Findings from a clinical audit in regional general practice of management of patients following acute coronary syndrome.

Patients with acute coronary syndrome (ACS) require ongoing treatment and support from their primary care provider to modify cardiovascular risk factors (including diet, exercise and mood), to receive evidence-based pharmacotherapies and be properly monitored and to ensure their take-up and completion of cardiac rehabilitation (CR). This study assesses adherence to National Heart Foundation guidelines for ACS in primary care in a regional centre in Western Australia. Patients discharged from hospital after a coronary event (unstable angina or myocardial infarction) or a coronary procedure (stent or coronary artery bypass graft) were identified through general practice electronic medical records. Patient data was extracted using a data form based on National Heart Foundation guidelines. Summary statistics were calculated and reported. Our study included 22 GPs and 44 patients in a regional centre. In total, 90% (n=39) of discharge summaries recorded medications. Assessment of pharmacological management showed that 53% (n=23) of patients received four or more classes of pharmacotherapy and that GPs often augmented medication beyond that prescribed at discharge. Of 15 smokers, 13 (87%) had advice to quit documented. Minimal advice for other risk-factor modification was documented in care plans. Patients with type 2 diabetes (n=20) were 70% more likely to receive allied health referral (P=0.02) and 60% more likely to receive advice regarding diet and exercise (P=0.007). However, overall, only 30% (n=13) of those eligible were referred to a dietician, and only 25% were referred to CR (n=10) with six completing CR. Although most GPs did not use standardised tools for mood assessment, 18 (41%) patients were diagnosed as depressed, of which 88% (n=16) were started on antidepressants and 28% (n=6) were referred to a psychologist. Although pharmacotherapy, mood management and smoking cessation management generally followed recommended guidelines, risk factor management relating to diet and exercise by GPs require improvement. Detailed care plans and referral to CR and allied health staff for patient support is recommended.

Evidence-based interventions in primary care following acute coronary syndrome in Australia and New Zealand: a systematic scoping review.

BACKGROUND: Coronary artery disease has a significant disease burden, but there are many known barriers to management of acute coronary syndrome (ACS). General practitioners (GPs) bear considerable responsibility for post-discharge management of ACS in Australia and New Zealand (NZ), but knowledge about the extent and efficacy of such management is limited. This systematic review summarises published evidence from Australia and New Zealand regarding management in primary care after discharge following ACS. METHODS: A search of PubMed, Scopus, CINAHL-Plus and PSYCINFO databases in August 2015 was supplemented by citation screening and hand-searching. Literature was selected based on specified criteria, and assessed for quality using the Mixed Methods Appraisal Tool (MMAT). Extracted data was related to evidence-based interventions specified by published guidelines. RESULTS: The search yielded 19 publications, most of which reported on quantitative and observational studies from Australia. The majority of studies scored at least 75 % on the MMAT. Diverse aspects of management by GPs are presented according to categories of evidence-based guidelines. Data suggests that GPs are more likely to prescribe ACS medications than to assist in lifestyle or psychological management. GP referral to cardiac rehabilitation varied, and one study showed an improvement in the number of ACS patients with documented ACS management plans. Few studies described successful interventions to improve GP management, though some quality improvement efforts through education and integration of care with hospitals were beneficial. Limited data was published about interventions effective in rural, minority, and Indigenous populations. CONCLUSIONS: Research reflects room for improvement in GP post-discharge ACS management, but little is known about effective methods for improvement. Additional research, both observational and interventional, would assist GPs in improving the quality of post-discharge ACS care.

Proteomics in mammary cancer research.

During the past few years, the intensified detection of small (mammary) carcinomas causes an increase in the number of mammary cancers. Cancer of the mammary tissues has an almost individually unpredictable behavior and aggressiveness. Therefore, a better insight in the molecular biological defects, which are responsible for initiation and progressive aggressiveness of mammary cancer, is necessary. Proteomics are an alternative to identify proteins which initiate carcinogenesis and can be useful to predict cancer prognosis. Today, the most commonly used technique for large-scale protein identification in clinical samples is two-dimensional electrophoresis (2-DE) in combination with image analysis and MS. Using these techniques, qualitative and quantitative information can be achieved regarding protein forms and post-translational modifications. In the following article we review proteomic techniques that are now commonly used in order to elucidate the role of proteins in breast cancer.

