Longer-term primary prevention for alcohol misuse in young people: a systematic review

OBJECTIVE

To identify and summarize rigorous evaluations of psychosocial and educational interventions aimed at the primary prevention of alcohol misuse by young people aged up to 25 years, especially over the longer term (>3 years).

METHODS

Cochrane Collaboration Systematic Review.

DATA SOURCES

A comprehensive search of 22 databases and recursive checking of bibliographies for randomized and non-randomized controlled trials and interrupted time-series studies.

MAIN OUTCOME MEASURES

Objective or self-report measures of alcohol use and misuse.

RESULTS

Fifty-six studies were selected for inclusion in the systematic review. Twenty of the 56 studies showed evidence of ineffectiveness. No firm conclusions about the effectiveness of prevention interventions in the short- and medium term were possible. Over the longer term (>3 years), the Strengthening Families Programme (SFP) showed promise as an effective prevention intervention. The Number Needed to Treat (NNT) for the SFP over 4 years for three alcohol initiation behaviours (alcohol use, alcohol use without permission and first drunkenness) was 9 (for all three behaviours). One study also highlighted the potential value of culturally focused skills training over the longer-term (NNT = 17 over 3.5 years for 4+ drinks in the last week)

CONCLUSIONS

(1) Research into important outcome variables needs to be undertaken; (2) the methodology of evaluations needs to be improved; (3) the SFP needs to be evaluated on a larger scale and in different settings; (4) culturally focused interventions require further development and rigorous evaluation; and (5) an international register of alcohol and drug misuse prevention interventions should be established and criteria agreed for rating prevention interventions in terms of safety, efficacy and effectiveness.

Multiple changes in gene expression in chronic human Achilles tendinopathy

Atlas cDNA cell interaction arrays (CLONTECH) were used to examine degenerate tissue from four patients with Achilles tendon disorders, in order to identify changes in expression of genes important in cell-cell and cell-matrix interactions. The greatest difference between normal (post-mortem) and degenerate tissue samples was in the level of MMP-3 (stromelysin) mRNA, which was down-regulated in all the degenerate samples. Quantitative RT-PCR assay of RNA extracted from paired 'normal' and degenerate Achilles tendon tissue samples taken from tendons during surgery mirrored the results of the arrays. Levels of MMP-3 mRNA were lower, whereas levels of type-I and type-III collagen mRNAs were significantly higher, in the degenerate compared to the 'normal' samples. Immunoblotting of proteins extracted from the same tendon samples showed that three of four normal tissue samples taken from individuals without apparent tendon disorder had much higher levels of MMP-3 protein than 'normal' or degenerate samples from patients with tendinosis. We suggest that MMP-3 may play an important role in the regulation of tendon extracellular matrix degradation and tissue remodelling.

Joint erosion in rheumatoid arthritis: interactions between tumour necrosis factor alpha, interleukin 1, and receptor activator of nuclear factor kappaB ligand (RANKL) regulate osteoclasts

BACKGROUND

Osteoclasts, specialised bone resorbing cells regulated by RANKL and M-CSF, are implicated in rheumatoid joint erosion. Lymphocyte-monocyte interactions activate bone resorption, this being attributed to tumour necrosis factor alpha (TNFalpha) and interleukin 1 beta (IL1beta) enhanced osteoblast expression of RANKL. In animal studies, TNF potently increases osteoclast formation in the presence of RANKL. RANKL-independent osteoclastogenesis also occurs, though IL1 is required for resorptive function in most studies. These inflammatory cytokines have a pivotal role in rheumatoid arthritis,

OBJECTIVE

To study the interactions of TNFalpha and IL1beta with RANKL, particularly the time course of the interactions and the role of lymphocytes.

METHOD

Cultures of lymphocytes and monocytes (osteoclast precursors) or of purified CD14(+) cells alone (osteoclast precursors) were exposed to various combinations of TNFalpha, RANKL, and IL1beta or the inhibitors osteoprotegerin, IL1 receptor antagonist, or neutralising antibodies to RANKL or to IL1. Osteoclastogenesis and resorptive activity were assessed on microscopy of dentine slices.

RESULTS

TNFalpha potently increased osteoclast proliferation/differentiation in the presence of RANKL. This effect was greatest when RANKL was present before but not after exposure of osteoclast precursor cells to TNFalpha. The resorptive activity of osteoclasts generated by TNFalpha in the absence of RANKL was critically dependent upon IL1, which was expressed by lymphocyte-monocyte interaction.

