Factors associated with male infertility: a case-control study of 218 infertile and 240 fertile men

OBJECTIVE

To determine the likely risk factors, such as smoking and drinking habits, and occupational groups, for infertility in a group of infertile men with no known cause, compared with a group of fertile men; and to examine the effects of the semen parameters, such as volume, density, motility, viability and normal morphology, on fertility.

DESIGN

A case-control study.

SETTING

The department of obstetric and gynaecology of a tertiary general hospital.

PARTICIPANTS

Six hundred and forty consecutive male partners of couples trying to conceive were recruited from an infertility clinic. Of these, the cases comprised 218 men who had no known cause for their infertility. Two hundred and forty men whose wives were pregnant at the time of the study were recruited as controls.

RESULTS

The semen parameters (e.g. density, total sperm counts, motility, viability and normal morphology) of all cases were significantly poorer than that of the controls. The risk of infertility is associated with smoking (crude OR 2 x 82, 95% CI 1 x 93-4 x 13; adjusted OR 2 x 96; 95% CI 1 x 98-4 x 42). Technicians (adjusted OR 2 x 81; 95% CI 1 x 51-4 x 24) and professional, senior officials and managers were also at a greater risk of infertility (adjusted OR 2 x 36; 95% CI 1 x 26-4 x 40), compared with service and clerical workers. The significant factors predicting infertility were smoking, density of sperm, and viability of sperm. Smoking increased the odds of being infertile. Higher sperm counts and larger percentage of viable sperm decrease the odds of infertility. Based on the multiple logistic regression model, the odds ratio for infertility = (94 x 70) x (2 x 88(smoking)) X (0 x 29(logdensity)) X (0 x 95(viability)).

CONCLUSION

Smoking, density of sperm and the viability of sperm are significant predictors for infertility among men.

Two dosing regimens for preinduction cervical priming with intravaginal dinoprostone pessary: a randomised clinical trial

OBJECTIVE

To compare the efficacy within 24 hours of a three-times-a-day intensive dosing regimen with a standard once daily dosing regimen using dinoprostone vaginal pessary in preinduction cervical priming.

DESIGN

Randomised controlled trial.

SETTING

Department of Obstetrics and Gynaecology, Singapore General Hospital.

PARTICIPANTS

One hundred singleton term primigravidae with cephalic presentation with unfavourable cervical scores (Bishop score < or = 5) requiring induction of labour.

METHODS

Eligible women were randomly assigned the standard regimen (3000 microg dinoprostone [Prostin, Upjohn, Crawley, UK] once daily) or an intensive regimen (3000 microg dinoprostone given sequentially three times daily four hours apart) for cervical priming until successful priming (Bishop score of > or = 6) or the onset of active labour occurred.

MAIN OUTCOME MEASURES

Number of women whose cervices were ripened successfully or who entered active labour within 24 hours of starting cervical priming, priming to induction interval, and priming to delivery interval.

RESULTS

Forty-nine women were assigned to the standard regimen and 51 to the intensive regimen. The median number (range) of dinoprostone pessaries used was two (one to seven) in the standard regimen and three (one to nine) in the intensive regimen. Forty-two women (82.4%) who underwent the intensive regimen achieved successful cervical ripening or active labour within 24 hours, compared with 21 assigned to standard regimen (OR 6.2, 95% CI 2.3-17.4). This difference was statistically significant. The median intervals from priming to induction, and from priming to delivery, were also statistically significantly shorter in women treated with the intensive regimen. Thirty-five women (68.63%) assigned the intensive regimen experienced pain, compared with 21 (42.86%) in the standard regimen (OR 2.92, 95% CI 1.19-7.21), with two and one women in the respective regimens requiring opiate analgesics. Five women with oligohydramnios had transient cardiotocographic abnormalities during priming with the intensive regimen, none of which required immediate intervention, and the babies were born in good condition. There were no cases of uterine hypertonus and the outcomes of labour were similar for women from both regimens.

CONCLUSIONS

Preinduction cervical priming with the intensive dosing regimen improves the chances of successful ripening within 24 hours for primigravidae with unfavourable cervical scores at full term singleton pregnancies, and shortens the interval from priming to induction, and priming to delivery. This regimen may be more cost effective by shortening the period of hospital stay. The overall incidence of adverse reactions to the mother and fetus during priming was low. However, close fetal surveillance must be maintained, particularly in pregnancies complicated with oligohydramnios.