Human papillomavirus DNA integration and messenger RNA transcription in cervical low- and high-risk squamous intraepithelial lesions in Austrian women.

The human papillomavirus (HPV) plays an important role in the progression of cervical carcinoma. High-risk (HR) HPV types have been mainly identified in cytologic high-grade squamous intraepithelial lesions (HSILs) and histologic invasive carcinoma of the cervix. We examined cervical swabs of patients with abnormal Papanicolaou (Pap) smears, diagnosed as low-grade squamous intraepithelial lesions (LSILs) including atypical squamous cells of uncertain significance or HSILs. Low-risk (LR) HPV and HR-HPV types were identified by the Digene Hybrid Capture II test. Two-dimensional (2D) gel electrophoresis was used to specify the physical state of HPV DNA sequences. Expression of E6/E7 messenger RNA (mRNA) transcripts was analyzed by reverse transcriptase-polymerase chain reaction. Histopathologic results were correlated to the patients' physical status and HPV DNA mRNA transcripts. Pap smears with HPV infections of LR and HR types were correlated to the degree of squamous intraepithelial lesions (SILs). Comparing the physical states of HPV DNA sequences with the expression of HPV E6/E7 mRNA transcripts, all types were identified only as extrachromosomal in benign cervical smears, cervical intraepithelial neoplasia (CIN) I and II. HPV16 showed all physical states in CIN III/carcinoma in situ (CIS), whereas HPV18 only existed in mixed and integrated forms. HPV31/33/52b/58 appeared in all stages of lesions most commonly in extrachromosomal form; in integrated form, they were present only in CIN III/CIS. Although integration of some HR-HPV types is not always necessary for progression of SILs, the above-mentioned method is useful to analyze the physical state of HPV DNA sequences and predict the progression of SILs.

Beyond "Asian": Specific East and Southeast Asian Races or Ethnicities Associated With Jaundice Readmission.

OBJECTIVES: Clinical practice guidelines have recognized "Asian" and "East Asian" as risk factors for newborn jaundice and readmission. We sought to identify more detailed and specific, parent-identified races or ethnicities associated with jaundice readmission. METHODS: We conducted a case control study of 653 newborn infants born (2014-2016) at a West-Coast, urban hospital to examine specific parent-described races or ethnicities that are associated with newborn hospital readmissions for hyperbilirubinemia. Parent-reported race or ethnicity was abstracted from the California Newborn Screening Test. RESULTS: Our sample included 105 infants readmitted for jaundice (cases) and 548 infants as controls. In the full cohort, 66 infants (10.1%) were Coombs positive, 39 infants (6.0%) were born before 37 weeks' gestational age, and 405 infants (62.0%) were born to first-time mothers. The parents described the 653 infants using 45 unique races and ethnicities. In a multivariable model that controlled for Coombs positivity, gestational age <37 weeks, and primiparity, infants described as "Far East Asian" (odds ratio [OR] = 3.17; 95% confidence interval [CI] = 1.94-5.18) or "Southeast Asian" (OR = 3.17; 95% CI = 1.66-6.08) had increased risk for jaundice readmission. Infants described as Southeast Asian (eg, Laotian, Cambodian, Indonesian, Vietnamese, and Filipino) and Far East Asian (eg, Chinese, Korean, Taiwanese, Japanese, and Mongolian) had an increased risk of readmission. Finally, we did not find an association between South Asian (OR = 0.79; 95% CI = 0.33-1.92) race or ethnicity and risk of jaundice readmission. CONCLUSIONS: In this study, we help clarify and move beyond the term "Asian" as a risk factor for readmission due to hyperbilirubinemia.

Does T1, N0-1 vulvar cancer treated by vulvectomy but not lymphadenectomy need inguinofemoral radiation?

