Cellular differences between true negative and false negative Papanicolaou smears

A matched case-control study of 123 false negative Papanicolaou smears and 488 true negative Papanicolaou smears was undertaken to determine the association between the types of cells present on the smear and the correctness of the cytology report. The false negative slides were significantly more likely to include endocervical columnar cells than the true negative slides (odds ratio 1.90, 95% confidence interval (CI) 1.21-3.01). No statistically significant difference in metaplastic cell status was evident (odds ratio 1.48, 95% CI 0.95-2.30). When considered together, metaplastic and/or columnar cells were significantly more likely to be present in false negative smears than in true negative smears (odds ratio 1.87, 95% CI 1.13-3.08). The implications of these findings for improving the accuracy of cervical cytology for the detection of precancerous lesions are discussed.

Pap smears collected by nurse practitioners: a comparison with smears collected by medical practitioners

This paper evaluates the results of a pilot study in which nurse practitioners (NPs) collected Pap smears to screen for cervical cancer in women in Victoria, Australia. A comparison is made between women screened by NPs and women screened by three other types of medical practitioners. Women screened by NPs were more likely to be older, of non-English-speaking background, and to have had fewer smears collected previously. The quality of the smears collected by the NPs and the other medical practitioners did not differ, but a higher proportion of smears collected by the NPs were from women who had undergone a hysterectomy. The abnormality rate was lower in the smears collected by the NPs. This difference was statistically significant, even after the data were age standardized. As a result of this short-term evaluation, it has been concluded that NPs are able to effectively screen a hard-to-reach group of women, collect technically adequate specimens, and arrange for appropriate follow-up care for women with screen-detected abnormalities.

Inappropriate publication of trial results and potential for allegations of illegal share dealing

There is increasing evidence of fraud in clinical research, and one aspect concerns trading in pharmaceutical company shares by people who may have confidential information about the results of clinical trials. Plainly this has implications for honest investigators, who may find themselves exposed to such allegations. In this paper Dr D S Freestone and Mr H Mitchell, QC, identify three interlinked issues which they think underlie the potential for these allegations. They are pressure for premature or inappropriate communication of research results; trading in pharmaceutical company shares by academic clinical investigators; and the possibility that clinical investigators might succumb to temptation. Dr Freestone and Mr Mitchell suggest that whenever possible results of clinical studies should be published in appropriate medical journals without prior public disclosure. This conflicts with Stock Exchange rules, which require that price sensitive information should be published at the earliest opportunity and preclude priority of publication in medical journals. Freestone and Mitchell believe that rarely rapid public disclosure is acceptable if it is to protect patients' interests but that it must not prejudice publication in the medical or scientific press. When rapid public disclosure is needed, they say, every attempt should be made to inform prescribers before patients. Dr Freestone and Mr Mitchell warn that academic clinical investigators who have access to unpublished price sensitive information about pharmaceutical companies whose shares they trade in will almost certainly be in breach of the Company Securities (Insider Dealing) Act 1985. Furthermore, disclosing such information to third parties, they say, exposes those people also to potential criminal liability. Freestone and Mitchell advise that when potential for allegations of conflict of interest exists clinical investigators should consider declaring their position to ethics committees and any sponsoring organisations.

Cytological reporting of cervical abnormalities according to endocervical status

An analysis of cytology reporting within Victorian Cytology Service demonstrates that the proportion of Papanicolaou smears which were reported as including an endocervical component increased from approximately one half during 1987-89 to more than three quarters during 1990-91. The improvement coincided with the routine provision of special sampling instruments to all practitioners supplemented by an education program. Despite the increase in endocervical sampling, no increase in the rate of reporting of high-grade intraepithelial lesions of the cervix has occurred. An increase between the two time periods in the cytological reporting of adenocarcinoma, adenocarcinoma in situ and endocervical dyskaryosis has occurred, but does not reach statistical significance.

