Is it time to consider population screening for fracture risk in postmenopausal women? A position paper from the International Osteoporosis Foundation Epidemiology/Quality of Life Working Group.

The IOF Epidemiology and Quality of Life Working Group has reviewed the potential role of population screening for high hip fracture risk against well-established criteria. The report concludes that such an approach should strongly be considered in many health care systems to reduce the burden of hip fractures. INTRODUCTION: The burden of long-term osteoporosis management falls on primary care in most healthcare systems. However, a wide and stable treatment gap exists in many such settings; most of which appears to be secondary to a lack of awareness of fracture risk. Screening is a public health measure for the purpose of identifying individuals who are likely to benefit from further investigations and/or treatment to reduce the risk of a disease or its complications. The purpose of this report was to review the evidence for a potential screening programme to identify postmenopausal women at increased risk of hip fracture. METHODS: The approach took well-established criteria for the development of a screening program, adapted by the UK National Screening Committee, and sought the opinion of 20 members of the International Osteoporosis Foundation's Working Group on Epidemiology and Quality of Life as to whether each criterion was met (yes, partial or no). For each criterion, the evidence base was then reviewed and summarized. RESULTS AND CONCLUSION: The report concludes that evidence supports the proposal that screening for high fracture risk in primary care should strongly be considered for incorporation into many health care systems to reduce the burden of fractures, particularly hip fractures. The key remaining hurdles to overcome are engagement with primary care healthcare professionals, and the implementation of systems that facilitate and maintain the screening program.

Differential relationships between parent-child DXA and pQCT bone measures: Results from the Southampton Women's Survey.

AIM: To investigate the associations between indices of bone health in childhood and corresponding parental measures. METHODS: The Southampton Women's Survey characterised 12,583 non-pregnant women aged 20-34 years; 3158 subsequently had singleton live births. In a subset, dual-energy X-ray absorptiometry (DXA) measurements of bone area (BA), bone mineral content (BMC) and areal bone mineral density (aBMD) lumbar spine and total hip were obtained in the parent/offspring (aged 8-9 years) trios. Another subset of children (aged 6-7 years), and their parents, had peripheral quantitative computed tomography (pQCT; 4% and 38% tibia) measures. Using multivariable linear regression we examined relationships between mother/father and offspring, adjusting for parental age, habitual walking speed and education; offspring age and sex; and the corresponding bone measure in the other parent (ß-coefficients (95%CI) unit/unit for each bone measure). RESULTS: Data were available for 260 trios with DXA and 99 with pQCT. There were positive associations for BA, BMC and aBMD between either parent and offspring. Mother-child associations were of greater magnitude than father-child; for example, mother-child aBMD (ß = 0.26 g·cm-2/g·cm-2 (0.21,0.32)) and father-child aBMD (ß = 0.16 g·cm-2/g·cm-2 (0.11,0.21)), P-difference in ß = 0.007. In the subset with pQCT there was a positive association for mother-offspring 4% tibial total area (ß = 0.33 mm2/mm2 (0.17,0.48)), but little evidence of a father-offspring association (ß = -0.06 mm2/mm2 (-0.17,0.06)). In contrast offspring 38% cortical density was more strongly associated with this measure in fathers (ß = 0.48 mg·cm-3/mg·cm-3 (0.15,0.82)) than mothers (ß = 0.27 mg·cm-3/mg·cm-3 (-0.03,0.56)). In general mother-father differences were attenuated by adjustment for height. CONCLUSIONS: Whilst offspring bone measures are independently associated with those of either parent, the magnitude of the association is often greater for maternal than paternal relationships. These findings are consistent with an in utero influence on offspring growth but might also reflect genetic and/or epigenetic parent of origin effects. SUMMARY: In an established parent-offspring cohort, associations between parent and offspring bone indices were generally greater in magnitude for mother-offspring than father-offspring relationships.

