Are adjunctive markers useful in routine cervical cancer screening? Application of p16(INK4a) and HPV-PCR on ThinPrep samples with histological follow-up

The objectives of the study were to evaluate 1) the diagnostic sensitivity and specificity of p16(INK4a) as a marker for high-grade cervical lesions, 2) the results of a real-time polymerase chain reaction detecting high-risk human papillomavirus, and 3) the interobserver variability of the p16(INK4a) interpretation.A total of 232 ThinPrep samples were stained for p16(INK4a), and HPV-DNA PCR was performed on 107 specimens with inclusion of both benign and abnormal cytology. Histological follow-up information was collected. The diagnostic sensitivity of ASC+ with CIN2+ in histology as endpoint was 96% for p16(INK4a) and 100% for HR-HPV DNA PCR, and the diagnostic specificity was 41% and 27%, respectively. If p16(INK4a) had been used for triage of the ASC samples, then 18 patients (42%) could have been spared unnecessary follow-up procedures compared to six patients (21%) with the HR-HPV DNA test.

Comparison of HIV-1 pol and env sequences of blood, CSF, brain and spleen isolates collected ante-mortem and post-mortem

OBJECTIVES

HIV-1 infects the central nervous system (CNS) early in the course of infection. However, it is not known to what extent the virus evolves independently within the CNS and whether the HIV-RNA in cerebrospinal fluid (CSF) reflects the viral population replicating within the brain parenchyma or the systemic infection. The aim of this study was to investigate HIV-1 evolution in the CNS and the origin of HIV-1 in CSF.

MATERIALS AND METHODS

Longitudinally derived paired blood and CSF samples and post-mortem samples from CSF, brain and spleen were collected over a period of up to 63 months from three HIV-1 infected men receiving antiretroviral treatment and presenting with symptoms of AIDS dementia complex (ADC).

RESULTS

Phylogenetic analyses of HIV-1 V3, reverse transcriptase (RT) and protease sequences from patient isolates suggest compartmentalization with distinct viral strains in blood, CSF and brain. We found a different pattern of RT and accessory protease mutations in the systemic infection compared to the CNS.

CONCLUSIONS

We conclude that HIV-1 may to some extent evolve independently in the CNS and the viral population in CSF mainly reflects the infection in the brain parenchyma in patients with ADC. This is of importance in understanding HIV pathogenesis and can have implications on treatment of HIV-1 patients.

The perception of pain and pain-related cognitions in subacute whiplash-associated disorders: its influence on prolonged disability

PURPOSE

To clarify the relations between the sensory, affective and cognitive dimensions of pain and to analyse what influence these components have on persistent disability in patients with subacute whiplash-associated disorders (WAD).

METHOD

The data was obtained from an on-going randomised controlled trial (RCT) on 47 patients. The sensory dimension of pain was evaluated with a visual analogue scale (VAS) diary and a Painometer. The affective dimension was assessed using the Painometer. The Tampa Scale for Kinesiophobia (TSK) and the Self-Efficacy Scale (SES) were used as measures of pain-related cognitions. The Pain Disability Index (PDI) was used as the outcome measure.

RESULTS

Forty patients (85%) completed the trial. The correlations between the sensory and affective dimensions of pain were non-significant, which indicates that they are two independent constructs that describe various dimensions of whiplash-related pain. High pain intensity and pain affect, more widespread pain, and high fear of movement/(re)injury corresponded to low self-efficacy. Multiple regression analyses showed that self-efficacy was the most important predictor of persistent disability contributing to 42% of the variation in the PDI score.

CONCLUSION

The treatment approach for patients with subacute WAD should incorporate the multidimensional nature of pain and to prevent disability special effort should be made to enhance the patient's self-efficacy beliefs.

Endovascular Recanalisation in Occlusive Mesenteric Ischemia—Feasibility and Early Results

OBJECTIVE

To evaluate a single centre experience of endovascular treatment of mesenteric ischemia caused by vascular occlusion.

DESIGN

Retrospective study.