Is routine procaine spirit application necessary in the care of episiotomy wound?

BACKGROUND

A randomised controlled trial to investigate the usefulness of local application of procaine spirit versus cleansing with water for care of episiotomy wound after normal vaginal delivery was conducted in 100 women.

PATIENTS

Fifty women entered the study arm and 50 entered the control arm of the study. Women in the two arms were similar in their demographic and obstetric characteristics.

RESULTS

The pain scores on a verbal analogue scale was highest (score = 2.5) on Day 1 of the delivery. This was the same in women in both arms. The number of paracetamol tablets consumed was also low and was similar in both groups of women. By the fourteenth day of delivery, all the women were pain-free and the wound had healed well. It was noted that all the women maintained a high standard of perineal hygiene with a mean of 5 washes a day.

CONCLUSION

It is concluded that in a woman with normal vaginal delivery, local application of procaine spirit is unnecessary in the care of a routine episiotomy wound.

What constitutes a normal seminal analysis? Semen parameters of 243 fertile men

A cross-sectional study was conducted to determine the semen parameters (i.e. volume, concentration, motility, viability and normal morphology) of proven fertile males in Singapore and compare it with the World Health Organization (WHO) recommended normal values and to examine some factors that may affect spermatogenesis. A total of 243 men, whose wives were pregnant at the time of collection of semen, provided a semen sample each after sexual abstinence for 3 days. A questionnaire was used to elicit occupational exposure, alcoholic consumption, smoking history and past significant medical history. Most subjects had normal sperm volume (56.4%), concentration (79.8%), motility (69.5%) and viability (53.5%) based on WHO criteria. However, fertile men had a low mean percentage of normal sperm morphology (20.0%), although they were normally distributed. Cigarette smoking was associated with significantly lower semen volumes even after adjusting for alcohol consumption. The sperm parameters (i.e. volume, density, motility, viability and normal morphology) were not significantly associated with ethnic differences. The WHO criterion for normal sperm morphology is too stringent, and should be adopted with caution. Normal sperm morphology is but one of many parameters for assessment of fertility. Social alcohol consumption, cigarette smoking, and 'recent fever' did not appear to affect sperm quality in this group of fertile men.

Single agent paclitaxel in resistant and relapsed epithelial ovarian cancer after first-line platinum-based chemotherapy--experience in an Asian population

The efficacy and toxicity profile of paclitaxel (Taxol) was studied in 33 Singaporean women with epithelial ovarian carcinoma who had either failed to respond or relapsed after an initial response to first-line chemotherapy with combined platinum and cyclophosphamide. Paclitaxel was given intravenously as a single agent at a dose of 200 mg/m2 over 3 hours, with standard pre-medication, at 4 weekly intervals. A total of 102 cycles were administered. The median number of cycles was 3 (range 1 to 8) per patient. Twenty-six patients were eligible for response evaluation. Six (23.2%) patients showed a complete response and 4 (15.4%) showed a partial response. Two (7.7%) patients had stable disease and 14 (53.8%) patients had progressive disease. The response rate was 22.2% (2 of 9 patients) for patients with progressive disease while on the first-line platinum-based chemotherapy, 37.5% (3 of 8 patients) for patients with response-relapse interval of less than 6 months, 40.0% (2 of 5 patients) for patients with response-relapse interval of 6 to 12 months, and 75% (3 of 4 patients) for patients with response-relapse interval of more than 12 months. The median duration of survival was 10 months for the entire cohort of patients, but all complete responders and 75% of partial responders survived the duration of the study period of 24 months, compared to 50% of patients with stable disease and 7% of patients with progressive disease. Toxicity of paclitaxel treatment was evaluated in 102 cycles. Grade 3 or 4 alopecia, grade 1 or 2 sensory peripheral neuropathy and mild facial flush occurred in all patients. Haematological toxicity was mild, with 9.8% of the cycles complicated by grade 3 or 4 neutropenia. Bone marrow suppression was of short duration. No treatment delay or dose modification was needed. It is concluded that the effectiveness of paclitaxel for salvage treatment of patients with resistant or relapsed epithelial ovarian carcinoma after first-line platinum-based chemotherapy among Asian patients is comparable to that reported in Western populations. The treatment was well tolerated by our patients. It should be considered the chemotherapy of choice for patients with relapsed ovarian cancer after prior platinum-based chemotherapy.

