The role of HPV DNA in the evaluation and follow-up of asymptomatic male sexual partners of females with CIN3.

PURPOSE: To determine whether and how asymptomatic sexual partners of females with high-grade cervical intraepithelial neoplasia (CIN3) lesions should be examined. METHODS: Sexual partners of females with CIN3 were evaluated for HPV-related lesions by scraping samples for high-risk HPV DNA and androscopy (colposcopic inspection of the penis, scrotum and peri-anal area). Abnormal androscopically detected lesions were sampled for cytology by Pap smears. RESULTS: 74 partners of 87 females were studied and underwent androscopy, and 17 (22.9%) had abnormal findings: 11/74 had clinical genital condyloma acuminata and 6/74 had aceto-white lesions on the penile shaft or scrotum. Cytology of the 17 abnormal androscopies showed that six smears were normal and 11 had atypia and koilocytosis. Positive high-risk HPV DNA indicated that 13/74 (17.5 %) were infected with HPV. Two partners (2/74, 2.8%) had concomitant HPV DNA 16. CONCLUSIONS: Male sexual partners of females with CIN3 should undergo androscopy and cytology of colposcopically detected abnormal areas.

Analysis of 104 twin pregnancies conceived with assisted reproductive technologies and 193 spontaneously conceived twin pregnancies.

OBJECTIVE: To evaluate pregnancy outcome of assisted reproductive technology (ART)-conceived twin pregnancies. DESIGN: Retrospective study. SETTING: A tertiary obstetric care center. PATIENT(S): All twin pregnancies delivered > or = 24 weeks of gestation from January 1, 1996, to December 31, 1997. INTERVENTION(S): Maternal and neonatal record review. MAIN OUTCOME MEASURE(S): Pregnancy and perinatal outcome. RESULT(S): The study group comprised 104 ART-conceived twin pregnancies, and 193 non-ART-conceived pregnancies served as controls. Mean maternal age, the proportion of nulliparae, and the percentage of women who delivered before 34 weeks' gestation was higher among the study women, whereas mean gestational age was younger. The incidences of pregnancy-induced hypertension, uterine bleeding, premature contractions, intrauterine growth retardation, fetal death, discordance, and cesarean section were significantly higher in the study group. Correspondingly, in the study group, the mean birth weight of both twins was lower; more neonates weighed < 1, 500 g, more had Apgar scores of < 7 at 5 minutes, more were admitted to the intensive care unit, and more second twin neonates died. The outcome of twin pregnancies conceived spontaneously was comparable with those conceived by ovulation induction. CONCLUSION(S): Assisted reproductive technology-conceived twin pregnancies are at greater risk than non-ART-conceived ones for pregnancy complications and adverse perinatal outcome.

Vertebral osteomyelitis: a rare complication of transvaginal ultrasound-guided oocyte retrieval.

OBJECTIVE: To present a case of vertebral osteomyelitis as a complication of transvaginal oocyte retrieval. DESIGN: Case report. SETTING: The IVF unit of a university-affiliated hospital. PATIENT(S): A 41-year-old woman who underwent IVF-ET treatment. INTERVENTION(S): Standard IVF-ET treatment cycles with the use of transvaginal ultrasound for oocyte retrieval and computed tomography-guided needle aspiration. MAIN OUTCOME MEASURE(S): Recovery of the patient, sequelae, and recurrence. RESULT(S): Vertebral osteomyelitis was diagnosed and treated with antibiotics. CONCLUSION(S): When severe low back pain occurs after ovum retrieval, vertebral osteomyelitis should be considered. Early diagnosis requires a high index of suspicion.

The effects of tamoxifen treatment on the endometrium.

OBJECTIVE: To investigate the association between tamoxifen and endometrial cancer. BACKGROUND: Tamoxifen is a nonsteroidal antiestrogenic drug that has been used successfully for 15 years in the treatment of all stages of breast carcinoma. In light of the positive results, several studies are now being conducted to test prolonged tamoxifen treatment as a prophylaxis against breast cancer in high-risk women. Although tamoxifen was thought to have only a few side effects, reports indicate that it is associated with an increased incidence of proliferative and neoplastic changes in the endometrium. As the current trend is to administer tamoxifen for prolonged periods and for more indications, the detrimental effects on the endometrium have vast implications. METHODS: Review of the current literature. RESULTS: Tamoxifen treatment is associated with an increased incidence of proliferative and neoplastic changes in the endometrium, with a 1.3 to 7.5 relative risk of developing endometrial carcinoma. CONCLUSIONS: The results of tamoxifen treatment in breast carcinoma override the risk of developing endometrial carcinoma. Any vaginal bleeding in women treated with tamoxifen should be investigated carefully and promptly. In the future it may be necessary to advise these women to undergo routine uterine cavity examination.