MATERIAL AND METHODS

Between 1995 and 2002 17 patients (12 females; mean age 61 years) with symptoms of bowel ischemia were treated endovascularly for arterial occlusion. Vessels were evaluated with angiography and pressure gradient measured. A mean gradient of > 20 mmHg or a stenosis of > 50% was considered significant. Patient data were recorded prospectively and follow-up was supplemented with retrospective chart review. Fifteen patients had follow up imaging, median 10 months (3-29 months) postoperatively. Median clinical follow up was 14 months (5-42 months).

RESULTS

Recanalisation was successful in 16 patients (94%). The average number of stents used was 1.6 per patient. For one patient recanalisation failed with subsequent SMA dissection. A celiac artery stenosis was stented but symptoms remained postoperatively. Perioperative mortality was 5.8% (n = 1). 14/17 patients (82%) displayed symptom relief/improvement. Six patients required secondary endovascular intervention; PTA (n = 3); stent/stentgraft (n = 3). Two of these patients required a third procedure. 4/6 patients that underwent secondary intervention were asymptomatic and of recurrent stenosis > 75% and a gradient > 15 mmHg mean pressure gradient on imaging. Two patients were treated because of a combination of angiographic findings and/or significant pressure gradient combined with clinical symptoms.

CONCLUSIONS

Endovascular treatment of mesenteric ischemia due to vessel occlusion is feasible with acceptable short-term results and limited complications. Most patients experience relief/improvement of symptoms. A significant number of patients might need endovascular re-intervention because of restenosis.

Peripheral arterial disease. Contrast-enhanced 3D MR angiography of the lower leg and foot compared with conventional angiography

PURPOSE

To determine whether contrast-enhanced 3D MR angiography (CE MRA) could replace digital subtraction angiography (DSA) for the evaluation of atherosclerotic peripheral vascular disease of the lower leg and foot.

MATERIAL AND METHODS

Thirty-five patients with symptoms of atherosclerotic disease of the leg were examined prospectively with CE MRA of the foot and the lower legs as well as with DSA from the aorta to the pedal arches. The MRA technique was focused on optimal imaging of the arteries of the foot.

RESULTS

The agreement between CE MRA and DSA for grading of stenosis was moderate to good (weighted kappa-values 0.48-0.80). The sensitivity of CE MRA for detection of significant stenosis (> or = 50%) was 92% and the specificity was 64% with DSA as gold standard.

CONCLUSION

CE MRA is a fairly accurate method for the demonstration of atherosclerotic disease below the knee including the pedal arches. It can replace DSA for the assessment of distal arteries in patients with impaired renal function. However, image quality and resolution still needs to be improved before CE MRA can become the method of choice in all patients.

Simple method for detection of mutations causing hereditary fructose intolerance

Aldolase B is critical for sugar metabolism, and a catalytic deficiency due to mutations in its gene may result in hereditary fructose intolerance (HFI) syndrome, with hypoglycaemia and severe abdominal symptoms. This report describes two cases of HFI, which were identified by intravenous fructose tolerance test and a new RFLP (restriction fragment length polymorphism) test that detects the two most common mutations, A149P and A174D. The method includes PCR of a 224-base-pair segment of exon 5, a subsequent 3 h incubation with Cac8I and agarose electrophoresis, which reveals either or both of the mutations in one single reaction. The method might be useful for screening of these mutations, which may account for more than 70% of the mutations causing HFI.