Placental volume at 11 weeks is associated with offspring bone mass at birth and in later childhood: Findings from the Southampton Women's Survey.

OBJECTIVES: To investigate associations between placental volume (PV) at 11 weeks' gestation and offspring bone outcomes at birth, 6 years and 8 years. METHODS: 3D ultrasound scanning was used to assess 11 week PV in a subset (n = 236) of the Southampton Women's Survey (a prospective mother-offspring cohort). Maternal anthropometric measures and lifestyle information were obtained pre-pregnancy and at 11 weeks' gestation. Offspring dual-energy x-ray absorptiometry scanning was performed within 2 weeks postnatally and at 6 and 8 years. Linear regression was used to assess associations between PV and bone outcomes, adjusting for offspring age at DXA and sex, and maternal age, height, smoking status, walking speed and triceps skinfold thickness. ß are SD change in bone outcome per SD change in PV. RESULTS: In adjusted models, 11 week PV was positively associated with bone area (BA) at all time points, with evidence of persisting associations with increasing childhood age (birth: n = 80, ß = 0.23 [95%CI = 0.03, 0.42], 6 years: n = 110, ß = 0.17 [-0.01, 0.36], 8 years: n = 85, ß = 0.13 [-0.09, 0.36]). Similar associations between 11 week PV and bone mineral content (BMC) were observed. Associations with size-corrected bone mineral content were weaker at birth but strengthened in later childhood (birth: n = 78, ß = 0.07 [-0.21, 0.35], 6 years: n = 107, ß = 0.13 [-0.08, 0.34], 8 years: n = 71, ß = 0.19 [-0.05, 0.43]). CONCLUSIONS: 11 week PV is associated with DXA bone measures at birth, with evidence of persisting associations into later childhood. Further work is required to elucidate the contributions of placental morphology and function to gestational influences on skeletal development.

COVID-19 and associations with frailty and multimorbidity: a prospective analysis of UK Biobank participants.

BACKGROUND: Frailty and multimorbidity have been suggested as risk factors for severe COVID-19 disease. AIMS: We investigated, in the UK Biobank, whether frailty and multimorbidity were associated with risk of hospitalisation with COVID-19. METHODS: 502,640 participants aged 40-69 years at baseline (54-79 years at COVID-19 testing) were recruited across UK during 2006-10. A modified assessment of frailty using Fried's classification was generated from baseline data. COVID-19 test results (England) were available for 16/03/2020-01/06/2020, mostly taken in hospital settings. Logistic regression was used to discern associations between frailty, multimorbidity and COVID-19 diagnoses, after adjusting for sex, age, BMI, ethnicity, education, smoking and number of comorbidity groupings, comparing COVID-19 positive, COVID-19 negative and non-tested groups. RESULTS: 4510 participants were tested for COVID-19 (positive = 1326, negative = 3184). 497,996 participants were not tested. Compared to the non-tested group, after adjustment, COVID-19 positive participants were more likely to be frail (OR = 1.4 [95%CI = 1.1, 1.8]), report slow walking speed (OR = 1.3 [1.1, 1.6]), report two or more falls in the past year (OR = 1.3 [1.0, 1.5]) and be multimorbid (≥ 4 comorbidity groupings vs 0-1: OR = 1.9 [1.5, 2.3]). However, similar strength of associations were apparent when comparing COVID-19 negative and non-tested groups. However, frailty and multimorbidity were not associated with COVID-19 diagnoses, when comparing COVID-19 positive and COVID-19 negative participants. DISCUSSION AND CONCLUSIONS: Frailty and multimorbidity do not appear to aid risk stratification, in terms of positive versus negative results of COVID-19 testing. Investigation of the prognostic value of these markers for adverse clinical sequelae following COVID-19 disease is urgently needed.

State of the art in osteoporosis risk assessment and treatment.

