Sequence variants of human papillomavirus type 16 from couples suggest sexual transmission with low infectivity and polyclonality in genital neoplasia

Human papillomavirus type 16 (HPV-16) is causally involved in the pathogenesis of genital neoplasia, but important details of the natural history of infection and disease are not yet understood. Many individual HPV-16 DNA isolates differ by characteristic point mutations. In a study of the HPV-16 variants from genital lesions of 32 married couples, HPV-16 was detected in both the husband and the wife in 8 couples. Of these, 4 demonstrated identical HPV-16 variants between husband and wife, and 4 had mismatching HPV-16 variants. Five of 31 biopsies showed simultaneous presence of two different HPV-16 variants. The data suggest that sexual transmission of HPV-16 does occur, but with low infectivity, and that HPV-16-related premalignant lesions are frequently polyclonal.

A simple and effective treatment for hemorrhagic radiation proctitis using formalin

Radiation proctitis is a common complication of radiotherapy for pelvic malignancy. In the more severe form, it leads to intractable or massive hemorrhage, which may require repeated hospital admissions and blood transfusions. Medical therapy in patients with radiation proctitis is usually ineffective, whereas surgery is associated with a high morbidity and mortality. Eight patients (seven females and one male) with hemorrhagic radiation proctitis were treated over a six-month period with endoluminal formalin. The technique used ensured minimal contact with formalin. The median age of the patients was 68 years (range, 42-73 years). Seven patients had had cancer of the uterine cervix, and one patient had had cancer of the prostate treated with radiotherapy at a median time of 30 months (range, 9-46 months) previously. The median duration of time of symptomatic rectal hemorrhage before formalin therapy was eight months (range, 1-12 months). The median number of units of blood transfused previously per patient was four (range, 2-32). The time taken for formalin therapy was 20 minutes (range, 10-70 minutes). One patient required repeat formalin application at two weeks. Bleeding ceased immediately in seven patients after formalin treatment. No further bleeding was noted, nor was any blood transfusion needed, at follow-up at four months (range, 1-6 months). Formalin therapy is a simple, inexpensive, and effective treatment for hemorrhagic radiation proctitis.

Treatment of bleeding gastroesophageal varices: a report of forty-four cases

Bleeding gastroesophageal varices is associated with a high morbidity and mortality. Forty-four cases of bleeding gastroesophageal varices were treated at the Department of Surgery, Universiti Kebangsaan Malaysia, General Hospital, Kuala Lumpur over four and a half years. Thirty-two of them had liver cirrhosis. Hepatitis B infection was noted in 13 and alcoholic abuse was present in 14 patients. Five patients had associated hepatoma. Thirty-four percent had gastric fundal varices and a third of these bled from them. A total of 179 endoscopic injection sclerotherapy sessions were performed averaging 4 per person. Rebleeding rate was 4% and mortality was high (50%) in these cases. It was concluded that injection sclerotherapy is a safe and effective means of controlling bleeding oesophageal varices. Operative surgery was employed in those who rebled after injection and would be considered in those in Child's A.

Risk factors and a risk scoring system for the prediction of malignancy in ovarian cysts

A retrospective study was carried out on 396 patients who presented with ovarian masses. Sixty five (16%) patients were found to have ovarian malignancy while the rest either had benign ovarian tumours (n = 159), endometriotic cysts (n = 130), physiological cysts (n = 20) or inflammatory masses (n = 7). The relative risk for ovarian malignancy among these patients increased significantly (p < 0.001) after the age of 40 years. The presence of ascites, abdominal distension, urinary complaints and loss of appetite and weight were significant individual risk factors for malignancy. Ultrasound image of a complex cyst is also associated with increased risk of malignancy in an ovarian mass. None of the individual risk factors was discriminatory between a benign and malignant cyst. However, these factors can be combined to form a 20-point risk scoring system. The risk of malignancy in an ovarian cyst increased with increasing scores. In this study, the median scores were 3 for benign cyst, 7 for borderline malignancy and 12 for malignant cysts. Using a total score of 7 as a cut off point, one can detect 75% of malignant cysts with a specificity of 84.1%, a positive predictive value of 47.5% and a negative predictive value of 94.6%. It is concluded that the majority of malignant ovarian cysts can be identified preoperatively to allow arrangement and planning of an optimal surgery.

