Women's sexual activity and experiences following female genital fistula surgery

BACKGROUND

Surgical repair has a transformative impact on the lives of women affected by female genital fistula; however, various physical, social, and economic challenges may persist postrepair and prevent complete reengagement in relationships and communities. Nuanced investigation of these experiences is needed to inform programming that aligns with women's reintegration needs.

AIM

We investigated the sexual activity resumption, experiences, and concerns of women in Uganda during the year following genital fistula repair surgery.

METHODS

Women were recruited from Mulago Hospital between December 2014 and June 2015. We collected data at baseline and 4 times postsurgery about sociodemographic characteristics and physical/psychosocial status; we also assessed sexual interest and satisfaction twice. We performed in-depth interviews with a subset of participants. We analyzed quantitative findings via univariate analyses, and qualitative findings were coded and analyzed thematically.

OUTCOMES

We assessed sexual readiness, fears, and challenges following surgical repair of female genital fistula using quantitative and qualitative measures of sexual activity, pain with sex, sexual interest/disinterest, and sexual satisfaction/dissatisfaction.

RESULTS

Among the 60 participants, 18% were sexually active at baseline, which decreased to 7% postsurgery and increased to 55% at 1 year after repair. Dyspareunia was reported by 27% at baseline and 10% at 1 year; few described leakage during sex or vaginal dryness. Qualitative findings showed wide variance of sexual experiences. Some reported sexual readiness quickly after surgery, and some were not ready after 1 year. For all, fears included fistula recurrence and unwanted pregnancy.

CONCLUSION

These findings suggest that postrepair sexual experiences vary widely and intersect meaningfully with marital and social roles following fistula and repair. In addition to physical repair, ongoing psychosocial support is needed for comprehensive reintegration and the restoration of desired sexuality.

HIGHLIGHTS

The social, economic, emotional, and physical experiences of caregivers for women with female genital fistula in Uganda: A qualitative study

ABSTRACTThis study aimed to explore the firsthand experiences of informal primary caregivers of women with female genital fistula in Uganda. Caregivers that accompanied women for surgery at Mulago National Teaching and Referral Hospital were recruited between January and September 2015. Caregivers participated in in-depth interviews and focus groups. Data were analysed thematically and informed adaptation of a conceptual framework. Of 43 caregivers, 84% were female, 95% family members, and most married and formally employed. Caregivers engaged in myriad personal care and household responsibilities, and described being on call for an average of 22.5 h per day. Four overlapping themes emerged highlighting social, economic, emotional, and physical experiences/consequences. The caregiving experience was informed by specific caregiver circumstances (e.g. personal characteristics, care needs of their patient) and dynamic stressors/supports within the caregiver's social context. These results demonstrate that caregivers' lived social, economic, emotional, and physical experiences and consequences are influenced by both social factors and individual characteristics of both the caregiver and their patient. This study may inform programmes and policies that increase caregiving supports while mitigating caregiving stressors to enhance the caregiving experience, and ultimately ensure its feasibility, particularly in settings with constrained resources.

Sustained efficacy and immunogenicity of the human papillomavirus (HPV)-16/18 AS04-adjuvanted vaccine: analysis of a randomised placebo-controlled trial up to 6.4 years

BACKGROUND

Prophylactic human papillomavirus (HPV) vaccines have to provide sustained protection. We assessed efficacy, immunogenicity, and safety of the HPV-16/18 AS04-adjuvanted vaccine up to 6.4 years.

METHODS

Women aged 15-25 years, with normal cervical cytology, who were HPV-16/18 seronegative and oncogenic HPV DNA-negative (14 types) at screening participated in a double-blind, randomised, placebo-controlled initial study (n=1113; 560 vaccine group vs 553 placebo group) and follow-up study (n=776; 393 vs 383). 27 sites in three countries participated in the follow-up study. Cervical samples were tested every 6 months for HPV DNA. Management of abnormal cytologies was prespecified, and HPV-16/18 antibody titres were assessed. The primary objective was to assess long-term vaccine efficacy in the prevention of incident cervical infection with HPV 16 or HPV 18, or both. We report the analyses up to 6.4 years of this follow-up study and combined with the initial study. For the primary endpoint, the efficacy analysis was done in the according-to-protocol (ATP) cohort; the analysis of cervical intraepithelial neoplasia grade 2 and above (CIN2+) was done in the total vaccinated cohort (TVC). The study is registered with ClinicalTrials.gov, number NCT00120848.

FINDINGS

For the combined analysis of the initial and follow-up studies, the ATP efficacy cohort included 465 women in the vaccine group and 454 in the placebo group; the TVC included 560 women in the vaccine group and 553 in the placebo group. Vaccine efficacy against incident infection with HPV 16/18 was 95.3% (95% CI 87.4-98.7) and against 12-month persistent infection was 100% (81.8-100). Vaccine efficacy against CIN2+ was 100% (51.3-100) for lesions associated with HPV-16/18 and 71.9% (20.6-91.9) for lesions independent of HPV DNA. Antibody concentrations by ELISA remained 12-fold or more higher than after natural infection (both antigens). Safety outcomes were similar between groups: during the follow-up study, 30 (8%) participants reported a serious adverse event in the vaccine group versus 37 (10%) in the placebo group. None was judged related or possibly related to vaccination, and no deaths occurred.

