Does the menstrual cycle and use of oral contraceptives influence the risk of low back pain? A prospective study among female soccer players

BACKGROUND: There is an increasing number of articles regarding the long term follow-up of Papanicolaou (Pap) smears with the diagnosis of atypical squamous cells of undetermined significance (ASCUS). Much controversy exists regarding the management of patients with this diagnosis. In a prior study in 1992, the authors performed automated rescreening of 101 ASCUS cases and 91 negative (control) cases. They found that through PAPNET-directed rescreening, 35 of 101 ASCUS cases (35%) could be reclassified as a squamous intraepithelial lesion (SIL). METHODS: These 192 women were followed since 1992 through manual look backs of subsequent Pap smears and surgical biopsies over a 4-year period. The population studied was comprised of predominantly black women between the ages of 14 and 85 years. The majority were considered a high risk population because many had a history of several sexual partners and multiple pregnancies. RESULTS: Eighteen of 74 patients (24.3%) with an original diagnosis of ASCUS were found on subsequent Pap smears to have an SIL. Only 4 of 64 patients (6%) who originally had a negative Pap smear subsequently were found to have a low grade squamous intraepithelial lesion (LGSIL) within 4 years. Through ordinal logistic regression analysis, it was found that patients with an ASCUS diagnosis had a risk of developing SIL that was 2.6 times greater than the risk for patients with a negative smear diagnosis. Comparing the surgical biopsies in the control and ASCUS groups, there was no statistically significant difference in the risk of developing SIL. This may be because the number of follow-up biopsies were small. CONCLUSIONS: A statistically significant difference of the risk of developing SIL exists between patients with a negative smear versus those with an ASCUS smear. Long term follow-up is essential in the management of the patients with an ASCUS smear because there is clearly an increased risk of developing SIL.     

Significant reduction in the rate of false-negative cervical smears with neural network-based technology (PAPNET Testing System)

False-negative cervical Pap smears may lead to disability or death from carcinoma of the uterine cervix. New computer technology has led to the development of an interactive, neural network-based vision instrument to increase the accuracy of cervical smear screening. The instrument belongs to a new class of medical devices designed to provide computer-aided diagnosis (CADx). To test the instrument's performance, 487 archival negative smears (index smears) from 228 women with biopsy-documented high-grade precancerous lesions or invasive cervical carcinoma (index women) were retrieved from the files of 10 participating laboratories that were using federally mandated quality assurance procedures. Samples of sequential negative smears (total 9,666) were retrieved as controls. The instrument was used to identify evidence of missed cytological abnormalities, including atypical squamous or glandular cells of undetermined significance (ASCUS, AGUS), low-grade or high-grade squamous intraepithelial lesions (LSIL, HSIL) and carcinoma. Using the instrument, 98 false-negative index smears were identified in 72 of the 228 index women (31.6%, 95% confidence interval [CI]: 25% to 38%). Disregarding the debatable categories of ASCUS or AGUS, there were 44 women whose false-negative smears disclosed squamous intraepithelial lesions (SIL) or carcinoma (19.3%; 95% CI: 14.2% to 24.4%). Unexpectedly, SILs were also identified in 127 of 9,666 control negative smears (1.3%; 95% CI: 1.1% to 1.5%). Compared with historical performance data from several participating laboratories, the instrument increased the detection rate of SILs in control smears by 25% and increased the yield of quality control rescreening 5.1 times (P < 0.0001). These data provide evidence that conventional screening and quality control rescreening of cervical smears fail to identify a substantial number of abnormalities. A significant improvement in performance of screening of cervical smears could be achieved with the use of the instrument described in this report.     

