whom no preparation was used. Ninety percent of the patients had successful acupuncture procedures. As judged by Hegar dilators, the increase in cervical dilatation in those 18 patients was significantly greater than in the controls. No significant side effects were observed. The effect of acupuncture on serum human chorionic gonadotropin (HCG) as a pregnancy marker was evaluated in 12 patients. No statistically significant difference in the change in HCG was noted in terms of the controls, indicating an absence of abortifacient activity with acupuncture.

The ovulating cynomolgus monkey secretes immunoreactive prolactin (PRL) into the uterine cavity. Consistent with human endometrial explant data, uterine PRL is undetectable in the early secretory phase, then increases from the mid to late secretory phase, peaking premenstrually. The anovulatory monkey does not produce detectable uterine PRL. Human chorionic gonadotropin given repeatedly fails to induce PRL secretion in anovulatory monkeys but prolongs the luteal phase and thereby PRL secretion in ovulatory monkeys. Progesterone (P) induces PRL secretion in anovulatory monkeys after estrogen priming with a time delay of several days, indicating probable de novo synthesis. P appears to be an important stimulating factor in the control of uterine PRL secretion.