Management of squamous atypia (borderline nuclear abnormalities): repeat cytology or colposcopy?

A prospective cytological, colposcopic and histological study was conducted in 44 women with cervical cytology showing borderline nuclear abnormalities insufficient for the diagnosis of dyskaryosis. Atypical squamous epithelium was found on colposcopy in 41 patients and cervical intraepithelial neoplasia (CIN) was diagnosed on histology in 33 patients (75%) including 10 with CIN 3. Repeat cytology obtained under colposcopic vision was negative in 12 (33.4%) patients with CIN. The high prevalence of CIN in smears showing only borderline nuclear abnormalities and the high false negative rate of repeat cytology indicate that colposcopy should be the first line of management for these patients.

Lymphocyte phenotypes in cervical intraepithelial neoplasia and human papillomavirus infection

Lymphocyte phenotypes in cervical mucosa were studied using a panel of monoclonal antibodies. T lymphocytes were predominant both within the epithelium and in the subepithelial stroma. In the normal cervix, both the T4+ (helper/inducer) and T8+ (suppressor/cytotoxic) subsets were present in a ratio similar to that in the peripheral circulation. In human papillomavirus (HPV) infection and cervical intraepithelial neoplasia (CIN) there was depletion of intraepithelial lymphocytes, especially of T4+ subset, with reversal of the ratio of T4+ to T8+ subsets to less than one. In contrast, there was no significant reduction in the number of lymphocytes in the subepithelial stroma. Tac+ (antigen primed and clonal expanding) lymphocytes were absent both within the epithelium and in the subepithelial stroma. These findings support our suggestion that there is a localized immunodeficiency in HPV infection and CIN. The aetiological and therapeutic implications are discussed.

Subpopulations of Langerhans' cells in cervical neoplasia

Multiple markers were used to count Langerhans' cells in the cervix. In the normal cervix, thymocyte antigen (T6) and adenosine triphosphatase (ATPase) demonstrated the largest population of Langerhans' cells. MHC Class II positive cells were equivalent to 60%, and S100 positive cells were equivalent to 35% of T6 or ATPase positive cells. Whereas Langerhans' cells demonstrated by T6, ATPase, and MHC Class II antigen were evenly distributed throughout the epithelium, the S100 positive cells were seen predominantly near lymphocytic aggregates and capillaries. In human papillomavirus infection and cervical intraepithelial neoplasia the numbers of T6, ATPase, or MHC Class II positive Langerhans' cells were reduced by 60% but the S100 positive cells were almost completely depleted. These findings suggested that there were different subpopulations of Langerhans' cells in the cervical epithelium. The depletion of Langerhans' cells, particularly the selective depletion of the S100 positive subpopulation, might cause a localized immunodeficiency that impairs immune surveillance and the cell-mediated immune response to human papillomavirus infection and cervical intraepithelial neoplasia.

A new fixed cryosection technique for the simultaneous immunocytochemical demonstration of T6 and S100 antigens

A formalin-calcium fixation method of preparing cryosections is described, which allows demonstration of Langerhans' cells by S100 antigen staining on frozen sections. The number of Langerhans' cells given by T6 antigen staining is also higher in formalin-calcium fixed frozen sections than acetone fixed frozen sections. The preparation is suitable for dual demonstration of the two antigens on the same section enabling a more accurate numerical evaluation of Langerhans' cell populations in the normal cervical epithelium.

T-lymphocyte populations in normal and coeliac small intestinal mucosa defined by monoclonal antibodies

Counts of T-lymphocytes within surface and crypt epithelium and lamina propria of normal and coeliac small intestinal mucosa using an immunoperoxidase method are described and related statistically to changes in mucosal structure determined by quantitative histology. The use of multiple pan-T-lymphocyte and subset antibodies allowed comparison of marker patterns in normal and abnormal mucosa. Total numbers of surface epithelial T-lymphocytes and subtypes were not found to be increased in coeliac disease, but there was an increase in density per unit length of epithelium. Distinctive changes in expression of Leu 1, Leu 2, and Leu 5 by the surface epithelial T-lymphocytes suggest that, although their total numbers are not increased, these cells are not passively crowded but have an active role, possibly as committed cytotoxic lymphocytes. Natural killer cells do not appear to be a major population in normal or coeliac small intestinal mucosa.