Combined chemotherapy using cisplatin, ifosfamide and bleomycin (PIB) in the treatment of advanced and recurrent cervical carcinoma

Combined cisplatin, ifosfamide and bleomycin (PIB) chemotherapy was given to 14 (11 recurrent and 3 advanced and metastatic) cervical carcinoma patients. At least 2 cycles of chemotherapy were given before assessment of tumour response. The overall response rate was 28.6%; the complete response rate was 14.3%. Sites of response included cervical lymph nodes and the lung. Toxicity was common. Alopecia was universal. Other toxicity included suppression of haematopoiesis (73%), leucopenia (71%) and nausea and vomiting. Two patients died from sepsis during the myelosuppressive phase. The role of PIB in the management of advanced and recurrent carcinoma of the cervix should be evaluated in a randomized-controlled trial.

Changes in thyroid hormones, thyroid stimulating hormone and cortisol in acute spinal cord injury

To determine the hormonal response to acute spinal cord injury, serial serum samples were collected from 18 patients with acute spinal cord injury and from 14 control patients with spinal fractures without cord injury. The first sample was taken within 24 hours of injury, the second at 24-48 hours; and the third at 7 days for determination of thyroxine (T4), free T4 (FT4), triiodothyronine (T3), reverse T3 (rT3), T3 uptake (T3U), thyroid stimulating hormone (TSH), thyroxine binding globulin (TBG), growth hormone (GH), cortisol, and insulin. Significant increases were observed in rT3 levels and transient changes were observed in the T4 and T3 levels in the spinal cord injured group but not in the group with spinal fractures alone. The changes in the spinal cord injured patients are consistent with the 'low T3 syndrome'. However, the persisting rise of rT3 at 7 days was an unexpected finding. In addition to the cord injury, these changes may also be related to dexamthasone administration and nutritional factors.

Patterns and implications of subclinical vulval human papillomavirus infection: the impact of PCR analysis

This study was performed to elucidate the presence of human papillomavirus (HPV) infection of the vulva by colposcopy, histology and the polymerase chain reaction (PCR). Colposcopy defined 5 patterns of vulval epithelial lesions inconspicuous to the naked eye. Of these 75 subclinical vulval lesions, HPV infection was diagnosed by histology in 20.0% of minor epithelial changes with faint acetowhitening, 52.2% of conspicuous acetowhite lesions, 63.0% of acetowhite areas with satellite lesions, 84.6% of villous lesions, and 85.7% of villous lesions with surrounding acetowhitening. The corresponding HPV DNA positivity rates by PCR were 60.0%, 73.9%, 70.4%, 84.6% and 100% respectively. The oncogenic HPV type 16 was detected by PCR in 37.3% of the samples. These results provide firm evidence for the prevalent existence of subclinical HPV lesions of the vulva. Some of these infections may not produce significant morphologic changes detectable by colposcopy or histology. Subclinical vulval lesions are common and may constitute a reservoir for repeated cervical HPV infections, as well as a source of contamination of cervical samples for HPV DNA detection by sensitive molecular techniques.

