Endoscopic ultrasonography for preoperative staging of esophageal carcinoma

OBJECTIVE: The objective was to determine the frequency with which regression or progression of disease without treatment occurred in women diagnosed with squamous cell cervical carcinoma in situ (CIS) during pregnancy. METHODS:. A retrospective chart review of all women evaluated at the University of Iowa Colposcopy Clinic diagnosed with CIS during pregnancy from 1987 through 1992 was used. Thirty-four women were evaluated during pregnancy, of which 26 also had postpartum evaluation. All pathology reports of initial cytology and biopsies, as well as colposcopic impressions, were reviewed and compared to the same evaluations postpartum. RESULTS: Of the 26 women evaluated both antepartum and postpartum, only 1 was treated (cone biopsy) during pregnancy. She had disease suspicious for microinvasion. She was disease free postpartum. Of the remaining 25, 20 (80%) had persistent disease, 2 (8%) had either missed disease or progressive disease postpartum, and 3 (12%) resolved without treatment at postpartum evaluation. No statistical significance was found between route of delivery and persistence (P = 0.34). No statistical significance was found between smoking and persistence of disease (P = 1.0). In 46% of women the initial cytology was CIN I or II, and the initial colposcopic impression was found to underestimate the severity of the disease in 35% of cases. Two women were found to have invasive disease postpartum. CONCLUSIONS: There is a high persistence rate of CIS complicating pregnancy. Given the relatively high rate of underestimation of disease severity by both cytology and colposcopic impression, the use of routine biopsy at the time of colposcopy is recommended. Invasive disease may be encountered on postpartum evaluation.     

Lack of effect of coumarin on unscheduled DNA synthesis in precision-cut human liver slices

OBJECTIVE: To evaluate the accuracy of cytologic screening in pregnancy through routine colposcopy and to confirm the safety of conservative management of cervical intraepithelial neoplasia (CIN) in pregnancy. STUDY DESIGN: In total, 3,658 pregnant women, screened for cervical cancer with either cytology or colposcopy, were prospectively evaluated. Patients with abnormal findings underwent colposcopically directed biopsy and, in case of CIN, repeat cytology and colposcopy. Biopsy was repeated in case of suspected progression of the lesion. Suspected microinvasion was the only reason for diagnostic conization during pregnancy. After delivery, excisional treatment provided a final specimen from all patients. Diagnostic methods were compared. RESULTS: Comparison between cytology and colposcopy showed 97.1% concordance with a few false positives (2.5%) and false negatives (0.2%). Abnormal cytology and colposcopy, as compared with histology, showed similar concordances, but the risk of underestimation by cytology was significantly higher (P < .05). Initial and final histology of the 63 cases of CIN and microinvasive carcinoma showed 88.9% concordance. Progression of the lesion was not observed. CONCLUSION: These data do not justify combined use of cytology and colposcopy to improve screening for cervical cancer in pregnancy. Delayed treatment of CIN after delivery is safe.     

Conservative management of options for patients with dysplasia involving endocervical margins of cervical cone biopsy specimens

OBJECTIVE: Our purpose was to study the feasibility of conservatively managing selected cases of dysplasia involving endocervical cone margins. STUDY DESIGN: A retrospective review of patients conservatively managed after being found to have squamous cell dysplasia involving the endocervical margins of their cervical cone biopsy specimens. In phase I patients who had cold-knife conization with positive endocervical margins underwent repeat Papanicolaou smears and colposcopy, with biopsies and endocervical curettage as indicated. Those found free of disease were followed up with frequent Papanicolaou smears. In phase II patients with dysplasia to the endocervical resection edges on loop electrical excision procedure biopsy specimens were followed up with frequent cytologic studies. RESULTS: In phase I, 31 patients with positive endocervical margins on cold-knife conization and no evidence of dysplasia on reevaluation were followed up for 1 to 18 years. Dysplasia was detected in one patient during cytologic surveillance. In phase II, 11 patients were followed up for 12 to 31 months; only one patient has dysplasia. CONCLUSION: Selected patients with squamous cell dysplasia at endocervical cone biopsy margins may avoid additional surgery.     

Management of cervical neoplasia with colposcopy

During a 44-month period the introduction of colposcopy to a metropolitan dysplasia clinic resulted in 1, 144 colposcopic examinations on 442 patients. Agreement between colposcopically directed biopsy and final diagnosis was found in 84%, and directed biopsy revealed the most advanced lesion in 42.5%. Satisfactory colposcopy was performed on 93% of patients, and some degree of histologic abnormality was obtained in 86% of patients with colposcopic abnormalities. Undetected invasive cervical cancer occurred in both cervical conization and colposcopic examinations with equal frequency. Endocervical curettage detected two cases of occult invasive cancer, and increased use of this procedure is recommended. Guidelines for management of cervical neoplasia are suggested.     