Histological and immunocytochemical study of cervical intraepithelial neoplasia (CIN) with associated HPV 6 and HPV 16 infections

Histological and immunocytochemical features of cervical intraepithelial neoplasia (CIN) associated with HPV 6 and HPV 16, either singly or in combination, were studied in 48 cases. Features of HPV infection (koilocytosis, binucleation, multinucleation, giant irregular nuclei and individual cell dyskeratosis) were present in high prevalence in both HPV 6 and HPV 16 associated CIN. Abnormal mitoses seemed to be a good indicator of CIN and were present in about 50% of cases of CIN associated with either HPV 6 or HPV 16 infection. This finding provides no support for the view held by some investigators that associated HPV 16 infection can be predicted by the presence of abnormal mitoses. Expression of HPV antigen was shown in about 40% of cases with a slight, but not significantly, higher prevalence in cases of combined HPV 6 and HPV 16 infection. Conventional histology and immunocytochemistry could not distinguish CIN associated with HPV 6 from CIN associated with HPV 16 infection.

Expression of fibronectin, laminin, and factor VIII-related antigen during development of the human cutaneous microvasculature

The regulation of angiogenesis during human skin development is poorly understood. Since fibronectin is involved in cell movement and organization during embryogenesis and morphogenesis in a variety of species, we investigated the expression of fibronectin and factor VIII-related antigen, a marker for endothelial cells, at various stages in the development of the human cutaneous microvasculature. Skin specimens were obtained from 4 human fetuses during the second trimester (14-18 weeks), from newborn foreskins, and from consenting normal adults. Cryostat sections were stained with both fluorescein-conjugated rabbit antihuman fibronectin and rhodamine-conjugated goat antihuman factor VIII-related antigen. Expression of fibronectin in the microvasculature was striking in fetal skin but became progressively less prominent with maturation. Fibronectin appeared in fetal blood vessels as a bright continuous linear array, in neonatal blood vessels as a bright interrupted linear and speckled array, and in adult blood vessels as a sparse interrupted linear and speckled array. In contrast, expression of factor VIII-related antigen by the endothelium became more prominent with the degree of maturation of the microvasculature. Granular factor VIII-related antigen staining was scant in the newly forming blood vessels of fetal skin, bright but focal in the microvasculature of newborn skin, and intense and almost confluent in the blood vessels of adult skin. Although expression of fibronectin and factor VIII-related antigen changed, expression of laminin was consistent throughout development. Staining of the same skin specimens with fluorescein-conjugated sheep antihuman laminin produced a bright continuous linear pattern in all blood vessels. The reciprocal relationship manifested by intense fibronectin staining during human blood vessel development and prominent factor VIII-related antigen staining in mature blood vessels supports the hypotheses that fibronectin plays a role in human blood vessel modulation and morphogenesis, and that factor VIII-related antigen is a marker for endothelial cell differentiation.

Prevalence of human papillomavirus type 16 DNA sequences in cervical intraepithelial neoplasia and invasive carcinoma of the cervix

The frequency of human papillomavirus (HPV) type 16 in premalignant and malignant lesions of the cervix was investigated and compared with the detection of HPV type 6. In cervical intraepithelial neoplasia (CIN) grades I-III HPV 6 was detected in 28% and HPV 16 in 62% of patients whereas 90% of malignant lesions contained HPV 16 only. In the CIN lesions there was an increase in HPV 16 detection as the severity of disease increased while the level of detection of HPV 6 decreased. Only three (18%) of the cervices that were colposcopically and histologically normal contained HPV genomes; although two of these three women had either a history of genital warts or a sexual partner with penile warts.