CONCLUSION

TNFalpha potently enhances RANKL mediated osteoclast activity. Interactions between TNFalpha and IL1 also result in osteoclastic activity independently of RANKL. These findings will inform therapeutic approaches to the prevention of joint erosion in rheumatoid arthritis.

Colocalization of glucocorticoid and mineralocorticoid receptors in human bone

Osteoporosis is a poorly understood but common complication of glucocorticoid therapy. The actions of glucocorticoids are mediated via glucocorticoid receptors (GRs), but in vitro, glucocorticoids also can bind to mineralocorticoid receptors (MRs). It is not known if MR protein is present in human bone and little is known of GR isoform expression (GRalpha and GRbeta). GR and MR protein expression and possible sites of action were investigated in neonatal rib and adult iliac crest biopsy specimens using antibodies specific for MR, GRalpha, and GRalphabeta. Colocalization [MR GRalpha] [MR GRalphabeta] was performed using fluorescent-conjugated secondary antibodies. GRalpha, GRbeta, and MR show distinct but overlapping patterns of expression, suggesting important functions for each receptor type. Osteoclasts showed no staining for GRalpha but strong staining for GRalphabeta, indicating expression of GRbeta and a specific role in addition to antagonizing the transcriptional activity of GRalpha. MR also was observed in osteoclasts and colocalized with GRalphabeta. Coexpression of MR, GRalpha, and GRalphabeta was seen in osteoblasts. Reverse-transcription-polymerase chain reaction (RT-PCR) of cultured osteoblast RNA confirmed expression of both GRalpha and GRbeta. Osteocytes stained with MR, GRalpha, and GRalphabeta antibodies but to a lesser degree than osteoblasts. In the neonatal rib cartilage, staining for GRalpha, GRalphabeta, and MR was present in approximately one-half of the resting and hypertrophic chondrocytes and in most of proliferating chondrocytes and chondrocytes within the mineralizing matrix. Identification of MR raises the possibility that the physiological and pharmacologic effects of glucocorticoids on bone may be mediated via MR as well as GR and that GRalpha, GRbeta, and MR synergize to influence corticosteroid metabolism in human bone.

Primary prevention for alcohol misuse in young people

BACKGROUND

Alcohol misuse is a cause of concern for health services, policy makers, prevention workers, the criminal justice system, youth workers, teachers and parents.

OBJECTIVES

1. To identify and summarize rigorous evaluations of psychosocial and educational interventions aimed at the primary prevention of alcohol misuse by young people. 2. To assess the effectiveness of primary prevention interventions over the longer-term (> 3 years).

SEARCH STRATEGY

Databases searched (no time limits): Project CORK, BIDS, PSYCLIT, ERIC, ASSIA, MEDLINE, FAMILY-RESOURCES-DATABASE, HEALTH-PERIODICALS-DATABASE, EMBASE, BIDS, Dissertation-Abstracts, SIGLE, DRUG-INFO, SOMED, Social-Work-Abstracts, National-Clearinghouse-on-Alcohol-and-Drug-Information, Mental-Health-Abstracts, DRUG-database, ETOH (all searched Feb-June 2002).

SELECTION CRITERIA

1. randomised controlled and non-randomised controlled and interrupted time series designs. 2. educational and psychosocial primary prevention interventions for young people up to 25 years old. 3. alcohol-specific or generic (drugs; lifestyle) interventions providing alcohol outcomes reported. 4. alcohol outcomes: alcohol use, age of alcohol initiation, drinking 5+ drinks on any one occasion, drunkeness, alcohol related violence, alcohol related crime, alcohol related risky behaviour.

DATA COLLECTION AND ANALYSIS

Stage 1: All papers screened by one reviewer against inclusion criteria. Stage 2: For those papers that passed Stage 1, key information was extracted from each paper by 2-3 reviewers.

MAIN RESULTS

20 of the 56 studies included showed evidence of ineffectiveness. No firm conclusions about the effectiveness of prevention interventions in the short- and medium-term were possible. Over the longer-term, the Strengthening Families Program (SFP) showed promise as an effective prevention intervention. The Number Needed to Treat (NNT) for the SFP over 4 years for three alcohol initiation behaviours (alcohol use, alcohol use without permission and first drunkeness) was 9 (for all three behaviours). One study also highlighted the potential value of culturally focused skills training over the longer-term (NNT=17 over three-and-a-half years for 4+ drinks in the last week).