Comparative evaluation of abnormal cytology, colposcopy and histopathology in preclinical cervical malignancy during pregnancy

The results of a two-and-a half-year study on cytodetection of preclinical cervical malignancy during pregnancy are presented. Of 3,534 pregnant women, 125 (3.5%) had cytologic diagnoses of dysplasia, carcinoma in situ or microinvasive carcinoma of the uterine cervix. These results are compared with those obtained from colposcopy and from tissue diagnosis following biopsy, cervical conization and hysterectomy. They are also analyzed in relation to the patients' age, parity and age at first sexual intercourse. The management of these patients during pregnancy is discussed, especially with regard to the authors' experience in dealing with patients from very poor socioeconomic and cultural backgrounds.     

Non-surgical prevention of uterine cancer

Non surgical prevention of uterine cervical cancer relies on regular performance of Pap smears and colposcopy. Screening for cervical dysplasia allows their treatment by laser vaporisation or cone biopsy, according to their grade, and therefore the prevention of invasive carcinoma. Unfortunately, 40% of the female population does not comply to cervical screening and Pap smears entail 20% false negative results. Prevention of endometrial carcinoma is even far more difficult in that endometrial smears are seldom practised. Periodic surveillance of women receiving oestrogenic hormonal therapy, addition of progesterone in order to eventually protect the endometrium, hysteroscopic detection of irregular endometrial hyperplasia, represent the only tools available today.     

Diagnosis and therapy of CIN in pregnant women

BACKGROUND: CIN is the most frequent neoplasm in pregnancy. At present, in Italy, Pap test and colposcopy are not included in routine examinations in prenatal visits. METHODS: In this study, we submitted 560 pregnant women to Pap test during prenatal visits. In case of abnormal or doubtful smears a colposcopy and target biopsy were performed. RESULTS: Of the 560 women studied, 124 had genital bleeding and the other 436 were asymptomatic. Six cases of CIN symptomatic women and 5 cases in the asymptomatic ones. In no cases we thought necessary a therapeutic operation. We limited the therapy to a follow-up. CONCLUSIONS: In our opinion, it is necessary to treat CIN during pregnancy.     

Management of gallstones in pregnancy

BACKGROUND: Biliary disease during pregnancy is rare and the management of cholecystitis during pregnancy is controversial. Cholecystectomy in the pregnant patient has generally been avoided because of the reported high incidence of associated fetal loss. Recent developments relating to diagnostic and anaesthetic management have altered the overall approach to symptomatic biliary tract disease in pregnant patients. METHODS: The literature was reviewed using Medline searches for cholelithiasis in pregnancy, to include pathophysiology, diagnosis and management. RESULTS AND CONCLUSION: Surgery should be performed only for complicated non-resolving biliary tract disease during pregnancy as in over 90 per cent of patients the acute process will resolve with conservative management. For patients requiring operative intervention, laparoscopic cholecystectomy has emerged as a safe and effective method of treatment.     

Adherence-related behavior in adolescents with asthma: results from focus group interviews

OBJECTIVE: To describe the factors that contribute to vertical transmission of human immunodeficiency virus (HIV) and review means of decreasing the risk of transmission. STUDY DESIGN: Medline search of the international English-language literature pertaining to HIV in pregnancy from 1989 to the present. Special emphasis was placed on articles published in the last three years related to vertical transmission as well as to antepartum, intrapartum and postpartum management to reduce transmission. RESULTS: High levels of maternal viral load and more advanced maternal disease are associated with a greater risk of vertical transmission of HIV. Antepartum and intrapartum maternal treatment with zidovudine and postpartum neonatal zidovudine treatment decreases the risk of transmission by two-thirds, at least in patients with earlier stages of the disease. Breast-feeding is a source of postpartum HIV transmission and may double the total transmission rate. CONCLUSION: Zidovudine should be used in pregnancy to decrease the viral load and reduce transmission of HIV to the fetus. Other antiviral agents should be used during pregnancy if indicated, although current information is lacking about their effects on the fetus and any potential benefits in decreasing vertical transmission of HIV. Breast-feeding should be avoided.     