INTERPRETATION

Our findings show excellent long-term efficacy, high and sustained immunogenicity, and favourable safety of the HPV-16/18 AS04-adjuvanted vaccine up to 6.4 years.

FUNDING

GlaxoSmithKline Biologicals (Belgium).

Lessons Learned

Although the incidence rate of cervical cancer has decreased over the last several years, low-income ethnic minority women remain at increased risk for morbidity and mortality from cervical cancer. We conducted a pilot study to examine the feasibility and acceptability of mindfulness-based stress reduction (MBSR) program among multiethnic low-income women with abnormal Pap smears. Spanish- and English-speaking women recruited through convenience sampling participated in MBSR classes 2 hours each week over 6 consecutive weeks. State anxiety and self-compassion were measured before and after the MBSR program. Focus groups and surveys were used to evaluate the program. Although 51 women were initially recruited, pre- and post-MBSR data were available only for 8 women. There was a significant reduction in anxiety and a trend toward increased self-compassion in this group of women. The participants evaluated the MBSR program very positively. The high attrition rate highlights the challenges of conducting MBSR research with this demographic of women. Potential strategies for improving recruitment and retention of low-income multiethnic women are discussed.

Angiogenic effects of norplant contraception on endometrial histology and uterine bleeding

Norplant, a sc contraceptive device, releases levonorgestrel in a sustained fashion. Its effectiveness is offset by irregular bleeding patterns. Because vascular endothelial growth factor (VEGF) is stimulated by synthetic progestogens in vitro and in vivo, we postulated that correlations between this angiogenic factor and uterine bleeding patterns might exist. Twenty-eight women who were exposed to Norplant and 13 control women were prospectively followed for 6-8 months. Bleeding diaries were collected, hysteroscopies were performed, endometrial biopsies were obtained for standardized histological evaluation, and VEGF histochemical immunostaining (H)-scores were assigned. Cluster determination-34 (CD34) staining was also performed to quantify the number of endometrial blood vessels per high-power field. Irregular uterine bleeding was common among women using Norplant devices. Endometrial VEGF H-scores were greater in women using Norplant than in control women. New findings of this study show that vessel density did not correlate with epithelial VEGF H-scores but was highly associated with the intensity of stromal and perivascular VEGF. VEGF expression in the latter regions correlated significantly with hysteroscopic abnormalities and irregular bleeding. The expression of this angiogenic protein, particularly in the stromal and perivascular compartments, correlated with microvascular density, hysteroscopically documented hypervascularity, and uterine bleeding profiles. Irregular bleeding with Norplant use appears to reflect paracrine-mediated effects on vascular function by angiogenic factors, such as VEGF.

Efficacy of a bivalent L1 virus-like particle vaccine in prevention of infection with human papillomavirus types 16 and 18 in young women: a randomised controlled trial

BACKGROUND

Vaccination against the most common oncogenic human papillomavirus (HPV) types, HPV-16 and HPV-18, could prevent development of up to 70% of cervical cancers worldwide. We did a randomised, double-blind, controlled trial to assess the efficacy, safety, and immunogenicity of a bivalent HPV-16/18 L1 virus-like particle vaccine for the prevention of incident and persistent infection with these two virus types, associated cervical cytological abnormalities, and precancerous lesions.

METHODS

We randomised 1113 women between 15-25 years of age to receive three doses of either the vaccine formulated with AS04 adjuvant or placebo on a 0 month, 1 month, and 6 month schedule in North America and Brazil. Women were assessed for HPV infection by cervical cytology and self-obtained cervicovaginal samples for up to 27 months, and for vaccine safety and immunogenicity.

FINDINGS

In the according-to-protocol analyses, vaccine efficacy was 91.6% (95% CI 64.5-98.0) against incident infection and 100% against persistent infection (47.0-100) with HPV-16/18. In the intention-to-treat analyses, vaccine efficacy was 95.1% (63.5-99.3) against persistent cervical infection with HPV-16/18 and 92.9% (70.0-98.3) against cytological abnormalities associated with HPV-16/18 infection. The vaccine was generally safe, well tolerated, and highly immunogenic.

INTERPRETATION

The bivalent HPV vaccine was efficacious in prevention of incident and persistent cervical infections with HPV-16 and HPV-18, and associated cytological abnormalities and lesions. Vaccination against such infections could substantially reduce incidence of cervical cancer.

Gene expression profiles during human CD4+ T cell differentiation

To develop a comprehensive catalogue of phenotypic and functional parameters of human CD4(+) T cell differentiation stages, we have performed microarray gene expression profiling on subpopulations of human thymocytes and circulating naive CD4(+) T cells, including CD3(-)CD4(+)CD8(-) intrathymic T progenitor cells, CD3(int)CD4(+)CD8(+) 'double positive' thymocytes, CD3(high)CD4(+)CD8(-) 'single positive' thymocytes, CD3(+)CD4(+)CD8(-) CD45RA(+)CD62L(+) naive T cells from cord blood and CD3(+)CD4(+)CD8(-) CD45RA(+)CD62L(+) naive T cells from adult blood. These subpopulations were sort-purified to >98% purity and their expressed RNAs were analyzed on Affymetrix Human Genome U133 arrays. Comparison of gene expression signals between these subpopulations and with early passage fetal thymic stromal cultures identify: (i) transcripts that are preferentially expressed in human CD4(+) T cell subpopulations and not in thymic stromal cells; (ii) major shifts in gene expression as progenitor T cells mature into progeny; (iii) preferential expression of transcripts at the progenitor cell stage with plausible relevance to the regulation of expansion and differentiation of these cells; and (iv) preferential expression of potential markers of recent thymic emigrants in naive-phenotype CD4(+) T cells from cord blood. Further evaluation of these findings may lead to a better definition of human thymopoiesis as well as to improved approaches to monitor and to augment the function of this important organ of T cell production.