Levels of vascular endothelial growth factor are elevated in patients with ectopic pregnancy: is this a novel marker?

OBJECTIVE: To determine serum levels of vascular endothelial growth factor (VEGF) and evaluate their capacity to serve as a marker for the diagnosis of ectopic pregnancy (EP). DESIGN: Prospective, case-controlled study. SETTING: A tertiary care center. PATIENT(S): Twenty women with EP, 10 women with normal intrauterine pregnancy, and 10 women with abnormal intrauterine pregnancy, all at comparable stages of gestation. INTERVENTION(S): Serum samples were obtained from all women. MAIN OUTCOME MEASURE(S): All samples were analyzed for VEGF, progesterone, and beta-hCG by specific methods. RESULT(S): Women with EP had higher serum levels of VEGF than women with normal intrauterine pregnancy and women with abnormal intrauterine pregnancy (median levels, 226.8 pg/mL, 24.4 pg/mL, and 59.4 pg/mL, respectively). With a cutoff level of 200 pg/mL, serum VEGF could distinguish intrauterine from extrauterine pregnancy with a sensitivity of 60%, specificity of 90%, and positive predictive value of 86%. CONCLUSION(S): The increased serum VEGF levels in women with EP may facilitate this challenging diagnosis and reduce maternal morbidity and mortality.

Bone scan and bone biopsy in the detection of skeletal metastases.

This study provides the first quantitative indication of the limits of sensitivity of a bone scan with technetium (99Tc-MDP) in detecting skeletal metastases and thereby also helps to explain the fact that bone scans may be negative when metastases are present in the bone marrow. Since 99Tc-MDP remains the least noxious and most widely used isotope for bone scanning, these results have direct clinical relevance in the evaluation of patients with solid tumors and possible metastatic spread.

Phase II study of carboplatin and etoposide as salvage treatment for patients with metastatic breast cancer.

A phase II study of carboplatin and etoposide as salvage polychemotherapy in metastatic, infiltrating breast carcinoma was carried out with 25 multiply pretreated patients. Six of 25 patients (24%) had a partial response that lasted an average of 3.5 months; of the six responders, four had undergone either four or five previous chemotherapeutic treatments. Eight of 25 patients (32%) had stable disease, and 11 (44%) manifested disease progression. The median survival from time of entry to the salvage protocol was 8 months. There were treatment responses in lung, chest wall, liver, and skeleton. The most common side effects were leukopenia (68% of 25 patients), thrombocytopenia (56%), anemia (40%), fever (28%), and weakness (16%). Carboplatin combined with etoposide may be an effective and tolerable salvage regimen in advanced breast cancer.

Low-molecular-weight heparin for the prevention of obstetric complications in women with thrombophilias.

OBJECTIVE: To evaluate the benefit of combined low-molecular-weight (LMW) heparin and aspirin for prophylaxis in women carriers of thrombophilia who had previously suffered from severe obstetric complications. METHODS: The 33 studied women had an earlier pregnancy complicated by severe preeclampsia, abruptio placentae, intrauterine growth retardation, or intrauterine fetal death. All were subsequently diagnosed as carrying inherited thrombophilias. In their subsequent pregnancy, prophylactic therapy consisting of LMW heparin 40 mg/day (Enoxaparin, Rhone-Poulenc-Rorer, France) and aspirin was administered. Patients who were found to be homozygotes for the methylenetetrahydrofolate reductase mutation also received folic acid supplementation throughout their pregnancy. RESULTS: Low-molecular-weight heparin was well tolerated and none of the women or the newborns developed any hemorrhagic complications. Only three (9.1%) of the women developed pregnancy complications. The mean gestational age and the mean birth weight at delivery in the previously complicated pregnancies were 32.1 +/- 5.0 weeks and 1175 +/- 590 g, respectively, compared to 37.6 +/- 2.3 weeks and 2719 +/- 526 g, respectively, in the treated pregnancies (p < 0.001). CONCLUSIONS: This uncontrolled trial suggests that patients with obstetric complications and an inherited thrombophilia may benefit from treatment with combined LMW heparin and aspirin in subsequent pregnancies. However, this needs to be verified by controlled trials before considering clinical application.