REVIEWER'S CONCLUSIONS

1. Research into important outcome variables needs to be undertaken. 2. Methodology of evaluations needs to be improved. 3. The Strengthening Families Programme needs to be evaluated on a larger scale and in different settings. 4. Culturally-focused interventions require further development and rigorous evaluation. 5. An international register of alcohol and drug misuse prevention interventions should be established and criteria agreed for rating prevention intervention in terms of safety, efficacy and effectiveness.

Mechanisms by which high-dose estrogen therapy produces anabolic skeletal effects in postmenopausal women: role of locally produced growth factors

Conventional hormone replacement therapy acts primarily by preserving bone, but cannot restore lost bone in women with established osteoporosis. Studies in rodents have shown that high doses of estrogens have anabolic skeletal effects, and recent observations in a group of women treated long term with high doses of estrogen indicated that similar effects occur in humans. This study examines the hypothesis that locally produced growth factors, including transforming growth factor-beta (TGF-beta) and platelet-derived growth factors (PDGFs), are involved in mediating the anabolic effects of high-dose estrogen. Transiliac-crest bone biopsies were taken from ten women, aged 52-67 years (mean 58 years), who had been treated with high-dose estrogen for 15 years. Control samples were obtained from four age-matched postmenopausal women not receiving estrogen therapy. TGF-betas and PDGFs were analyzed for mRNA and protein expression by reverse transcriptase-polymerase chain reaction (RT-PCR) and immunohistochemistry. Results showed both TGF-beta1 and -beta2 mRNA, expressed as a ratio to GAPDH, were increased in the estrogen-treated group with an eightfold increase for TGF-beta1 (0.258 +/- 0.246 [mean +/- SD] vs. 0.032 +/- 0.053 in the control group, p = 0.02) and a twofold increase for TGF-beta2 (p = n.s.). TGF-beta3 analysis showed only negligible amounts in both groups. Protein expression levels for TGF-beta1, -beta2, -betaRI and -RII were higher in the estrogen-treated group than in controls, the most marked effects being seen for TGF-beta1. PDGF-A protein expression was also significantly higher in osteoblasts and osteocytes in women treated with estrogen, whereas PDGF-B showed only modest differences. The percentage of bone surface occupied by osteoclasts, as determined by tartrate-resistant acid phosphatase (TRAP) staining, was significantly reduced in the estrogen-treated group (p = 0.001). These results demonstrate that high-dose estrogen therapy is associated with increased TGF-beta, TGF-betaR, and PDGF synthesis and decreased osteoclast activity, consistent with the hypothesis that these growth factors may mediate the actions of estrogen in bone.

Does histological incomplete excision of cervical intraepithelial neoplasia following large loop excision of transformation zone increase recurrence rates? A six year cytological follow up

OBJECTIVE

To determine the risk of recurrent cervical intraepithelial neoplasia (CIN) in women with complete or incomplete excision of cervical intraepithelial neoplasia treated by large loop excision of transformation zone (LLETZ).

DESIGN

A retrospective study

SETTING

One consultant-led colposcopy clinic at Leicester Royal Infirmary

POPULATION

Three hundred and ninety-four women referred consecutively to the colposcopy clinic between 1991 and 1992.

MAIN OUTCOME MEASURES

The histological recurrence rate of CIN, length of cytological follow up following treatment related to degree of completeness of excision at initial treatment.

RESULTS

Three hundred and twenty-two women had complete cytological or histological follow up. The mean length of follow up was 73 months with a mean number of six smears. Women with incomplete excision of CIN had a significantly higher risk of recurrent CIN (relative risk 8.23) occurring in a significantly shorter time compared with women with complete excision.

CONCLUSIONS

This study demonstrates that large loop excision of transformation zone is successful in over 95% of cases. Cytological surveillance is satisfactory for follow up of women who have complete excision of CIN. Women with incomplete excision of CIN at initial LLETZ remain at significant risk of developing further CIN and long term colposcopic and cytological follow up is necessary.

