Prediction of recurrence after treatment for high-grade cervical intraepithelial neoplasia: the role of human papillomavirus testing and age at conisation

OBJECTIVES

The aim of this study was to examine the accuracy of the presence of high-risk human papillomavirus (HR-HPV) DNA (HR-HPV DNA test) postconisation as prediction of recurrent or residual cervical intraepithelial neoplasia (CIN) after treatment of high-grade cervical intraepithelial lesions (CIN2+) in a prospective study and to compare this with follow-up cytology and the marginal status of the excised tissue.

DESIGN

Prospective follow-up study.

SETTING

Unselected women presenting at colposcopy clinic of University Hospital Gasthuisberg, Leuven.

POPULATION

Seventy-two women treated with conisation for CIN2 or CIN3.

METHODS

Women were followed by HR-HPV DNA test (Hybrid Capture II test of Digene) every 3 to 6 months. The same vial was used for cytology and the HR-HPV DNA test (SurePath). All women were further followed by colposcopy and cytology for 24 months at 6-month intervals. The outcome of the study was presence of >CIN2, proven with colposcopy-directed biopsy occurring within 24 months after treatment. HR-HPV status was correlated with recurrent or residual CIN2+.

MAIN OUTCOME MEASURES

Sensitivity, specificity, predictive values and diagnostic odds ratios to predict treatment failure or cure were computed for HR-HPV testing, marginal status and follow-up cytology. HR-HPV status was also correlated with section margins postconisation and with the first cervical smear.

RESULTS

In 6 of the 72 treated women (8%), residual or recurrent CIN occurred. Women with recurrence were significantly older than women without a recurrence (51.5 +/- 9.6 versus 39.8 +/- 12.2 years, P= 0.007). All six women with recurrence were HR-HPV positive, four had a positive follow-up smear (>or=atypical squamous cells of uncertain significance = ASCUS+) and only two had involved section margins. Among the 66 cured women, 15 were HR-HPV positive, 6 had an abnormal smear and 12 had positive section margins. Sensitivity of cytology, positive section margins and HR-HPV DNA positivity was 66.7, 33.3 and 100% to predict treatment failure. Specificity of the three tests was, respectively, 90.9, 81.8 and 77.3%. Women with HR-HPV DNA at 3 to 6 months showed recurrent or residual CIN in 15% (2/13) if they had normal follow-up Pap smears and in 50% (4/8) if they had abnormal Pap smears. Margin status was not statistically significantly associated with human papillomavirus status.

CONCLUSION

Persistence or clearance of HR-HPV DNA is an early valid prognostic marker of failure or cure after treatment for CIN2+ and is more accurate than cytology or section margin status at the time of conisation. The absence of HR-HPV DNA has a 100% negative predictive value. Higher age at conisation may be a previously unrecognised risk factor for recurrence.

Carbon dioxide laser for laparoscopic enterocele repair

The use of the carbon dioxide (CO2) laser for laparoscopic enterocele repair was evaluated in four women with an enterocele as the only pathology. Three women had a large enterocele after earlier hysterectomy, and one young woman had a congenital enterocele. The technique consists of vaporizing the peritoneum of the enterocele; however, it is important first to delineate carefully the lesion's circumference because of the strong retraction during vaporization. Subsequently, a posterior culdotomy is performed taking care to restore the horizontal position of the upper vaginal axis by shortening the uterosacral ligaments, which are sutured together on the midline and the posterior vaginal wall. The (CO2) laser has the advantage that the superficial vaporization it produces is rapid (<5 min), safe, and completely bloodless. The shrinking during vaporization facilitates subsequent repair. Postoperative morbidity and recovery were uneventful for all patients. The (CO2) laser seems to have some advantages over sharp endoscopic resection of enteroceles. The relative simplicity of technique and the low postoperative morbidity suggest that endoscopy could become routine in pelvic floor surgery, improving diagnosis and complementing vaginal surgery while avoiding laparotomy.

[Problems of electroconvulsive treatment in advanced age--its possible applications and necessities, indications criteria, method and effectiveness]

After a critical discussion with antiquated and actual problems to the electroconvulsive therapy the problem-important peculiarities of progress and treatment of the psychosis in the higher age are exhibited. In search of satisfactoring solutions we used Dexamethazon as a supplemental premedication in the electroconvulsive therapy and by this way we found out a remarkable minimize of complications which allowed to put in more frequently the electroconvulsive therapy during the psychosis in the higher age. This leads to a general optimation of prognosis of the late psychical diseases. Beside the method itself the urgency of indications and exclusion of standards are described in the same way, also there are shown the few complications in comparison with the successes of therapy of 2010 electricalconvulsive therapies from 433 patients.