Bone tumor radiograph review by pathologists prior to pathologic diagnosis: a receiver operator curve analysis of diagnostic utility

OBJECTIVE: To assess the performance of quick rescreening as an internal quality control for cervical smears previously screened as negative and to compare this method with clinically indicated rescreening of negative smears and with further 10% random rescreening. STUDY DESIGN: In a small-workload laboratory with many different types of indications for cytology, during a three-month period, all gynecologic cytology smears considered negative for significant findings (anything above atypical squamous cells of undetermined significance (ASCUS)/atypical glandular cells of undetermined significance (AGUS) in the Bethesda System) or inadequate were quickly rescreened using a 10 x objective. RESULTS: Of the total 2,188 smears processed, 164 (7.5%) were excluded from rapid review because they were positive on routine screening, and 2,024 cases were subjected to rapid rescreening: 1,925 (95.1%) cases were considered negative and 99 (4.9%) positive for significant findings; 58 of the latter were confirmed and 41 not confirmed by the cytopathologist's detailed examination. The 58 confirmed cases were classified as: 43 ASCUS/AGUS, 14 of low grade squamous intraepithelial lesion and 1 of invasive cancer. No cases of high grade squamous intraepithelial lesion were detected. CONCLUSION: Considering that the routine screening and internal quality control of the laboratory had detected 117 positive cases, the additional 58 represent a definite increase in the efficiency of a small-workload laboratory. In such a clinical setting, no additional case of a high grade lesion was detected by rapid rescreening. The increase in cost and time was considered very reasonable, and the method was incorporated as quality control for the laboratory. Clinically indicated rescreening of negative smears and random 10% rescreening after random rescreening did not add significantly to quality assurance.     

Atypical squamous cells of undetermined significance. Stratification of the risk of association with, or progression to, squamous intraepithelial lesions based on morphologic subcategorization

OBJECTIVE: To analyze follow-up data on atypical squamous cells of undetermined significance (ASCUS) based on morphologic characteristics. STUDY DESIGN: Five years of follow-up was obtained on a cohort of 437 consecutive patients from 1986 who had initial diagnoses of ASCUS, with a further categorization of type based on the maturity of the atypical cells. All such categorizations were made on the basis of specific cytologic criteria. Follow-up cytology and/or biopsy was available on 366 patients. RESULTS: During the follow-up period, 40 patients (13.5%) with ASCUS were diagnosed as having a squamous intraepithelial lesion (SIL); 15 (5%) were interpreted as high grade. When stratified by type of ASCUS based on cellular maturity, the following association/progression rates were noted: mature ASCUS, 10%; metaplastic ASCUS, 24%; and immature metaplastic ASCUS, 42%. In metaplastic and immature metaplastic ASCUS cases, high grade SIL accounted for 42% and 60% of those subsequently diagnosed with a squamous intraepithelial lesion, respectively, versus 30% for mature ASCUS. CONCLUSION: With well-defined and consistent criteria for the diagnosis of the variety of "squamous atypias," a stratification of risk of progression to or association with SIL can be made. When features of metaplasia and immature metaplasia are noted in the cells of ASCUS, patients were observed to be at increasingly greater risk for the detection of SIL; those cases were proportionately more likely to be high grade.     

Lower moiety heminephroureterectomy in the duplex refluxing kidney: the accuracy of isotopic scintigraphy in functional assessment

OBJECTIVE: To estimate the incidence of dysplasia in patients with Papanicolaou smears showing atypical squamous cells of undetermined significance (ASCUS) and low-grade squamous intraepithelial lesions (SIL) and to identify clinical predictors of dysplasia in these patients. METHODS: Patients referred for ASCUS and low-grade SIL were reviewed retrospectively. All patients were evaluated with immediate colposcopy. A multivariate logistic regression analysis was performed to identify clinical predictors of histologic SIL and histologic high-grade SIL. RESULTS: One hundred thirty-seven (34%) of 406 consecutive patients had histologic SIL. Regression analysis identified age (under 35 versus 35 years or above) and initial smear (low-grade SIL versus ASCUS) as statistically significant predictors of histologic SIL and high-grade SIL (P < .001). When patient outcomes were analyzed by age and initial Papanicolaou smear results, the subgroup of patients 35 years or older with ASCUS had low incidences of histologic SIL (14%) and high-grade SIL (1%). The other subgroups (under 35 years with ASCUS, under 35 years with low-grade SIL, and 35 years or older with low-grade SIL) had incidences of histologic SIL and histologic high-grade SIL of at least 28% and 14%, respectively. CONCLUSION: The high incidence of dysplasia in patients with minimally abnormal Papanicolaou smears suggests that immediate colposcopy might be appropriate for many of these patients. Age and initial Papanicolaou smear are predictive of dysplasia and might be used to select patients who have low incidence of dysplasia and might not require immediate colposcopy.     

