In vivo diagnosis of cervical intraepithelial neoplasia using 337-nm-excited laser-induced fluorescence

Laser-induced fluorescence at 337-nm excitation was used in vivo to differentiate neoplastic [cervical intraepithelial neoplasia (CIN)], nonneoplastic abnormal (inflammation and human papilloma viral infection), and normal cervical tissues. A colposcope (low-magnification microscope used to view the cervix with reflected light) was used to identify 66 normal and 49 abnormal (5 inflammation, 21 human papilloma virus infection, and 23 CIN) sites on the cervix in 28 patients. These sites were then interrogated spectroscopically. A two-stage algorithm was developed to diagnose CIN. The first stage differentiated histologically abnormal tissues from colposcopically normal tissues with a sensitivity, specificity, and positive predictive value of 92%, 90%, and 88%, respectively. The second stage differentiated preneoplastic and neoplastic tissues from nonneoplastic abnormal tissues with a sensitivity, specificity, and positive predictive value of 87%, 73%, and 74%, respectively. Spectroscopic differences were consistent with a decrease in the absolute contribution of collagen fluorescence, an increase in the absolute contribution of oxyhemoglobin attenuation, and an increase in the relative contribution of reduced nicotinamide dinucleotide phosphate [NAD(P)H] fluorescence as tissue progresses from normal to abnormal in the same patient. These results suggest that in vivo fluorescence spectroscopy of the cervix can be used to diagnose CIN at colposcopy.

Compartment syndrome associated with infection of the upper extremity

Compartment syndrome is a potentially devastating entity associated with a great variety of injuries, but to the authors' knowledge there are no known reports of infection documented as a cause. A retrospective review of 263 patients with upper extremity infections admitted to the orthopaedic infection ward during 1992 was conducted to identify patients with compartment syndrome directly associated with infection. Four patients' clinical presentations fulfilled the criteria: two presented with infection and compartment syndrome, and two developed compartment syndrome 2-12 hours after admission. All four had beta-hemolytic streptococci on initial culture; three of four grew Group A streptococcus. Fasciotomies and serial debridements were necessary. One patient ultimately underwent amputation through the elbow.

Nucleolar organizer regions: a potential prognostic factor in adenocarcinoma of the endometrium

Nucleolar organizer regions, which are evaluated using a silver stain for paraffin-embedded sections (AgNOR), can be used as a measurement of cellular proliferative activity. In the endometrium significant differences have been seen between benign and malignant lesions. To determine if AgNOR counts are of prognostic value in endometrial cancer, we examined 28 patients who developed recurrent disease after surgical stage Ib and Ic endometrial cancer and compared this group with a matched control group of patients who did not develop recurrence. The mean AgNOR number per cell was significantly higher in patients with recurrent disease (P = 0.001). Only five of these patients had values less than 4, whereas only three of the control group had values higher than 4. There was also a significant difference in the percentage of cells with more than 5 and more than 8 AgNORs (P = 0.001). After radiation therapy, the number of AgNORs per cell decreased. Recurrent tumors had higher AgNOR counts than the respective primary tumors. In conclusion, patients at increased risk for recurrent endometrial cancer can be identified by high AgNOR counts. Further evaluation of this parameter and comparison to other prognostic factors seems warranted.

Hyponatremia and neuroleptic-induced obesity in rats

The weight gain and hyperphagia induced by chronic administration of sulpiride in female rats were not prevented by the concomitant administration of an extra source of sodium. In addition, serum sodium levels were not affected, but potassium levels were significantly reduced by sulpiride administered for 1 week. These results suggest that sulpiride-induced obesity in rats is not related to sodium imbalance. The mechanism for the decrease in serum potassium levels and its relation with sulpiride-induced weight gain warrant further investigation.

Visible light effects on tumoral cells in a culture medium enriched with tryptophan and riboflavin

When NSO/2 myeloid cell line and teratocarcinoma F9 cells were irradiated in Dulbecco's modified Eagle medium enriched with tryptophan and riboflavin, toxic photoproducts for these tumoral cells were generated. The active participation of 1O2 and .OH was established using specific scavengers and quenchers. A cytotoxic effect was also observed when unirradiated tumoral cells were incubated in a previously irradiated culture medium enriched with tryptophan and riboflavin. When irradiated medium was used alone, enriched only with tryptophan or only with riboflavin, no toxic effect was observed. The relevance of charge transfer processes between triplet riboflavin and tryptophan in the generation of cytotoxic photoproducts is discussed.