Evaluation of a new assay for pancreatic amylase: performance characteristics and estimation of reference intervals

We have evaluated a new assay for the specific determination of pancreatic (P) isoamylase, the principle being based on a synergistic inhibitory effect of two monoclonal antibodies directed towards salivary (S) amylase. After 3 min incubation, activities were determined with maltoheptaoside-PNP as substrate on a Hitachi 705 analyzer at 25, 30 and 37 degrees C, respectively. Coefficients of variation ranged from 0.6 to 5.4% for within-run and 2.1 to 9.9% for day-to-day precision. Linearity held up to 1200 U/L (25 degrees C) and 2300 U/L (37 degrees C). Comparison of the new method with the wheat germ inhibitor technique showed an excellent correlation, with coefficients ranging from 0.990 to 1.00. Using purified P- and S-amylase we observed no inhibiting cross-reactivity of the antibodies with the P-isoenzyme, but an incomplete blockage of S-amylase: residual activity was approximately 2% at 25 and 30 degrees C, and 2.5% at 37 degrees C. The distribution pattern of P-, S- and total amylase activity in serum of healthy subjects was only slightly skewed to the right. We found neither an influence of sex nor of age on the reference ranges. In random urine samples, distribution of activities was strongly skewed. However, if the activity was related to the urinary creatinine concentration, an approximately normal distribution was obtained, allowing, as in serum, the establishment of upper and lower reference values.

Evaluation of a new alpha-amylase assay using 4.6-ethylidene-(G7)-1-4-nitrophenyl-(G1)-alpha-D-maltoheptaoside as substrate

The determination of alpha-amylase activity using an ethylidene-blocked 4-nitrophenyl-maltoheptaoside (EPS) has been evaluated in five laboratories on eight different analysers at 25 degrees C, 30 degrees C and 37 degrees C. The protecting ethylidene group inhibits hydrolysis at the non-reducing end of the substrate molecule by the auxiliary enzyme, alpha-glucosidase. The combined reagent is therefore stable for at least 10 days at 2-8 degrees C. HEPES is used, because the molar absorbance of 4-nitrophenol is independent of temperature in the presence of this buffer. Compared with the method using unprotected substrate 4-nitrophenyl-alpha-D-maltoheptaoside (4NP-G7), the present method is equal or better with respect to the imprecision, linearity and interlaboratory transferability of results in human and control sera. Since the protected and unprotected substrates differ in their turnover rate, the new assay yields activities which differ from those of the 4-nitrophenyl-alpha-D-maltoheptaoside method. Based on the homogeneous results obtained in method comparisons between EPS and 4-nitrophenyl-alpha-D-maltoheptaoside, and in order to maintain the 4-nitrophenyl-alpha-D-maltoheptaoside reference values, a conversion factor was derived to eliminate the above differences: activityEPS x 2.50 = activity4NP-G7. The temperature and instrument independence of this relationship was demonstrated in a total of 720 human sera and plasmas.

A multicentre evaluation of the Boehringer Mannheim/Hitachi 704 analysis system

The selective multitest Boehringer Mannheim/Hitachi 704 analysis system was examined according to the ECCLS guidelines in a multicentre evaluation involving four laboratories. Ten routine parameters, covering most of the application settings of the instrument, were measured in the respective laboratory at temperatures 25, 30 or 37 degrees C. The trial lasted four months and gave more than 40,000 data. It yielded the following results: 1. Within the four laboratories the mean coefficients of variation for three control sera at different concentrations were found to be equal to or better than 1.6% for the within-run imprecision and 2.8% or better for the between-day imprecision. 2. No drift was observed during eight hours. 3. Because of the high linear measuring range a re-run analysis was seldom necessary. 4. Sample-related carry-over was not seen. Reagent-dependent carry-over was measured from cholesterol to uric acid and from triacylglycerols to lipase. Through modification of the cholesterol and triacylglycerol reagents, the carry-over effect was practically eliminated. 5. The recovery of the assigned values of control sera showed average values between 99 and 104%. For bilirubin, creatinine, creatine kinase and alanine aminotransferase some control sera showed deviations greater than 10%. 6. In all cases, regression analysis of the results obtained in comparisons of the present instrument with the Hitachi 705 or 737 yielded slopes close to unity with extreme values of 0.95 and 1.06. 7. During the entire evaluation period there was no malfunction or breakdown of the instruments. The evaluators came to the conclusion that the analytical performance as well as the reliability and practicability of the Hitachi 704 can be rated as excellent.

Pregnancy after transcatheter embolization of a uterine arteriovenous malformation

A 25-year-old woman with a congenital uterine arteriovenous malformation had a long history of repeated excessive vaginal bleeding. She was successfully treated with transarterial embolization. She had normal menstrual periods for 6 months and subsequently conceived. She was delivered of a normally grown baby at 35 weeks. To the best of our knowledge, this is the third pregnancy described after successful embolization of an arteriovenous malformation.