BACKGROUND: Osteoporosis constitutes a major public health problem, through its association with age-related fractures, particularly of the hip, vertebrae, distal forearm, and humerus. Over recent decades, it has evolved from being viewed as an inevitable consequence of ageing, to being recognised as a serious and eminently treatable disease. MATERIALS AND METHODS: In this article, we review the literature pertaining to the epidemiology of osteoporosis, associated health burden, approaches to risk assessment and treatment. RESULTS: Although there is some evidence that fracture incidence has reached a plateau, or even started to decline, in the developed world, an ageing population and adoption of westernised lifestyles in transitioning populations is leading to an increasing burden of osteoporosis across the world. Whilst the clinical definition of osteoporosis has been based solely on bone mineral density, the prediction of fracture at the individual level has been improved by consideration of clinical risk factors in tools such as FRAX®, derived from a greater understanding of the epidemiology of osteoporosis. Such advances in approaches to primary and secondary prevention of fractures, coupled with elucidation of the underlying biology, and the development of a range of highly effective antiosteoporosis medications, have enabled a step change in our ability to prevent osteoporosis-related fractures. However, there remains a substantial disparity between the number of individuals at high fracture risk and number treated globally. CONCLUSION: Urgent work is needed at the level of health care systems, national and international policy, and in communication with patients and public, to ensure that all patients who should receive treatment for osteoporosis actually do so.

Prior fragility fracture and risk of incident ischaemic cardiovascular events: results from UK Biobank.

In the large UK Biobank population-based cohort, we found that amongst men, but not women, prior fragility fracture was associated with increased risk of admission with ischaemic heart disease. INTRODUCTION: We aimed to investigate the relationship between prior fracture and risk of incident ischaemic cardiovascular events in a UK population-based cohort. METHODS: UK Biobank is a large prospective cohort comprising 502,637 men and women aged 40-69 years, with detailed baseline assessment. History of fracture was self-reported, and details of hospital admissions for ischaemic heart disease (IHD) (ICD-10:I20-I25) were obtained through linkage to UK Hospital Episode Statistics. Cox proportional hazards models were used to investigate the prospective relationships between prior fracture and hospital admission for men and women, controlling for age, BMI, smoking, alcohol, educational level, physical activity, systolic blood pressure, calcium and vitamin D use, ankle spacing-width, heel BUA and HRT use (women). RESULTS: Amongst men, a fragility fracture (hip, spine, wrist or arm fracture resulting from a simple fall) within the previous 5 years was associated with a 35% increased risk of IHD admission (fully adjusted HR 1.35; 95%CI 1.00, 1.82; p = 0.047), with the relationship predominantly driven by wrist fractures. Associations with hospitalisation for angina in men were similar in age-adjusted models [HR1.54; 95%CI: 1.03, 2.30), p = 0.037], but did not remain statistical significant after full adjustment [HR 1.64; 95%CI: 0.88, 3.07); p = 0.121]. HRs for admission with angina were lower in women, and neither age- nor fully adjusted relationships attained statistical significance. CONCLUSIONS: Prior fragility fracture is an independent risk factor for incident ischaemic cardiovascular events in men. Further work may clarify whether this association is causal or represents shared risk factors, but these findings are likely to be of value in risk assessment of both osteoporosis and cardiovascular disease.

Bone mineral content and areal density, but not bone area, predict an incident fracture risk: a comparative study in a UK prospective cohort.