Natural history of false-negative papanicolaou smears: a prospective study using screening colposcopy in addition to cytology

The regular Papanicolaou (Pap) smear is cornerstone of women's preventive healthcare. The introduction of the regular Pap smear as a screening tool for cervical cancer has markedly decreased the number of deaths from cervical cancer. During the past decade, however, the rate of death from cervical cancer has remained relatively static. This screening method is known to have a high rate of false-negative results; therefore, serial examinations are necessary for optimal sensitivity. The sensitivity of the routine pelvic examination is further increased with the addition of colposcopy to cytologic screening. Patients identified as having disease by colposcopy and biopsy but not by Pap smear (false-negative), are followed up, and the progression of their disease is documented until the Pap smear reflects the known change. A total of 276 patients whose Pap tests showed "no abnormal cells" and mild dysplasia (CIN-1 [cervical intraepithelial neoplasia]) by colposcopy and biopsy, who opted not to be treated, were followed up as a function of time. The results of the Pap test on the 276 patients progressed to a low-grade squamous intraepithelial lesion (LGSIL) or higher within 42 months. In this study, false-negative Pap tests that were identified by simultaneously performed colposcopy became positive within 42 months; therefore, careful repetitive screening is necessary. The author argues that a definitive, prospective study on the addition of colposcopy or similar adjunct procedure to the routine pelvic examination, in selected cases, is needed.     

The management dilemma of the mildly abnormal smear: fact or fiction?

For at least 10 years, there has been much controversy regarding the management of women presenting with a first mildly dyskaryotic cervical smear. Argument has centred on many key issues, including the risk of progression to more serious disease, the anxiety caused to the patient, the risk of overtreating patients with minor disease and, more recently, the financial implications of prompt intervention and treatment. Essentially, it has been established for many years that only two main management options are appropriate. The first is a policy of referring all patients with mild dyskaryosis for prompt colposcopy and intervention. The second option is to keep such patients under cytological surveillance, with recourse to colposcopy only if the lesion persists or progresses on subsequent cytological screening. This review article aims at appraising the evidence that is currently available in an attempt to try and resolve the management dilemma posed by a mildly abnormal smear.     

Colposcopy and selective biopsy in patients with abnormal cervical cytology

Patients with atypical or positive findings on cervical cytology should be referred to a special colposcopy clinic as the next step in investigation. Colposcopy complements cytology, and when combined with selective biopsy of the worst-affected area allows a high level of diagnostic accuracy (90,7%). The necessity for diagnostic conization with its risks is markedly reduced. When all three modalities were used in combination, only 0,7% of invasive cancers were missed.     

Rhenium-186 HEDP: palliative radionuclide therapy of painful bone metastases. Preliminary results

Dengue hemorrhagic fever is a common tropical disease in Thailand that nowadays has an increasing incidence during adulthood. We managed three cases of dengue hemorrhagic fever during pregnancy which developed during the antepartum, intrapartum and postpartum periods. We diagnosed dengue hemorrhagic fever during pregnancy with clinical pictures of fever, hemoconcentration and thrombocytopenia with serological proof in all cases. All cases were treated conservatively except for the second one, in which cesarean delivery was inevitable due to severe preeclampsia with unfavorable cervix. All patients and their babies were in good condition before discharge. With increasing incidence during adulthood, more cases of dengue hemorrhagic fever in pregnancy can be found. Conservative treatment should be conducted in all cases. We believe that this is the first case report of intrapartum dengue hemorrhagic fever during pregnancy.     

Cryptococcal pneumonia complicating pregnancy

In the present report we describe 4 previously healthy women who developed cryptococcal pneumonia during pregnancy, and 1 pregnant woman with cryptococcal meningitis. These cases illustrate a previously uncharacterized spectrum of cryptococcal disease. We also discuss 24 patients previously reported who had cryptococcal meningitis during pregnancy. Finally, we review the available data for each therapeutic option and present an algorithm for management based on appraisals of disease severity and risk to the unborn fetus. This report emphasizes the need for heightened awareness of cryptococcosis in the differential diagnosis of pneumonia, chest pain, and hypoxemia in the pregnant patient, but at present, there are insufficient epidemiologic data to determine whether incidences of pulmonary or disseminated cryptococcosis actually increase during pregnancy. The risk of congenital cryptococcosis to the unborn fetus is low, and the most likely mechanism whereby neonates acquire invasive fungal pulmonary infection is through aspiration. While it is unclear whether there is any real increased risk of spontaneous abortion or premature labor, the data indicate that overall fetal outcome depends on effective treatment of maternal infection. For patients with dense air-space consolidation, progressive pulmonary disease, or dissemination, antifungal therapy is necessary. Optimal treatment is determined by the acuity and severity of the clinical presentation. Amphotericin B (approximately 1 g) with or without flucytosine represents the choice for initial treatment of the more acutely ill patient with disseminated or progressive pulmonary cryptococcosis who requires hospitalization (whether during or after pregnancy). Oral fluconazole appears to be safe and effective alternative therapy after delivery for the less severely ill patient who can be managed on an outpatient basis. While the use of fluconazole during pregnancy generally appears safe in terms of fetal outcome (49, 58), the class C status and single report of fetal malformation (62) preclude confident recommendation for its use during pregnancy. The risks and benefits of this effective and generally less toxic drug should be discussed with the parents and weighed against the use of amphotericin B. For pregnant women with limited pulmonary cryptococcosis (segmental or nodular infiltrates) and no evidence of dissemination, we recommend close follow-up without antifungal therapy similar to the recommendation for normal hosts with minimal disease. However, it is important to note that there is no extensive experience upon which to base this recommendation for pregnant individuals (45, 55, 103, 108). It is prudent to use frequent physical examinations (for example, every 1-2 months), combined with chest roentgenograms and serum cryptococcal antigens to monitor progression and/or development of disease in both the mother and child for approximately 6 months postpartum. In conclusion, cryptococcosis during pregnancy presents a special challenge to the clinician. A balanced therapeutic approach holds great promise for successful maternal and fetal outcomes.     