Social support among African-American adults with diabetes. Part 1: Theoretical framework

BACKGROUND: Atypical squamous cells of undetermined significance (ASCUS) is a cytopathologic term used to describe cases without specific pathologic substratum. Between 10-60% of ASCUS cases correspond to squamous intraepithelial lesions (SIL). METHODS: The objectives of this study were: 1) to detect the pathologic significance of ASCUS in study patients, 2) to determine whether PAPNET identifies these cases, and 3) to compare the results of PAPNET with those of a second conventional screening. One hundred and sixty-three consecutive patients with the cytologic diagnosis of ASCUS and adequate follow-up were selected. Of these, 111 patients had colposcopic lesions and biopsies were performed; in the remaining 52 cases colposcopy was negative, as were 3 consecutive annual Papanicolaou smears. In a blind review, all 163 cases were rescreened using PAPNET. A second manual screening was performed for comparison. RESULTS: One hundred and twenty-six of the 163 cases (77.3%) showed no SIL on biopsy or follow-up. Of the 37 pathologic cases, the diagnosis was koilocytosis (flat condyloma) in 13 cases (8%), cervical intraepithelial neoplasia (CIN) type I in 11 cases (6.8%) low grade SIL [LSIL] in a total of 24 cases [14.8%]), and CIN II-III or high grade SIL (HSIL) in 11 cases (6.8%). In the review using PAPNET, 57 previous ASCUS cases were classified correctly as negative, and 7 of 13 koilocytosis cases (54%), 9 of 11 CIN I cases (82%), and 7 of 11 CIN II-III cases (64%) were diagnosed correctly. In the second conventional screening, 74 cases were negative and 77 cases were ASCUS; only 3 of 13 koilocytosis cases (23%), 4 of 11 CIN I cases (36.4%) and 5 of 11 CIN II-III cases (45.5%) were reclassified correctly. CONCLUSIONS: Among 163 patients with ASCUS, 77.3% had no precancerous squamous lesions. Concordance with definitive diagnosis was more accurate in our study using PAPNET analysis (Kappa index [K] = 0.7158) than by second conventional screening (K = 0.4537). Furthermore, we reclassified 35% of smears as negative and 15% as SIL.     

Microwave staining of enteric neurons using cuprolinic blue (Quinolinic phthalocyanin) combined with enzyme histochemistry and peroxidase immunohistochemistry

OBJECTIVE: To evaluate routine use of the NeoPath AutoPap 300 QC System (AP 300) as it influences diagnostic quality and operations in a large cytology laboratory. STUDY DESIGN: During a three-month period, 35,143 conventionally prepared consecutive cervical cytologic smears taken from non-high-risk women and evaluated as negative by our staff of 25 cytotechnologists were selected for processing by four AP 300 instruments. Slides flagged for review by the AP 300 were reevaluated by our five quality control (QC) cytotechnologists. False negative (FN) results were compared with results of our current practice (CP), random-selection QC method, used during the preceding six months. RESULTS: A 240% increase was seen in the FN detection rate for atypical squamous cells of undetermined significance (ASCUS) and squamous intraepithelial lesions (SIL) (n AP = 65 FN in 5,034 QC, n CP = 77 FN in 22,052 QC) and a 744% increase in the FN detection rate for low and high grade SIL (n AP = 24 FN/5,034 QC, n CP = 12 FN/22,052 QC). The rate of overcall by cytotechnologists did not increase. The QC ASCUS/SIL ratio improved. FN biopsy correlation increased from 45% to 85% (n CP = 17/38 agreement, n AP = 23/27 agreement). Turnaround time increased by one or more days for negative and 1.5 days for QC result reporting. Sensitivity varied among instruments. CONCLUSION: More FN results and greater specificity were seen using the AP 300 than using CP. As with other instrumentation, each laboratory should establish acceptable ranges of performance and baseline values for sensitivity and specificity.     