PURPOSE: The objective of our study was to demonstrate differences in relapse rates, total survival times, and complication rates between inguinofemoral radiation and its absence in cases of invasive vulvar carcinoma without lymph node involvement (FIGO Stages T1, N0-1). METHODS AND MATERIALS: From 1974 to 1990, 135 patients with invasive vulvar carcinoma in Stage T1 without clinical evidence of inguinal lymph node involvement underwent simple vulvectomy performed by hot-knife resection without lymphadenectomy. Although 65 patients (Group 1) received postoperative inguinofemoral radiation therapy, 70 patients (Group 2) did not, and none received local vulva irradiation. RESULTS: The 5-year survival rates were 93.7% in Group 1 and 91.4% in Group 2 (p = NS). Although clitoris involvement was significantly more prevalent in the irradiation group (p = 0.04), inguinal relapse was found less frequently in Group 1 (4.6% or 3 out of 65 patients) than in group 2 (10% or 7 out of 70 patients) (p = 0.32). The complication rates were, 7.7% in Group 1 and 2.9% in Group 2, 2.7% for vaginal stenosis (two patients in each group), 1.5% for inguinal pain (one patient in Group 1), 1.5% for rectovaginal fistula (one patient in Group 1), 1.5% for vulvar infection (one patient in Group 1). CONCLUSION: No statistically significant differences in the relapse rates and survival times were found. Risk factors were equally distributed in both study groups except for clitoris involvement. The 5-year survival rates in both groups were similar to those reported in the literature for radical vulvectomy and inguinal lymph-node dissection (83-96%). Morbidity in our study was low. Although our data showed similar results in both groups, we are not recommending at this time to omit groin radiation in general, but it may be justified in low-risk cases.

Papilloma virus and c-erbB-2 expression in diseases of the mammary nipple.

PURPOSE: The detection of low/intermediate/high risk genital groups of human papillomavirus (HPV) in correlation with a growth-factor receptor c-erbB-2 in benign tumors of the mammary nipple. MATERIALS AND METHODS: Ten nipple duct adenomas (NDAs) and twenty papillomas, all embedded in paraffin and taken from the breast, were analyzed for HPV DNA of the low- and high/intermediate-risk groups. Polymerase chain reaction (PCR) with HPV consensus primers (types 6/11/16/18/33) and dot-blot hybridization with type-specific primers were used for the detection of these HPV-DNA sequences. Indirect in situ PCR (ISPCR) was also used in one case of an HPV-DNA-positive papilloma. In addition, we examined c-erbB-2 oncogene expression in NDAs and central carcinomas of the mamma from an immunohistochemical perspective. RESULTS: Using PCR and dot-blot hybridization we could not detect the gene sequences that are specific for the low- and high/intermediate-risk groups in any of the ten NDAs. Regarding the 20 cases of papilloma, a positive result for HPV types 6/11 was detected by indirect ISPCR; in one case in combination with a condyloma of the skin around the mammary nipple. The oncogene expression of c-erbB-2 displayed a strong signal in the papilloma cells and in the NDAs of the breast. CONCLUSION: Our results showed that the HPV-DNA types of the low- and high/intermediate-risk groups are without relevance for the pathogenesis of benign diseases of the nipple. It was, therefore, not possible to establish a correlation between the oncogene expression of c-erbB-2 and the HPV-DNA types.

Detection of human papillomavirus on Papanicolaou-stained cervical smears using indirect in situ polymerase chain reaction hybridization.

OBJECTIVE: Polymerase chain reaction (PCR) and indirect in situ hybridization were combined to detect human papillomavirus (HPV) DNA on Papanicolaou (PAP)-stained cervical smears. To our knowledge, this is the first report of an experiment using indirect in situ PCR (IS-PCR) on PAP-stained cervical smears. DESIGN: We collected native cell specimens from cervicovaginal lavage of 162 patients with squamous intraepithelial lesions. Solution-phase PCR (SP-PCR) was performed as the reference method in the detection of HPV DNA. Indirect IS-PCR was carried out for the same patients to detect the HPV DNA types 6/11 and 16/18 after the PAP-stained smears had been decolorized. Low-risk and high-risk HPV DNA types were also detected by both SP-PCR and indirect IS-PCR. RESULTS: In the evaluation by indirect IS-PCR, 48 of 81 PAP-stained cell smears of low-grade squamous intraepithelial lesions were positive for HPV DNA, as compared to 40 positive cell smears determined by indirect SP-PCR (sensitivity of indirect IS-PCR compared to SP-PCR, 98.1%). Forty-two of 42 high-grade squamous intraepithelial lesion samples were positive for HPV DNA, as determined by both methods (sensitivity of IS-PCR, 100%). Cell lines investigated in this study as positive or negative controls for HPV DNA were confirmed by indirect IS-PCR and SP-PCR. CONCLUSIONS: Our data show that in comparison to SP-PCR, indirect IS-PCR is a highly sensitive method to detect HPV DNA in cell smears from the uterine cervix. The advantages of indirect IS-PCR are (a) low numbers of cells needed, (b) the possibility of using PAP-stained specimens, and (c) cytologic details of smears can be preserved.