Prevalence rates and demographic characteristics associated with depression in pregnancy and the postpartum.

Examined the prevalence of depression in a heterogeneous sample of 360 pregnant women. Subjects were assessed with respect to both depressive symptomatology and diagnostic status during pregnancy and after delivery. At both assessments, approximately 25% of the sample reported elevated levels of depressive symptomatology. In contrast, 10% of the women met diagnostic criteria for depression during pregnancy, and 6.8% were depressed postpartum. However, only half of the cases of postpartum depression were new onset (3.4%); the remaining women receiving a diagnosis in the postpartum had also been depressed during pregnancy. Finally, depression during pregnancy was related to different sociodemographic variables than was postpartum depression, suggesting that depression at these two times may be associated with different psychological or etiological factors. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Comparing two modalities of management of women with cytologic evidence of squamous or glandular atypia: early repeat cytology or colposcopy

Early repeat cytology is recommended in most screening programs for cervical cancer in subjects with squamous or glandular abnormalities not amounting to neoplasia (atypical squamous cells of undetermined significance, ASCUS), but immediate colposcopy is also recommended in some countries, especially those where there is easy access to colposcopic facilities. We evaluated the cost-effectiveness of the two procedures in a prospective study of women with cytologic ASCUS, invited to cytocolposcopic assessment after 6 months. Colposcopy-directed biopsy was assumed as the gold standard, and the accuracy of colposcopy at 6 months was assumed to be equal to that of immediate colposcopy. Out of 874 compliers, punch biopsy was performed in 303 cases (34.7%), and 19 CIN2+ lesions were detected (CIN2 = 12, CIN3 = 6, microinvasive carcinoma = 1). Detecting 13 CIN2+ lesions at colposcopy required 874 colposcopies and 303 directed biopsies: the cost per CIN2+ lesion detected with the procedure was 2,749 US$. Detecting 15 CIN2+ lesions at repeat cytology required 874 cytologic examinations, 137 colposcopies, 64 directed biopsies, and 6 diagnostic large-loop resections, the latter being performed in subjects with high-grade squamous intraepithelial lesion and less severe lesions at punch biopsy: the cost per CIN2+ lesion detected with the procedure was 1,961 US$. The policy of repeat smear was more cost-effective than immediate colposcopy. According to such results, the protocol of the Florence screening program has been modified since October 1996.     

loop electrosurgical excision procedure: a review of our recent experience

OBJECTIVE: To investigated whether persistence or recurrence of cervical intraepithelial neoplasis (CIN) is associated with an involved excisional margin during loop electrosurgical excision procedure (LEEP). METHODS: The records of 256 consecutive LEEP were studied. After LEEP, all patients were followed up by colposcopy and cytology at 4 to 6 month intervals for at least two years. A patient was classified as having persistent disease if SIL was seen within one year of treatment or recurrent disease if SIL was detected after one year of treatment. All relevant patient details including cytology, colposcopy findings, treatment histology, complications, recurrence or persistence of disease entered into a computer database. RESULTS: Complications occurred in 8 patients (3.1%). LEEP was successful in treating 226 patients (95.4)%. Eleven patients (4.6%) had persistent SIL. Involvement of the resection margin was a significant risk factor for persistent disease (3.1% for uninvolved margins vs 11.4% for involved margins, P < 0.05). Similarly, recurrent disease occurred in 9.1% of patients with involved resection margins vs 2.1% with uninvolved margins (P < 0.05). Eleven patients (4.3%) had microinvasive carcinoma. Only 3 were identified by colposcopy and directed biopsy. CONCLUSION: LEEP is established as a safe and efficacious method for the treatment of CIN, long term morbidity including the effect on subsequent fertility must be observed.     