A comparison of urinary incontinence among African American, Asian, Hispanic, and white women

OBJECTIVE

This study was undertaken to compare urodynamic findings and the rate of incontinence diagnoses among various ethnic groups.

STUDY DESIGN

Data were collected for all new patients referred to the urogynecology clinic during a 10-year period. One hundred ninety-five Hispanic, 95 white, 66 Asian, and 59 African American women had urodynamic testing and were included in the study. All women had a complete history, physical examination, and multichannel urodynamic studies. Demographic data, urodynamic data, and final diagnoses differences were analyzed.

RESULTS

African American women had higher maximum urethral closure pressures than Hispanic, white, or Asian women (58 cm H2O vs 47, 47, and 48 cm H2O; P =.001, P =.005, and P =.02). African American women were less likely to be diagnosed with genuine stress incontinence than were Hispanic or white women (42% vs 67% and 59%; P <.001 and P =.046). Detrusor instability was diagnosed more often in African American women than in Hispanic, white, or Asian women (29% vs 8%, 15%, and 14%; P <.001, P =.04, and P =.04).

CONCLUSIONS

African American women with urinary incontinence have different urodynamic diagnoses than Hispanic, white, or Asian women. Hispanic, white, and Asian women have similar rates of genuine stress incontinence. Although African American women have lower rates of genuine stress incontinence than Hispanic and white women, they have higher rates of detrusor instability than all 3 groups.

Ovarian steroid and cytokine modulation of human endometrial angiogenesis

A key mechanism underlying the cyclical growth of the endometrium is its ability to regenerate a vascular capillary network. In normal cycling human endometrium, angiogenesis is influenced by both endocrine and paracrine factors. Hormonal manipulation of the endometrium, such as that occurring during the use of steroidal contraception, appears to result in capillary proliferation and fragility. As a consequence of these vascular changes, contraceptive users may be predisposed to unpredictable uterine bleeding, which is responsible for the high frequency of contraceptive discontinuation. In this paper we address mechanisms responsible for vascular endothelial cell proliferation in normal and contraceptive steroid-exposed endometria. We propose that regulation of endometrial angiogenesis is mediated indirectly, via steroid and cytokine actions on vascular endothelial growth factor (VEGF), and we present data indicating that VEGF expression in normal endometrial stromal cells is increased by oestrogens and progestins. Three proinflammatory cytokines with angiogenic effects in other systems (i.e. interleukin-1beta, tumour necrosis factor-alpha and interferon-gamma) do not appear to up-regulate VEGF expression in normal endometrial stromal cells. Well-characterized in-vitro models in conjunction with immunohistochemistry provide useful experimental systems to study endometrial neovascularization under physiological conditions and in those potentially perturbed via the use of contraceptive steroids.

Lower genital tract neoplasia in women with HIV infection

Women who are infected with human immunodeficiency virus (HIV) are at greater risk for the development of lower genital tract neoplasia than are HIV-negative women. Among HIV-positive women, those who are more severely immunosuppressed appear to be at higher risk for cervical intraepithelial neoplasia (CIN), also known as squamous intraepithelial lesions (SILs). Women who are HIV-positive also are more likely than HIV-negative women to have multifocal lower genital tract neoplasia. Cervical cancer is one of the most important acquired immune deficiency syndrome (AIDS)--related malignancies in women. Cancer and intraepithelial neoplasia of the lower genital tract can be persistent, progressive, recurrent, and difficult to treat in HIV-positive women. The most effective method for treating SILs has not been determined. Regular performance of Pap smears in HIV-positive women is of critical importance, as is careful examination of the entire lower genital tract. Also, women with high-grade intraepithelial or cervical cancer should be tested for HIV.

Importance of atypical glandular cells of uncertain significance in cervical cytologic smears

OBJECTIVE

To determine the clinical implications of atypical glandular cells of uncertain significance (AGCUS) in cervical cytologic smears.

STUDY DESIGN

Retrospective analysis.

RESULTS

Eighty-eight of 32,181 (0.27%) cervical smears obtained during the study period contained AGCUS. Of the 47 women with AGCUS, 16 had intraepithelial or invasive neoplasms (34%; 95% confidence interval, 21-49%), including 9 low or high grade squamous intraepithelial lesions, 1 adenocarcinoma in situ of the cervix, 3 adenocarcinomas of the cervix, 2 adenocarcinomas of the endometrium and 1 adenoid basal cell carcinoma of the cervix.

CONCLUSION

The high prevalence of cervical and endometrial neoplasia among women with the isolated finding of AGCUS on cervical cytologic smears warrants a thorough diagnostic evaluation.