Costs of conventional radical radiotherapy versus continuous hyperfractionated accelerated radiotherapy (CHART) in the treatment of patients with head and neck cancer or carcinoma of the bronchus. Medical Research Council CHART Steering Committee

We have compared the results of targeted manual rescreening of 1211 randomly selected smears with the results of PAPNET-assisted rescreening of 1613 cervical smears, containing at least 6.3% low-grade squamous intraepithelial lesion (SIL). PAPNET diagnosis and the targeted rescreening diagnosis were compared with the initial report, issued on the corresponding smear. Reproducibility scores for inadequacy, presence of endocervical and endometrial cells, specific infections and squamous cell abnormalities were determined. The reproducibility scores for the diagnosis of inadequate smears and specific infections were lower with the PAPNET-assisted rescreening. The detection of squamous cell abnormalities was excellent for both methods (> 0.95), with a higher detection rate for false-negative smears with the PAPNET testing system.     

The ankle and hindfoot of rheumatoid arthritis patients: study with computerized tomography]

According to the recommendations of the Bethesda System, the diagnosis of atypical squamous cells of undetermined significance (ASCUS) should be further qualified, when possible, as to whether a reactive or a squamous intraepithelial lesion (SIL) is favored. To determine the utility of this recently proposed terminology, we undertook this study to correlate the diagnosis of ASCUS (with or without qualifiers) with results obtained from examination of biopsy specimens. All patients were identified for the study who had a coloposcopically obtained cervical biopsy specimen or endocervical curettage specimen recorded in the surgical pathology files at Beth Israel Hospital, Boston, Massachusetts, from April 1994 through September 1994 and had either prior or concurrent Pap smear(s) reported as ASCUS, ASCUS-favor reactive, ASCUS-favor SIL, or SIL-low grade (SIL-LG). Patients with a cytologic diagnosis of SIL-LG served as a reference group. A total of 435 patients with 485 Pap smears were included. The prevalence rates of biopsy-proven SIL in patients with a cytologic diagnosis of ASCUS-favor reactive, ASCUS, ASCUS-favor SIL, and SIL-LG were 10, 28, 36, and 55%, respectively. The difference between cases diagnosed as ASCUS (with or without qualifiers) and SIL-LG, with respect to the presence of SIL at examination of the biopsy specimen, was statistically significant (P < 0.001 for all correlations). Cases diagnosed as ASCUS-favor reactive had a significantly lower rate of biopsy-proven SIL compared with those diagnosed as ASCUS and ASCUS-favor SIL (P < 0.01 for both correlations). A significant proportion of biopsy specimens with Pap smear diagnosis of ASCUS-favor SIL had SIL-high grade (15%). In contrast, an underlying SIL-high grade is much less likely in patients with ASCUS (unqualified) (3%) or when a reactive process is favored (3%). It seems justified to manage patients with ASCUS-favor SIL in a manner similar to those with SIL-LG. A conservative management seems appropriate for patients with ASCUS and ASCUS-favor reactive.     

Radiotherapy of humero-scapular periarthritis using ultra-hard photons. Evaluation by MRI findings

OBJECTIVE: To determine the clinical implications of atypical glandular cells of uncertain significance (AGCUS) in cervical cytologic smears. STUDY DESIGN: Retrospective analysis. RESULTS: Eighty-eight of 32,181 (0.27%) cervical smears obtained during the study period contained AGCUS. Of the 47 women with AGCUS, 16 had intraepithelial or invasive neoplasms (34%; 95% confidence interval, 21-49%), including 9 low or high grade squamous intraepithelial lesions, 1 adenocarcinoma in situ of the cervix, 3 adenocarcinomas of the cervix, 2 adenocarcinomas of the endometrium and 1 adenoid basal cell carcinoma of the cervix. CONCLUSION: The high prevalence of cervical and endometrial neoplasia among women with the isolated finding of AGCUS on cervical cytologic smears warrants a thorough diagnostic evaluation.     