Accuracy and survival benefit of cytological prediction of endometrial carcinoma on routine cervical smears

Among 359 women who received a cytology report of endometrial malignancy from the Victorian Cytology Service during 1982-87, the positive predictive value for a later histological diagnosis of endometrial malignancy was 64%. The positive predictive value was significantly higher for the group of women in whom the cytopathologists made definite predictions of endometrial malignancy as compared to the group where the cytologic features were only suggestive of endometrial malignancy (75% vs. 50%, chi 2 = 23.4; p < 0.001). The sensitivity of cervical cytology performed within two years of the diagnosis of endometrial malignancy was 28%. The odds ratio of death from endometrial cancer among women where the cytology may have allowed for an early diagnosis in comparison to women where cytology did not hasten the diagnosis was 0.78 (95% confidence interval = 0.25-2.47; p > 0.05). We conclude that while cervical cytology can predict the presence of malignancy for a small proportion of women with endometrial cancer, there remains no evidence that a cervical cancer screening program will make a major impact on reducing the morbidity and mortality from endometrial cancer.

Influence of endocervical status on the cytologic prediction of cervical intraepithelial neoplasia

A case-control analysis of the endocervical status of smears that preceded a histologic diagnosis of cervical intraepithelial neoplasia (CIN) showed that smears which correctly predicted CIN were significantly more likely to include metaplastic cells than were smears reported to be negative. There was no significant difference between the smears with respect to the presence of columnar cells. A high level of agreement was apparent between scientists in determining both columnar and metaplastic cell status. A discussion of the definition, role and potential impact of endocervical status in the prevention of cervical cancer is presented.

A study of women who appear to default from management of an abnormal Pap smear

A study of nonattendance at a Dysplasia Clinic found that 20% of women who had an appointment in 1988 failed to attend the clinic during the next 18 months. Most of the nonattendance was among women who had previously been assessed at the Dysplasia Clinic. Only 6% of the nonattending women had cytological/histological evidence of CIN which remained untreated. If all women who did not default from attendance at the Dysplasia Clinic were correctly managed, then 1% of all women who have appointments made for the Dysplasia Clinic were potentially receiving inadequate management for lesions considered to have a precancerous potential. A questionnaire to the women who failed to attend these appointments identified pregnancy and seeking management elsewhere as the most commonly stated reasons for the nonattendance.

Helicobacter pylori-associated gastritis is rare in AIDS: antibiotic effect or a consequence of immunodeficiency?

Helicobacter pylori is the principal cause of type B histologic gastritis. AIDS is associated with increased susceptibility to Gram-negative enteric infections. Using a retrospective study design, we have determined the prevalence of H. pylori-associated histologic gastritis (based on gastric histopathology) in 201 patients with AIDS. These data were compared with H. pylori prevalence rates (based on serology) from healthy HIV-negative, age-matched Australian controls (n = 785) and a cohort (n = 137) of HIV-negative, dyspeptic patients undergoing panendoscopy and antral biopsy, at a community endoscopy center. Twenty-five of 201 (12.5%) patients with AIDS had histologic gastritis and, of these, six (25%) had H. pylori. The 3% (six of 201) H. pylori prevalence rate in the AIDS patients was significantly less than age-matched HIV-negative controls (22%) p = 0.001 and endoscopy center controls (59%) p = 0.009. The explanation for this unexpectedly low prevalence of H. pylori is not possible from these data. It may be a consequence of antimicrobial therapy. Other potential explanations may include specific HIV-related host factors, including hypochlorhydria or an inadequate mucosal inflammatory response, which may impair successful colonization of H. pylori.

Reporting of an endocervical component after a previous cervical biopsy

The rate of reporting endocervical cells in the Papanicolaou smears of 579 women with a past history of cervical biopsy was compared with an age matched control group of women. During a time period when only spatulae (Ayre Lerner and Aylesbury) were used for sampling, 55% of the cases and 53% of the controls had the presence of endocervical cells reported. When cytobrushes as well as spatulae were used, the proportion rose to 70% for cases and 73% for controls. We conclude that the probability of endocervical cells being reported is not influenced by a past history of cervical biopsy, but is substantially improved if a combination of cytobrush and spatula is provided for sampling.

Cervical cancer screening: a comparison of recruitment strategies among older women

OBJECTIVE

To compare the effectiveness of different recruitment strategies in encouraging older women to have a Papanicolaou (Pap) test.

DESIGN

A 2 x 2 factorial study.

SETTING

Two rural areas of Victoria, Australia.

PARTICIPANTS

A total of 10,620 persons aged between 40 and 69 years and designated as female on electoral lists.

INTERVENTIONS

A personal letter of invitation and a community-based campaign of 4 weeks' duration alone and in combination. A control group received no active intervention.