Pertussis in Massachusetts, 1981-1991: incidence, serologic diagnosis, and vaccine effectiveness

Massachusetts provides diphtheria-tetanus toxoid-pertussis (DTP) vaccine, and since 1980 has monitored pertussis with a statewide diagnostic service. The incidence of bacteriologically confirmed pertussis was 104.5 per 100,000 person-years in 1-month-old infants and declined progressively thereafter. Infants < 6 months old experienced disproportionate morbidity: 44% of bacteriologically confirmed pertussis, 64% of hospitalizations, and 71% of hospital days. Most children with pertussis had received < 3 DTP doses during childhood, whereas 87% of adolescents with pertussis had received > or = 4 doses. Serodiagnosis by single serum anti-pertussis toxin antibody ELISA increased the incidence of confirmed pertussis in persons 11-19 years old from 3.0 to 12.9 per 100,000 and in persons > or = 20 years old from 0.16 to 0.56 per 100,000. Bacteriologic methods underestimate pertussis incidence, but a single serum anti-pertussis toxin antibody ELISA is a practical method for population-based diagnosis in adolescents and adults.

Community prevalence of hepatitis C viraemia: a polymerase chain reaction study

In order to estimate the prevalence of HCV carriage in an inner city health district, we undertook a polymerase chain reaction (PCR) based survey of sera collected from 1,0002 patients attending general practitioners for reasons unrelated to liver disease. The series comprised 305 sample selected sera patients sample from sera 995 patients previously screened by C100 antigen-based anti-HCV tests. Overall, 7 patients were positive for HCV RNA. Four cases had anti-C100 antibodies to HCV, 2 were strictly negative but had high-normal/borderline optical densities by ELISA assay, while one was completely anti-HCV negative. All but one had normal liver function tests. Only 3/7 PCR positive cases had any serum marker for hepatitis B (HBV) exposure (2 HBsAg positive, 1 IgM anti-HBc positive). The minimum point prevalence of HCV carriage in this community is 0.7%, approximating the HBsAg carriage in the same population (1%). HCV carriage in this inner city population is considerably higher than would be predicted by blood donor surveys. A positive anti-HCV anti-body (anti-C100) test is poorly predictive (approximately 10%) of HCV RNA carriage in a general practice based population in which measurement of "surrogate" (HBV related) HCV markers would have detected only 3/7 cases of presumed chronic HCV carriage.

Riboflavin-sensitized photoprocesses of tryptophan

The photodegradation of tryptophan in oxygen saturated aqueous solution sensitized by riboflavin is accompanied by the generation of the following reactive oxygen species: 1O2, OH., H2O2 and O2.-. When parallel photodegradation experiments are run with 14C-riboflavin in one case and 14C-tryptophan in the other and the irradiation products are separated by Sephadex G-15 and C18-HPLC, the generation of the following species is detected: aggregate forms of riboflavin, indolic products associated to flavins, indolic products of molecular weight higher than tryptophan, formylkynurenine, and other tryptophan photodecomposition products. The significance of the riboflavin anion radical and tryptophan cation radical as intermediates in the photoproduct formation is discussed.

Fluorescence spectroscopy: a diagnostic tool for cervical intraepithelial neoplasia (CIN)

A spectroscopic system incorporating a pulsed nitrogen laser, an optical fiber probe, and an optical multichannel analyzer was utilized to record fluorescence spectra of the intact cervix at colposcopy. Spectra were obtained from 66 colposcopically normal areas and 49 histologically abnormal areas (5 pathologic inflammation, 21 HPV infection, 9 CIN I, 10 CIN II, and 4 CIN III) in 28 patients. The resulting spectra could be used to differentiate histologically abnormal tissues from colposcopically normal tissues with a sensitivity, specificity, and positive predictive value of 92, 90, and 88%. Furthermore, CIN could be differentiated from nonneoplastic abnormal tissues with a sensitivity, specificity, and positive predictive value of 87, 73, and 74%. These results suggest that laser-induced fluorescence can be used in the recognition and differential diagnosis of CIN at colposcopy.