Duodenal bulb plasma cells in duodenitis and duodenal ulceration

Using an immunoperoxidase technique IgA, IgM, IgE and IgG plasma cells were studied in endoscopic duodenal bulb biopsies taken from 14 controls, 25 patients with grade 1 duodenitis (Whitehead classification), 12 patients with grade 2 duodenitis and three with grade 3 duodenitis. The control counts were compared with those in the jejunum and rectum. In addition cell counts were compared in 16 pairs of patients, with and without duodenal ulcer, exactly matched for grade of duodenitis. The control counts were not significantly different from counts in jejunum or rectum except for IgG which were higher in the jejunum (p = 0.03). IgA plasma cell counts were significantly increased in both grade 1 and grade 2 duodenitis compared with controls (p less than 0.05 and p less than 0.01). There was no significant difference for the other plasma cells. All plasma cell counts were decreased in the small group of grade 3 duodenitis compared with the other groups. There was no significant difference between counts in duodenitis whether or not there was associated duodenal ulceration. The isolated IgA plasma cell response of the duodenal bulb mucosa in duodenitis is very different from that of the jejunal mucosa in coeliac disease, and the rectal mucosa in inflammatory bowel disease and bacterial colitis and probably represents the basic response to any mucosal damage.

Defining duodenitis: quantitative histological study of mucosal responses and their correlations

Biopsies from 56 patients with endoscopically normal duodenal bulbs, duodenitis, or duodenal ulceration were studied for counts of plasma cells, polymorphs, and eosinophils and extent of gastric metaplasia, villous atrophy, and mucosal oedema. A correlation matrix showed that the counts of different types of plasma cells were closely correlated with each other and that there was also a close correlation between the presence of intraepithelial polymorphs, villous atrophy, and gastric metaplasia. Cluster and discriminant analysis indicated that the histological changes could be grouped by their statistical association into three simple categories: normal, which includes many cases incorrectly labelled in some classification systems as mild or chronic duodenitis; histologically defined mild duodenitis, characterised by an appreciable plasma cell response and oedema usually with intraepithelial polymorph infiltration and gastric metaplasia; and severe duodenitis, with an appreciable polymorph response and villous atrophy but decreased plasma cells. Decreased plasma cells may be an important indication of peptic ulceration.

Long-term ambulatory treatment of metastatic colorectal adenocarcinoma by continuous intravenous infusion of 5-fluorouracil

To delineate the efficacy of continuous intravenous 5-fluorouracil (5-FU) infusion therapy for advanced colorectal adenocarcinoma, a study of 36 patients with measurable metastatic disease was conducted. Patients received a daily intravenous infusion of 300 mg/m2 5-FU over a 24-h period utilizing portable infusion devices and central venous catheters. In a population characterized by substantial pretreatment exposure to radiotherapy, chemotherapy, and other indicators of poor prognosis, 13/36 (36%) patients achieved an objective response. An additional 10/36 (28%) patients manifested stable disease (no change) and experienced survival comparable to that of patients with objective response. Toxicity was minimal; patients were able to continue 5-FU infusions 95% of the total time on protocol. There were no adverse hematologic effects or catheter complications. Because previously untreated patients benefited more frequently (positive response, 50%), continuous intravenous infusion should be evaluated further as a primary modality option when 5-fluorouracil antitumor chemotherapy is contemplated.

Comparison of prevalence of human papillomavirus antigen in biopsies from women with cervical intraepithelial neoplasia

Human papillomavirus antigen was found in 39 (16%) of 253 colposcopic biopsies from a group of women at high risk for cervical cancer who had been examined in the early 1970s. Immunohistochemical evidence of papillomavirus infection was found in 20 (30%) of 67 cervical intraepithelial neoplasia lesions infected with wart virus from these patients. When these results were compared with results of a similar study carried out in the early 1980s there was no significant difference in the prevalence of human papillomavirus antigen in cervical intraepithelial neoplasia lesions infected with wart virus from women who had been examined over a decade apart.

Social adjustment after closed head injury: a further follow-up seven years after injury

A group of severely head injured patients were reassessed 7 years after injury. This group was the same as that previously reported 2 years after injury. There was no change in their physical or cognitive status; personality problems were still commonly reported but the less disabled had made further progress in returning to their former level of vocational and social activity.