OUTCOME MEASURE

The proportion of eligible women having a Pap test report issued by the Victorian Cytology Service during the 12 weeks after the intervention compared with the 12 weeks before the intervention, with an intervening two-week washout period.

RESULTS

The odds ratio of an eligible woman being screened during the intervention period relative to the pre-intervention period was 3.00 for women who were exposed to the campaign and sent the letter of invitation (95% confidence interval, 2.38-3.77, P less than 0.001), 1.86 for women who were exposed to the campaign (95% confidence interval, 1.49-2.33, P less than 0.001), 1.61 for women who were sent the letter of invitation (95% confidence interval, 1.34-1.92, P less than 0.001). The baseline was a control group who received no active intervention.

CONCLUSIONS

Both personal invitation letters and community-based campaigns are effective in recruiting women for Pap test screening. Combined strategies are more effective than single strategies.

Correlation of plasma methotrexate concentration with human chorionic gonadotropin and therapeutic response to low-dose methotrexate-citrovorum factor in low-medium-risk gestational trophoblastic tumors

Seventeen patients with low- or medium-risk gestational trophoblastic tumors (GTT) and one patient with a placental-site trophoblastic tumor were treated according to an 8-day schedule of low-dose methotrexate (LDMTX) alternating with citrovorum factor (CF). Plasma concentrations of methotrexate (MTX) were correlated with serum human chorionic gonadotropin (hCG) levels and clinical response. After an intramuscular dose of 50 mg, plasma MTX levels rose rapidly, reached a peak concentration of 5.8 x 10(-6) M/liter at 1 hour and persisted above 10(-6) M/liter normally considered inhibitory for DNA synthesis, for approximately 7 1/2 hours. Rapid plasma clearance followed with plasma levels reaching 5-7 x 10(-8) M/liter at the time of CF administration. At 48 hours, plasma MTX levels continued to exceed 10(-8) M/liter--the break point for the appearance of clinical toxicity due to MTX. In six of sixteen, or 38%, an initial rise in hCG levels was observed. Five of the seventeen patients, or 29%, and the one patient with PSTT developed MTX resistance. The administered dose (approximately 30 mg/M2) and plasma pharmacokinetics did not differ significantly between the tumors that responded and became resistant to MTX. The authors conclude that MTX resistance in GTT occurs as a result of impaired cell membrane uptake, gene amplification of dihydrofolate reductase, or both.

Longitudinal study of women with negative cervical smears according to endocervical status

A longitudinal study of 20,222 women who received negative cervical smear reports in 1987 showed that the incidence of definite or equivocal cervical intraepithelial neoplasia (CIN) was not significantly different between those whose first smear lacked an endocervical component and those whose smear included an endocervical component. The incidence of definite cytological evidence of CIN was significantly lower in women whose first smear did not include an endocervical component. It is concluded that women whose smears are reported as negative but lack an endocervical component should not be rescreened any earlier than women with negative smears that include an endocervical component.

Risk of subsequent cytological abnormality and cancer among women with a history of cervical intraepithelial neoplasia: a comparative study

A longitudinal study of 1,281 women with a histological diagnosis of cervical intraepithelial neoplasia (CIN) during 1974-76 is presented. After 12 years of follow-up, 30 percent of the women had further cytological abnormalities reported. The rate of subsequent abnormality was highest during the first 12 months of follow-up; thereafter, there was no evidence of any decline in the rate of subsequent abnormality with increasing duration of follow-up. Women from the CIN cohort had twice as many later cytological abnormalities as an age-matched cohort of women who were negatively screened during 1974-76 (excluding abnormalities within 12 months of entry to the study and after adjustment for smear frequency). The CIN cohort remained at substantially greater risk for a subsequent diagnosis of squamous cell carcinoma of the cervix compared with the control group of negatively-screened women (rate ratio 19.8, 95 percent confidence interval 2.4-163.6, P less than 0.01). These results indicate that women who have received surgical intervention for CIN continue to have substantial morbidity from cervical abnormalities during medium-term follow-up.