Photoreactions of riboflavin with spermine and their role in tryptophan photoconsumption induced by riboflavin

The influence of spermine (Spr) on riboflavin (Rb) and riboflavin-tryptophan (Rb-Trp) solutions irradiated at 450 nm under aerobic and anaerobic conditions was studied. In both systems, it is shown that Spr interacts with 3Rb probably giving spermine-derived and flavin-derived radicals. In the presence of oxygen, modified Rb is regenerated with the simultaneous production of the active oxygen species O2.- and/or HO2.. The addition of Spr to the Rb-Trp system under aerobic conditions leads to a small protection of Trp consumption, although oxygen consumption is increased. This small protection arises as a consequence of competitive interaction of Trp and Spr with 3Rb. The competition of Spr and oxygen for 3Rb could also explain the autocatalytic oxygen consumption observed in the presence of the amine. Under anaerobic conditions Spr produces a larger protection of Trp consumption, which is compatible with the larger Rb triplet lifetime expected under these conditions.

Traumatic rupture of the stomach secondary to Heimlich maneuver

The case of a 93-year-old man who received a Heimlich maneuver while choking is reported. After the procedure, the patient presented with abdominal pain and ultimately was found to have developed a gastric rupture. He was hospitalized for 66 days. Review of the literature showed that only four gastric perforations related to the Heimlich maneuver have been documented. Other complications have occurred. It is reasonable to perform the procedure as an alternative to asphyxiation, but emergency physicians must be aware of the fact that life-threatening complications may ensue.

Absence of hepatitis C virus in British patients with type 1 autoimmune chronic active hepatitis--a polymerase chain reaction and serological study

Despite several studies from continental Europe reporting a high prevalence of antibodies to the hepatitis C virus (HCV), there has been little evidence of such infection in patients from the United Kingdom. The use of the polymerase chain reaction combined with two separate second generation anti-HCV assays is reported here in 58 UK patients with well-documented autoimmune chronic active hepatitis. All patients were in corticosteroid induced remission. All sera were collected prospectively for the specific purpose of this study. HCV-RNA was not detected by use of the polymerase chain reaction in any of the patients and antibodies to HCV were only detected in one patient. No evidence was found for the involvement of the hepatitis C virus in UK patients with classical, corticosteroid sensitive autoimmune chronic active hepatitis.

[Intraoperative echography in biliary tract surgery. A comparative study of intraoperative echography/cholangiography in the detection of calculi in the common bile duct]

We report 3 years of experience with operative ultrasonography on 200 patients who underwent cholecystectomy for biliary lithiasis. Intraoperative ultrasonography and intraoperative cholangiography were performed on all of these patients and compared with the operative findings. The diagnostic accuracy of sonography was 98% and that of cholangiography 96% in the whole patient group. The predictive value of a positive ultrasonography was 92.5% while that of a positive cholangiogram was lower at 81.5%. In 32 patients who underwent surgical exploration of the common duct the use of these two intraoperative screening tests together led to a positive common duct exploration in 75% of the patients. Overall morbidity in this series was 4.8% against 12.8% (common duct exploration) and retained stones following duct exploration were present in 1 patient in intra-hepatic situation. The overall mortality rate of the entire patient group was 0%. Operative ultrasonography of the biliary tract as a screening procedure is a reliable method, a possible substitute for operative cholangiography, but perhaps in reality both methods are complementary.

Relationships between c-Ki-ras mutations, HPV types, and prognostic indicators in invasive endocervical adenocarcinomas

OBJECTIVE

Ras gene mutations have been identified in squamous cell carcinomas of the cervix and are associated with advanced-stage tumors. The current study was designed to determine the prevalence of c-Ki-ras mutations in invasive endocervical adenocarcinomas and associations between mutations, HPV status, and known prognostic indicators.

