A review of smoking cessation services in women attending colposcopy clinics in Scotland.

The most common reason for women being referred to colposcopy clinics is an abnormal smear suggesting pre-cancerous change within the cervix. It has been demonstrated that in women with low-grade lesions, smoking cessation led to a reduction in size of the cervical lesion over a 6-month period. Smoking is also recognised as an independent risk factor for treatment failure of cervical intraepithelial neoplasia. As 'stop smoking' services have become an integral part of the colposcopy clinic at St John's Hospital, Livingston, a national survey was undertaken. The aim of the survey was to establish what smoking cessation information, advice and support is available in colposcopy clinics throughout Scotland, and if staff had attended standardised training on raising the issue of smoking. The study demonstrated that 52% of colposcopy clinics in Scotland always establish smoking status but only 37% of clinics discuss the benefits of smoking cessation in relation to abnormal cervical smears. There was inaccurate and inconsistent written and verbal advice given on the benefits of cessation and whether women should cut down or stop smoking completely. The majority of staff had not attended standardised training on how to raise the issue of smoking and very few clinics have established referral pathways for smoking cessation support.

Elastase-mediated fibrinogenolysis by chemoattractant-stimulated neutrophils occurs in the presence of physiologic concentrations of antiproteinases.

Plasma levels of the HNE-derived fibrinopeptide A alpha 1-21 reflect in vivo enzyme activity. To provide a possible explanation for the presence of circulating A alpha 1-21 in individuals with normal plasma antiproteinase concentrations we investigated whether PMN-associated HNE is more resistant to inhibition than the free enzyme. PMN were stimulated to migrate across 125I-fibrinogen-coated nitrocellulose filters in response to 10(-7) M FMLP, and the extent of fibrinogenolysis was determined by measuring release of A alpha 1-21 and 125I-labeled fibrinogen degradation products. The fibrinogenolytic activity of migrating PMN was then compared with that of free HNE present in PMN lysates or secreted by PMN stimulated with FMLP. Whereas the fibrinogenolytic activity of soluble HNE was completely inhibited by low concentrations (1%) of plasma or serum and macromolecular antiproteinase (alpha 1 proteinase-inhibitor and soybean trypsin-inhibitor), even in the presence of undiluted plasma or serum the activity of the migrating PMN was incompletely blocked (81-85%). Further, concentrations of alpha 1 proteinase-inhibitor and soybean trypsin-inhibitor that totally inhibited free HNE activity also incompletely blocked (88-89%) the fibrinogenolytic activity of migrating PMN, indicating that FMLP-stimulated PMN demonstrate significant fibrinogenolytic activity in the presence of antiproteinases as small as 20,000 mol wt. A specific low molecular weight HNE inhibitor (MeO-Suc-Ala2-Pro-ValCH2Cl), however, totally blocked PMN-mediated fibrinogenolysis without affecting intracellular HNE activity, HNE secretion from PMN, or PMN migration in response to FMLP. These findings support the hypothesis that PMN migrating on a fibrinogen-coated surface form zones of close contact with fibrinogen, thus preventing access of plasma antiproteinases to HNE released at the cell-substrate interface. The occurrence of this phenomenon in vivo would explain the presence of circulating A alpha 1-21 in individuals with normal antiproteinase concentrations.

Lethality of endotoxin in mice genetically deficient in the respiratory burst oxidase, inducible nitric oxide synthase, or both.

Two classes of oxidants are thought to play a critical role in tissue damage in septic shock: reactive oxygen intermediates (ROI) and reactive nitrogen intermediates (RNI). Particular importance has been ascribed to peroxynitrite, a product arising from the reaction of nitric oxide with superoxide. A major source of ROI is the respiratory burst oxidase of neutrophils, eosinophils, monocytes, and macrophages. A major source of RNI is inducible nitric oxide synthase (iNOS), an enzyme expressed in leukocytes, hepatocytes, vascular smooth muscle cells, endothelium, and cardiac myocytes during inflammation. In previous studies using various mouse models of endotoxic shock, genetic deficiency of iNOS as a sole intervention did not consistently alter survival. Here, using Salmonella typhimurium endotoxic bacterial lipopolysaccharide (LPS) as a sole challenge, genetic deficiency of iNOS was associated with no protection or a reduction in survival, depending on the dose of LPS. Further, no protection from lethality was observed when LPS was injected into mice genetically deficient in the 91 kDa subunit of the respiratory burst oxidase (gp91phox) nor in mice genetically deficient in both gp91phox and iNOS (gp91phox-/-/NOS2-/- mice). For the latter experiments, mice were challenged either with S. typhimurium LPS alone or with inactivated bacille Calmette-Guerin (BCG) followed by Escherichia coli LPS. Deficiency of gp91phox impaired the inflammatory response to inactivated Propionobacterium acnes, rendering survival studies following priming with P. acnes difficult to interpret. Thus, in two models of endotoxic shock, major reductions in the ability to form nitric oxide or superoxide, alone or in combination, failed to improve survival.