Evaluation of a new inhibitor test for isoamylase on Hitachi 705 analyser

We describe a simple and rapid method for measuring pancreatic and salivary type amylases using the Hitachi 705 analyser. The determination is based on the inhibition of salivary amylase using an inhibitor isolated from wheat germ. The precision of the proposed method was very good: within-day precision varied from 0.4 to 2.5% (CV) and day-to-day precision from 2.2 to 3.7% (CV). The new application correlated well with another commercially available inhibition method. As the standardization is very stable and the assay procedure exactly the same as for the total amylase assay, the proposed method is suitable for routine isoamylase determination. Reference values for pancreatic and salivary amylase activities are presented.

Transcatheter embolization of uterine arteriovenous malformations

A case of congenital arteriovenous malformation of the uterus in a 25-year-old woman with a long-standing history of recurrent menometrorrhagia is reported. Radiological diagnosis was based on hysterographic, computed tomographic, and angiographic findings. Treatment was performed with percutaneous transcatheter embolization.

Five methods for measuring low-density lipoprotein cholesterol concentration in serum compared

Five methods for the quantification of low-density-lipoprotein cholesterol were compared: ultracentrifugation, electrophoresis, precipitation with polyvinyl sulfate or heparin, and an indirect calculation procedure (Friedewald formula). Excellent agreement of results was obtained with all procedures for 49 of 51 sera. Discrepancies were as much as 1.69 g/L for the remaining two cases, which contained appreciable amounts of "floating" beta-cholesterol as detected with a combination of ultracentrifugation and electrophoresis.

Five methods for measuring low-density lipoprotein cholesterol concentration in serum compared

Five methods for the quantification of low-density-lipoprotein cholesterol were compared: ultracentrifugation, electrophoresis, precipitation with polyvinyl sulfate or heparin, and an indirect calculation procedure (Friedewald formula). Excellent agreement of results was obtained with all procedures for 49 of 51 sera. Discrepancies were as much as 1.69 g/L for the remaining two cases, which contained appreciable amounts of "floating" beta-cholesterol as detected with a combination of ultracentrifugation and electrophoresis.

[Probability in the clinical diagnoses of Pick disease and Alzheimer disease]

This paper is dedicated to the honour of Prof. Dr. Erich Sternberg. The diagnostical strategy of well-known specialists for the Morbus Pick and Morbus Alzheimer is considered. As a result of our own experiences and analyses the psychopathological factors are assigned to the following groups: change of vitality; change of personality; reversible organic psychoses; fuzzy brain-local symptoms; development of dementia. For these groups growth curves are given for which the analytic description by a special type of a differential equation, is used. The different behaviour of the development of the dementia to the Morbus Pick and Morbus Alzheimer is found.

Investigations on the mechanism of photodynamic action of different psoralens with DNA

Investigations on the photodynamic action of psoralens with DNA were performed, using experimental techniques of fluorescence lifetime and NMR-CIDNP, as well as SCF-MO and CNDO molecular orbital calculations. It has been shown that the formation of a biradical through the triplet state is the decisive step for psoralen dimer formation, as well as for cyclobutane addition with thymine, while singlet oxygen production is responsible for enzyme inactivation (e.g., lysozyme and trypsin). The molecular orbital calculations, in agreement with experimental results, indicate that the differences in biological effectivity of different psoralens are based on variations in triplet formation probability.

[Are envelope curves of arterial pulse waves suited to the telemetric evaluation of the course of psychotic disease?]

The wave model of endogenous psychoses constructed by us is based on special properties of the envelopes of arterial pulse waves. It has been tested and used by the Bechterev Institute in Leningrad. We could confirm us that all examined patients are classified into the right class of psychosis solely by their measurement vector of the envelope curve. Also statements about the progress of the psychosis are possible.

[Classification of endogenous psychoses by centrally regulated variations of the cardiac rhythm. Preliminary report]

After the successful classification of endogenous psychoses only by a vector of measuring dates of covering curves of the arterial pulse waves was tested, whether the concrete state of activity of the generally activating reticular system observed in this case may be described also according to the peculiarity of centrally regulated variations of the cardiac rhythm. Using the vectors of the measuring values of these regulation influences we also got a rate of correct classification of endogenous psychoses of about 80%.

[Alcohol and central and peripheral nervous system disorders]

It belongs to the definition of chronic alcoholism that also clinically established lesions of the organs can be proved. As to the nervous system the case in question are multilocular defects which concern the central and peripheral nervous system. The local accentuation, the developmental speed and the intensiveness of the alcoholic defect of the cellular metabolism lead to different courses. The suggestion of their individuality must at the same time take into consideration the character of chronic alcoholism which on principle affects the whole nervous system.

[The significance of the arterial pulse waves and their enveloppe curves in endogenous depression]

The envelope curves of arterial pulse waves are carries of information about the central circulatory and respiratory regulation. Using a discriminence analysis, the mean width of the wave peak of this curve appears as a characteristic feature of the activity form of the generally activating reticular system which is changed in endogenous depressions. By means of this feature, it is possible to distinguish patients with endogenous depression from healthy test persons without using psychopathological findings.