Immunological identification of a basic homologue to acidic virus-inducible cucumber peroxidase

BACKGROUND: The 1991 Bethesda System for cervical/vaginal cytology reporting defined adequacy criteria for the unsatisfactory designation. Most laboratories have implemented these criteria, but clinical implications have not been established. METHODS: Researchers at two university hospitals retrieved by computer search all unsatisfactory Papanicolaou (Pap) smears taken between January 1994 and July 1995. Of 71,872 total Pap smears, 208 (0.3%) were unsatisfactory (corresponding atypical rate of 9% and a dysplasia/carcinoma rate of 6.5%). Time interval to follow-up and clinicopathologic outcome were determined. RESULTS: Approximately 26% of unsatisfactory Pap smears were from patients with a history of epithelial abnormalities. The majority (129 of 208 specimens; 62%) of follow-up Pap smears or biopsies occurred within 6 months, 5.7% within 6-12 months, and 1.4% in 12-18 months. Approximately 31% had no follow-up. The first repeat Pap smear or histologic specimen in 144 patients with follow-up was negative in 107 (74%), unsatisfactory in 6 (4%), atypical squamous cells of undetermined significance in 15 (10%), squamous intraepithelial lesion (SIL) in 13 (9%), and malignant in 3 (2%). Nonmalignant conditions contributing to the unsatisfactory smears on histologic specimens (12%) included cervicitis, endometritis, endometrial hyperplasia, and polyps. Progressive abnormalities after the first repeat specimen were noted in 7 patients (5%). A total of 23 of 144 initial unsatisfactory specimens (16% )were found to be from patients diagnosed with SIL or malignancy when all follow-up specimens were analyzed. CONCLUSIONS: The majority of patients with unsatisfactory Pap smears had follow-up studies within 6 months. A significant number (16%) of those with follow-up had eventual diagnoses of SIL or neoplasia. Benign pathologic conditions also contributed to unsatisfactory smears. This patient subset was more likely to have a history of abnormalities, confirming the importance of peer/hierarchical review of unsatisfactory smears.     

Quality of life of women with stress urinary incontinence with or without pollakiuria]

BACKGROUND: The optimal management of low grade Papanicolaou (Pap) smear abnormalities remains controversial. This center's experience with recommending cytologic follow-up for women with atypical cells of undetermined significance (ASCUS) or low grade squamous intraepithelial lesions (LSIL) was reviewed to determine outcome and patient/physician compliance. METHODS: The records were reviewed on women with Pap smears reported as either ASCUS (320) or LSIL (112) who did not have a history of dysplasia. The cytologic and colposcopic follow-up for a 2-year period was obtained from the laboratory data base that includes the colposcopy and cancer referrals for this region. Repeat Pap smear in 6 months was recommended. If patients subsequently demonstrated high grade SIL (HSIL) or persistent ASCUS or LSIL over three time intervals, colposcopic evaluation was recommended. RESULTS: The outcome was determined by the most significant diagnosis among the follow-up Pap smears or colposcopic biopsies. 29% of patients were lost to follow-up. Of the remaining patients, 70.5% reverted to normal or benign cellular changes, 25.3% persisted as ASCUS or LSIL, and 5.2% progressed to HSIL. The majority of patients (68%) were referred for colposcopy for persistent mildly abnormal Pap smears. The timing of referral ranged from 3-30 months. CONCLUSIONS: These results suggest that cytologic follow-up of women with low grade Pap smear abnormalities will identify a large number whose smears will regress to normal. A small but significant proportion of women showed subsequent HSIL. Most HSIL was detected within 1 year of the initial abnormal Pap smear and the majority of intervening Pap smears also were abnormal. Approximately one third of patients did not have follow-up within the study system and their outcome was uncertain. Although the recommendations are standard, patterns of follow-up and referral to colposcopy varied widely, suggesting that the guidelines need to be reinforced to both patients and physicians. [See editorial on pages 1-4, this issue.]     