Co-expression of the hepatitis B surface and core antigens using baculovirus multiple expression vectors

The hepatitis B (HB) virus DNA sequences coding for the pre-core (preC) or C antigens (HBpcAg, HBcAg) have been inserted into the baculovirus plasmid transfer vector, pAcYM1, such that the HB viral sequences are under the control of the polyhedrin promoter of Autographa californica nuclear polyhedrosis virus (AcNPV). Spodoptera frugiperda cells infected with either of the derived recombinant plasmids in the presence of infectious AcNPV DNA yielded recombinant, polyhedrin-negative viruses that expressed high levels of the respective HBpcAg or HBcAg (representing approx. 5 to 10% and approx. 40% of the stained cellular proteins, respectively). The particulate 27 nm HBcAgs have been purified to homogeneity from infected cell extracts by density gradient centrifugation. Dual expression transfer vectors containing the HBcAg gene sequences and the coding sequences of the HB viral S antigen (HBsAg), each gene under the control of its own copy of the polyhedrin promoter, have also been constructed and used to derive recombinant viruses. The recombinant with the HB C and S genes expressed high levels of the HBcAg (approx. 40% of the cellular proteins) and low levels of the HBsAg (approx. 2% of the stained cellular proteins). Dual expression, occluded, recombinant baculoviruses that make HBsAg, as well as the AcNPV polyhedrin protein, have been prepared that are highly infectious for Trichoplusia ni caterpillars, allowing reproducible preparation of the antigen in larvae. Using radioimmunoassays (RIAs) and ELISAs, the recombinant HBcAg (RIA) and HBsAg (ELISA) have been used to identify human antibodies to HB virus with results that compare favourably with the data obtained with non-recombinant antigens.

Osteoclast formation and bone resorption are inhibited by megakaryocytes

It has been previously reported that addition of megakaryocytes (MKs) to osteoblasts in vitro results in increased osteoblastic collagen and osteoprotegerin (OPG) production, suggesting a role for MKs in bone formation. To further investigate this role, we have studied the effects of MKs on osteoclast formation and activity. Human osteoclasts were generated from CD14 monocytes isolated from peripheral blood and cultured in the presence of M-CSF and sRANKL on dentine and calcium phosphate substrates. MKs were generated from CD34+ cells isolated from either human peripheral blood or cord blood and cultured in liquid medium for 6 days, after which time maturing MKs (CD61-positive cells) were isolated and added to monocyte cultures. After 6 and 9 days of culture, the number of osteoclasts identified morphologically and by TRAP staining was counted. Cells were removed and the area of resorption was identified by von Kossa staining and quantitatively assessed by image analysis. The addition of MKs to osteoclast cultures at day 0 inhibited the number of osteoclasts formed 1.9-fold (p>0.003), whereas addition at 3 days had no effect on osteoclast number. The presence of MKs inhibited resorption 8.7-fold when co-cultured with osteoclasts from day 0 (p>0.004), but only by 3.1-fold when co-cultured from day 3 (p>0.01). In dose-response experiments, it was found that 1-10% of MKs added to monocyte cultures elicited the greatest inhibition of resorption. Similar osteoclast cultures were treated with CD61-negative cells (non-MKs) to confirm that the inhibition of osteoclast formation and activity was specifically due to MKs. Experiments with a cell-impermeable membrane indicated that both cell to cell contact and release of soluble factor(s) were involved in mediating these effects. These results show that MKs inhibit osteoclast formation and activity. The most pronounced effects were seen when MKs and osteoclasts were co-cultured from day 0, suggesting that MKs act primarily on osteoclast precursors.

Invasive cancer of the cervix after laser treatment

Over a period of 8 years and 6 months, 1979-1988, 4222 women were treated with laser ablation for cervical intraepithelial neoplasia (CIN) with or without papillomavirus infection of the cervix. Of 3738 patients followed up, nine were diagnosed as having invasive cancers of the cervix, four of which were microinvasive. It is stressed that each woman treated with laser must have frequent, long-term cytological follow-up.

