Magnitude and variability of sequential estradiol and progesterone concentrations in women using depot medroxyprogesterone acetate for contraception

OBJECTIVE: To describe the magnitude and variability of sequential serum estradiol and progesterone concentrations throughout one depot medroxyprogesterone (DMPA) injection interval. DESIGN: Prospective study.Setting: Family planning and women's health clinics. PATIENT(S): Thirty-one women, ages 19 to 46, using DMPA for contraception. INTERVENTION(S): Serum for estrogen and progesterone was collected weekly throughout one DMPA injection interval. MAIN OUTCOME MEASURE(S): Serum estradiol and progesterone concentrations; estradiol patterns produced from data plotted across the entire DMPA injection interval. RESULT(S): The average daily estradiol concentrations ranged from 7.9 to 69.1 pg/mL, with a mean of 18.9 +/- 12.9 and a median of 15.4 pg/mL. Average daily progesterone concentrations ranged from 0.14 to 1.1 ng/mL, with a mean of 0.40 +/- 0.19 ng/mL and a median of 0.36 ng/mL. Two general patterns of estradiol concentrations were identified. One pattern, observed in approximately one third of the participants, reflected estradiol concentrations that were extremely low (mean, 12.7 +/- 3.6 pg/mL; median, 13.4 pg/mL) and consistently flat across the DMPA injection interval. The second pattern, seen in the remaining participants, reflected estradiol concentrations that were higher (mean, 22.2 +/- 14.9 pg/mL; median, 17.3 pg/mL) and quite variable. CONCLUSION(S): This study demonstrated that estradiol concentrations were lower than the 40 to 50 pg/mL reported in most studies and, for the majority of women, varied substantially across the DMPA injection interval.     

Octogenarians reaching end-stage renal disease: cohort study of decision-making and clinical outcomes

The fate of octogenarians reaching end-stage renal disease (ESRD) is poorly defined, and implicit dialysis rationing may be practiced in this age group. The main objectives of this study were to analyze the characteristics of pre-ESRD octogenarians offered dialysis or not and to identify factors influencing mortality while on dialysis, to improve prognosis assessment and decision-making. In this single-center cohort, 146 consecutive pre-ESRD octogenarians were referred to a nephrology unit over a 12-yr period (1989 to 2000). Main outcome measures were baseline characteristics of patients offered dialysis and conservative therapy and overall and 1-yr survival according to effective treatment. A therapeutic decision was made for 144 patients. Octogenarians who were not proposed dialysis (n = 37) differed from those who were proposed dialysis (n = 107) mainly in terms of social isolation (43.3% versus 14.7%; P = 0.03), late nephrologic referral (51.4% versus 28.9%; P = 0.01), Karnofsky score (55 +/- 18 versus 63 +/- 20; P = 0.03), and diabetic status (22.2% versus 6.5%, P = 0.008). Six patients refused the dialysis proposal. During the 12-yr observation period, 99 patients died (68.7%). Median survival was 28.9 mo (95% CI, 24 to 38) in patients undergoing dialysis, compared with 8.9 mo (95% CI, 4 to 10) in patients treated conservatively (P < 0.0001). In multivariable piecewise Cox analysis, independent predictors of death within 1 yr on dialysis were poor nutritional status, late referral, and functional dependence. Included in a survivor function, these covariates predict groups with low and high 1-yr mortality risk. Beyond 1 yr on dialysis, the only independent predictor of death was the presence of peripheral vascular disease. It is concluded that beside a patient's individual refusal, late referral, social isolation, low functional capacity, and diabetes may have oriented medical decision toward withholding dialysis in a significant proportion of pre-ESRD octogenarians. Although most patients on dialysis experienced a substantial prolongation of life, identification of mortality predictors in this age group should improve the process of decision-making regarding the expected benefit of renal replacement therapy.     

Tumour involvement of the re-excision specimen following clear local excision of breast cancer with positive margins

Background: Breast conservation surgery and subsequent radiotherapy is an acceptable method of treating breast cancer. Complete excision of the primary tumour is important to minimize the risk of local recurrence. Re‐excision is usually carried out if the initial primary tumour excision shows positive margins. However, a significant proportion of re‐excision specimens are negative for tumour. The aim of the present study was to identify factors predicting a histologically positive re‐excision specimen. Methods: The case records of all patients with invasive and in situ breast cancer referred to the William Buckland Radiotherapy Centre between January 1996 and December 2001 were reviewed. The factors evaluated were patient age, whether or not tumours were detected by screening mammography, use of hook‐wire needle localization, whether tumours were marked with orientating sutures, histopathological characteristics of the tumour and involvement of axillary nodes. Univariate analysis was performed. Results: In the study period, a total of 1128 patients were reviewed. Of these, 742 underwent breast conservation surgery. Twenty‐nine (3.9%) of the 742 had positive surgical margins and underwent re‐excision. Data were insufficient for six, leaving 23 patients eligible for the study. The number of patients entering the study was small, limiting the statistical analysis. Of these, 21 patients had invasive cancer and two patients had ductal carcinoma in situ only. Of 23 re‐excisions, 11(48%) contained residual tumour. Univariate analysis of the data revealed no significant factors that were likely to predict tumour in the re‐excision specimen. The local recurrence after re‐excision in patients with positive margins was 4.3%. Conclusion: The results suggest that it is not possible to predict which patients will have tumour in the re‐excision specimen. However, approximately 50% of re‐excision specimens showed residual cancer. Therefore it is recommended that all excisions with positive margins need further surgery.