The diagnostic value and patient acceptability of outpatient endometrial sampling with Gynoscann

Endometrial sampling with Gynoscann was performed in the outpatient department in 70 women with abnormal vaginal bleeding prior to dilatation and curettage (D&C). Successful endometrial sampling was achieved in 62 (89%) patients; Of the samples obtained 44 (71.0%) were adequate for cytological assessment and 46 (74.2%) for histological assessment, compared to 80% of D&C samples being adequate for histological examination. In those patients in whom outpatient endometrial sampling was adequate, both the cytological and histological diagnosis agreed with the D&C. The outpatient endometrial sampling was well tolerated by the patients since the majority (89%) experienced either no or little pain. Vaginal bleeding following the procedure was minimal in all except 1 patient. Endometrial sampling with Gynoscann may be useful for endometrial assessment prior to commencement of hormonal therapy and hysterectomy. It is a potentially useful screening test for early detection of endometrial cancer in patients at risk.

Spurious labor: a high risk factor for dysfunctional labor and fetal distress

This is a retrospective case controlled study comparing the outcome of labor and neonates in pregnancies complicated by spurious labor at term. The first stage of labor was significantly longer and the proportion of cases requiring oxytocin augmentation was higher in the study group when compared to the controls. More infants in the study group displayed intrapartum CTG abnormalities and five had a depressed Apgar score at 5 min, compared to none in the controls. Of these five neonates, three were admitted to the neonatal intensive care unit and one died from meconium aspiration syndrome and asphyxia. The findings in this study support the view that spurious labor at term constitutes a high risk factor for the ensuing labor.

Sequence variants of human papillomavirus type 16 in clinical samples permit verification and extension of epidemiological studies and construction of a phylogenetic tree

Genomic variability between different viral isolates provides a powerful epidemiological tool for verifying ultrasensitive diagnostic procedures, understanding infectious pathways in individuals and human populations, and studying viral evolution. The potential of this approach has not yet been exploited for the diagnosis of human papillomaviruses (HPVs) like HPV type 16 (HPV-16), which are involved in genital cancer. Toward this end, we amplified by polymerase chain reaction, cloned, and sequenced a 364-bp noncoding segment of the HPV-16 genome from cell lines, cervical biopsy specimens, and cervical smears. The HPV-16 genomes in the cell lines SiHa and CaSki showed an identical point mutation, and in the SiHa cell line it had an additional 38-bp deletion. Only 4 of 22 cervical lesions biopsied from patients at several hospitals in Singapore contained HPV-16 DNA with the prototype sequence, while the DNAs of the other 18 cervical lesions differed by 1 to 10 mutations. This excludes contaminations with cloned HPV-16 DNA as the source of this DNA. To test whether this diversity was a geographic idiosyncrasy, we analyzed 25 cervical biopsy specimens from Brazil. Eight of these contained the prototype sequence, while 17 were mutated. Altogether, 11 genomic variants were found in the Singaporean samples and 12 genomic variants were found in the Brazilian samples, and only 5 of these occurred identically in both cohorts. All variants could be connected to form a phylogenetic tree, with some branches being specific for each cohort. This suggests that the variants did not originate over a short period in the individual patient but, rather, evolved consecutively while spreading throughout humankind.(ABSTRACT TRUNCATED AT 250 WORDS)

Subclinical human papillomavirus infection of the male lower genital tract: colposcopy, histology and DNA analysis

In 25 partners of women with genital human papillomavirus (HPV) infection or cervical intraepithelial neoplasia, colposcopic examination revealed the existence of subclinical HPV infection of the male lower genital tract in 22 cases. It manifested either as short papillae tipped with acetowhite changes, or flat acetowhite lesions on the foreskin, glans, periurethral region, scrotum, perineum and/or perianal region. Multiple lesions involving several anogenital areas were common. Some of these abnormalities were small and inconspicuous. Of these 22 cases, 17 had histological evidence of HPV infection. Although Southern blot hybridization detected HPV DNA in only one case, polymerase chain reaction (PCR) analysis revealed HPV DNA in 20 cases. There were 10 cases of HPV 16. Subclinical HPV disease is best identified by colposcopy and confirmed by PCR. In treating HPV disease, colposcopic recognition of subclinical HPV disease forms an essential part of the management plan.

Is genital human papillomavirus infection always sexually transmitted?