Moderate alcohol intake increases fibrosis progression in untreated patients with hepatitis C virus infection

Although excessive alcohol consumption in combination with hepatitis C virus (HCV) infection is known to increase the risk of liver cirrhosis, the effect of moderate alcohol intake remains to be elucidated. The aim of this study was to evaluate the effect of moderate alcohol consumption on fibrosis progression in HCV infection. A group of 78 patients with HCV infection and moderate alcohol consumption were analysed retrospectively. All patients had undergone two liver biopsies, with a median time between biopsies of 6.3 years, and had not received any antiviral therapy. Their lifetime drinking history was recorded. All patients except one had daily alcohol consumption below 40 g of ethanol (median 4.8 g/day, interquartile range 1.1-11.6 g/day) during the period between the biopsies. The patients whose liver fibrosis had deteriorated had a higher total alcohol consumption and higher drinking frequency between the biopsies. The degree of fibrosis progression was greater in patients with a total alcohol intake and drinking frequency above the median level for the group. A multiple logistic regression analysis showed that drinking frequency and time between biopsies were independently associated with fibrosis progression. Hence, even moderate alcohol intake seems to increase fibrosis progression in HCV-infected patients. From that point of view, total abstention ought to be recommended. If this is not achieved, occasional use of alcohol is probably less harmful than daily drinking for patients with low or moderate alcohol consumption.

Hepatitis B virus genotypes in Mongols and Australian Aborigines

Hepatitis B virus (HBV) is spread worldwide. Seven genotypes, A-G, have been described, differing by more than 8% of the genome. In eastern Asia and Oceania genotypes B and C are predominant. However, little is known about genotypes in Mongolia and Australian aborigines. We analysed the preS and S regions of HBV from 9 Mongols and 5 Australian Aborigines. All Mongolian strains were of genotype D and were most similar to Central Asian sequences. All the Australian strains were genetically of serotype ayw3, and could not be reliably classified by the S region analysis, but placed on a separate branch. By preS analysis, they were however clearly of genotype C. The 6-7% nucleotide difference from published Asian genotype C sequences suggests that they diverged from Asian genotype C branch more than 1000 years ago.

Phylogenetic origin of hepatitis B virus strains with precore C-1858 variant

Mutations that prevent the expression of the hepatitis B e antigen frequently emerge in the immunoreactive phase of infection. The predominant mutation, the precore G-->A-1896 mutation, is restricted by the variability at position 1858 and is rare in strains with cytosine at nucleotide 1858. The C-1858 variant is characteristic of genotype A. It also occurs in genotypes C and F, but not in B, D, or E, explaining the geographical variation in the prevalence of precore mutants. C-1858 strains have been frequently observed in southeast Asia, but have not been phylogenetically characterized. By sequencing eight complete hepatitis B virus genomes, C-1858 variants of east Asian origin were found to constitute a phylogenetic entity within genotype C that probably diverged several hundred years ago. Further study of the distribution of this variant is warranted.

Virological response to interferon therapy of chronic hepatitis B as measured by a highly sensitive assay

In the interferon (IFN) treatment of chronic hepatitis B, there is no accepted definition of virological response as measured by highly sensitive HBV DNA assays. In the present study of 98 patients given IFN (10 MU/day for 1 week, then 10 MU TIW for 11 weeks) with or without prednisolone priming, a virological response was identified as log HBV DNA/mL below 6.0 (by Amplicor Monitor, Roche) 6 months post-treatment. At this time, 92% (33/36) of the sustained responders (SR) still had detectable viraemia with log HBV DNA/mL at 4.30 +/- 0.15 (+/- SEM), as compared with 8.69 +/- 0.097 in nonsustained responders. Pretreatment viraemia below a threshold at 500 million copies/mL was associated with higher chance of response (P=0.023). Prednisolone enhanced the sustained response (53% vs. 30%, P=0.025), and in particular end-of-treatment response (ETR, 50% vs. 10%, P < 0.0001). ETR was predictive for SR (P < 0.0001), especially when log HBV DNA/mL was < 4.0 (PPV=92%). The potential value of differentiating the therapy of chronic hepatitis B on the basis of viraemia levels, as measured by highly sensitive assays, should be further investigated.