Pelvic inflammatory disease in women infected with HIV

Pelvic inflammatory disease (PID) and HIV infection are frequently coincident. The diagnosis of PID can be more difficult to make in HIV-infected than in uninfected women. In general, HIV-infected women with PID have a good response to standard intravenous antibiotic therapy. However, surgical therapy is more frequently required for HIV-infected women with PID, especially those with more severe degrees of immunosuppression, than for uninfected women.

Risk factors for plasma cell endometritis among women with cervical Neisseria gonorrhoeae, cervical Chlamydia trachomatis, or bacterial vaginosis

OBJECTIVE

We sought to determine potential risk factors for upper genital tract inflammation in women with cervical Neisseria gonorrhoeae, Chlamydia trachomatis, or bacterial vaginosis.

STUDY DESIGN

In a case-controlled study we compared 111 women with cervical Neisseria gonorrhoeae, Chlamydia trachomatis, or bacterial vaginosis (the study group) with 24 women who had negative tests for each of these infections (the control group). We evaluated potential risk factors for upper genital tract inflammation by use of bivariate and then logistic regression analysis.

RESULTS

We found plasma cell endometritis in 53 of 111 women in the study group and 3 of 24 controls (odds ratio = 6.4, 95% confidence interval 1.7 to 35.0). On logistic regression, the study group women who were in the proliferative phase had increased likelihood of plasma cell endometritis (odds ratio = 4.5, 95% confidence interval 1.6 to 12.4).

CONCLUSION

The proliferative phase of the menstrual cycle seems to be the primary risk factor for ascending infection by organisms associated with pelvic inflammatory disease. This may be due to a hormonal effect or to the loss of the cervical barrier during menstruation.

Vulvar intraepithelial neoplasia in women with HIV

The increasing incidence of lower genital tract neoplasia in HIV-infected women and the inherent difficulties in diagnosis and treatment have undermined effective management and contributed significantly to the morbidity of this population. The Centers for Disease Control and Prevention has included high-grade squamous intraepithelial lesions, as well as cervical carcinoma in situ, as part of the classification of HIV, with invasive cervical cancer as an AIDS-defining condition. The incidence of vulvar intraepithelial neoplasia (VIN) nearly doubled between 1973 and 1987. In one study, VIN has been reported to occur 29 times more frequently in HIV-infected women than in a control group of self-identified non-HIV-infected women. Because women with HIV are now living longer, they face an increased possibility of the development of these infections along with the long-term sequelae and the risk of transformation to cancer. Treatment of VIN is guided by the size and location of the lesion, the grade of the dysplasia, and identification of coexisting disease in other sites. The case study presented exemplifies many of the management and education issues encountered following women with HIV disease and lower genital tract neoplasia, one of the most difficult issues being that the best mode of treatment for VIN has yet to be determined. Screening of the entire lower genital tract, including the vulva for dysplasia, is recommended for early detection and timely initiation of management.

Gynecology and family planning care for the woman infected with HIV

This article reviews the interactions between HIV infection and a variety of gynecologic conditions, including lower genital tract neoplasia, pelvic inflammatory disease, menstrual disorders, sexually transmitted diseases, and vaginitis. Important considerations in choosing a family planning method for women infected with HIV-infected women will respond to standard therapy, but require multiple courses of treatment or use of innovative treatment methods. All HIV-infected women deserve careful evaluation for and treatment of gynecologic diseases.

Does vaginal cuff closure decrease the infectious morbidity associated with abdominal hysterectomy?

BACKGROUND

Infectious morbidity after total abdominal hysterectomy includes fever (31%) and antibiotic administration (45%). Whether vaginal cuff closure reduces postoperative infectious morbidity remains unresolved.

STUDY DESIGN

We reviewed the records of 172 consecutive abdominal hysterectomies for nonmalignant disease performed at an inner-city hospital. We identified potential risk factors for infectious morbidity by univariate analysis and determined adjusted odds ratios by multiple logistic regression analysis.

RESULTS

The open vaginal cuff technique was associated with an increased risk of wound infection. Use of prophylactic antibiotics was associated with a decreased risk of febrile morbidity and a decreased risk of prolonged hospitalization. Body weight in the heaviest quartile was associated with increased risk of wound infection, increased risk of prolonged hospitalization, and decreased risk of postoperative vaginal cuff granulation tissue. Older age was associated with an increased risk of prolonged hospitalization.

CONCLUSIONS

Closure of the vaginal cuff and use of prophylactic antibiotics at total abdominal hysterectomy were associated with decreased infectious morbidity in a high-risk population.

Operations for stress urinary incontinence in the United States, 1988-1992

OBJECTIVES

To determine the frequency and cost of operations for stress urinary incontinence in the United States.

METHODS

We reviewed data from the 1988-1992 National Hospital Discharge Surveys and the 1991 California Office of Statewide Health Planning Survey. We determined the frequency and type of surgical procedures performed for stress urinary incontinence and estimated the total direct costs of these operations in the United States.

RESULTS

From 1988 to 1992, the total number of operations for stress incontinence increased from 78,000 to over 100,000. The rate of operations increased most in women older than 65 years of age. The total direct cost for treatment of stress urinary incontinence in the United States in 1991 was about $0.5 billion.

CONCLUSIONS

Operations for treatment of stress urinary incontinence are increasing in frequency in the United States. They are both more commonly performed and more costly than have been previously reported.