Effect of desferrioxamine cardioplegia on ischemia-reperfusion injury in isolated rat heart.

BACKGROUND: The protective effect of desferrioxamine against myocardial ischemia-reperfusion injury remains uncertain. In this study we examined a broad range of ischemia-reperfusion indices to determine the effect of desferrioxamine cardioplegia in a model that reflects surgical practice. METHODS: Isolated rat hearts were subjected to 90 minutes of ischemia with cold cardioplegia, with or without 0.5-mmol/L desferrioxamine. Left ventricular mechanical function and the levels of thiobarbituric acid-reactive substances and nonprotein thiol compounds were measured after reperfusion. Electron microscopic analysis of mitochondria was performed using diaminobenzidine staining, together with histochemical staining for glycogen and marker enzymes in left ventricular muscle and the atrioventricular node. RESULTS: The desferrioxamine group showed better preservation of diastolic function (chamber stiffness coefficient at 15 minutes and maximum rate of decrease of left ventricular pressure at 45 minutes of reperfusion). Histochemical analysis showed that mitochondria-specific succinate dehydrogenase and the nonspecific esterase of the atrioventricular node were better preserved in the desferrioxamine group. CONCLUSIONS: The findings from this study indicate that there is added protection against ischemia-reperfusion injury when desferrioxamine is added to the cardioplegic solution; however, the study also highlighted that, in this clinically applicable model, desferrioxamine is not universally protective against all aspects of ischemia-reperfusion injury.

Detection of antisperm antibodies in seminal plasma by flow cytometry: comparison with the indirect immunobead binding test.

OBJECTIVE: To compare flow cytometry with the established indirect immunobead binding test (IBT) for the detection of antisperm antibodies in seminal plasma. DESIGN: A prospective, comparative study. SETTING: University-based andrology unit. PATIENT(S): One hundred and fifty-eight men with suspected male factor subfertility. INTERVENTION(S): Seminal plasma samples were incubated with antisperm antibody-negative donor sperm. Surface-bound antibody was detected with fluorescence-labeled antihuman antibody in the flow cytometry assay or with immunobead-labeled antihuman antibody in the IBT. MAIN OUTCOME MEASURE(S): The percentage of sperm that tested positive for surface-bound antibody was determined in the two assays. Seminal plasma was antisperm antibody-positive when > or = 20% of the sperm were antibody-bound, and clinically significant levels were present when > or = 50% of the sperm were antibody-bound. RESULT(S): Of 71 samples that were negative by the IMT, 66 (93%) also were negative by flow cytometry. Of 63 samples that had > or = 50% immunobead binding, 55 had equivalent results by flow cytometry. Overall statistical analysis showed a good correlation between the two assays. CONCLUSION(S): There is a good correlation between the indirect IBT and indirect flow cytometry for the detection of antisperm antibodies in seminal plasma.

A comparison of intrauterine insemination in superovulated cycles to intercourse in couples where the male is receiving steroids for the treatment of autoimmune infertility.