METHODS

Paraffin-embedded tissue samples from 32 cases of invasive adenocarcinoma of the endocervix were analyzed for the presence of c-Ki-ras mutations by amplification of DNA extracted from paraffin blocks using the polymerase chain reaction (PCR) and subsequent restriction enzyme digestion of the amplimers. This method allows detection of aspartic acid mutations of the c-Ki-ras gene at codons 12 and 13. Samples were also analyzed for the presence of HPV DNA using PCR and either "consensus sequence" primers or "type-specific" primers for HPVs 16 and 18. Patients' charts were reviewed for clinical information and correlations between clinical outcome and known prognostic indicators and the presence of c-Ki-ras mutations was assessed.

RESULTS

c-Ki-ras codon 12 mutations were detected in only 4 of the 32 cases (12.5%) of invasive endocervical adenocarcinomas examined. No codon 13 mutations were detected. Fifty-nine percent of the cases were HPV 16 or HPV 18 DNA positive and only 1 of the 4 cases with a codon 12 mutation was associated with HPV 16 or HPV 18. There were no significant associations between stage or grade of tumor or outcome and the presence of codon 12 mutations. However, using the observed survival as computed by the Berkson Gage Method at 12 months, the estimated median survival for patients with c-Ki-ras codon 12 mutations is 29 months compared to 68 months for patients lacking codon 12 mutations.

CONCLUSIONS

These results indicate that c-Ki-ras codons 12 and 13 mutations are uncommon in invasive endocervical adenocarcinomas.

Study of the fluorescence properties of normal and neoplastic human cervical tissue

Fluorescence excitation-emission matrices (EEMs) were obtained in vitro for 18 cervical biopsies from 10 patients. At all excitation emission maxima, but especially at 330 nm excitation, 385 nm emission, the average normalized fluorescence intensity of histologically normal tissue is greater statistically than that of histologically abnormal tissue. A diagnostic algorithm based on the relative intensity at 330 nm excitation, 385 nm emission can differentiate histologically normal and abnormal biopsies with a higher sensitivity (89%), but a lower positive predictive value (67%) and specificity (44%) than colposcopy (78%, 88%, 89%, respectively). However, paired comparison of histologically normal and abnormal biopsies from the same patient results in a sensitivity of 75%, positive predictive value of 86% and specificity of 88% for spectroscopic identification of histologic abnormality similar to that of colposcopy. This pilot study indicates that fluorescence spectroscopy may be useful in differentiating normal and abnormal tissue; based on these results, a strategy for in vivo studies is discussed.

Uterine papillary serous carcinoma (UPSC) treated with cisplatin, doxorubicin, and cyclophosphamide (PAC)

Uterine papillary serous carcinoma (UPSC) is an aggressive malignancy that accounts for a disproportionate number of intraabdominal failures among endometrial carcinoma patients. The histologic appearance and tendency toward intraabdominal spread resemble those of papillary serous adenocarcinoma of the ovary. Because approximately 70% of untreated ovarian carcinoma patients respond to platinum-based chemotherapy, it has been suggested that UPSC patients might respond to similar treatment regimens. Twenty patients with UPSC were treated with cisplatin, doxorubicin (Adriamycin), cyclophosphamide (PAC) chemotherapy between January 1982 and December 1989. They included 9 patients with advanced primary disease, 5 with recurrence, and 6 who received PAC as adjuvant therapy. Patients received a mean of five cycles of PAC. Only 2 of 11 patients with measurable disease greater than 2 cm achieved complete clinical responses of 12 and 31 months duration; there were no partial responses. Actuarial 5-year survival for all patients was 23%. The mean progression-free interval was 9 months. Patients with clinical stages I or II disease had a higher survival rate than those with stage III or IV disease (P = 0.003). Survival did not correlate with depth of myometrial invasion (P = 0.81) or size of residual tumor following initial surgery (P = 0.16). Estrogen or progesterone receptors were detected in 10 of 11 tumors tested. Seven of 9 patients tested had elevated serum levels of CA-125 (greater than 35 U/ml). Correlation between CA-125 value and clinical course was demonstrated in 3 of 5 patients who had serial measurements. Of all patients, 3 are currently alive; 1 has documented disease. Moderate to severe toxicity was seen in 14 patients (70%). There was one possible treatment-related death from cardiomyopathy. UPSC, despite its histologic and clinical similarities to ovarian carcinoma, was relatively resistant to PAC chemotherapy in this mixed group of patients.