Pre-eclamptic toxemia: potential new therapy based on animal studies

OBJECTIVE: Pre-eclamptic toxemia (PET) affects 4 to 8% of human pregnancies. Presently, reliable specific therapies to treat this disorder are not available. This study was designed to develop a new therapeutic approach in the management of PET using an animal model. DESIGN: Pregnant rats (5/group) infused with 50 mg L-NAME daily via osmotic mini pumps from day 17 of gestation developed a PET-like syndrome. Systolic blood pressure (BP) was monitored daily during pregnancy and up to 7 days postpartum by the tail cuff method. Pup weight and mortality were recorded immediately after delivery. We examined the effect of CGRP to ameliorate L-NAME-induced hypertension during pregnancy, and the efficacy of CGRP and progesterone in combination to inhibit L-NAME-induced hypertension during the post-partum period. RESULTS: Blood pressure in L-NAME-treated rats was significantly elevated (P < 0.01) throughout pregnancy (141 +/- 3 to 166 +/- 10 mm Hg). CGRP 10 micrograms/day did not cause hypotension, the values being similar to controls which received only saline. On the other hand, CGRP infusion inhibited L-NAME-induced hypertension to normotensive levels (116 +/- 3 to 122 +/- 2) during pregnancy (up to day 22 of gestation), but not during postpartum period (137 +/- 8 to 148 +/- 2). During the post-partum period, neither progesterone nor CGRP by itself was effective in lowering L-NAME-induced hypertension. The combination of CGRP with progesterone decreased BP to control levels in the post-partum period, and also significantly improved foetal mortality and growth (P < 0.05). CONCLUSIONS: CGRP inhibited L-NAME-induced hypertension during pregnancy and not during postpartum period. The same phenomenon was evident in the presence of adequate levels of progesterone in the post-partum period. We believe that CGRP regulates vascular adaptations during pregnancy and these effects may be progesterone-dependent. This combination treatment of CGRP plus progesterone may be a promising therapy in the management of PET in humans.     

The Royal College of Obstetricians and Gynaecologists micro-invasive carcinoma of the cervix study: preliminary results

OBJECTIVES: To determine how micro-invasive carcinoma of the cervix is diagnosed and treated in the United Kingdom. To record the frequency of the various pathological features which comprise the histological diagnosis of micro-invasion, and to assess their relevance to outcome. DESIGN: Prospective observational study. SETTING: Hospitals throughout the United Kingdom. SUBJECTS: Two hundred and eighty-six cases were submitted for entry into the study. Following independent review of the histological material 116 cases were excluded: 41 were not accompanied by histological slides for review, 55 had no evidence of invasive disease, 17 had invasive disease greater than FIGO Stage 1a, and three were adenocarcinomas. The remaining 170 cases were registered for the study but follow up was incomplete in 18. This report concerns the 152 women with complete follow up to 1991. RESULTS: The age of the 152 women ranged from 22 to 65 years (median 36 years). In 116 women (76%) the diagnosis was made by cone biopsy (cold knife, loop diathermy, or laser) or wedge biopsy, in 9 women (6%) the diagnosis was made by hysterectomy, and in 27 women (18%) punch biopsy suggested an invasive lesion and subsequent excisional treatment (including radical hysterectomy with node dissection in three) demonstrated micro-invasion. The depth of invasion was up to 3 mm in 142 women (93%) and 3.1 to 5 mm in 10 women (7%). Capillary-like space involvement was present in 12 women (8%). Treatment methods used were local cervical surgery in 79 women (52%), simple hysterectomy in 63 (41%), and radical hysterectomy in 10 (7%). There was only one known recurrence and death due to cervical carcinoma. CONCLUSION: There is no uniformity in the management of micro-invasive carcinoma of the cervix. The frequency of recurrence, lymph metastases, and death is low. Nonradical surgery appears to give satisfactory results.     

Needle arthroscopy in rheumatology--its role in diagnosis and therapy

Needle arthroscopy is a new technique in rheumatology. The procedure is only marginally more invasive than a normal joint puncture, because small instruments are available. The method allows repeated interventions, e.g. synovial biopsy under visual inspection during the course of a disease. The procedure is demonstrated in detail, and the possibilities in the management of rheumatic diseases offered by needle arthroscopy are discussed.