OBJECTIVE: To compare IUI with timed intercourse in men receiving oral steroid therapy for the treatment of infertility associated with antisperm antibodies. DESIGN: A prospective, randomized, cross-over trial. SETTING: All patients were managed and treated at the Andrology Unit, Churchill Hospital, Oxford, United Kingdom. PATIENTS AND PARTICIPANTS: Thirty males who were found to have antisperm levels of > or = 50% [using the indirect immunobead test with isotypes immunoglobulin (Ig) G, IgA, and IgM (GAM) beads] in either seminal plasma or serum on routine testing were recruited with their partners into the study. MAIN OUTCOME MEASURES: Antisperm antibody levels in seminal plasma and serum, sperm parameters, conception rates, and pregnancy outcome. RESULTS: There was a statistically significant reduction in seminal plasma antisperm antibody levels associated with steroid therapy. There was a significant improvement in certain spermatozoan parameters during steroid therapy. The cumulative pregnancy rate over four cycles of IUI was 39.4%. The cumulative pregnancy rate over four cycles of natural intercourse was 4.8%. There was a significantly higher chance of achieving a pregnancy with IUI. CONCLUSION: Intrauterine insemination significantly improves the chance of achieving a conception when used as an adjuvant therapy to cyclical intermediate dose steroid therapy. Antisperm antibody levels in seminal plasma are significantly reduced during treatment with cyclical intermediate dose steroid therapy, although levels in serum appear to be unaffected. Cyclical intermediate dose steroid therapy significantly improves certain sperm parameters but, when used in isolation, is associated with a low pregnancy rate.

Does large loop excision of the transformation zone of the cervix predispose to the development of antisperm antibodies in women?

OBJECTIVE: To determine whether large loop excision of the transformation zone of the uterine cervix for cervical intraepithelial neoplasia predisposes to the development of female isoimmunity to human spermatozoa. DESIGN: A prospective, controlled study. SETTING: Colposcopy and Andrology units at the John Radclife and Churchill Hospitals, Oxford, United Kingdom. INTERVENTIONS: Serum samples were collected from 33 women before large loop excision of the transformation zone of the cervix and repeated at a minimum time interval of 4 months after the procedure. Women were questioned regarding the procedure and subsequent reproductive function. A control population of 30 women not undergoing cervical surgery also underwent serial serum screening for antisperm antibodies. MAIN OUTCOME MEASURE(S): The detection of serum antisperm antibodies by flow cytometry. RESULTS: None of the serum samples before large loop excision of the cervical transformation zone had clinically significant levels of antisperm antibodies. There was, however, a significant rise in antisperm antibody levels in women following large loop excision of the transformation zone. Apparent risk factors for the development of antisperm antibodies included a short duration of sexual abstinence and the use of nonbarrier contraception after surgery. There was no rise in antisperm antibody levels in the control population. CONCLUSION: Large loop excision of the transformation zone of the cervix is a risk factor for the development of antisperm antibodies in women. Women should be advised to use barrier contraception or avoid sexual intercourse until complete healing of the cervix has occurred.

The prevalence of salt sensitivity in an African-American adolescent population.

This study examined the prevalence of salt-sensitivity (SS) in 140 healthy African-American adolescents. SS was defined as an increase in mean blood pressure > or =5 mm Hg from a 5-day low salt (Na+) diet (50 mmol/24 hr) to a 10-day high Na+ diet (150 mmol/24 hr NaCl supplement); remaining subjects were classified as salt-resistant (SR). Dietary compliance was defined as Na+ excretion < or =50 mmol/24 hr for the low Na+ diet and > or =165 mmol/24 hr for the high NaCl supplement diet. 31 (22%) subjects were classified as SS and 109 (78%) as SR. There were no significant differences between SS and SR subjects on baseline characteristics, family history of hypertension, or on resting blood pressure or heart rate measures. As expected, SS subjects showed a greater increase in mean, systolic, and diastolic blood pressures (P<.001 for all) than SR subjects in response to the high NaCl supplement. There was a greater increase in weight (P<.01) and Quetelet Index (P<.05) for SS than SR subjects in response to Na+ loading. These results are the first to show that SS is prevalent in a subgroup of healthy African-American adolescents.

Hysterectomy following failed endometrial resection.