Outcome of obstructive uropathy after pelvic irradiation in patients with carcinoma of the uterine cervix

The natural history and outcome of intervention for obstructive uropathy were studied retrospectively in 20 patients managed at the Department of Urology, Singapore General Hospital between 1991 and 1997. The diagnoses of these strictures were made between 10 months and 21 years after the initial treatment. There were 9 (45%) malignant and 11 (55%) benign strictures. The site of ureteric obstruction was in the lower ureter in 15 patients, in the middle ureter in 3 patients and in the upper ureter in 2 patients. Comparisons between malignant and benign strictures showed that patients with higher original stage of tumour were more likely to have malignant strictures. Besides latency period between primary treatment of the tumour and diagnosis of uropathy, bilaterality and site of strictures showed no discernible difference between benign and malignant strictures. Ureteric stenting provided good outcome in 5 patients with benign strictures and in 3 patients with malignant strictures. Open surgical reconstruction was performed on 2 patients with benign strictures and 2 patients with malignant strictures. All these four patients showed good outcome. Ureteric stenting is an acceptable treatment of benign ureteric stricture and for selected patients with malignant strictures. Open surgery is recommended in patients with benign strictures who could not be treated successfully on stenting.

Outcome of early cervical carcinoma treated by Wertheim hysterectomy with selective postoperative radiotherapy

Seventy-five consecutive patients with histologically confirmed FIGO stage IB-IIA cervical carcinoma who underwent Wertheim hysterectomy were studied retrospectively. Poor prognostic factors were found in 42 (56%) patients in whom postoperative adjuvant pelvic irradiation was given. The overall disease-free survival rate was 78% at 5 years and 75% at 9 years. The tumour recurrence rate was 12.1% in the low-risk patients and 35.7% in the high-risk patients. Tumour recurrences occurred significantly more frequently in patients with tumours with high grade squamous cell carcinomas and adenosquamous carcinoma. No recurrences occurred in patients with adenocarcinomas. After adjuvant radiotherapy, there was no statistically significant difference in the recurrence rates between lymph node positive and negative patients (26.7% and 19.6% respectively), however extrapelvic recurrences were more common in those with diseased lymph nodes. The recurrence rate was 40% in patients with involved resection margins compared to 16.7% of patients with clear margins. The recurrence rates were similar for patients with and without tumour embolisation of vascular/lymphatic channels. Wertheim hysterectomy with postoperative pelvic irradiation for selected high-risk patients was an effective treatment for FIGO stage IB-IIA cervical carcinoma. Despite radiotherapy, the high-risk patients still experienced a high tumour recurrence rate.

Adrenal hemangioma: two cases report

Adrenal hemangiomas are rare, nonfunctioning benign tumors. They are well circumscribed and comprise of closely adjacent vascular channels of varying sizes that are lined with a single layer of endothelium. When they occur, they are frequently located in the skin and liver. There are no characteristic symptoms of adrenal hemangioma unless the tumor reaches a size large enough to exert pressure. To our knowledge, there have been 14 clinical cases of adrenal hemangiomas reported, all with similar pathologic features. We present 2 additional cases, which were identified incidentally after non-urologic complaints (epigastric fullness and low back pain in patient 1 and patient 2, respectively). In these 2 patients, the tumors were surgically removed and diagnosed postoperatively as adrenal hemangiomas. Preoperative radiologic findings on plain film and abdominal computerized tomography showed the characteristic round calcifications with translucent centers, typical of phleboliths, to be pathognomonic of adrenal gland hemangiomas. Unfortunately, this characteristic feature of adrenal hemangioma existed in only one case report. In conclusion, the preoperative diagnosis of adrenal hemangioma is difficult but should be kept in mind as being part of the differential diagnosis of adrenal tumors.