Cancer of the uterine cervix and screening of Aboriginal women

Carcinoma of the cervix has not been widely reported as an important health problem for Aboriginal women. From four sources, we have studied cervical cancer death rates, abnormalities detected by cervical cytology screening, and the proportion of women who had been screened. First, from the Northern Territory for the years 1979-1983, we present a relative risk of 6.3 (95% confidence interval, 3.0-11.6) for cervical cancer deaths in Aboriginal women compared with all Australian women. Second, the screening and disease rates in Aboriginal women were profiled within a large laboratory in Victoria. Since 1984, a fourfold increase in the number of smears taken at Aboriginal health services is apparent. In women attending these services, a high rate of significantly abnormal smears is evident. Third, to study the extent of screening, we interviewed Aboriginal women in a Victorian country setting and fourth, we examined a random sample of medical records from an Aboriginal Health Service. The proportion screened at least once rose from 5/47 (11%) among women whose most recent consultation with the Health Service was during the years 1974-1980 to 51/170 (31%) women who attended from 1981-1987 (p less than 0.01). Aboriginal communities may interpret these trends favourably as they encourage their women to be screened regularly to reduce cervical cancer mortality.

Cervical cancers diagnosed after negative results on cervical cytology: perspective in the 1980s

OBJECTIVES

To assess the magnitude of the problem of interval cancers of the cervix (those that are diagnosed within a short time after negative screening test results) in the 1980s, to compare the nature of interval cancers in younger women with that in older women, and, by reviewing negative cervical smears, to determine the proportion of interval cancers that might represent the development of malignancy anew compared with the proportion that might be associated with difficulties in sampling or errors in reporting.

DESIGN

An audit of the interval cases of cervical cancer that had been diagnosed within 36 months of a smear having been reported as negative by the Victorian Cytology Gynaecological Service among women registered with cervical cancer during 1982-6.

SETTING

The Victorian Cytology Gynaecological Service, a free public sector cytology laboratory in Victoria, Australia.

SUBJECTS

138 Women, all of whom had had cervical cancer diagnosed during the 36 months after having had a negative cervical smear. Subjects were divided into two age groups: younger women, aged less than 35; older women, aged 35-69.

INTERVENTIONS

Negative slides were reviewed for evidence of optimal sampling and for the presence of cellular abnormalities that had been missed at the time of the original reporting.

MAIN OUTCOME MEASURES

The number of interval cases of cancer of the cervix registered during 1982-6. The proportion of interval cases occurring in younger women and the proportion occurring in older women. Division of women into three risk categories based on clinical history and screening history that broadly corresponded to the probability that a diagnosis of cervical cancer might be expected during the 36 months after the issuing of a negative smear report.

RESULTS

138 Of 1044 (13.2%) women who had been registered with cervical cancer during 1982-6 had had one or more negative smears during the 36 months preceding the diagnosis of cancer. Interval cancers comprised a larger proportion of registrations of cervical cancer in women aged less than 35 years than in women aged 35-69 (21.1% v 11.0%, p less than 0.01). Women with interval cancer who had had at least three negative smears during the 10 years before the diagnosis of cancer were commoner in the younger age group than in the older age group (7.0% v 2.5%, p less than 0.01). When, however, the number of observed cases of squamous cell carcinoma was related to the number of expected cases in the absence of screening, no significant difference was found between the two age groups (6.8% v 4.8%, p greater than 0.10). The rate of diagnosis of interval cancer per 100,000 negative tests was lower among younger women than among older women (10/100,000 v 16/100,000). Review of the negative slides showed that 11.9% were again considered to be negative with an optimal sample having been obtained as evidenced by the presence of endocervical cells or metaplastic cells, or both.

CONCLUSIONS

Interval cancers might comprise a larger proportion of all registered cases of cervical cancer among younger women owing to the larger proportion of such cancers being prevented in this age group. Among women with interval cancer review of the negative slides showed that most were accounted for by suboptimal sampling or by errors of reporting.

An update on human papillomavirus infection of the cervix

Human papillomavirus infection (HPV) of the cervix has been an area of intense research during the 1980s. Knowledge has expanded rapidly and new advances have often challenged previous ideas. This review is designed to help the general practitioner remain up-to-date with recent research findings and to assist in the management of women with HPV infection.