Biotin and phosphorus-isotopic labelled DNA/RNA probes for the detection of human papilloma virus sequences.

In this study, the diagnostic accuracy and practicability of different hybridization techniques for the detection of human papilloma virus (HPV) DNA were tested. Cervical cell scrapes (n = 67) were analysed for HPV-DNAs 6/11 and 16, in order to compare a commercially available in situ DNA hybridization-assay with the conventional Southern-blot analysis. The in situ DNA hybridization-assay gave a sensitivity of 81.5%, a specificity of 97.5% and a diagnostic efficiency of 91.0% for HPV-DNAs 6/11. Using the same assay, we observed a sensitivity of 100%, a specificity of 96.3% and a diagnostic efficiency of 97.0% for HPV-DNA 16. The practicability of dot-blot DNA hybridization technique was tested on 176 cervical cell scrapes, in order to determine the prevalence rate of HPV-genotypes 6/11, 16/18 and 31/33/35. In the random control group (n = 106), 1.9% of the cases were HPV-DNA positive. In the cancer prevention group (n = 70), patients with reactive and reparative cell changes showed a HPV-DNA positivity of 55.0%, with mild (slight) dysplasia/CIN 1 of 73.7%, and with moderate to severe dysplasia/CIN 2 to CIN 3, including the carcinoma in situ/CIN 3 of 80.0%. Patients with squamous cell carcinoma of the cervix uteri gave HPV-DNA positive results in 96.2% of the cases. The suitability of in situ DNA hybridization for morphological studies was tested on tissue biopsies (n = 68). The HPV-DNAs 6/11 were found predominantly to 72.7% of the examined condylomas. The HPV-DNA positive cervices increased with the severity of the cytological dysplasia.(ABSTRACT TRUNCATED AT 250 WORDS)

[Latent cervical virus infection as a possible cause of early abortion]. / Latente zervikale Virusinfektion als mögliche Ursache des Frühaborts.

Cervical smears of 50 women who had an abortion were examined by dot-blot hybridization for human papillomavirus (HPV), herpes simplex virus (HSV) types 1 and 2, and cytomegalovirus (CMV) DNA. HPV DNA type 16 or 18 positivity was shown in 17.6% of the cases; in the aborted material, however, it amounted to 30.8%. IgM-positive titres were present in a few cases. In cervical smears of intact pregnancies, positivity for HPV DNA types 6 and 11 was detected in 9.5% and for the HSV DNA types 1 and 2 and CMV DNA in 48.0% of the cases. In this group of patients mostly positive IgM and IgG titers were present.

Human papillomavirus detection of endometrioid carcinoma with squamous differentiation of the uterine corpus.

Many studies have shown a link between human papillomavirus (HPV) and cervical carcinoma. However, studies on the association of HPV with endometrioid carcinoma of the corpus uteri are sparse and controversial. In this study, 33 formalin-fixed, paraffin-embedded tissue samples of endometrioid carcinoma with squamous cell differentiation in grade 1 (adenoacanthoma) and 10 additional samples of endometrioid carcinoma with less squamous cell differentiation in grade 2 or 3 (adenosquamous carcinoma) were examined by the hybrid capture system for the presence of the 14 most common anogenital HPV types, consisting of low-risk HPV types 6, 11, 42, 43, and 44, and intermediate- and high-risk HPV types 16, 18, 31, 33, 35, 45, 51, 52, and 56. No evidence of high-risk HPV DNA types was found in any of these samples. The low- risk HPV DNA types were found in three samples and showed borderline results (+/-) in 6 samples by the hybrid capture system. The 43 samples were tested by dot blot hybridization with HPV probes 6/11, 16/18, and 31/33/35. Only 1 sample was positive for HPV 6/11. The results of this study did not indicate an association between HPV infection and endometrioid carcinoma with squamous cells, though the endometrial mucosa of the corpus uteri is anatomically connected to the endocervical epithelium, and in some cases HPV has been postulated to possibly cause squamous cell differentiation of the endometrium. Our findings are in accord with the concept that HPV infection leading to malignancy is highly site- and tissue-specific. In conclusion, the endometrium may not be a suitable host epithelium for HPV replication and maturation.