Recurrent immature teratoma: lack of correlation between serum level and immunohistochemical detection of serum alpha-fetoprotein

We present the clinicopathologic and immunohistochemical features of a pure immature ovarian teratoma that had arisen in a 15-year-old girl. At original diagnosis immature extra ovarian implants were noted (grade 3) accompanied by moderately elevated serum alpha-fetoprotein (AFP) levels. AFP was immunohistochemically demonstrable in immature endodermal elements. The immature neural tissue present was negative for AFP, and no other tumor elements were recognisable. Serum AFP fell post-operatively to within normal limits. Despite five courses of chemotherapy and asymptomatic status, the patient re-presented 15 months after original diagnosis with a massive abdominal and pelvic tumor recurrence with predominantly mature glial tissue, but some persistent immature foci. There was no associated increase in serum AFP at this time. AFP was, however, persistently detectable immunohistochemically in immature endodermal components only. Immature neural elements were no longer identified. Disappearance of immature neural tissue in the tumor recurrence may have been related to chemotherapy. This case demonstrates the lack of correlative ability of serum AFP levels with both clinical behaviour and immunohistochemical demonstration of AFP expression in the tumor recurrence.

Outcome of hysterectomy for pelvic pain in premenopausal women

The outcome of abdominal hysterectomy for pelvic pain in premenopausal women was studied retrospectively in 228 women. In 17 women, pelvic pain was the sole indication while in the others, pelvic pain was one of the contributory indications for hysterectomy. The most common surgical histopathological diagnoses were uterine leiomyoma (73.9%), uterine adenomyosis (40.4%), benign ovarian cyst (19.3%) and endometriosis (7.9%); 118 (51.8%) patients had single pathology and 48.2% had multiple pathologies. The agreement between operative clinical diagnosis and histopathological diagnosis was 66.1% for leiomyoma, 57.1% for uterine adenomyosis and 30% for endometriosis. The incidence of early postoperative complication was 20.6%, mainly minor morbidities including urinary tract infection (3.9%), wound infection (3.1%) and unexplained fever (6.0%). These complications significantly prolonged the duration of hospital stay from an average of 7 days to 9-17 days. Of 98 patients with pain as the sole or the most predominant indication for hysterectomy, 72% responded to an outcome survey 12 or more months after hysterectomy. Of these, 62 (87%) were satisfied with the operation, 8 were unsure and 1 was dissatisfied; 68 (95.8%) patients reported relief of their symptoms. Relief of symptoms did not correlate with the patient's report of her satisfaction with hysterectomy. Pain in the abdominal wound a year or more after surgery was one of the commonest reasons cited for dissatisfaction with hysterectomy. We conclude that in well-selected cases, hysterectomy is an appropriate and satisfactory treatment for premenopausal women with pelvic pain irrespective of clinical evidence of associated pathology. Effective measures to reduce postoperative complications and wound pain are needed to further improve the outcome of abdominal hysterectomy.

Phase I study of immunotherapy of cutaneous metastases of human carcinoma using allogeneic and xenogeneic MHC DNA-liposome complexes

The generation of strong tumor-specific immunity by in situ gene therapy is an attractive approach for the eradication of human cancer lesions. The objectives of this study were to examine the toxicities of employing the human HLA-A2, HLA-B13 and the murine H-2K genes to generate tumor regression in patients with different cancer types via DC-Chol/DOPE cationic liposomes. The study was composed of two phaseI/II trials involving a total of 19 late-stage cancer patients. The patients were given four weekly injections of a DNA-liposome mixture directly into a cutaneous nodule. These procedures resulted in no significant clinical side-effects. The HLA-A2 gene gave the highest level of expression in situ. Although all patients treated had progressive systemic disease and eventually succumbed to their disease, strong local responses were generated in the treated nodules. Of the eight patients whose cutaneous nodules received HLA-A2 DNA, two completely regressed while four tumor nodules gave a partial local response. All but one of the patients who received HLA-A2-liposome mixtures and had a subsequent local response were either cervical or ovarian carcinoma patients. This local response, seen in a group of patients who had relapsed stage IV systemic metastatic disease and were refractory to all available therapies, demonstrates the generation of a strong local immune response following our in situ gene therapy protocol. Further studies to investigate the use of HLA-A2 DC-Chol/DOPE cationic liposomes for immunotherapy of cervical and ovarian cancers are warranted.