Age and time trends in the prevalence of cervical intraepithelial neoplasia on Papanicolaou smear tests, 1970-1988

Substantial increases in the prevalence of cervical intraepithelial neoplasia (CIN) in women of all age groups are apparent from Papanicolaou smear test reports issued by the Victorian Cytology (Gynaecological) Service between 1970 and 1988. Most of the change in prevalence is due to an increase in reports of neoplasia of a lesser severity than CIN III. A progressive lowering of the age group having the highest prevalence of "definite" CIN is evident, from women aged 40-49 years in 1970-1973 to women aged 25-29 years in 1982-1988. The prevalence of "possible" CIN has consistently been highest among the youngest age groups screened. While 6.7% of screened women from the age group 20-24 years received a report of "definite" or "possible" CIN in 1988, only 0.08% of women in this group received a report of CIN III. Cohort analysis revealed that for women born between 1949 and 1958, the prevalence of CIN III continued to increase during 1988.

Inspection time and high-speed ball games

It has been suggested that successful batsmen in cricket are not distinguished by their fast speed of visual information intake. A study is presented in which a season's batting averages for twenty regular cricketers, all members of the same local team, were correlated with the cricketers' visual inspection times. The correlation was -0.63 (p less than 0.005), suggesting that the successful batsmen were faster at picking up information from briefly presented visual displays. When the age factor was eliminated, the partial correlation between inspection time and batting average remained significant at -0.52 (p less than 0.01). This finding is discussed with respect to the sources of information available from a ball in flight.

Evidence against diathermy as a beneficial treatment for human papillomavirus infection of the cervix

An observational study of the influence of diathermy on the rate of subsequent cytological evidence of cervical intraepithelial neoplasia and/or human papillomavirus infection among women with a histological diagnosis of cervical human papillomavirus infection is presented. After the histological diagnosis of human papillomavirus infection, 35% (23/65) of women who were not diathermied had persistence/recurrence of cytological abnormalities compared with 30% (60/203) of the women who were diathermied at the time of the biopsy. The rate ratio for further abnormality among women who did not have a diathermy relative to those who did was not significantly different at 1.25 (95% confidence interval 0.77-2.03). This study had a power of 77% to detect a true rate ratio of 2 at the 0.05 level of significance. This data does not provide strong evidence that diathermy is appropriate management for women with cervical human papillomavirus infection without evidence of dysplasia.

Statistical measurements of accuracy in cervical cytology

Statistical measures that can be used to monitor the level of accuracy of cervical cytologic screening are examined: sensitivity, the false-negative rate, the interval cancer rate among women with negative reports and the predictive value of a positive test. Sensitivity and the false-negative rate are subject to biases and problems of determination that may make them less useful as measures of accuracy. The interval cancer rate and the positive predictive value may be better methods of assessing the frequency of serious abnormalities following negative cytologic reports and the accuracy of cytologic reports of serious abnormalities, respectively. It is important to recognize that no single measure of accuracy can adequately define a laboratory's performance. The use of statistical analyses can be invaluable in placing in context the criticisms of cervical cytology as an appropriate screening test for the prevention of cervical cancer; statistical analysis should be used as one component of quality control.

Adherence to recommendations for early repeat cervical smear tests

OBJECTIVE

To assess adherence to recommendations for an early repeat cervical smear test in women with reports of cytological abnormalities, and to evaluate the impact of reminder letters to medical practitioners when such smear tests are overdue.

DESIGN

Observational study.

SETTING

Cytology (gynaecological) service for Victoria, Australia.

SUBJECTS

Two groups of women who had abnormal cervical smears during 1985. Women in group A had some evidence of an important dysplasia and were advised to have a repeat smear in three months' time whereas women in group B had a less serious abnormality and were advised to have a repeat smear test in six months' time. In all, 971 of the 1036 women in group A and 1401 of the 1464 women in group B were eligible to have a repeat smear analysed by the service.

INTERVENTION

If a repeat smear had not been received within three months of the recommended date a reminder letter generated by the service's computer was sent to the medical practitioner who had taken the smear.

END POINT

Thirty six months after the report on the abnormal smear was issued.

MEASUREMENTS AND MAIN RESULTS

In all, 870 (90%) of the women in group A and 1154 (82%) of the women in group B had a repeat smear test. The mean time to a repeat test was 3.0 months (95% confidence interval 0.5 to 16.4) in group A and 6.0 months (1.2 to 30.3) in group B. The reminder letter to the practitioner potentially increased the rate of return for a repeat smear test by 18% in group A and 24% in group B. Adherence to the recommendation for a repeat test increased with increasing age.