Bacillary angiomatosis of the cervix and vulva in a patient with AIDS

BACKGROUND

Bacillary angiomatosis is a clinicopathologic entity that most often is identified in the skin of patients with AIDS. This report presents an example of bacillary angiomatosis of the female genital tract.

CASE

Bacillary angiomatosis presented as red-purple nodules of the vulva and cervix in a 32-year-old woman with AIDS. Histologic examination revealed the lobular epithelioid vascular proliferation and hazy clumps of bacteria that characterize bacillary angiomatosis. The diagnosis was confirmed on Warthin-Starry-stained issue and by blood cultures, which were positive for Bartonella (Rochalimaea) henselae.

CONCLUSION

Accurate diagnosis of this infection is important because 1) bacillary angiomatosis is commonly mistaken for Kaposi sarcoma, 2) it is effectively treated with inexpensive antibiotics, and 3) undiagnosed and/or untreated bacillary angiomatosis may lead to overwhelming disseminated infection and death.

Vulvar intraepithelial neoplasia in women infected with human immunodeficiency virus-1

The purpose of this study was to determine the response of vulvar intraepithelial neoplasia (VIN) lesions to standard treatment methods in women infected with human immunodeficiency virus (HIV). We reviewed all cases of VIN over a 4-year period at an inner-city hospital. We reviewed the clinical records of these women to abstract demographic information as well as information about tobacco use, injection drug use, results of HIV testing, T cell count, stage of HIV infection, colposcopic and cytologic findings, treatment of lesions, and follow-up. Eight of the 28 women (29%) with VIN were infected with HIV. The relative risk for recurrence or persistence of VIN after treatment was 3.3 (95% confidence interval, 1.4-7.4; P = 0.01) in the HIV+ compared with the HIV- group. The high rate of HIV infection among women with VIN supports recommendation of HIV testing for women with VIN. Women known to have HIV infection should be carefully examined for vulvar lesions. Further study is needed to determine the optimum treatment for VIN in women infected with HIV.

Commonly used diagnostic criteria for pelvic inflammatory disease have poor sensitivity for plasma cell endometritis

BACKGROUND

The majority of women with tubal damage do not have a history of acute pelvic inflammatory disease. The prevalence of upper genital tract inflammation was evaluated in women deemed not to have pelvic inflammatory disease by common diagnostic criteria.

GOAL OF THIS STUDY

To compare clinical signs and laboratory tests used to diagnose pelvic inflammatory disease with endometrial biopsy histopathology.

STUDY DESIGN

Endometrial biopsy and commonly used physical and laboratory tests were performed on 52 women with pelvic tenderness, 51 with vaginosis or cervicitis, and 22 control subjects who had no evidence of infection with Neisseria gonorrhoeae or Chlamydia trachomatis and who tested negative for bacterial vaginosis using vaginal swab Gram's stain.

RESULTS

Thirty-six of 52 patients (69%) with pelvic tenderness, compared with 22 of 51 patients (43%) with vaginosis or cervicitis and two of 22 control subjects (9%), had plasma cell endometritis. The Centers for Disease Control and Prevention minimal diagnostic criteria for pelvic inflammatory disease had a sensitivity of 33% for plasma cell endometritis.

CONCLUSIONS

The clinical diagnosis of pelvic inflammatory disease using published criteria correlates poorly with plasma cell endometritis.

Gynecologic disease in women infected with human immunodeficiency virus type 1

Gynecologic disease is commonly encountered in women infected with the human immunodeficiency virus (HIV). The clinical course of cervical intraepithelial neoplasia, invasive cervical cancer, pelvic inflammatory disease, syphilis, and vaginal candidiasis may be altered by HIV infection and may be refractory to standard treatment, especially with increasing degrees of immune suppression. Careful screening for gynecologic disease and vigilant surveillance for treatment failure are important in the care of women infected with HIV.

Multifocal lower genital tract neoplasia in women with HIV disease

Lower genital tract neoplasia appears to occur often and in multiple sites in women infected with the human immunodeficiency virus (HIV). To describe the prevalence of lower genital tract neoplasia in HIV-infected women in our clinic we performed a retrospective chart review of 38 HIV-infected women who had received screening colposcopy. Fourteen percent of the women had VIN on biopsy. In addition, 50% of the women had abnormal Pap smears and 24% had CIN on biopsy. In this study, lower genital tract neoplasia was multifocal in nature and included a relatively high prevalence of VIN not previously reported in the literature.

Plasma cell endometritis in women with symptomatic bacterial vaginosis

OBJECTIVE

To evaluate the endometrial microbiology and histopathology in women with symptomatic bacterial vaginosis but no signs or symptoms of upper genital tract disease or other vaginal or cervical infections.

METHODS

Endometrial biopsies were performed on 41 women complaining of vaginal discharge or pelvic pain at a sexually transmitted disease clinic. These women had neither culture nor serologic evidence of Neisseria gonorrhoeae or Chlamydia trachomatis infection. Twenty-two women with bacterial vaginosis diagnosed by Gram stain examination of vaginal fluid, but with neither signs nor symptoms of upper genital tract infection, were compared with 19 women who had no evidence of bacterial vaginosis on vaginal fluid Gram stain. Endometrial biopsies were evaluated for histopathologic evidence of plasma cell endometritis and were cultured for N gonorrhoeae, C trachomatis, aerobic and anaerobic bacteria, Mycoplasma species, and Ureaplasma urealyticum.