Evaluation of the PAPNET system for prescreening triage of cervicovaginal smears

OBJECTIVE: To assess the PAPNET System for prescreening triage of cervical smears. STUDY DESIGN: We prospectively prescreened 5,170 consecutive cervicovaginal smears with the PAPNET System. The slides were then manually screened by cytotechnologists blinded to the PAPNET diagnoses. Cases identified as abnormal by either PAPNET or manual screening were reviewed by a cytopathologist. The PAPNET and manual diagnoses were correlated. RESULTS: Diagnostic concordance between PAPNET and manual screening was seen in 4,340 (84%) of the cases (3,167 negative, 1,038 abnormal and 135 unsatisfactory). Noncorrelation between PAPNET and manual diagnosis occurred in 794 cases (543 abnormal by PAPNET and negative manually, 228 negative by PAPNET and abnormal manually, 8 abnormal by PAPNET and unsatisfactory manually, 29 unsatisfactory by PAPNET and negative manually, 7 negative by PAPNET and unsatisfactory manually). The diagnostic sensitivity of the PAPNET System was 82%, diagnostic specificity 85%, predictive value of a positive test 66% and predictive value of a negative test 93.4%. The false negative fraction of PAPNET was 6.4% for low grade squamous intraepithelial lesion and above. CONCLUSION: PAPNET performed effectively for prescreening triage, increasing the accuracy of screening and reducing the screening time.     

Complete excision of the lower trunk and C8 and T1 nerve roots in a patient with Pancoast tumor with a resulting fully functional hand

OBJECTIVE: To establish the frequency of the atypical glandular cells of uncertain significance (AGCUS) category, and its subcategories, as defined by the Bethesda System (TBS). METHODS: Our computerized records of cervical/vaginal cytology specimens submitted from January 1, 1993, through December 31, 1995, were retrospectively reviewed for specimens diagnosed as AGCUS. When appropriate, our subcategory of "AGCUS favor premalignant/malignant lesion" was further qualified as "favor endocervical adenocarcinoma in situ" or "suspicious for endometrial carcinoma." The number of specimens and patients diagnosed for each subcategory were grouped by calendar year. Differences in frequency between time periods were tested for statistical significance using chi 2 analysis. RESULTS: AGCUS was diagnosed in 1181 of 177,715 submitted specimens (0.66%). The frequency of subcategories was as follows: "favor reactive" (65%), "unable to further classify" (30%), "favor premalignant/malignant" (2.9%), "suspicious for endometrial carcinoma" (1.9%), and "favor endocervical adenocarcinoma in situ" (0.4%). From 1993 to 1995 there was an increase in the rate of diagnosis of AGCUS (0.55 to 0.73%; P < 0.001) and a decrease in the percentage of specimens with AGCUS subclassified as "favor premalignant/malignant" (6.2 to 0.5%; P < 0.001). Other subcategories showed no significant change in frequency over this time period. The rate of biopsy-proven preinvasive or invasive lesions in AGCUS patients also showed no significant change from year to year over this time period. CONCLUSION: The AGCUS diagnosis can be anticipated at a low but consistent rate from a cytology laboratory using TBS. Any comparison of laboratories should take into consideration the change in reporting frequencies that occurs as part of the "learning curve" following introduction of TBS reporting. Uniform diagnostic criteria and additional reports with large numbers of cytologic specimens will be needed to establish the expected frequency of AGCUS and its subcategories.     

Use of the Thin Prep Pap Test in clinical practice

The Thin Prep Pap Test (Cytyc Corp., Boxborough, MA) received approval by the Food and Drug Administration in May 1996 as an alternative to the traditional conventional smear. The present direct-to-vial study assessed the utility of thin-layer technology for cervicovaginal screening in clinical practice. From May 1997-February 1998 (10 mo), 15,006 cervical smears were processed and evaluated; of these, 5,423 (36.1%) were conventional smears (CS) and 9,583 (63.9%) were Thin Prep slides (TP). Both methods were analyzed to compare specimen adequacy and detection rates of cervical lesions. The TP method reduced the "satisfactory but limited by" rate by 97% and the unsatisfactory rate by 63%. For low-grade squamous intraepithelial lesions (LSILs), TP slides yielded 3.6% (348/9,583) as compared to 0.98% (53/5,423) for CS, an increase of 267%. The TP method detected a threefold increase in the number of high-grade squamous intraepithelial lesions (HSILs) of 1.0% (100/9,583), as compared to 0.3% (17/5,425) for the CS group. The atypical squamous cells of undetermined significance/squamous intraepithelial lesion (ASCUS SIL) ratio was reduced by 54% in the TP group. In routine usage in our laboratory, the Thin Prep Pap Test yielded a significant increase in the detection of LSILs and HSILs as compared to conventional smears. Specimen adequacy was significantly improved.     