We studied a prospective UK cohort of women aged 20 to 80 years, assessed by dual-energy X-ray absorptiometry (DXA) at baseline. Bone mineral content (BMC) and areal bone mineral density (aBMD), but not bone area (BA), at femoral neck, lumbar spine and the whole body sites were similarly predictive of incident fractures. BACKGROUND: Low aBMD, measured by DXA, is a well-established risk factor for future fracture, but little is known about the performance characteristics of other DXA measures such as BA and BMC in fracture prediction. We therefore investigated the predictive value of BA, BMC and aBMD for incident fracture in a prospective cohort of UK women. METHODS: In this study, 674 women aged 20-80 years, recruited from four GP practices in Southampton, underwent DXA assessment (proximal femur, lumbar spine, total body) between 1991 and 1993. All women were contacted in 1998-1999 with a validated postal questionnaire to collect information on incident fractures and potential confounding factors including medication use. Four hundred forty-three women responded, and all fractures were confirmed by the assessment of images and radiology reports by a research nurse. Cox proportional hazard models were used to explore the risk of incident fracture, and the results are expressed as hazard ratio (HR) per 1 SD decrease in the predictor and 95% CI. Associations were adjusted for age, BMI, alcohol consumption, smoking, HRT, medications and history of fracture. RESULTS: Fifty-five women (12%) reported a fracture. In fully adjusted models, femoral neck BMC and aBMD were similarly predictive of incident fracture. Femoral neck BMC: HR/SD = 1.64 (95%CI: 1.19, 2.26; p = 0.002); femoral neck aBMD: HR/SD = 1.76 (95%CI: 1.19, 2.60; p = 0.005). In contrast, femoral neck BA was not associated with incident fracture, HR/SD = 1.15 (95%CI: 0.88, 1.50; p = 0.32). Similar results were found with bone indices at the lumbar spine and the whole body. CONCLUSIONS: In conclusion, BMC and aBMD appear to predict incident fracture with similar HR/SD, even after adjustment for body size. In contrast, BA only weakly predicted the future fracture. These findings support the use of DXA aBMD in fracture risk assessment, but also suggest that factors which specifically influence BMC will have a relevance to the risk of the incident fracture.

Secular trends in fracture incidence in the UK between 1990 and 2012.

We studied sex-specific incidence rates in a population 50 years or older in the UK. In the period of 1990-2012, the overall rate of fracture did not change, but there were marked secular alterations in the rates of individual fracture types, particularly hip and spine fractures in the elderly. INTRODUCTION: There is increasing evidence of secular changes in age- and sex- adjusted fracture incidence globally. Such observations broadly suggest decreasing rates in developed countries and increasing rates in transitioning populations. Since altered fracture rates have major implications for healthcare provision and planning, we investigated secular changes to age- and sex-adjusted fracture risk amongst the UK population aged 50 years or above from 1990 till 2012. METHODS: We undertook a retrospective observational study using the Clinical Practice Research Datalink (CPRD), which contains the health records of 6.9 % of the UK population. Site-specific fracture incidence was calculated by calendar year for men and women separately, with fracture type categorised according to ICD-9 classification. Linear regression analysis was used to calculate mean annualised change in absolute incidence. For presentational purposes, mean rates in the first 5 years and last 5 years of the period were calculated. RESULTS: Overall fracture incidence was unchanged in both women and men from 1990 to 2012. The incidence of hip fracture remained stable amongst women (1990-1994 33.8 per 10,000 py; 2008-2012 33.5 per 10,000 py; p trend annualised change in incidence = 0.80) but rose in men across the same period (10.8 to 13.4 per 10,000 py; p = 0.002). Clinical vertebral fractures became more common in women (8.9 to 11.8 per 10,000 py; p = 0.005) but remained comparable in men (4.6 to 5.9 per 10,000 py; p = 0.72). Similarly, the frequency of radius/ulna fractures did not change in men (9.6 to 9.6 per 10,000 py; p = 0.25), but, in contrast, became less frequent in women (50.4 to 41.2 per 10,000 py; p = 0.001). Secular trends amongst fractures of the carpus, scapula, humerus, foot, pelvis, skull, clavicle, ankle, patella, and ribs varied according to fracture site and sex. CONCLUSION: Although overall sex-specific fracture incidence in the UK population 50 years or over appears to have remained stable over the last two decades, there have been noticeable changes in rates of individual fracture types. Given that the impact of a fracture on morbidity, mortality, and health economy varies according to fracture site, these data inform the provision of healthcare services in the UK and elsewhere.