RESULTS

Ten of 22 women with bacterial vaginosis had plasma cell endometritis, compared with one of 19 controls (odds ratio [OR] 15, 95% confidence interval [CI] 2-686; P < .01). Bacterial vaginosis-associated organisms were cultured from the endometria of nine of 11 women with and eight of 30 women without plasma cell endometritis (OR 12.4, 95% CI 2-132; P = .002).

CONCLUSION

Plasma cell endometritis was frequently present in women with bacterial vaginosis and without other vaginal or cervical infections. This suggests the possibility of an association between bacterial vaginosis and nonchlamydial, nongonococcal, upper genital tract infection.

Torsion angle differences as a means of pinpointing local polypeptide chain trajectory changes for identical proteins in different conformational states

We discuss a facile and sensitive method of determining conformational differences based on the changes in the phi and psi angle values between chemically identical proteins in different conformations. It complements the conventional r.m.s. deviation technique, but offers some advantages. Two classes of conformational difference can be distinguished by this method: (i) abrupt local trajectory deformations where the chains flanking the locus of deformation remain simultaneously superposable and (ii) localized 'hinge bending' that generates domain shifts, thereby causing only one domain to be superposable on the other at one time. In the second case, the r.m.s. deviation method requires two or more calculations of r.m.s. deviation as a function of sequence after optimal alignment of each domain to demonstrate the superposability of the shifted domains, and hence the conservation of internal domain structure. On the other hand, the method of plotting delta phi and/or delta psi as a function of sequence demonstrates in one graph the superposability of shifted domains, without the prior need to perform rotational and translational alignments whose outcomes vary with the subjective choice of alignment parameters. Also, an analysis of the r.m.s. deviation in C alpha alone will miss torsion angle rotations that happen to preserve C alpha positions. The method pinpoints residues contributing singly to localized, major movements of a conformational change; however, it is insensitive to conformational changes achieved through small, concerted movements spread over a number of residues.(ABSTRACT TRUNCATED AT 250 WORDS)

Sensitivity of the Papanicolaou smear in human immunodeficiency virus-infected women

OBJECTIVE

To determine the sensitivity of the Papanicolaou smear in human immunodeficiency virus (HIV)-infected women.

METHODS

Fifty-two HIV-seropositive women underwent colposcopy and had cytologic and histologic specimens obtained. Eighty-five consecutive women seen in our colposcopy clinic who stated that they were HIV-seronegative formed the comparison group. Demographic features of the groups and cytology and histology findings were compared.

RESULTS

In HIV-infected patients, the prevalence of cervical dysplasia was 50%. An additional 15% had vulvar lesions alone. The sensitivity of cytologic smears for cervical dysplasia was 63% and specificity was 84%. These findings were not significantly different from those of a control group of women undergoing colposcopy for standard indications (P > .05). Twelve of 38 seropositive women for whom future appointments were scheduled were lost to follow-up.

CONCLUSIONS

The sensitivity of the Papanicolaou test does not appear to be diminished in HIV-seropositive women. Screening colposcopy may be justified in view of the high prevalence of cervical and vulvar dysplasia, as well as the high noncompliance rate observed in this patient population.

Three-dimensional model of a human interferon-alpha consensus sequence

A computer-built, three-dimensional, atomic-level model for human interferon-alpha (IFN-alpha) was constructed. This model was prepared using the primary amino acid sequence of consensus IFN-alpha (IFN-alpha Con1) and the alpha-carbon Cartesian coordinates of murine IFN-beta as a homolog guide to the model building. In agreement with an earlier report from this laboratory, the two domains 29-35 and 123-140 are in close spatial proximity in this model, and may constitute a receptor recognition domain, whereas the region bounded by residues 78-95 is somewhat removed from this region on the molecule and may constitute an alternative active site. Extrapolating from the model, we propose that, of the stretch 123-140, the residues that are exposed are 123, 125, 126, 128-130, and 132-139; and of the stretch 29-35, all are accessible. Additionally, we propose that there may be sufficient complexity in the Type 1 IFN receptor to account for the differential sensitivities between IFN-alpha s and IFN-beta that may be associated with residue differences in the region 78-95, specifically at residues 84, 86, and 87. This model conforms with experimental data that identify specific amino acid residues in human IFN-alpha that either do, or do not, affect the active conformation and biological activities of the molecule.

Does use of permanent suture material affect outcome of the modified Pereyra procedure?

OBJECTIVE

To determine the effect of absorbable versus permanent suture on outcome of the modified Pereyra procedure for stress urinary incontinence.

METHODS

A review was performed of case-series reports of outcome of the modified Pereyra procedure for stress urinary incontinence that provided at least 1 year of follow-up and that specified the suture material used. Outcomes of cases in which permanent suture was used were compared with cases in which absorbable suture was used. The groups were further stratified according to whether success of the procedure was determined objectively or subjectively. Chi-square analysis was performed.

RESULTS

Fourteen case-series reports were examined, representing a total of 988 modified Pereyra operations. Overall, the relative risk (RR) of failure when absorbable suture was used was 1.8 times higher than with permanent suture (95% confidence interval [CI] 1.4-2.3; P < .0001) using objective or subjective outcome criteria. The RR of failure using absorbable suture when judged by objective criteria only was 1.6 (95% CI 1.1-2.3; P = .03) and when judged by subjective outcome only was 2.3 (95% CI 1.5-3.4; P < .0001).