The AutoPap system for primary screening in cervical cytology. Comparing the results of a prospective, intended-use study with routine manual practice

OBJECTIVE: To evaluate the effectiveness of the AutoPap System in detecting abnormal and normal cervical smears when used in a primary screening/quality control mode, as compared with currently established laboratory practices. STUDY DESIGN: Slides were obtained prospectively and were initially processed in the routine fashion with cytotechnologist screening followed by 10% random quality control rescreening. Slides were then processed on the AutoPap System and allocated into the following groups: (1) approximately 25% of the lowest-ranking slides were placed in the laboratory's archives as within normal limits; (2) the remaining approximately 75% of slides were subjected to manual screening. Approximately 15% of the highest-ranking slides in this group underwent quality control rescreening. For each slide needing manual screening, the cytotechnologist was supplied with a report giving the ranking score of that slide. All discrepant slides for either adequacy or diagnosis were subjected to a truth-determination process. The results obtained from the two arms of the protocol were then compared. RESULTS: The AutoPap System-assisted arm of the study was superior to the current practice arm for the identification of abnormal slides at the level of atypical squamous cells of undetermined significance and above (ASCUS+), low grade squamous intraepithelial lesion (LSIL) and higher LSIL+. AutoPap System-assisted practice was equivalent to current practice for the identification of unsatisfactory and satisfactory but limited by slides. All results showed statistical significance. In addition, AutoPap System-assisted practice in the study indicated improved specificity of diagnosis. CONCLUSION: AutoPap System-assisted practice shows superior sensitivity and specificity when compared to current practice. Its clinical use as a primary screening device should improve the overall practice of cervical cytology as well as provide potential enhancement in overall laboratory productivity.     

Pap smear screening in an urban STD clinic. Yield of screening and predictors of abnormalities

BACKGROUND: Pap smear screening studies in STD clinics have reported high rates of squamous intraepithelial lesions (SIL); however, there are limited data on levels of unsatisfactory smears of characteristics associated with cytologic abnormalities. GOAL: To assess the yield to Pap smear screening in an STD clinic and to evaluate the rates of and risk factors for atypia, low-grade SIL (LSIL), and high-grade SIL (HSIL). STUDY DESIGN: A chart review of the clinic records of women undergoing Pap smear screening between 1991 and 1994 was conducted. Results were assessed from two different screening protocols, the first using a Dacron swab to obtain the endocervical sample and the second using a cytobrush. RESULTS: Of 2034 Pap smears, 1313 (64.6%) were negative, 202 (9.9%) were unsatisfactory, 257 (12.6%) were atypical, 211 (10.4%) had LSIL, and 51 (2.5%) had HSIL. With the change to the cytobrush protocol, the rate of unsatisfactory smears decreased from 14.4% to 3% (p < 0.001), atypia increased from 10% to 16.7% (p < 0.001), and HSIL rose from 1.7% to 3.7% (p < 0.001). By multivariate analysis, atypia was associated with genital warts (odds ratio (OR) 1.53, 95% confidence interval (CI): 1.16-2.02); LSIL with younger age (p < 0.001, for trend), black race (OR 1.51, 95% CI: 1.08-2.10), genital warts (OR 1.81, 95% CI: 1.33-2.47), and an abnormal appearance of the cervix on examination (OR 2.49, 95% CI: 1.85-3.35); and HSIL with a previous abnormal Pap smear (OR 2.48, 95% CI: 1.08-2.10). Overall, abnormality rates were significantly higher in adolescents (35.5%) than older women (21.7%) (p < 0.01). CONCLUSIONS: Obtaining satisfactory Pap smears among women undergoing screening in an STD clinic is feasible and cytologic abnormalities are common. These results continue to support the need for Pap smear screening in STD clinics, but the high rates in adolescents, a group in whom the natural history of cytologic abnormalities has not been well-defined, raise questions about the need to develop age-appropriate screening and management strategies.     