The occurrence of genital human papillomavirus (HPV) infection was studied prospectively by colposcopy and histology in 43 virginal and 162 sexually active women attending a colposcopy clinic. The study also included 111 husbands of the latter group. By colposcopic criteria, the prevalence of HPV infection was 51.1% in the virginal and 69.1% in the sexually active women. The prevalence was 77.1% among men whose wives had HPV infection compared to 13.3% among men whose wives did not have the infection (p less than 0.01). There was a strong association in genital HPV infection between husbands and wives as expected from a sexually transmissible disease. However, the high prevalence of the infection among the virginal women indicated that transmission of HPV by nonsexual modes was common. Genital HPV infection is ubiquitous and in women is not exclusively a venereal disease.

Studies on cervical intraepithelial neoplasia: the level of octadeca-9,11-dienoic acid and measurement of free radical content by electron spin resonance spectroscopy

The efficacy of electron spin resonance spectroscopy (a technique that measures free radicals) in detecting cervical intraepithelial neoplasia was evaluated in 68 women. In addition, electron spin resonance spectroscopic data were correlated with the phospholipid-esterified octadeca-9,11-dienoic acid (18:2(9,11]/octadeca-9,12-dienoic acid (18:2(9,12] molar ratio, a suggested marker of free radical damage to linoleic acid. Incubation of cervical epithelial cells with the spin-trap N-tert-butyl-alpha-phenylnitrone and subsequent examination by electron spin resonance spectroscopy gave signals from a nitroxide radical, which has been tentatively assigned to an adduct from either a carbon-centered lipid radical or a lipid alkoxyl radical; no significant differences in either the type of radical detected or the intensity of the signals was found between patients with cervical intraepithelial neoplasia and normal control subjects. There was no significant correlation between the intensity of the electron spin resonance signal and the phospholipid-esterified 18:2(9,11)/18:2(9,12) molar ratio. This finding provides no support for the classification of 18:2(9,11) as a "free radical product."

A histological and immunohistological study of cervical intraepithelial neoplasia in relation to recurrence after local treatment

A retrospective histological study was performed on 23 patients who had presented with recurrent cervical intraepithelial neoplasia (CIN) 18 months or more after apparently adequate local destructive treatment and a comparable control group of 23 patients who had no recurrence at 18 months. All recurrences were in women with CIN 3. Detailed examination of pretreatment biopsies showed that there were significant differences in both the extent of crypt involvement (P less than 0.01) and maximum depth of CIN (P less than 0.01) between the recurrent groups and the comparison group of women without recurrence. There was also a significant difference in mitotic count between the two groups (P less than 0.01). Immunocytochemical staining for Langerhans' cells or human papilloma virus common antigen showed no significant difference between the two groups. A mitotic count of 35 per ten high-power fields or a depth of crypt involvement greater than 1.7 mm in the pretreatment biopsy was invariably associated with recurrence and identified 13/22 (59%) cases of recurrent disease. The histological reporting of these features may be of value in predicting a group of women at high risk of recurrence of CIN after local treatment.

Traumatic pseudocyst of the pancreas--a case report

Blunt trauma to the pancreas is not common. The pancreatic injury can range from simple bruising to complete transection often associated with other visceral injuries. Pseudocyst of the pancreas is a late complication presenting usually within six weeks of the injury. The treatment of choice is distal pancreatectomy.

Primary mesenteric venous thrombosis--a case report

Mesenteric venous thrombosis has been described to occur in cases where there has been no apparent cause. The diagnosis is usually delayed because the signs and symptoms are non-specific. A case of primary mesenteric venous thrombosis is reported below. Its presentation and pathology are discussed. Treatment is surgery with resection of gangrenous bowel and primary anastomosis. Post-operative anticoagulation is advocated.