Monitoring virological responses to interferon-ribavirin and interferon monotherapy of chronic hepatitis C re-treated due to relapse or non-response

Adding the nucleoside analog ribavirin (RBV) to interferon (IFN) for treatment of HCV has improved the sustained response rates, but the mechanism by which RBV mediates viral clearance is not fully understood. In this study, a highly sensitive method (Codes Amplicor HCV Monitor) was used to monitor the early (first 12 weeks of therapy) and long-term virological response in 20 patients who were treated first with IFN and later, due to non-sustained response, with IFN-RBV. All 10 IFN relapsers displayed a prompt virological response at week 4 to both IFN and IFN-RBV therapy; nine of them showed a sustained response to IFN-RBV. Out of 10 IFN non-responders, five showed a sustained response to IFN-RBV. Four of these were HCV RNA-negative at week 4 of IFN-RBV therapy and two of them had a transient early virological response (RNA-negative at weeks 4-8) to IFN alone. Overall, of the 14 patients (nine IFN relapsers, five IFN non-responders) with a sustained response to IFN-RBV, 11 and 13 had HCV RNA below 2000 copies/ml at week 4 of IFN and IFN-RBV, respectively, as compared with one and one of six patients without a sustained response to IFN-RBV (p < 0.02). Thus, addition of RBV to IFN increased both viral clearance during the first 12 weeks of therapy and the rate of sustained response. Loss of viremia at week 4 of IFN was associated with a sustained response to IFN-RBV and was seen in 11 of 13 patients (85%) with genotypes 2 or 3, as compared with one of seven patients (14%) with genotype 1 (p = 0.0044).

Stent-graft repair of a splenic artery aneurysm

We present a case of splenic artery aneurysm (SAA) treated with stent-grafts. This new method offers the benefit of preserving the blood flow through the splenic artery. This in turn allows for subsequent sequential embolization of the spleen when indicated, as in our patient with hypersplenism. This is the first reported case of stent-graft repair of SAA.

Aneurysm expansion and retroperitoneal hematoma after thrombolysis for stent-graft limb occlusion caused by distal endograft migration

PURPOSE

To describe a complication of thrombolytic therapy used to treat graft limb occlusion precipitated by distal migration and kinking of an abdominal aortic stent-graft.

CASE REPORT

A 5.5-cm abdominal aortic aneurysm (AAA) in a 66-year-old woman was treated with Vanguard bifurcated stent-graft. At the 1-year follow-up, she complained of left leg claudication. Computed tomography (CT) showed a 36% reduction in maximum AAA diameter, but the stent-graft had migrated distally approximately 5 mm, and the left graft limb was occluded. Thrombolysis was initiated, but after approximately 8 hours, abdominal pain began. Emergent CT scanning revealed rapid aneurysm expansion and a retroperitoneal hematoma. Thrombolytic treatment was stopped; transfusions and thrombogenic drugs were given to restore hemodynamic stability. The aneurysm began to decrease in size. The occluded graft limb had been reopened by the lytic therapy, uncovering a stenosis in the native artery distal to the graft limb. Stent placement restored outflow. The retroperitoneal hematoma resolved over time, and the aneurysm sac shrank to its prelytic diameter. The patient is well with a functioning endograft 18 months after the occlusion (30 months after stent-grafting).

CONCLUSIONS

Caution must be taken when using thrombolysis in patients with endovascular aortic grafts because unexpected bleeding complications might arise. Thrombectomy, femorofemoral bypass, or stent or stent-graft extensions might be safer alternatives for treating occluded stent-graft limbs.

Levels of viraemia in subjects with serological markers of past or chronic hepatitis B virus infection

Subjects with serological markers for a past HBV infection may still have HBV DNA in their serum, but the levels of viraemia in such cases are not known. In the present study, of 63 consecutive HBsAg-negative, anti-HBc-positive serum samples with or without anti-HBs, 20 were HBV DNA-positive as analysed by a highly sensitive quantitative PCR, the Cobas Amplicor HBV Monitor test. However, all of these 20 samples had viraemia levels below 1000 copies/ml, compared with median viraemia levels of 10(8.6) and 10(4.3) copies/ml, respectively, in 98 HBeAg-positive and 124 HBeAg-negative HBsAg carriers. There was no difference in viraemia between subjects with anti-HBc alone compared with both anti-HBs and anti-HBc, nor between those with or without hepatitis C virus antibodies. The findings indicate that HBsAg-negative subjects may retain a low infectivity. Their risk for progressive liver damage is probably low, but this deserves further study.