Of the first 500 women in Oxford to undergo transcervical resection of the endometrium, 101 (20%) have subsequently undergone hysterectomy. This study was undertaken to assess the reasons for failure of endometrial resection. An audit of the case notes of the 101 women requiring hysterectomy was performed. Data collection included the patient's age, weight, parity, reasons for endometrial resection, details of the endometrial resection, reasons for hysterectomy, hysterectomy findings and uterine histology. Six (6%) hysterectomies were performed as emergency operations during endometrial resection, 33 (33%) were performed for persistent menorrhagia, 39 (39%) for recurrent menorrhagia and in 18 women (18%) for pelvic pain. The duration of success following endometrial resection ranged from 0 to 21 months. Hysterectomy was significantly more common in older women under 40 years of age, in the presence of an enlarged fibroid uterus, when complications at endometrial resection had occurred and in women operated on by relatively inexperienced surgeons. Endometrium ws present in 96% of hysterectomy specimens. Uterine malignancy that had not been diagnosed at transcervical resection of the endometrium was present at hysterectomy in two women. Hysterectomy should be considered in preference to endometrial resection for treatment of menorrhagia in women who are less than 40 years old and in the presence of large intramural fibroids.

Management of ectopic pregnancy in a Scottish teaching hospital: implications for training.

An audit was undertaken to assess the management of 50 consecutive women with an ectopic pregnancy at a teaching hospital in Scotland. The ectopic pregnancy was removed laparoscopically in 62% and of these women 80% were discharged home on the first postoperative day. In a minority of patients, elements of substandard care were identified including failure to operate when the ectopic pregnancy had been visualised on ultrasound or in the presence of static hCG levels in patients with an empty uterus and adnexal pain. Fewer than 50% of consultants and no junior registrar reported competency in the laparoscopic management of these patients. We suggest that the management of ectopic pregnancy could be improved by following published algorithms with high diagnostic accuracy. In addition, either skilled endoscopic teams should be developed to take on the responsibility of the management of these patients or universal consultant competency in laparascopic surgery is required if we are to offer laparoscopy to all women with ectopic pregnancy.

The long-term success of abdominovaginal sling operations for genuine stress incontinence and a cystocoele--a questionnaire-based study.

Abdominovaginal sling surgery is performed in women with genuine stress incontinence. It is not usually a primary operation because of the higher morbidity compared to the colposuspension. Slings are indicated in incontinent women with previous failed surgery, urethral hypermobility, intrinsic sphincter weakness, significant anterior vaginal wall prolapse or those with restricted vaginal mobility. This study was undertaken to assess long-term patient perceived success of abdominovaginal sling surgery in women with genuine stress incontinence (GSI) in the presence of a cystocoele. The case notes were reviewed of all 37 women undergoing sling surgery for GSI in the presence of a significant cystocoele between 1988 and 1999. Patients were sent a questionnaire at a minimum follow-up of 12 months enquiring about urinary symptoms. The mean duration of follow-up was 49 months. Six weeks following surgery 33/37 (89%) were completely dry. Thirty-three women (89%) responded to the questionnaire. Of these 14/33 (42%) were totally dry, 10/33 (30%) had insignificant leakage and 9/33 required regular protection. The mean visual analogue score of improvement in incontinence was 75.3 (+/-30.1). The operation was deemed successful in 24/33 (72%) women. Voiding difficulty was reported in 12% and recurrent prolapse occurred in 15%. Of the failures 8/9 reported urge incontinence and 4/9 stress incontinence. Frequency, urgency and urge incontinence were significantly more common in the women in whom the operation failed. This study demonstrates a 72% long-term success of abdominovaginal sling operations in women with GSI and a significant cystocoele. Development of DI accounted for most of the operative failures.

Deformation of DNA during site-specific recombination of bacteriophage lambda: replacement of IHF protein by HU protein or sequence-directed bends.

Escherichia coli IHF protein is a prominent component of bacteriophage lambda integration and excision that binds specifically to DNA. We find that the homologous protein HU, a nonspecific DNA binding protein, can substitute for IHF during excisive recombination of a plasmid containing the prophage attachment sites attL and attR but not during integrative recombination between attP and attB. We have examined whether IHF and HU function in excisive recombination is mediated through DNA bending. Our strategy has been to construct chimeric attachment sites in which IHF binding sites are replaced by an alternative source of DNA deformation. Previously, we demonstrated that properly phased bends can substitute for the binding of IHF at one site in attP. Although this result is highly suggestive of a critical role of IHF-promoted bending in lambda integration, its interpretation is obscured by the continued need for IHF binding to the remaining IHF sites of these constructs. In the present work, we engineered a population of sequence-directed bends in the vicinity of the two essential IHF sites found in attR and attL. Even in the absence of IHF or HU, pairs of these attachment sites with properly phased bends are active for both in vitro and in vivo excision. This success, although tempered by the limited efficiency of these systems, reinforces our interpretation that IHF functions primarily as an architectural element.