Photon-gated spectral hole burning by donor-acceptor electron transfer.

We have observed a new mechanism for photon-gated spectral hole burning, donor-acceptor electron transfer, in a material composed of a zinc-tetrabenzoporphyrin derivative (donor) with chloroform acceptors in poly(methyl methacrylate) thin films. Gated holes form when we simultaneously excite the donor 0-0 singlet absorption (630 nm) and the donor triplet-triplet absorption (350-550 nm), with the largest gating enhancement (>30) occurring for gating light near 480 nm. The gating action spectrum and the photoproduct spectrum confirm that the mechanism is electron transfer from an excited triplet of the porphyrin donor to the chloroform acceptor. This result opens up a new class of materials for photon gating that should be of interest for frequency-domain optical storage applications as well as high-resolution spectroscopy of electron transfer processes in solids.

The influence of cotinine on interleukin 6 expression in smokers with cervical preneoplasia.

BACKGROUND: Several epidemiological investigations have shown that cigarette smoking leads to increased serum IL-6 levels and is a risk factor for cervical cancer. METHODS: We examined the levels of interleukin 6 (IL-6) and the amount of cotinine in the cervical fluid of 78 women and compared the presence of human papillomavirus (HPV) in smokers and nonsmokers. RESULTS: The results of our study showed that IL-6 levels were higher in the cervical mucus of smokers than in nonsmokers. Fourteen percent of smokers were in the category with highest IL-6 levels compared to 6% of nonsmokers. However, our IL-6 results were not significant as they were probably influenced by the higher rates of HPV infection in smokers (17 cases) than in nonsmokers (4 cases). Significant findings showed that smokers had a higher prevalence of squamous intraepithelial lesions (SILs) than nonsmokers. Smokers' cotinine levels also exceeded those of nonsmokers: 13.95 ng/ml compared with 5.00 ng/ml. However, less IL-6 activity was evident in smokers with high-grade SILs and HPV infection of high-risk types. CONCLUSION: Our results suggest that smoking has a stimulatory effect on the production of IL-6 in the cervix. Furthermore, smokers show a higher genital HPV infection rate and a higher prevalence of SILs.

Salpingitis caused by Chlamydia trachomatis and its significance for infertility.

Between July and November 1991, 32 women (mean age 24.8 years) were examined laparoscopically in our department for suspected tubal sterility. All women had smears taken from cervix, vagina, and urethra, and all were negative regarding an infection with Chlamydia trachomatis. All women had open fallopian tubes, however, with inflammatory changes that varied in degree. Fifteen women reported pains and were classified as PID (pelvis inflammatory disease)-positive, as compared to the PID-negative group of 17 women without pain. In the group of the 15 PID-positive women, we could detect Chlamydia trachomatis in the form of salpingitis in 11 cases in the direct demonstration of the infectious agent. IgA antibodies were detected in the serum of all of these women, in 12 of them IgA + IgG antibodies. In the group of the 17 PID-negative women, three were positive in the direct detection of the infectious agent, and IgA and/or IgG antibodies were detected in five cases. 38% of the women in the PID-positive group and 68% in the PID-negative group conceived within a period of one year after having completed a treatment with antibiotics.

Reliability of in-situ hybridization of smears and biopsies for papilloma virus genotyping of the uterine cervix.