Hepatitis B virus DNA levels, precore mutations, genotypes and histological activity in chronic hepatitis B

The present study aimed to clarify how viraemia levels reflect the clinical stages of chronic hepatitis B virus (HBV) infection, in particular studying whether 'healthy carriers' can be identified by analysing HBV DNA levels with a highly sensitive quantitative assay. Histology activity index (HAI), alanine aminotransferase (ALT) level, genotype and precore mutations were compared with the HBV DNA level, as measured using the Amplicor HBV Monitor assay in a prospective study. In 124 hepatitis B e antigen-negative (HBeAg-) patients, the majority with mild liver disease, log HBV DNA levels showed a Gaussian distribution around a geometric mean of 33 000 genome copies ml-1, and increasing HBV DNA level was associated with significantly higher inflammation (HAIinfl) and fibrosis (HAIfibr) scores and higher ALTi (ALT / the upper reference value). Severe inflammation (HAIinfl > or = 7) was seen in 83% (five of six), 36% (eight of 22) and 3% (one of 37) of HBeAg- patients with HBV DNA > 107, > 2 x 105 and < 104 copies ml-1, respectively. In severe HBeAg- hepatitis, patients with precore wild-type infection had lower HBV DNA levels than those with precore mutants. In 36 HBeAg-positive (HBeAg+) patients, no correlation between HBV DNA level and liver damage was seen. Ninety-six per cent of HBeAg- patients with ALTi < 0.5 had HAIinfl < or = 3. In HBeAg- carriers with ALTi 0.5-1.0, the relative risk for severe inflammation, comparing HBV DNA > 2 x 105 copies ml-1 vs < 2 x 105 copies ml-1, was 14.7. In conclusion, in HBeAg- carriers, HBV DNA < 104 copies ml-1 or ALTi < 0.5 indicates mild inflammation, while > 2 x 105 copies ml-1 of HBV DNA may justify further investigations. Precore status may be relevant for the interpretation of viraemia.

Acute hepatitis B in Western Sweden--genotypes and transmission routes

A retrospective study of acute hepatitis B (AHB) during 1995-1996 in Göteborg, Sweden, was carried out to investigate whether the increasing number of hepatitis B virus (HBV) carriers due to immigration in northwestern Europe has influenced the incidence or genotype heterogenicity. 24 cases of AHB were identified, the probable transmission route of which was intravenous drug use (IVDU) in 11 (46%), heterosexual in six (25%), homosexual in one, hemodialysis in two and unknown in four cases. In no case was the source an immigrant with chronic HBV infection. Genotype D was seen in 12 patients, seven being anti-HCV-positive IVD users, two probably infected heterosexually and three with an unknown source. Genotype A was found in six patients: three IVD users, a sexual partner of an IVD user and two dialysis patients. Genotype B was found in one patient infected during travel to Vietnam, and genotype C in one patient, probably infected sexually from a previously identified chronic carrier. In conclusion, genotype D is the main genotype and IVDU still the major risk factor for AHB in Goteborg, while transmission from immigrants appears to be of minor importance despite the fact that this group comprises over 90% of the young, highly infectious carriers.

Primary stenting in infrarenal aortic occlusive disease

PURPOSE

To evaluate the results of primary stenting in aortic occlusive disease.

METHODS

Thirty patients underwent primary stenting of focal concentric (n = 2) and complex aortic stenoses (n = 19), and aortic or aorto-iliac occlusions (n = 9). Sixteen patients underwent endovascular outflow procedures, three of whom also had distal open surgical reconstructions. Median follow-up was 16 months (range 1-60 months).