Heparin pretreatment does not alter heparin requirements during cardiopulmonary bypass.

Heparin infusion may cause heparin resistance and may affect monitoring by measurement of the activated coagulation time (ACT), making the assessment of anticoagulation difficult, with the risk of over- or undertreatment, especially during cardiac surgery. We studied two groups of patients undergoing cardiopulmonary bypass (CPB): patients on heparin infusions (group H) and heparin-naive controls (group C). All patients received heparin 300 IU kg(-1) before CPB and a further dose of 5000 IU if the ACT 5 min after commencing bypass was less than 400 s. Measurements of ACT, heparin concentration, antithrombin-3, thrombin-antithrombin complex, prothrombin fragment F(1+2) and D-dimers were made before and 5 and 20 min after start of CPB. A second dose of heparin was given to eight out of 18 patients in group C and 10 out of 24 in group H. Antithrombin-3 in group H was significantly less than in group C at 5 min [59 (14) vs 52 (9)%, P<0.05]. ACT was significantly lower in group H than group C at 20 min [387 (64) vs 431 (67) s, P<0.05]. Despite ACTs of less than 400 s in both groups, no coagulation was seen, suggesting that 300 IU kg(-1) heparin is a safe dose for anticoagulation in CPB even after heparin therapy.

Effects of human neutrophil chemotaxis across human endothelial cell monolayers on the permeability of these monolayers to ions and macromolecules.

We have developed a method for studying the permeability properties of human endothelia in vitro. Human umbilical vein endothelial cells (HUVEC) were cultured on a substrate of human amnion. Confluent monolayers of these cells demonstrated 6-12 delta.cm2 of electrical resistance (a measure of their permeability to ions) and restricted the transendothelial passage of albumin from their apical to their basal surface. To determine whether leukocyte emigration alters endothelial permeability in this model, we examined the effects of migrating human polymorphonuclear leukocytes (PMN) on these two parameters. Few PMN migrated across the HUVEC monolayers in the absence of chemoattractants. In response to chemoattractants, PMN migration through HUVEC monolayers was virtually complete within 10 minutes and occurred at random locations throughout the monolayer. PMN migrated across the monolayer via the paracellular pathway. Although one PMN migrated across the monolayer for each HUVEC, PMN migration induced no change in electrical resistance or albumin permeability of these monolayers. At this PMN:HUVEC ratio, these permeability findings were correlated morphologically to measurements that HUVEC paracellular pathway size increases by less than 0.22% with PMN migration. This increase is insufficient to effect a measurable change in the electrical resistance of the endothelial cell monolayer. These findings demonstrate that increased permeability of cultured endothelial cell monolayers is not a necessary consequence of PMN emigration.

Does isolated teratozoospermia affect performance in in-vitro fertilization and embryo transfer?

The effect of the strict classification of spermatozoal morphology on the outcome of in-vitro fertilization and embryo transfer treatment cycles has been assessed in a retrospective analysis of 2144 consecutive cycles. The patients all had a standardized long protocol gonadotrophin-releasing hormone analogue cycle, with luteal phase start, to achieve down-regulation. All treatment cycles where the sperm density was abnormal (< 20 x 10(6)/ml), or where progressive motility was abnormal (< 40%), were excluded. The study excluded treatment cycles where the oocytes inseminated did not include at least one grade 1 or grade 2 oocyte. The percentage of couples achieving the normalized results of the clinic, including median fertilization rate per patient, insemination rates, numbers of embryos transferred, rates of 'spare embryo' blastocyst formation, cumulative pregnancy rates and pregnancy outcome, were calculated. No statistically significant difference arose between the two groups of patients with regard to the percentage of patients achieving the normalized median fertilization rate or higher (group 1 with > 14% normal forms, and group 2 with > or = 4%, < or = 14% normal forms). There was a statistically significantly lower chance of achieving this rate in patients of group 3 (< 4% normal forms) (P < 0.005), but 68.6% did achieve that fertilization rate or higher. There was no statistically significant difference in any of the other end points. In conclusion, a morphological classification may be appropriate as an indicator for counselling patients with regard to treatment expectations, but its use would be seem inappropriate as an index of fertilizing potential in clinical management.(ABSTRACT TRUNCATED AT 250 WORDS)

Peptidomimetic fluoromethylketone rescues mice from lethal endotoxic shock.