CONCLUSIONS

Achieving high rates of follow up smear tests and appropriate management in women with cytological abnormalities is critical to the impact of a screening programme for cervical cancer. The reminder system used in this study was not labour intensive or expensive and provided a fail safe mechanism for ensuring that reports of abnormal smears were not overlooked.

Is there a role for screening by cervicography in Australia?

A review of published studies that have evaluated cervicography as a screening-test for the presence of cervical cancer is presented. Significant problems with the use of cervicography at a population level can be anticipated, in particular, a high proportion of women with uninterpretable test-results and an unacceptably-low positive predictive value. Colposcopy was unable to distinguish adequately the true status of many women with suspicious cervicograms; half the women with a cervicogram that was suggestive of cancer and an abnormal result by colposcopy had normal or benign histological findings. The impact of cervicography on the morbidity and mortality of cervical cancer is unproved. On current evidence, cervicography would not appear to be suitable for use as a screening-test, either as a replacement for, or as a supplement to, the Papanicolaou smear-test.

Pap smear results of Victorian teenagers, 1980-1987

Pap smears reported by the Victorian Cytology (Gynaecological) Service between 1980 and 1987 for teenagers show a profile of abnormality which is similar to that for women for all ages. More than 90% of the cytology report have consistently been reported as normal or showing minor benign abnormalities only. No evidence of an increasing rate of infection with human papillomavirus is apparent, with the infection rate as determined cytologically being constant at around 4% to 5% during 1981 to 1987. Some increase in the proportion of women having associated changes of CIN is apparent. No case of invasive cancer in teenagers has yet been confirmed. These data suggest that the teenagers in Victoria who are having Pap smears reported by the Victorian Cytology (Gynaecological) Service are not a high risk group for cervical cancer during their teenage years, but may be a high risk group during later years.

Quality control measures for cervical cytology laboratories

The results of three quality control measures for evaluating a cytopathology laboratory's performance in the diagnosis of cervical abnormalities are presented. The sensitivities of cervical cytology were estimated to be 95.5% or 93.1% (using two different methods of analysis) for the detection of histologically diagnosed invasive squamous cell carcinoma of the cervix and 60% for the detection of adenocarcinoma and adenosquamous carcinoma of the cervix in 1983. The positive predictive values for a histologic diagnosis of neoplasia after cytologic reports of CIN III and invasive carcinoma were 92.5% and 99%, respectively. Repeatability of a negative cytologic result exceeded 98%. These results indicate that accurate cervical cytologic reporting can be achieved. Regular monitoring of the type described, which is both practical and reasonably comprehensive, is recommended for all laboratories.

Declining mortality from stroke in Allegheny County, Pennsylvania. Trends in case fatality and severity of disease, 1971-1980

Mortality rates for stroke in 1971, 1974, 1977, and 1980 were obtained for residents of Allegheny County in western Pennsylvania. Hospital case fatality ratios were also obtained in the same 4 years for those discharged with the diagnosis of stroke (ICD 430-438 of the Eighth and Ninth Revisions of the International Classification of Disease) in two large hospitals (greater than 400 beds). Age-adjusted mortality rates per 100,000 population have declined significantly in this period for the whole county as well as for the four sex-race groups. Case fatality ratio in the two hospitals of the study has decreased from 19.6 to 11%. A change in the severity of the disease manifested by a reduction in the number of comatose patients has occurred, and this reduction in comatose patients was responsible for greater than 80% of the decline in case fatality ratio. Coma appears to be the best predictor of mortality among hospitalized stroke cases (r = 0.6, p less than 0.00001). The recent introduction of computed tomography for the diagnosis of stroke in the late 1970s was accompanied by a twofold increase in the survivorship of stroke patients. However, this increase in survivorship may reflect selection bias and is based on ecological association. Further studies are needed to examine the role of computed tomography in improving survival.

Papanicolaou smears in Victoria: are the wrong women being screened?