RESULTS

Guidewire crossing of two aorto-biiliac occlusions failed, resulting in a 93% (28/30) technical success. Major complications included one access hematoma, one myocardial infarction, one death (recurrent thromboembolism) in a patient with widespread malignancy, and one fatal hemorrhage during thrombolysis of distal emboli from a recanalized occluded iliac artery. One patient did not improve his symptoms, resulting in a 1-month clinical success of 83% (25/30). Following restenting the 26 stented survivors changed their clinical limb status to +3 (n = 17) and +2 (n = 9). During follow-up one symptomatic aortic restenosis occurred and was successfully restented.

CONCLUSIONS

Primary stenting of complex aortic stenoses and short occlusions is an attractive alternative to conventional surgery. Larger studies with longer follow-up and stratification of lesion morphology are warranted to define its role relative to balloon angioplasty. Stenting of aorto-biiliac occlusions is feasible but its role relative to bypass grafting remains to be defined.

Long-term mutation rates in the hepatitis B virus genome

Mutations in the hepatitis B virus (HBV) genome have so far been investigated in cross-sectional or short-term longitudinal studies. Information about long-term changes is lacking due to the difficulty of sampling over long observation periods. In this study, a retrospective approach was used that allowed the analysis of changes in the viral genome from transmission to late stages of infection without the requirement for sampling early during this period. The entire viral genome was sequenced from serum samples of three mothers and their 10 adult children, who presumably had been infected vertically. The emergence of mutations between birth and sampling (mean 26.5 years) was assessed by comparing the individual sequences with the sequence of the strain assumed to have been transmitted. The mean differences from this sequence were 0.02 and 0. 28% in seven asymptomatic and one symptomatic hepatitis B e antigen (HBeAg)-positive carriers, respectively, and 0.62 % in five HBeAg-negative carriers. Mutations occurred throughout the genome and 88% of the mutations caused amino acid substitutions spread over all genes. In HBeAg-negative carriers, the number of nucleotide and amino acid changes was independent of the severity of liver disease and, except the (1762)AGG(1764)-->TGA changes, no specific mutation was associated with liver disease. In conclusion, by using a novel method it was found that the entire HBV genome is extremely stable over long periods of time during the HBeAg-positive phase if the immune response (inflammation) is weak, whereas an average of 20 mutations emerged after development of hepatitis and/or loss of HBeAg without association with clinical outcome.

Endovascular repair of descending thoracic aortic aneurysms: an early experience with intermediate-term follow-up

PURPOSE

The purpose of this study was to report an initial experience with the endovascular repair of descending thoracic aortic aneurysm. Complications and intermediate-term morphologic changes were identified with the intent of altering patient selection and device design.

METHODS

Endografts were placed into 25 patients at high-risk for conventional surgical repair over a 3(1/2)-year period. Devices were customized on the basis of preoperative imaging information. Follow-up computed tomography scans were obtained at 1, 3, 6, and 12 months and yearly thereafter. Additional interventions occurred in the setting of endoleaks, migration, and aneurysm growth.

RESULTS

The overall 30-day mortality rate was 20% (12.5% for elective cases; 33% for emergent cases). There were 3 conversions to open repair. Neurologic deficits developed in 3 patients; 1 insult resulted in permanent paraplegia. Neurologic deficits were associated with longer endografts (P =.019). Three endoleaks required treatment, and 1 fatal rupture of the thoracic aneurysm treated occurred 6 months after the initial repair. Migrations were detected in 4 patients. The maximal aneurysm size decreased yearly by 9.15% (P =.01) or by 13.5% (P =.0005) if patients with endoleaks (n = 3 patients) were excluded. Both the proximal and distal neck dilated slightly over the course of follow-up (P =.019 and P =.001, respectively). The length of the proximal neck was a significant predictor of the risk for endoleakage (P =.02).

CONCLUSION

The treatment of descending thoracic aortic aneurysms with an endovascular approach is feasible and may, in some patients, offer the best means of therapy. Early complications were primarily related to device design and patient selection. All aneurysms without endoleaks decreased in size after treatment. Late complications were associated with changing aneurysm morphologic features and device migration. The morphologic changes remain somewhat unpredictable; however, alterations in device design may result in improved fixation and more durable aneurysm exclusion.