BACKGROUND: Septic shock is a leading cause of mortality in intensive care units. No new interventions in the last 20 years have made a substantial impact on the outcome of patients with septic shock. Identification of inhibitable pathways that mediate death in shock is an important goal. MATERIALS AND METHODS: Two novel caspase inhibitors, (2-indolyl)-carbonyl-Ala-Asp-fluoromethylketone (IDN 1529) and (1-methyl-3-methyl-2-indolyl)-carbonyl-Val-Asp-fluoromethylketone (IDN 1965), were studied in a murine model of endotoxic shock. RESULTS: IDN 1529 prolonged survival when given before or up to 3 hr after high-dose LPS (p < 0.01) and increased by 2.2-fold the number of animals surviving longterm after a lower dose of LPS (p < 0.01). Despite its similar chemical structure, IDN 1965 lacked these protective effects. Both compounds inhibited caspases 1, 2, 3, 6, 8, and 9, and both afforded comparable reduction in Fas- and LPS-induced caspase 3-like activity and apoptosis. Paradoxically, administration of IDN 1529 but not IDN 1965 led to an increase in the LPS-induced elevation of serum cytokines related directly (IL-1beta, IL-18) or indirectly (IL-1alpha, IL-1Ra) to the action of caspase 1. CONCLUSIONS: A process that appears to be distinct from both apoptosis and the release of inflammatory cytokines is a late-acting requirement for lethality in endotoxic shock. Inhibition of this process can rescue mice even when therapy is initiated after LPS has made the mice severely ill.

Echocardiographic and survival studies in mice undergoing endotoxic shock: effects of genetic ablation of inducible nitric oxide synthase and pharmacologic antagonism of platelet-activating factor.

Evidence implicating inducible nitric oxide synthase (iNOS) in the alterations of cardiac function characteristic of septic shock has come mostly from studies on anesthetized animals, isolated hearts, cultured myocytes, or hosts treated with pharmacologic inhibitors that lack complete specificity for iNOS. Platelet-activating factor (PAF) can participate in the induction of iNOS and has also been implicated in cardiac dysfunction in sepsis. The present studies assessed cardiac function in a model of sepsis in awake mice in which the gene for iNOS was either normal or selectively disrupted. Mice of each genotype were treated with parenteral fluids or with a highly specific antagonist of PAF. Endotoxic shock was induced by challenge with bacterial lipopolysaccharide (LPS) after priming with heat-killed Propionobacterium acnes. Wild-type mice increased stroke volume and cardiac output in response to LPS. These changes were absent in iNOS-deficient mice. When treated with parenteral fluids, LPS-challenged wild-type and iNOS-deficient mice both had a marked reduction in cardiac output. Antagonism of PAF had no effect on echocardiographic indices in wild-type mice, but selectively overcame the bradycardia and reduced cardiac output elicited by fluid administration in LPS-shocked, iNOS-deficient mice. Thus, there are major cardiovascular effects of PAF that are shared by rather than mediated by iNOS. Neither complete iNOS deficiency nor antagonism of PAF improved survival, whether tested as single or combined intervention. On the contrary, complete deficiency of iNOS was detrimental to survival. Finally, we tested the hypothesis that iNOS deficiency might improve survival if the deficiency were specific but partial. For this, we used mice with one normal and one disrupted gene for iNOS. No survival advantage was evident for these iNOS heterozygotes. Thus, partial or complete inhibition of iNOS, with or without antagonism of PAF, afforded no evident benefit beyond the previously demonstrated reduction in hypotension. Finally, these studies demonstrate that echocardiography preceded by acclimatization is feasible in unanesthetized mice, a finding which should expand the value of genetically manipulated animals for analysis of cardiac function.