Muscle pyruvate kinase deficiency: glycogen storage disease or mitochondrial myopathy?

Defects of muscle glycogen metabolism are well documented causes of metabolic myopathy, presenting with a spectrum of symptoms which show some relationship to the position of defective enzyme within the glycolytic pathway. We present three women with metabolic myopathic conditions which show some features associated with a glycogen storage disease and some features of a mitochondrial defect. Muscle histochemistry and electron microscopy showed only minor and non-specific changes. However biochemical analysis of muscle biopsies in these three cases revealed a defect in glycolysis at the level of pyruvate kinase (PK), a defect as yet undescribed. Further investigation of the enzyme's properties, revealed that the residual muscle PK activity was due to the muscle (M1) isoform.

Changes in the myelinated axons of femoral nerve in amyotrophic lateral sclerosis.

Myelinated fibres in femoral nerves removed from amyotrophic lateral sclerosis (ALS) cases at post mortem were compared with age matched controls. A technique for processing whole transverse sections of the nerves for osmication and subsequent morphometric analysis is described. Although areas depleted in myelinated fibres were seen in the nerves from the ALS group, no statistically significant difference was shown due to wide variations in the controls. However, the ALS nerves showed a degree of disruption in the myelin which was not apparent in the controls. The most obvious effect was widespread "wrinkling" of the myelin in both large and small fibres from the ALS nerves. This phenomenon is the initial stage of a process which eventually results in uneven myelin thickness and nodal swellings and finally myelin ovoids and balls. We illustrate the steps in the progression of this degeneration with teased nerve studies and electron microscopy and propose that there are qualitative changes in the myelin of peripheral nerve in ALS. It seems likely that these are secondary effects resulting from axonal degeneration caused by deterioration and loss of anterior horn cells in the spinal cord.

Quantitation of synaptic, neuronal and glial development in the intermediate and medial hyperstriatum ventrale (IMHV) of the chick Gallus domesticus, pre- and post-hatch.

A quantitative analysis was made of the development of synapses, neurons and glia in both left and right intermediate and medial hyperstriatum ventrale (IMVH) of the forebrain of the domestic chick, Gallus domesticus from 16 days in ovo to 9 days post-hatch. There was a marked increase in total synapse numerical density (NVsyn), from 10 synapses per 100 microns3 at 16 days in ovo to 50 synapses per 100 microns3 at 9 days post-hatch; no significant left/right hemispheric differences were evident but there were differences between the development profiles for synapses with asymmetric as compared to symmetrical synaptic junctions. In contrast to synaptic development, the number of neurons per unit volume, NVneu, decreased by approximately 50% from the value at 16 days in ovo to that at day 0 (hatching). The neuronal population density remained unchanged to 3 days post-hatch and then, in 9-day-old birds, declined to almost a quarter of the original population size; no significant left/right hemisphere differences were evident. Glial cells declined in number from 16 days in ovo to 19 days in ovo, and then gradually increased to 9 days post-hatch. When the synapse to neuron ratio was examined, a trend was observed of a gradual increase with age, but no hemispheric differences were present. It is concluded that these changes are major events which must be considered in experiments aimed at determining the effects of behavioural, and/or environmental manipulations, on the morphology of the IMHV because they may mask other, more subtle, structural changes that occur as a result of behavioural experiences.

GABAergic structures in the chick telencephalon: GABA immunocytochemistry combined with light and electron microscope autoradiography, and Golgi impregnation.