Treatment of bilateral multiple primary ovarian leiomyomas during pregnancy by way of conservative surgery: a case report.

Primary ovarian leiomyoma is a rare, unilateral and solitary, benign tumour. We report a unique case of bilateral, multiple, primary ovarian leiomyomas diagnosed incidentally during caesarean section. As opposed to previously reported cases, conservative surgery was performed which resulted in preservation of ovarian function and anatomy.

Breech delivery: the value of X-ray pelvimetry.

OBJECTIVE: The study was conducted to compare maternal and neonatal outcome of two groups of nulliparae with breech presentations, who were selected for vaginal delivery by protocols differing only in their use of X-ray pelvimetry. STUDY DESIGN: We reviewed all term singleton breech deliveries of nulliparous patients who were eligible for vaginal trial of labour in our Centre between 1992 and 1994. In Group A (n=85) X-ray pelvimetry was performed, and in Group B (n=70) it was not. Obstetric management was otherwise similar. Admission to the two departments was on alternate days. RESULTS: The rate of caesarean section was similar in both groups (Group A, 36.4% vs. Group B, 42.8%; P>0.05), however, the indications for caesarean section differed. Neonatal outcome was similar in both groups. Maternal febrile morbidity was higher in Group B patients, especially those who underwent caesarean section after a trial of labour. CONCLUSION: X-ray pelvimetry in nulliparae with breech presentation is associated with reduced maternal febrile morbidity, but does not improve neonatal outcome.

High- and low-power CO2 lasers. Comparison of results for three clinical indications.

In this prospective study, three groups of patients were enrolled: group 1, patients with high grade squamous intraepithelial lesions (CIN 2 and 3) and carcinoma in situ (n = 56); group 2, patients with benign vulvar and perineal human papillomavirus lesions (n = 83); and group 3, patients with disseminated foci of penile shaft condylomatous lesions (n = 65). Each of the groups was randomly equally divided into two subgroups. One subgroup was treated with a laser beam with an output of 60 W and a spot size of 1-1.5 mm, creating high power density (HPD) ranging between 3,4000 and 7,640 W/cm2, while the other was treated with low power density (LPD) with an output of 20 W and the same spot sizes, creating an LPD ranging between 1,136 and 2,547 W/cm2. In group 1, the time to complete treatment was shorter using the HPD technique (P < .0003), and more satisfactory histologic edges were available (P < .007). HPD was also associated with a significantly shorter healing time and improved cosmetic results in groups 2 and 3 (P = .001). No difference was found in the time to complete therapy or the occurrence of infection when the different modalities were compared. The results of this study suggest that for specific disease entities, HPD is associated with better treatment outcomes than is LPD.

Morphologic and histopathologic characteristics of placentas from twin pregnancies spontaneously conceived and from reduced and nonreduced assisted reproductive technologies.

OBJECTIVE: To prospectively evaluate morphologic and histopathologic characteristics of placentas from twin pregnancies obtained by assisted reproductive technologies (ART) and non-ART and to evaluate the influence of previous fetal reduction on placental features. STUDY DESIGN: Fifty-five placentas from consecutive deliveries of ART-obtained and 50 placentas from consecutive deliveries of non-ART-conceived twin pregnancies were investigated by one pathologist, who was blinded to specimen origins. The patients' demographic and clinical data were also recorded. RESULTS: The mean maternal and gestational ages were similar in both groups. ART-obtained pregnancies were associated with an increased incidence of pregnancy complications and lower mean birth weight. Placentas from ART-obtained pregnancies were mostly of the dichorionic type and were thinner, weighed less and had more infarctions as compared to non-ART-conceived pregnancies. Placental characteristics of reduced ART-obtained twin pregnancies were comparable to those of nonreduced ones. The second twin's placenta in all groups weighed less and had a higher incidence of anomalous umbilical cord insertion. CONCLUSION: Placentas from ART-obtained twin pregnancies appear to have more pathologic features as compared to those of non-ART-conceived ones. Fetal reduction does not significantly affect the remaining placentas.