Langerhans cell population in early invasive squamous cell carcinoma of the uterine cervix

Langerhans cell counts were performed using indirect immunoperoxidase staining for S100 protein in 10 cases of early invasive squamous cell carcinoma of the cervix and 20 controls from routine hysterectomy specimens. There was a significant (p < 0.01) reduction in the number of Langerhans cells per unit sectional area of tumour tissue compared to the normal cervical epithelium. The density of Langerhans cells in the 3 patients with tumour metastasis in pelvic lymph nodes was further reduced. The low density of Langerhans cells in invasive squamous cell carcinoma compared to the normal state may reflect poor local immunosurveillance and may be related to progression and spread of the tumour.

Tissue macrophage response in human papillomavirus infection and cervical intraepithelial neoplasia

Tissue macrophages in the uterine cervix were studied immunocytochemically with monoclonal antibody (MoAb) 3.9 which reacts with the majority of macrophages, and E11 which is specific for the C3b receptor, CR1. Samples from five normal women, six with human papillomavirus (HPV) infection and 10 with cervical intraepithelial neoplasia (CIN) were tested. A small population of MoAb 3.9 positive and only occasional MoAb E11 positive macrophages were found in the normal cervix. In HPV infection and CIN there was a significant infiltration of MoAb 3.9 positive and MoAb E11 positive macrophages in both the epithelium and the stroma. The pattern of infiltration in these groups of women suggests that these macrophages were most likely to be functioning as the first line of defence against the spread of the virus infection, either through a direct anti-virus mechanism or non-specific phagocytosis.

Routine papillomavirus antigen staining of cervical punch biopsy specimens

Immunocytochemical staining for papillomavirus antigen was carried out on 1147 consecutive cervical punch biopsy specimens over 12 months. Of 876 cases with cervical intraepithelial neoplasia (CIN) 351, were antigen positive and of 49 cases with histological evidence of human papillomavirus (HPV) infection but no CIN, 14 were positive. There were 204 cases reported to be normal on routine histological examination and 12 cases reported to show features suggestive but not diagnostic of HPV infection. Of the normal group, 24 (12%) were antigen positive and of the equivocal group, two were positive. In 122 of the normal or equivocal groups cytological examination was repeated at the time of colposcopy, and dyskaryosis was reported in 36. In only four cases was disease shown by HPV antigen staining when there was no diagnostic histological or cytological abnormality. HPV antigen staining assists in the recognition of the range of histological changes associated with productive HPV infection but is an insensitive test and has only limited value in supplementing histological and cytological examinations as a diagnostic aid in routine colposcopic pathology.

Natural killer cells in cervical intraepithelial neoplasia and human papillomavirus infection

A semiquantitative immunocytochemical study of natural killer (NK) cells in cervical mucosa was performed by the immunoperoxidase technique using anti-Leu-7 and anti-Leu-11 monoclonal antibodies. NK cells were present in two of the five normal controls and five of six specimens showing human papillomavirus (HPV) infection. Of the 12 CIN studied, six were positive for both Leu-7 and Leu-11 staining and three were positive for Leu-11 alone. NK cells were found predominantly in the subepithelial stroma. The frequency and pattern of distribution of these cells were similar in all grades of CIN. The number of NK cells present was usually small but the degree of infiltration by Leu-11 positive cells was pronounced in two HPV infections and in one CIN 1. NK cells may have a role in surveillance against HPV infection and the development and progression of CIN.

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

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

Recognition of cervical neoplasia by the estimation of a free-radical reaction product (octadeca-9,11-dienoic acid) in biopsy material

Linoleic acid (18:2(9,12)) and its diene-conjugated isomer (18:2(9,11)) were measured in 65 cervical biopsy samples. Both the 18:2(9,11) concentration and the 18:2(9,11)/18:2(9,12) molar ratio showed highly significant differences between the normal and precancerous groups. Both showed a further significant increase in 4 invasive carcinomas. The findings in histologically normal areas from organs with precancer correlated significantly with the results in the precancerous lesions.