While a mismatch is evident in the age distribution of women who are smear-tested by the Victorian Cytology (Gynaecological) Service (VC(G)S) and the women who are developing and dying of invasive cancer of the cervix, evidence is presented that the screened population have significant morbidity from precursor lesions. Women whose cervical cytological examination is undertaken by the VC(G)S have higher detection rates for carcinoma-in-situ than does the general population; a more than three-fold excess over the SA Cancer Registry rates is evident. During 1984 one in 148 of the women who were screened by the VC(G)S had histologically-proved dysplasia or carcinoma-in-situ in contrast with one in 5606 Australian women who were diagnosed as having invasive cancer of the cervix. These results indicate that the women who are currently screened should not be considered an intrinsically low-risk group for cervical malignancy.

Delay times to definitive diagnosis after an abnormal Pap smear

The delay between the issuing of an abnormal cytology report and the subsequent histological diagnosis has been studied for women diagnosed with carcinoma in situ, microinvasive cancer and invasive cancer in Victoria during 1985-1986. The median delay was 0.75 weeks for women with invasive cancer, 6.2 weeks for women with microinvasive cancer and 4.9 weeks for women with carcinoma in situ. Little variation was apparent with the type of practitioner taking the smear or with the area of residence of the woman. Ten of the 235 women in this study had delays of greater than 20 weeks. Five of these women were ultimately shown to have microinvasive or invasive cancer where the cytology report had indicated a lesser degree of neoplastic change. It is possible that the lesions progressed during this time.

Computerized evaluation of Valsalva's Maneuver before and during alpha-adrenoceptor blockade with alfuzosin

Methodological differences exist in the evaluation of Valsalva's Maneuver. Linear and nonlinear mathematical models were described for beat-to-beat changes in blood pressure and R-R intervals occurring during the strain and release phases of Valsalva's Maneuver. This study indicated that the strain phase is linear, whereas the release phase is nonlinear; the release phase consists of a "lag phase," a "breakpoint," and an "overshoot phase." The alpha-adrenoceptor antagonist, alfuzosin, reduced baroreflex-mediated tachycardia during the strain phase and prolonged the "time lag" and "pressure lag" during the release phase; the latter change was due entirely to the reduced systolic pressure that occurred with alfuzosin at the end of the strain phase.

Human papillomavirus infection of the cervix in Victoria, 1982-1985

Cytological evidence of human papillomavirus infection was present in 4.1% of the smear-tests that were received by the Victorian Cytology (Gynaecological) Service during 1982-1985. The prevalence rate among women was estimated to be 2.6% in 1984; for one-third of the women this was a change from their previous cytological status. The prevalence of papillomavirus infection was noted to vary with age and referral source; higher proportions were seen in the age group, 20-24 years, and in the cytological results of women who were attending either a sexually-transmitted diseases clinic or Aboriginal health cooperatives.

Cytologic detection of human papillomavirus infection

In recent years there has been a dramatic increase in the incidence of human papillomavirus infection of the female genital tract. Since the primary diagnosis of this condition is almost invariably based on cytologic observations, the diagnostic criteria are of paramount importance. The diagnosis is usually based on the presence of koilocytes, or balloon cells, and dyskeratotic cells. Although these cells remain fundamental to the diagnosis, it is important to recognize other possible cytologic manifestations of the disease. Follow-up studies indicate clearly that any woman with cytologic evidence of HPV infection has a greatly increased risk of developing cervical intraepithelial neoplasia. Morphologic attempts to quantify this risk are unreliable. The studies described and quoted in this paper would suggest that all women with the cytologic changes of HPV infection, with or without evidence of cervical intraepithelial neoplasia, should be managed with extreme caution.

Prospective evaluation of risk of cervical cancer after cytological evidence of human papilloma virus infection

846 women with cytological evidence of human papillomavirus infection on their Papanicolaou smears in 1979 were followed for the subsequent development of cervical malignant disorders. Carcinoma-in-situ developed in 30 women during the next 6 years, compared with an expected number of 1.9 by general population incidence figures, giving a relative risk of 15.6. The risk was greatly increased (38.7) in women younger than 25 years when the cytological diagnosis of human papillomavirus infection was made.

Perception of life event stress in patients with chronic duodenal ulcer. A comparison of the rating of life events by duodenal ulcer patients and community controls

Stress is often claimed by doctors and patients to be an aetiological factor in peptic ulcer disease. The aim of the present study was to investigate whether ulcer patients perceive that they would react more strongly than normal to life event stress. Seventy-three patients with duodenal ulcer and their sex- and age-matched controls rated 81 events for the amount of distress and life change they considered the events would cause them personally. With regard to individual events, only one difference emerged: female patients rated promotion at work significantly lower for distress than did controls, when event experience was taken into account. There was a systematic tendency for ratings of male patients to be lower than those of controls. These observations suggest that duodenal ulcer patients do not perceive that their reaction to life events would be in excess of normal.