The distribution of gamma-aminobutyric acid (GABA)-ergic elements in 3 forebrain regions (medial mid-telencephalic hyperstriatum ventrale; paleostriatum augmentatum; lobus parolfactorius) of two-day-old domestic chicks was investigated using (1) light and electron microscope autoradiography following [3H]GABA uptake in vitro in combination with pre-embedding GABA immunocytochemistry and (2) Golgi impregnation and 'gold-toning' combined with postembedding GABA immunocytochemistry. In both the paleostriatal regions and the medial (mid-telencephalic) hyperstriatum ventrale, GABA immunolabelling was demonstrated with the pre-embedding technique. Radiolabelling with [3H]GABA was also shown in these regions, co-localised in many cases with the immunolabelling. In the paleostriatal regions, the majority of perikaryal labelling was found in ovoid, elongated or fusiform cell bodies of 6-7 micron diameter whereas in the medial (mid-telencephalic) hyperstriatum ventrale, larger (10-15 micron) multipolar and smaller (5-6 micron) bipolar neurons were found labelled. In the latter region, Golgi impregnated neurons of similar morphology were found to be immunopositive to GABA using the postembedding technique. The ultrastructure of [3H]GABA accumulating cells is characterised by pale or moderately granular nuclei with small invaginations, few mitochondria and a prominent Golgi apparatus. Astrocytes and ependymal cells are also labelled with [3H]GABA. GABA-labelled axon terminals represent 29-36% of the total in the 3 brain regions studied. They appear as electron-lucent boutons with few and often scattered synaptic vesicles and in most cases they form symmetrical axo-dendritic junctions.

Development of gamma-aminobutyric acid immunoreactivity in chick hyperstriatum ventrale and cerebellum: light and electron microscopical observations.

The presence of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA) in the avian hyperstriatum ventrale and dorsal cerebeller vermis was investigated immunocytochemically using a recently characterized antiserum raised against GABA. Tissue from domestic chicks aged from 19 days in ovo to 28 days posthatch was studied with both light and electron microscopy using pre-embedding immunocytochemistry. Basket, stellate and Golgi cells in the cerebellum, considered to be GABA-ergic, exhibited specific GABA-like immunolabelling in perikarya and in axonal and dendritic processes throughout the developmental period investigated. Purkinje cells also exhibited specific GABA-like immunoreactivity in both pre- and posthatch birds but the distribution and intensity of the immunolabelling varied with age and also in its location within the Purkinje neuron. In prehatch birds Purkinje perikarya exhibited heavy immunostaining which was substantially reduced posthatch, whereas the Purkinje primary dendrites remained immunopositive throughout the developmental period. A small population of cells in the medial hyperstriatum ventrale (mHV) were GABA-positive prehatch, but no immunopositive perikarya were evident in any posthatch samples. Small GABA-positive punctate profiles, representing boutons and transversely sectioned axons or dendrites, were present in the neuropil of all age groups studied. Possible reasons for these findings are discussed and it is suggested that the loss of perikaryal immunostaining, both in the cerebellar Purkinje cells and in those of the mHV, may be governed by maturational processes.

Actinomyces and the intrauterine contraceptive device: aspects of the fluorescent antibody stain.

Using fluorescein-conjugated globulins specific for Actinomyces israelii and Arachnia propionica, we observed large dispersed actinomycete populations in vaginal smears of several asymptomatic women. Mycelial granules, commonly revealed by the Papanicolaou stain, were not seen. These observations are discussed in regard to the threat of infection and sensitivity of the fluorescent stain.

PIP: Using fluorescein-conjugated globulins specific for Actinomyces israelii and Arachnia propionica, the authors sobserved large dispersed actinomycete populations in vaginal smears of several asymptomatic women. Mycelial granules, commonly revealed by the Papanicolaou stain, were not seen. These observations are discussed in regard to the threat of infection and sensitivity of the fluorescent stain.

Actinomyces in the vaginas of women with and without intrauterine contraceptive devices.