Visual effect of partogram designs on the management and outcome of labour

A prospective study of 3 partogram designs was performed in 990 women in labour with singleton pregnancy. Partogram A, B and C showed a progressively flatter steepness of the curve of labour progression. Oxytocin was administered in 35.1% of partogram-A users, 45.9% of partogram-B users (p = 0.001) and 44.1% of partogram-C users (p = 0.035). Significantly fewer patients among the partogram-A users (10.2%) were administered oxytocin too early compared to 18.6% of partogram-B users and 20.5% of partogram-C users. Of those with spontaneous onset of labour, a significantly smaller total dose of oxytocin was administered to the partogram-A users compared to the other 2 groups. Ominous electrocardiotocographic fetal heart patterns were detected less frequently during the first stage of labour in partogram A users (0.4%) compare to partogram-B users (1.1%) and partogram-C users (3.0%). Significantly fewer infants born to partogram-A users had depressed Apgar scores at 1 and 5 minutes. Partograms displaying a flat graph, compared to a steep graph, were more often considered to have a slow progress of labour. Adoption of partograms showing a steep graph of progress of cervical dilatation is recommended.

Laparoscopic treatment of ectopic pregnancies--a study of 100 cases

The experience of laparoscopic treatment of ectopic pregnancies (EPs) in a single institution was studied. Of the 358 cases of EPs treated between January 1990 and December 1995, 100 (27.9%) were treated laparoscopically. The mean age of these patients was 27.6 years and 65% were parous. The preoperative haemoglobin levels ranged between 7.1 and 13.2 g/dl. Haemoperitoneum was present in 83% of these cases and ectopic gestation was sited within the ampullary region in 66% of cases. Of the 100 cases of laparoscopically-treated EPs, 63 were treated by salpingectomy and 37 by linear salpingostomy. The mean operative time was 58 min (range 30 to 90 min). Except one patient with deteriorating vital signs in the immediate postoperative period needing a repeat laparoscopy, no other intra or postoperative morbidity was encountered. Majority of patients were ambulant within 12 hours of surgery and 84% were discharged home within 36 hours of their surgery. Laparoscopic treatment of EPs is safe and effective. Resident specialists in Obstetrics and Gynaecology should be trained in therapeutic laparoscopy early in their career so that more patients with EP can benefit from this minimally invasive surgery.

Efficacy of inosine pranobex oral therapy in subclinical human papillomavirus infection of the vulva: a randomized double-blinded placebo controlled study

A randomized double-blind placebo controlled study was carried out to assess the efficacy of inosine pranobex (1 g orally 3 times a day for 6 weeks) in the treatment of symptomatic subclinical human papillomavirus infection of the vulva. In a series of 55 women, 22 patients in the inosine pranobex group and 24 patients in the placebo group were suitable for analysis. A total of 14 (63.5%) of the inosine pranobex treated patients and 4 (16.7%) of the placebo treated patients showed significant vulval epithelial morphological improvement (P = 0.005) at 2 months after initiation of treatment. Whereas 13 (59.1%) and 9 (37.5%) patients in the respective groups showed significant improvement in the severity of pruritus vulvae (P = 0.435). Twelve (66.7%) of 18 patients with morphological improvement compared to 10 (35.7%) of 28 patients with no morphological improvement experienced significant symptomatic alleviation of pruritus vulvae (P = 0.041). Similar results were seen at the second assessment 4 months after the initiation of treatment. Adverse drug reactions were reported by 2 patients in the treatment group and by 2 patients (skin rash) in the placebo group. These adverse reactions were mild and self limiting. It is concluded that inosine pranobex demonstrated a significant pharmacological activity in subclinical HPV infection of the vulva and should be considered an alternative treatment for the condition.

Immunotherapy of human cancers

Advances in molecular biology technologies have significantly facilitated the identification of functional genes which cause, promote or control a variety of human diseases. Through recombinant DNA and polymerase chain reaction technologies, individual genes responsible for specific diseases have been identified, and consequently, the prospect that these diseases might be "cured" through replacement of the defective genes by their normal counterparts become distinct possibilities. Therefore, the goal of gene therapy is to apply this technology to the treatment of human diseases. In addition to its logical role for the correction of inherited diseases caused by a missing or defective gene product, gene therapy also holds promise for treatment of acquired disorders such as human cancer through the introduction of genes whose products have been implicated in controlling the growth of cancer. In this report, we present our results on the introduction of allogeneic major histocompatibility complex genes into cancer cells as an approach to increase the host's immune response against cancer. Various gene delivery strategies have been optimized for the introduction of DNA into various human tumour cells and these data are presented.