The sensitivity of placental trophoblast cells to intraplacental and allogeneic cytotoxic lymphocytes

The NK-susceptibility of trophoblast cells to allogeneic and autologous intraplacental natural killer (NK), antibody-dependent (K), and mitogen-induced cell-mediated cytotoxicity was studied, using untreated and neuraminidase-treated trophoblast cells from normal, full-term deliveries. The work was preceded by systematic studies of placental cell separation and labelling techniques, and the effects of these techniques on the NK target, K562. The results indicated that maternal NK cells are present among intraplacental lymphocytes, but that their activity is lower than that of peripheral blood lymphocytes and they are not stimulated by interferon to the same extent as peripheral blood lymphocytes (PBL). Trophoblast cells were rarely susceptible to allogeneic NK cells, with low cytotoxicity at high effector-target cell ratios in only two of five experiments. Interferon (IF)-boosted NK cells mediated some cytolysis of trophoblasts in three of four experiments, but high effector/target cell ratios were also required for the effect to be observed. The trophoblast cells could be lysed, however, by K cells and lectin-induced cytotoxicity. Removal of surface sialic acid by neuraminidase treatment of the trophoblast cells had little effect on the susceptibility of these cells to unstimulated NK cells (one of four experiments), but resulted in susceptibility to IF-boosted NK cells in four of four experiments. Normal trophoblast cells did not compete in IF-NK(K562) assays and neuraminidase-treated cells competed weakly in only one of three such experiments, indicating that the NK "target structure" is only weakly expressed on human trophoblast cells. Intraplacental lymphocytes lysed autologous trophoblast cells to a lower extent than allogeneic PBL.(ABSTRACT TRUNCATED AT 250 WORDS)

The psychosexual histories of young women with bulimia

While it is known that anorexia nervosa patients show a wide range of sexual knowledge, attitudes and practices, the psychosexual histories of bulimia patients have not been studied. In this paper the psychosexual histories of 20 bulimic patients and 20 matched control subjects are presented. Bulimic patients were more likely to experience orgasm with masturbation, were more likely to have experimented with anal intercourse, and were more likely to describe their libido as 'above average.' Control subjects were more likely to experience orgasm during sexual intercourse. Bulimic patients associated high body weights with unattractiveness, and tended to withdraw from social and sexual activity at high weights. In other aspects of their sexual behaviour, and in their attitudes to sexual matters, the two groups were similar.

Baseline characteristics of patients in the National Heart, Lung, and Blood Institute Percutaneous Transluminal Coronary Angioplasty Registry

The efficacy of PTCA was evaluated in several subgroups of patients. Of special clinical interest were the comparisons between subgroups of patients with multivessel disease vs 1-vessel disease, unstable angina vs stable angina, older age vs younger age, and female sex vs male sex. As a prerequisite for such comparisons, baseline characteristics of patients in the subgroups were examined. Compared with the subgroup with 1-vessel CAD, the subgroup with multivessel CAD had more elderly patients (age 65 years and older) and more of these patients had previous MI or CABG. PTCA was more often unsuccessful in patients with multivessel CAD because of inability to pass the catheter across the lesion. The subgroup of women tended to be older than men, and more women had severe and unstable angina, although fewer had multivessel CAD, previous MI or previous CABG. The PTCA success rate was 5% lower in women because of a greater frequency of inability to pass the lesion. Compared with younger patients, older patients had a higher prevalence of severe angina, multivessel CAD and lesions with larger diameters. The older patients had a 5% lower PTCA success rate, once again because of a greater frequency of inability to pass the lesion. The learning experience with PTCA was measured by the overall success rate as well as by the rate of ability to pass the lesion and the rate of dilating it once it was passed. These rates improved significantly by the investigators' case accumulations and independently by calendar year. Multivariate prediction of crossing the lesion and of overall success showed that favorable lesion characteristics and increasing physician experience were more important than the patient characteristics just discussed, although both female sex and multivessel CAD remained significant independent risk factors.