Either Actinomyces israeli, A. naeslundii, or Arachnia propionica was found, by immunofluorescence studies, in cervicovaginal mucus from 36% of 50 women. One or more of these organisms were found in a surprising 27% of those with neither intrauterine contraceptive devices (IUDs) nor intravaginal foreign bodies. The only common finding was abundant vaginal mucus, and no clinical features were more serious than vaginal itching, odor, or vague discomfort. Among those women who harbored actinomycetes, the average duration of continuous IUD use was 5.3 years; the comparable figure for those with no infection was 2.1 years.

PIP: This study compares the presence of Actinomyces in the vaginas of women with and without IUDs. Mucus samples were collected from the external cervical os of 50 randomly selected women. The smears were air-dried, heat-fixed, and stained directly with fluorescent antibody conjugates for A. israelii, A. naeslundii, and Arachnia propionica (Actinomyces species with clinical significance in human beings). A fluorescent microscope with oil immersion magnification of about 400x was used, and identification of the specific organisms depended upon both cellular morphologic features and the brilliant greenish yellow fluorescence of the cell membrane. Either 1 of 3 A. species was positively identified in 18 of 50 patients (36%). 1 or more species were found in 8 of 30 patients with no internal devices (27%). Of 18 IUD wearers, 8 were positive for Actinomyces (44%). 1 patient with a retained vaginal tampon and another 1 with a pessary also had positive smears. A. israelii and Arachnia propionica were the most commonly identified species. If the organism was found, average duration of continuous IUD use was 5.3 years (range, 1 to 15 years). Where these organisms do not exist, average continuous use was 2.1 years. Age of patients positive for Actinomyces ranged from 18 to 52 years. These findings do not show the true incidence of these organisms in either the general population or IUD wearers. However, they suggest the presence of such organisms in asymptomatic women, with or without intravaginal devices. Papanicolaou staining is not sufficient in identifying the presence of the organisms. Further studies must be done. The immunofluorescence technique is a simple, rapid and universally available technique for identifying the organism. Further studies should be done to determine whether these organisms lie dormant until some pathogens or trauma precipitate disease. Also, the disease actinomycosis should be carefully distinguished from the mere presence of Actinomycetaceae in the vagina.

Demonstration of Actinomyces and Arachnia species in cervicovaginal smears by direct staining with species-specific fluorescent-antibody conjugate.

For direct observation of microaerophilic actinomycetes by fluorescent antibody, a procedure was developed in which pepsin treatment and rhodamine conjugate of normal serum were used to reduce nonspecific staining in cervicovaginal smears. Actinomyces israelii, Actinomyces naeslundii, and Arachnia propionica were observed in cervicovaginal smears from women who did use and who did not use an intrauterine contraceptive device. A. israelii was found more commonly in women with an intrauterine contraceptive device, but no evidence was obtained that the use of an intrauterine contraceptive device influenced the presence of either A. propionica or A. naeslundii.

PIP: A procedure was developed for the direct observation of microaerophilic actinomycetes by fluorescent antibody. In the procedure pepsin treatment and rhodamine conjugate of normal serum were used to reduce nonspecific staining in cervicovaginal smears. Observations of "A. israelli," "A. naeslundii." and "A. propionica" in cervicovaginal smears are reported. These organisms were identified by direct staining with flurescein isothiocyanate (FITC)-labeled rabbit globulin specific for each organism and by observing for a typical actinomycete morphology. In initial experiments with FITC conjugates, "A. israelli" could not be demonstrated in tissue sections known to be positive by culture and Gram stain. By using the conjugates specific for each species, examination of the sections of endometrium and endocervix showed actinomycotic filaments staining only with the anti-"A. israelli" conjugate. Examination of cervicovaginal smears from the first 25 patients with phase-control microscopy were not suitable for observations of actinomycete elements. Of the smears from the 19 patients with an IUD, 39% were postive for "A. israelli," and 17% were positive for "A. propionica." None of the smears was positive for "A. naeslundii." Only 12% and 6% of the slides from 32 patients without an IUD stained positively for "A. israelli" and "A. naeslundii," respectively.