Genital oncogenic human papillomavirus infection: a short review on the mode of transmission

The most common oncogenic human papillomaviruses (HPVs) detected in the female lower genital tract are HPV types 16 and 18. They are ancient viruses which have evolved with mankind over the last 200 000 years. The identification of their roles in the development of carcinoma of the uterine cervix in the last decade fills the gap between the long-sought link between sexual behaviour and risk of cervical cancer. Indeed, epidemiological, clinical and sophisticated molecular studies employing the polymerase chain reaction (PCR) and DNA sequencing techniques have established the sexual transmissibility of these viruses. However, there is also compelling evidence indicating that these viruses can be transmitted through non-sexual routes. These include vertical transmission when an infant passes through the HPV-infected birth canal of the mother during vaginal delivery, and transmission by formites contaminated by HPV-infected cells. The long latent phase of HPV infection poses difficulties for accurate identification of the route of infection in an individual patient. Genital oncogenic HPV infection in a woman should not be treated as a venereal disease exclusively, and such patients should be counselled appropriately.

High long-term cure rate justifies routine treatment of cervical intraepithelial neoplasia grade I

The long-term clearance of cervical intraepithelial neoplasia (CIN) Grade 1 after one treatment was studied retrospectively in 105 patients. Treatment was by CO2 laser vaporization (74 patients), cone biopsy (8), loop electroexcision (LEEP) (7), electrodiathermy (1) and hysterectomy (2); 79 of the 92 treated patients (85.9%) had normal cervical cytology and colposcopy on a mean follow-up period of 36.7 months (95% confidence interval between 33.1-40.4 months). Life table analysis showed that the probability of the cervix remaining disease free was 81% at 72 months of follow-up. Of the 13 patients with a cervical abnormality after the initial treatment, 4 had persistent CIN 1, 3 persistent human papillomavirus (HPV) infection, 2 recurrent CIN 1 and 4 had recurrent HPV infection. In contrast, of the 13 untreated patients with CIN 1, 7 (53.8%) continued to demonstrate an abnormality on the cervix after a mean follow-up period of 27.5 months (95% confidence interval between 18.8 and 36.3 months). No significant perioperative morbidity was recorded in the treated patients. The results of this study suggest that CIN 1 can be effectively eradicated in more than 80% of women with 1 treatment alone. The treatment should be considered for all these patients to spare them the psychological and emotional trauma of having to face repeated abnormal cervical cytology on follow up.

Comparison of the usefulness of serum CA 125 level and a risk scoring system in detecting malignancy in ovarian cysts

A prospective study was carried out to compare the sensitivity, specificity, positive and negative predictive values, and the accuracy of serum CA 125 measurement with a clinical risk scoring system in the detection of malignant ovarian cysts. One hundred and three patients admitted to one department of obstetrics and gynaecology within a 12-month period were studied. There were 22 cases of malignant ovarian cysts. The sensitivity, specificity, positive and negative predictive values, and accuracy were 81.8%, 72.0%, 43.9%, 93.7% and 75.0% respectively for a raised serum CA 125 measurement (> or = 35 u/ml) alone, and 90.9%, 64.8%, 40.8%, 96.4% and 70.2% respectively for a high risk score system (> or = 7 scores) alone. The specificity and positive predictive value were both further improved to 93.9% by combining a raised CA 125 level and high risk score of 7 or more as the predictive test. When used alone, the clinical risk scoring system picked up more FIGO stage I ovarian cancer than the raised serum CA 125 level. The findings of this study indicated that the risk scoring system is a useful predictor of malignant ovarian cysts. It needs to be assessed further in populations with different prevalence of ovarian cysts of various pathological types and malignancy before it can be advocated for general application, particularly in selecting ovarian cysts for laparoscopic surgery.

APC mutation associated with late onset of familial adenomatous polyposis

Familial adenomatous polyposis is an autosomal dominantly inherited disorder. Mutation studies in the corresponding gene (APC) may provide information for predictive tests for persons at risk in affected families. We report here a new mutation in exon 6 (codon 233) of the APC gene and clinical data in a large family with late onset of the disease in most affected persons.