CONCLUSION

Until a randomized controlled trial is done, the available evidence supports the use of permanent suture material whenever the modified Pereyra procedure is performed.

Pelvic inflammatory disease in human immunodeficiency virus-infected women

OBJECTIVE

To determine whether the clinical course of pelvic inflammatory disease differs between women with human immunodeficiency virus (HIV) infection and seronegative controls.

METHODS

All admissions for acute pelvic inflammatory disease from January 1, 1986 to December 31, 1992 at San Francisco General Hospital were reviewed, identifying 23 HIV-seropositive women. Their clinical course was compared with a control group of 108 seronegative women admitted for acute pelvic inflammatory disease.

RESULTS

Human immunodeficiency virus-seropositive women with acute pelvic inflammatory disease had significantly lower abdominal tenderness scores (P < .05), lower admission and discharge white blood cell counts (WBC) (P < .01, P < .05), and fewer gonococcal infections (odds ratio 0.3, 95% confidence interval [CI] 0.1-0.9; P < .05) than the seronegative controls. There were no significant differences in duration of treatment, length of hospitalization, or incidence of tubo-ovarian abscess. Significantly more HIV-positive women with acute pelvic inflammatory disease required surgical intervention than seronegative women (odds ratio 5.5, 95% CI 1.0-29.3; P < .05).

CONCLUSION

Human immunodeficiency virus-seropositive women with acute pelvic inflammatory disease may have an altered immune response, resulting in inadequate response to antimicrobial agents and the need for more surgical intervention. Future studies must include larger numbers of HIV-infected women, and the results must be stratified for CD4 counts, clinical HIV stage, and other measures of immunocompromise.

Distribution and complementarity of hydropathy in multisubunit proteins

A survey of 40 multisubunit proteins and 2 protein-protein complexes was performed to assay quantitatively the distribution of hydropathy among the exterior surface, interior, contact surface, and noncontact exterior surface of the isolated subunits. We suggest a useful way to present this distribution by using a "hydropathy level diagram." Additionally, we have devised a function called "hydropathy complementarity" to quantitate the degree to which interacting surfaces have matching hydropathy distributions. Our survey revealed the following patterns: (1) The difference in hydropathy between the interior and exterior of subunits is a fairly invariant quantity. (2) On average, the hydropathy of the contact surface is higher than that of the exterior surface, but is not greater than that of the protein as a whole. There was variation, however, among the proteins. In some instances, the contact surface was more hydrophilic than the noncontact exterior, and in a few cases the contact surface was as hydrophobic as the protein interior. (3) The average interface manifests significant hydropathy complementarity, signifying that proteins interact by placing hydrophobic centers of one surface against hydrophobic centers of the other surface, and by similarly matching hydrophilic centers. As a measure of recognition and specificity, hydropathy complementarity could be a useful tool for predicting correct docking of interacting proteins. We suggest that high hydropathy complementarity is associated with static inflexible interactions. (4) We have found that some subunits that bind predominantly through hydrophilic forces, such as hydrogen bonds, ionic pairs, and water and metal bridges, are involved in dynamic quaternary organization and allostery.

Charge redistribution in proteins via linear hydrogen-bond chains

It is proposed that proteins might activate specific atomic positions within bound substrates or co-factors by means of hydrogen-bond chains. As a result of a concerted proton (tautomeric) shift in the linked residues of the hydrogen-bond chain, which includes the bound molecule, a charge separation occurs. The charge thus generated at a specific atom of the bound molecule renders it nucleophilic or electrophilic, as the case may be, and hence 'activated' towards subsequent chemical events. To test the feasibility of the theory a survey of published X-ray diffraction determined structures was performed. A search was made for hydrogen-bond chains which emanate away from bound substrates, co-factors or metal ions in order to validate the existence of such structural arrangements. Secondly, an attempt was made to incorporate the proposed proton dynamics into the proteins' mechanisms of action. Examples in which these criteria were satisfied are carboxypeptidase A, carbonic anhydrase, haemoglobin, dihydrofolate reductase, glutathione reductase and p-hydroxybenzoate hydroxylase.

Protein that induces cell differentiation causes nicks in double-stranded DNA

The growth and differentiation of myeloid hematopoietic cells are regulated by different macrophage and granulocyte inducing proteins, those that induce growth and others that induce differentiation. The proteins that induce differentiation but not those that induce growth bind to double-stranded DNA. We now report that purified myeloid cell differentiation-inducing protein causes single strand breaks (nicks) in double-stranded DNA. This DNA nicking may initiate the changes in gene expression that are required for differentiation.

Identification of the collar-like structure of the 30S ribosomal subunit from E. coli by dark field electron microscopy

We have used dark field electron microscopy to study a fragment of the small (30S) subunit of the E. coli ribosome. This fragment is almost the same size as the parent particle but RNA sequencing studies have shown it to lack, as a major constituent, a 150-nucleotide stretch at the 3' end of the rRNA, and two minor sections constituting 20 nucleotides from the 5' end and the 15 nucleotides of the sequence 687-701. The protein composition of the fragment was essentially unchanged. Samples of this material, and controls, were examined in the electron microscope after treatment with a buffered uranyl acetate solution for positive staining. Careful comparison revealed the following differences. The structural feature that we call the "collar" was missing in the fragment. Of the three parallel uranyl-staining bands that we have observed in micrographs of whole 30S subunits, the fragment consistently lacked the uppermost band. These observations identify the top uranyl-adsorbing band as being the 3' end of the ribosomal RNA and show that it can be equated with the collar-like structure.