Two sampling methods, biopsy and cell smear, were investigated for their reliability in the biotin in-situ hybridization test for human papilloma virus deoxyribonucleic acid (HPV-DNA)-6/11 and 16/18. Cervical smears and biopsies were obtained simultaneously from 81 women with cervical lesions. The sensitivity of the in-situ hybridization was tested on human cervical carcinoma cell lines. As a reference method, HPV-DNA was probed in biopsies using a Southern blot with 32P-labelled DNA probes. This reference method detected HPV-DNA in 45% of the reactive and reparative cell changes, in 75.9% of intraepithelial neoplasias, and in 83.3% of squamous cell carcinomas of the cervix. Of the examined cervices 61.7% were HPV-DNA-positive. As tested by in-situ hybridization, 56.8% of the biopsies were HPV-DNA-positive. Three biopsies were HPV-DNA-negative by the in-situ hybridization but positive by the Southern blot. One biopsy was HPV-DNA-6/11 positive by the in-situ hybridization but negative in the Southern blot. As tested by in-situ hybridization, 55.6% of the cervical smears were HPV-DNA-positive. Five smears were HPV-DNA-positive by the in-situ hybridization but negative by the reference method, thus demonstrating the dependence of the HPV positive rate on the sampling method. Four cell smears were negative by the in-situ hybridization but positive by the reference method, which shows that the biotin in-situ hybridization is less sensitive. The reference method confirmed the HPV-DNA-positivity of in-situ hybridization for 97.8% of biopsies, and for 91.8% of cell smears.(ABSTRACT TRUNCATED AT 250 WORDS)

Amplification and expression of the c-erbB-2 oncogene in Müllerian-derived genital-tract tumors.

This study focused on 18 uterine corpus tumors and 7 ovarian endometrioid tumors, all of them malignant and Müllerian derived. Differential polymerase chain reaction (DPCR), dot blot hybridization, and immunohistochemical technique were employed to determine c-erbB-2 amplification and expression. Of 25 Müllerian-derived tumors, 17 (68.0%) demonstrated amplified c-erbB-2 (two to eight copies) by DPCR. These 25 samples were reexamined by dot blot and immunohistochemical technique, revealing c-erbB-2 amplification and expression of to be 52.0 and 40.0%, respectively. There seemed to be a slight correlation between the amplification and expression of c-erbB-2 and patient survival. Although c-erbB-2 was frequently present in Müllerian-derived genital-tract tumors, it is uncertain whether this oncogene may serve as their sole prognostic marker. The question remains whether c-erbB-2 alone, or in conjunction with other oncogenes or suppressor genes, accounts for the pathogenesis of Müllerian-derived tumors. However, these results suggest for the first time in the literature that DPCR is a sensitive enough technique for detecting c-erbB-2 amplification in M ullerian-derived tumors.

Co-expression of ErbB-family members in human breast cancer: Her-2/neu is the preferred dimerization candidate in nodal-positive tumors.

Over-expression of members of the ErbB-receptor family has been associated with malignant transformation. The amplification of Her-2/neu in tumor tissue is now an established prognostic factor in breast cancer. In order to initiate signal transduction, ErbB-receptor monomers need to form homo- or heterodimers. The composition of these dimers is thought to influence both quality and quantity of downstream signaling pathways, and to determine the biological response. We have investigated the protein expression pattern of the four ErbB-receptors EGFR, Her-2/neu, Her-3 and Her-4, and correlated it with their putative ligands EGF, TGF-alpha and HRG in 74 women with invasive breast cancer. Using western blot-analysis on cell membrane isolates, we detected the co-expression of all four ErbB-family members in 79.7% of cases, and of all of the three investigated ligands in 82.4%. We did not observe a correlation between EGFR and Her-2/neu or Her-4 protein expression, EGFR and Her-3 (p = 0.005), and Her-3 and Her-4 (p = 0.05) were clearly co-expressed. The strongest overall correlation, was found between Her-2/neu and Her-3 (p < 0.001) and between Her-2/neu and Her-4 (p = 0.001). This was particularly true in nodal-positive tumors (p < 0.001 and p = 0.002) whereas in nodal-negative tumors the co-expression was either less significant (Her-2/neu and Her-3; p = 0.01) or not significant (Her-2/neu and Her-4). The co-expression of EGFR/Her-3 was associated with the expression of all ligands, whereas the Her-2/neu/Her-3 was correlated with HRG (p = 0.002), thereby indicating a functional relation between specific receptor-dimer combinations and putative ligands. Taken together, we have performed the first comprehensive survey of ErbB-system expression in breast cancer, and have demonstrated the presence of a co-regulated receptor/ligand system in vivo. We have further shown that Her-2/neu is the preferred co-expression partner in nodal-positive tumors and thus the most likely dimerization candidate in malignant breast tumors.