Continent pouch ileostomy

Continent pouch ileostomy is fashioned for patients who need a proctocolectomy. It is usually indicated for cases of ulcerative colitis and familial adenomatous polyposis where the anal sphincter can no longer maintain normal function or has to be removed. A case of familial adenomatous polyposis with features of Gardner's syndrome is reported. The patient presented with carcinoma of the rectum. Abdominoperineal resection followed by completion pancolectomy was performed. A continent pouch ileostomy was fashioned for him. He resumed work as a labourer within six months. The pouch was troublefree, needed to emptied four to six times a day and was fully continent of fluid, flatus and faeces until his demise three years later from liver secondaries. Continent pouch ileostomy is a better alternative than permanent end ileostomy. All care should be taken to rule out the existence of Crohn's disease. It is proposed that continent pouch ileostomy should be offered to patients needing permanent ileostomy if the expertise is available.

Primary lymphangiomyomatosis with chylous ascites

Primary lymphangiomyomatosis is a benign tumour of lymphatic channels and lymph nodes, clinically manifested by chylous ascites. This disease is usually progressive and unresponsive to surgery, chemotherapy or irradiation. A case of a 36-year-old lady with chylous ascites due to underlying primary lymphangiomyomatosis is reported.

Correlation of serum, urinary and salivary CA 125 levels in patients with adnexal masses

A prospective study was made of 105 consecutive patients admitted to one department of obstetrics and gynaecology for surgery for adnexal masses. The objective was to investigate if CA 125 level is measurable in the urine or saliva and to correlate these measurements with serum CA 125 level in patients presenting with adnexal masses. The final diagnosis and grouping of patients for analysis were based on histopathological examination of the adnexal masses. Serum, urine and salivary samples were collected simultaneously from all patients on the morning before surgery. CA 125 levels in each sample were determined in duplicate using Abbott CA 125-E1A monoclonal test kits (Abbott Laboratories, USA). The mean inter-assay variability was 10%. CA 125 was detectable in the serum, urine and saliva from all the patients and the concentration was highest in the saliva and lowest in urine. There were no discernible differences in the distributions of salivary CA 125 concentrations between patients with ovarian malignancies and those with benign ovarian cysts. In contrast, both serum and urinary CA 125 levels were significantly higher in the ovarian cancer group. There was no correlation in CA 125 concentrations between serum and urine, or between serum and saliva. For detection of ovarian malignancies, the sensitivity, specificity, and positive and negative predictive values for serum CA 125 measurement (> or = 35 U/mL) were 88.9%, 79.2%, 27.6% and 98.7 respectively. The corresponding figures for urinary CA 125 measurement (> or = 10 U/mL) were 88.9%, 66.7%, 19.5% and 98.4% respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Evolution of human papillomavirus type 18: an ancient phylogenetic root in Africa and intratype diversity reflect coevolution with human ethnic groups

Papillomaviruses are an ideal model system for the study of DNA virus evolution. On several levels, phylogenetic trees of papillomaviruses reflect the relationship of their hosts. Papillomaviruses isolated from remotely related vertebrates form major branches. One branch of human papillomaviruses (HPVs) includes an ape and two monkey papillomaviruses, possibly because the diversification of the viruses predated the separation of the infected-primate taxa. This hypothesis predicts that the root of the evolution of some if not all HPV types should point to Africa, since humans evolved from nonhuman primates in this continent. We tested this hypothesis and compared the genomic sequences of HPV type 18 (HPV-18) isolates from four continents. Diversity within HPV-18 correlates with patterns of the evolution and spread of Homo sapiens: HPV-18 variants, just like HPV-16 variants, are specific for the major human races, with maximal diversity in Africa. Outgroup rooting of the HPV-18 tree against HPV-45, which is closely related to HPV-18, identifies African HPV-18 variants at the root of the tree. The identification of an African HPV-45 isolate further reduces the evolutionary distance between HPV-18 and HPV-45. HPV-18 variants from Amazonian Indians are the closest relatives to those from Japanese and Chinese patients and suggest that a single point mutation in the phylogenetically evaluated genomic segment represents at least 12,000 years of evolution. We estimate that diversity within HPV-18 and probably within other HPV types evolved over a period of more than 200,000 years and that diversity between HPV types evolved over several million years.