The Cronkhite-Canada syndrome: an ultrastructural study of pathogenesis

Electron microscopical and cytochemical studies of intestinal biopsies from a patient with typical features of the Cronkhite-Canada syndrome show that the primary process affects the crypts. This results in cystic dilatation associated with expansion and focal degeneration of the crypt compartment of the intestinal epithelium. The villous epithelium compartment is reduced but ultrastructurally normal. Inflammation and oedema of the lamina propria follows from leakage of mucin through breaks in the abnormal crypts.

A microcomputer system in the delivery suite

Microcomputer systems have been installed in the delivery suites of two obstetric units which cater between them for nearly 10 000 deliveries annually. The midwifery and medical staff enter administrative, antenatal, anaesthetic and delivery details during labour and as soon after delivery as possible. The computer prints out the official Birth Notification, the entry for the Midwives Register and the record of labour and delivery for the patient's notes. Subsequently the postnatal doctor and anaesthetist, where relevant, enter details of puerperium and anaesthetic follow-up, before the production by the computer of discharge and anaesthetic summaries for the community and records. In the first 6 months of use at the Bristol Maternity Hospital (July to December 1982) 2229 patients were delivered and have had obstetric details recorded on the computer. A general obstetric audit of these patients is presented.

Epidemiological monitoring of environmental lead exposures in California State Hospitals

Blood lead screening of 8062 state hospital residents in California revealed 143 residents with excessive lead levels (greater than or equal to 30 micrograms/dL). This screening was part of the Childhood Lead Project and was performed in 1978. The purpose of this study was to identify "critical" lead sources in California State Hospitals. Accurate identification is crucial if subsequent abatement programs are to be effective. The strategy involved the following sequence of steps: 1) Selection of cases based on blood lead and erythrocyte protoporphyrin screening. 2) Determination of pica habits and environmental exposures through interviews with ward's staff and/or parents. 3) Measurement of lead levels in environmental samples reflecting exposures. 4) Interpreting these data in order to identify critical lead sources. 5) Reducing exposure to critical lead sources. 6) Following up of cases and controls to validate the effects of this strategy. A group of 36 lead-burdened cases with pica (30-60 micrograms Pb/dL blood) and 36 matched controls (PbB less than 20 micrograms/dL) were selected from among the developmentally disabled residents of two California State Hospitals. These subjects were studied in order to identify the lead sources to which they were exposed and to abate the major ones. Three major lead sources were found in the state hospitals: wall and furniture paints (100-45,400 micrograms Pb/g paint); surface soil (33-570 micrograms Pb/g soil); educational format was presented to all involved staff. The results have indicated a trend towards lower lead intake by the lead-burdened cases. In one of the two hospitals a "lead-free unit" had been established. All the lead-burdened cases were transferred to this unit in August 1981. A few months later the blood lead levels of all the cases dropped below 30 micrograms/dL. Initial epidemiological monitoring indicated where there were preventable hazards, which abatement efforts succeeded in reducing. Further monitoring of such problems is indicated in this and other developmentally-disabled populations.

Small intestinal plasma cells in coeliac disease

Using a modified immunoperoxidase technique to achieve optimum staining and reproducible counts of plasma cells in paraffin embedded tissue, IgA, IgM, IgE, and IgG plasma cells were studied in small bowel biopsies from 20 controls, 23 untreated coeliac patients, 19 treated coeliac patients, and seven patients with Crohn's disease not involving duodenum or jejunum. In controls the ratio of the mean counts for IgA, IgM, IgE, and IgG plasma cells was 2.5:1:1:1 respectively. In patients with untreated coeliac disease, counts of all types of plasma cell were significantly increased approximately two-fold compared with controls although for IgG cells there was considerable overlap. The ratio of the mean plasma cell counts in the untreated coeliac patients was 3.5:1.5:2:1. Counts fell significantly after treatment with a gluten-free diet. There was no significant difference between counts in the controls and the Crohn's disease patients. The changes found in coeliac disease may simply be a non-specific response to mucosal damage. The increases in IgA and IgM plasma cells, however, suggest that the deposits of extracellular IgA and IgM observed in coeliac mucosa are locally produced, and the increase in IgE plasma cells raises the possibility that reaginic type hypersensitivity may be involved in coeliac disease.