Taking a satisfactory cervical cytologic smear. Is it really an easy procedure?

OBJECTIVE: To evaluate the correlation between the experience of the cervical cytologic smear provider and the quality of the smears in terms of the percentages of satisfactory smears and contribution of the various factors affecting the smear's adequacy. STUDY DESIGN: A newly available quality control system was used to evaluate the adequacy of 4,000 smears. RESULTS: Of 4,000 smears, 660 (16.5%) were classified as "satisfactory but limited" or "unsatisfactory." Technical factors contributed 1.0%, while 15.5% were due to sampling factors, considered human errors. Thus, human error accounted for 90% of the total number of unsatisfactory smears. CONCLUSION: Greater experience with smear sampling is associated with fewer unsatisfactory smears. The results correlate directly with the total number of smears taken annually. Sampling skill improves in steps, with improvement limited beyond a certain point.

Cervical adeno-carcinoma and partial hydatidiform mole.

Partial hydatidiform mole was found in a 39-year-old grand-multiparous Jewish woman, having a polypoid cervical adeno-carcinoma. The patient was treated by surgery followed by internal and external pelvic irradiation, with excellent results. Four and a half years after the initial diagnosis she is very well. This is the first reported case of a rare combination. The literature regarding the association between pregnancy and cervical malignancies is reviewed briefly and the possible pathogenetic relationship between hydatidiform mole and carcinoma of the cervix is discussed.

Sensitivity and specificity of sonohysterography for the evaluation of the uterine cavity in perimenopausal patients.

Sonohysterography is a technique for evaluating the uterine cavity by the instillation of sterile saline solution through an 8 Fr Foley catheter, before performing an ultrasonographic evaluation. The sensitivity and specificity of the procedure were evaluated in comparison to hysteroscopy. In a prospective double-blind study, 47 postmenopausal patients were evaluated first by sonohysterography, and within 1 week by hysteroscopy. After comparing the hysteroscopic and sonohysterographic results, sonohysterography showed a sensitivity of 86% and specificity of 100%. Sonohysterography is an accurate mode of diagnosis for pathologic intrauterine processes in perimenopausal patients.

Treatment of male genital condylomatous lesions by carbon dioxide laser after failure of previous nonlaser methods.

Carbon dioxide laser was used to treat 119 male patients with condylomata acuminata after other treatments had failed. In 82.3% of the patients, the treatment resulted in complete disappearance of the lesions, whereas in the others two to three treatments were required. Advantages of the laser treatment are discussed.

Prevalence of human papillomavirus infection and HPV DNA among male partners of Israeli women with genital premalignant and human papillomavirus lesions.

The role of the males who are sexual partners of females with genital human papillomavirus (HPV) infection and premalignant lesions is explored in the present study. Within a period of 3 years, 391 females with genital premalignant and HPV-associated lesions were examined and treated at the Cervical Pathology Unit of the Tel Aviv Medical Center. The male partners of all the women were asked to attend this unit, and 322 of them responded. All participants underwent colposcopic examination of the anogenital area followed by colposcopically guided biopsies from the most representative lesions, when present, part of which included in situ hybridization (ISH) of HPV DNA sequences 6/11 and 16/18. The histological prevalence of HPV among the male partners was 86.6% (185 of 213 biopsies). Of the 48 couples who had ISH evaluations, the ISH could not identify any copy of HPV DNA in 58.3% of the males (28 cases) and 41.6% of the females (20 cases). Among the males, HPV 6/11 and 16/18 were found in 17 (35.4%) and 3 cases (6.2%), respectively, and among the females there were 23 (48.0%) and 5 cases (10.4%), respectively. Correlation of HPV DNA sequences 6/11 and 16/18 between the couples was found in six (12.5%) and in one (2.0%), respectively. These data do not support a direct contamination by the current male partner. The question of treating the male partner of a woman with genital HPV and premalignant lesions remains to be evaluated.