Multimeric complexes of differentiation-inducing protein bound to DNA

Myeloid hematopoietic precursor cells are induced to differentiate by the macrophage and granulocyte differentiation-inducing protein MGI-2 (DF). This differentiation-inducing protein bound to double-stranded but not to single-stranded mammalian DNA. The bound MGI-2 was not eluted by high salt, but was eluted by sodium dodecyl sulfate (SDS). MGI-2 also bound to double-stranded E. coli DNA, but with this DNA the bound MGI-2 was eluted by high salt. This indicated a difference in the binding affinities of MGI-2 to mammalian and E. coli DNA. MGI-2 bound to DNA was examined by electron microscopy. The results indicate that MGI-2 formed a multimeric complex with double-stranded DNA and that the size of the complex was correlated with the strength of protein binding to the DNA. The multimeric complex bound to DNA was disrupted by deoxyribonuclease. The data indicated that binding of this differentiation-inducing protein to DNA involves the formation of a multimeric complex in which the monomers are held together by DNA. It is suggested that the formation of such multimeric complexes of MGI-2 and DNA may allow activation of the multiple pathways of gene expression that is required for differentiation.

A model for the three-dimensional structure of glucagon

A literature search on the structural aspects of glucagon in dilute aqueous solution has been undertaken. We have found that a compact, well-defined structure must exist and propose a model for that structure. In doing so, care was taken to distinguish between the raw data themselves and the interpretations drawn from them, and to bring about a model consistent with as much of the data as possible. The model building was performed on Corey-Pauling-Koltun (CPK) space-filling models using secondary structure prediction rules, experimental data such as fluorescence quenching, circular dichroism, NMR and high resolution dark field electron microscopy, and was guided by a hierarchy of intramolecular interactions which places hydrophobic bonding first and hydrogen bonding second. This last criterion places a strict requirement on the model-building to maximize contacts among complementary hydrophobic surfaces; this means that no empty spaces are allowed inside the folded molecule. The resultant model is consistent with all the relevant data. Furthermore, as demanded by any structure building exercise, the model suggests structure-function relationships. One of the predictions drawn from the structure--the binding of guanosine-5'-triphosphate (GTP)--has been confirmed by a preliminary experiment (reported elsewhere). Another aspect of the structure suggests a subtle mechanism for allostery.

A survey of 50 S ribosomal subunits by dark field electron microscopy

A survey of dark field electron micrographs of the 50 S ribosomal subunit of E. coli has been performed and supplemented, for comparative purposes, by examination of negatively stained or metal shadowed specimens in the bright field mode. Attention was directed to the so-called "crown" and "kidney" views. The elongated appendage seen in negatively stained crown profiles was not observed in unstained or positively stained samples examined in dark field; these showed only symmetrical crown profiles regardless of changes in buffer type and drying method and of the presence or absence of uranyl acetate treatment and glutaraldehyde fixation. The crown view occasionally displayed a bifurcation in one of the lateral lobes, while the kidney profile showed a groove near the base of the convex edge. Uranyl acetate treatment produced delicate stripes which may give an indication of the surface RNA distribution.

Specific visualization of ribosomal RNA in the intact ribosome by electron spectroscopic imaging

The recently developed electron microscopic technique of electron spectroscopic imaging has been used to map the distribution of phosphorus, and therefore of RNA, in situ in the ribosomal subunits of E. coli. The results indicate that the RNA moiety of both subunits is concentrated toward the centre of the particle somewhat more than is the total mass, but reaches the outer surface at several places. The micrographs also reveal certain distinctive features in the shape of the RNA component that may be related to the overall shape of the ribosome. The method yielded a reasonably accurate estimate of the phosphorus content of the 30 S ribosome.

The topology of the 30 S ribosomal subunit and a proposal for the surface distribution of its RNA by dark field electron microscopy

A three-dimensional model of the Escherichia coli 30 S ribosome has been derived from an extensive dark field electron microscopic investigation of unstained and unshadowed ribosomes. Subsequent studies of specimens lightly stained with uranyl acetate have added information on the location of regions that preferentially bind uranyl ions and may represent surface RNA. The model is an elongated cone-shaped structure 180-200 A long and is divided into identifiable sections: a "head" partly encircled by a collar-like structure, a middle section carrying a 20-A protuberance, and a "tail." A groove separates the middle section from the tail. Uranyl-binding regions can be seen on the protuberance and the collar's ridge, in two bands below the collar and parallel to it, and in a patch on the back of the head. The staining technique described may offer a method for mapping the external nucleic acid of nucleoprotein complexes.

Three-dimensional structure of herring sperm protamine Y-I with the aid of dark field electron microscopy

High resolution electron micrographs of herring sperm protamine (clupeine) Y-I provide sufficient detail to constrain the folding of the known amino-acid sequence of the protein into a unique three-dimensional configuration. The structure consists of a loose helix of turns of various sizes held together at one edge, spread apart along the other. This form appears to represent the shape of several fish protamines.