Serum leptin concentration and insulin sensitivity in men with abdominal obesity

Papillary immature metaplasia (PIM) of the cervix (immature condyloma) is a variant of low-grade squamous intraepithelial lesions (LSIL). It is frequently associated with human papillomavirus (HPV) types 6 and 11. The purpose of this study was to characterize the cytologic changes associated with this lesion. We analyzed 10 cases of PIM from our files and reviewed the Papanicolaou smears taken proximate to the time of the biopsy. Four cases had either reactive epithelial changes (2 cases) or cytologic findings typical of low-grade SIL, with koilocytosis (2 cases). Six cases displayed a spectrum of metaplastic cells with varying maturation that ranged from atypical reactive cells to atypical immature metaplastic cells. Binucleation was common. Some cells exhibited features characteristic of SIL, although the degree of nuclear atypia generally was less than that associated with high-grade SIL. Papanicolaou smears from all cases were interpreted as atypical (ASCUS) metaplasia or low-grade SIL. Follow-up biopsy in one case revealed a PIM in association with a high-grade SIL, the latter undiagnosed by smear alone. PIM is a distinct histologic entity that can present with a spectrum of cytologic findings. Its recognition histologically can resolve some cytologic/histologic discrepancies. Confusion with an immature HSIL or atypical immature metaplasia can occur in some instances and the diagnosis of PIM by cytology alone is not recommended, unless the diagnosis is qualified.     

Atypical squamous cells of undetermined significance in the pediatric population. Implications for management and comparison with the adult population

OBJECTIVE: To determine the significance of an atypical squamous cells of undetermined significance (ASCUS) diagnosis in patients 18 years or younger. STUDY DESIGN: From June 1994 to June 1995, 630 cervicovaginal smears were performed on patients 18 years or younger (mean age 16.4, range 14-18) at University Hospitals of Cleveland. Of these patients, 69 (10.9%) were diagnosed with ASCUS or ASCUS with a qualifying statement. Follow-up cervicovaginal smears, biopsies and charts were reviewed for a 12-18-month period following the initial diagnosis of ASCUS. RESULTS: The study population was sexually active: 63% were gravid, 21% were multigravid, 68% had a history of sexually transmitted diseases (STDs), and 32% had multiple STDs. Follow-up cervicovaginal smears or biopsies were obtained on 46 patients (32 cervicovaginal smears and 14 biopsies/endocervical curettage cases). Mild to moderate dysplasia was identified in 21.6% of patients (10.8% on cervicovaginal smears and 10.8% on biopsies), and a repeat diagnosis of ASCUS was given in 37%. In patients with a repeat diagnosis of ASCUS, a follow-up cervicovaginal smear or biopsy revealed dysplasia in an additional 13%. The overall rate of dysplasia was 34.7%. CONCLUSION: Regardless of age, the diagnosis of ASCUS in a sexually active patient population has significant implications. Furthermore, we recommend that these patients be managed the same way as high-risk adult patients.     

Dietary thiamin supply during gestation effects thiamin status of lactating rats and their suckling offspring

A paired-comparison study of manual and automated (PAPNET) screenings of cervico-vaginal smears (Pap tests) was conducted to determine whether primary PAPNET screening was a reliable alternative to manual screening. A series of 5,037 consecutive Pap tests was first screened by the manual method. Next they were scanned by the PAPNET system, the DAT tapes were reviewed, and using a nonspecific triage protocol, abnormal tests were identified for limited, manual rescreening. False-negative rates (FNR) for each method were calculated and analyzed for due cause. By manual and PAPNET screening, respectively, there were 436 (8.6%) and 250 (4.9%) abnormal results. Manual screening missed 18 abnormals (5 SIL) and PAPNET 202 (7 SIL). The primary, manual screenings relating to the PAPNET false-negative tests were reviewed and revised to normal in 30. Based on the changes in the other 172 tests, cellular features ostensibly missed by the PAPNET system were listed to form part of a specific triage protocol, and were used to scrutinize the companion 172 DAT tapes: 150 tapes were abnormal. The manual FNR for an abnormal (SIL) result was 4% and (8.8%), respectively. Equivalent FNR pre- and postreviews for the PAPNET system were 44.6% (10.6%) and 5.2% (1.3%), respectively. This study discovered that the evaluation of some cell features in monitor-based, video images was the most important factor limiting the application of the PAPNET system as a primary screener. When governed by a specific triage protocol incorporating these features, primary PAPNET screening has the potential to equal the laboratory threshold of manual screening and be a better detector of SIL.