Role of centralization of surgery in Stage IB carcinoma of the cervix: a review of 498 cases

A review was undertaken of 498 patients with stage IB carcinoma of the cervix managed over a 15-year period in the Regional Gynaecological Oncology Centre, Gateshead. All but 4 were treated by radical hysterectomy, with adjuvant radiotherapy and/or chemotherapy for those with involved pelvic nodes. The overall 5-year survival in those with negative nodes was 91.4% compared with 50.5% in those with positive nodes (P less than 0.05). Of those dying from the disease, 7 patients only (1.4%) developed central recurrence, the remainder experiencing pelvic side-wall or distant recurrence. There was no difference in survival related to patient age. There were three deaths related to surgery and a fistula rate of only 1.2%. Bladder hypotonia and lymphocyst affected a minority of patients in the long term. The data support the case for radical surgery in stage IB carcinoma of the cervix, managed on a centralized referral basis.

Panic disorder in patients attending a clinic for vestibular disorders

In a study of the prevalence of panic and other anxiety disorders in persons with complaints of dizziness, 87 patients referred to a clinic for vestibular disorders completed self-rating measures of anxiety and depression; 32 also underwent a structured diagnostic interview. Thirteen (14.9%) of the patients met the DSM-III-R criteria for panic disorder, agoraphobia, or both. They rated themselves as much more disabled by their dizziness than the patients with no psychiatric disorder. Panic disorder was equally prevalent among patients with and without vestibular disease. In some cases panic disorder may provide an explanation for the dizziness, whereas in others it may be a comorbid condition compounding the disability attributable to the vestibular disorder.

The effects of silicate ions on human osteoblast adhesion, proliferation, and differentiation

Silicon has been shown to have important effects on skeletal development and repair, and soluble silicate ions have been found to stimulate the expression of type-I collagen in osteoblast-like cell cultures. Furthermore, silicon has been incorporated into the hydroxyapatite lattice and enhanced metabolic activity of human osteosarcoma cells was observed when cells were cultured on this material. In vivo assessments have demonstrated enhanced bioactivity of silicon-substituted hydroxyapatite (Si-HA) over pure HA. However, detailed mechanisms for the stimulative effects of Si-HA have not been described. In this study, we found that silicon substitution into hydroxyapatite affects the adhesion of human osteoblast-like cells (HOBs) in culture, with 0.8 wt % silicon substitution being optimal. In addition, metabolic activity and proliferation of HOBs were increased by supplementation of the growth medium with 30 microM silicon. It was determined that this response may depend on the proportion of cells at different stages of differentiation within the cultures.

Is routine colposcopic assessment necessary following laser ablation of cervical intraepithelial neoplasia?

The colposcopic and cytological findings at follow-up of 1000 women treated by laser ablation for cervical intraepithelial neoplasia or human papillomavirus infection at the Regional Department of Gynaecological Oncology, Gateshead, were reviewed. Colposcopy detected six of 27 patients with residual disease compared with cytology which was abnormal in 26 of the 27 and detected 21 as abnormal on the first visit after laser treatment. In our unit invasive disease after laser treatment was never detected solely on initial colposcopic review.

The management of the patient with abnormal vaginal cytology following hysterectomy

Thirty-two patients presenting with abnormal vaginal cytology following hysterectomy were studied. Seven (21.8%) had had hysterectomy for benign conditions whilst 25 (78.1%) had cervical intraepithelial neoplasia (CIN) or invasive cervical carcinoma. Twenty-five patients had partial or total vaginectomy (15 as the primary procedure), and one required laser treatment following vaginectomy. Of 11 (34.3%) patients treated primarily by laser, five subsequently required vaginectomy because of persistent or recurrent cytological abnormality. All four patients treated with topical 5-fluorouracil or dinitrochlorobenzene subsequently required surgery. Nine of the 32 patients (28.1%) proved to have invasive carcinoma of the vagina on histological examination of the vaginectomy specimen. At the time of writing all patients in the study are well with no evidence of disease.

Mucin production in cervical intraepithelial neoplasia and in stage 1b carcinoma of cervix with pelvic lymph node metastases

Sections from cervical intraepithelial neoplasia (CIN 3) and stage 1b carcinoma of the cervix were stained with periodic acid-Schiff (PAS) and alcian blue to identify the presence of intracellular mucin. One out of seven specimens of CIN 3 demonstrated intracellular mucin. In a series of 33 patients with stage 1b carcinoma of the cervix with pelvic lymph node metastases, PAS demonstrated intracellular mucin staining patterns that were similar in both tumour and lymph node in most patients. In the subgroup of 23 patients classified as having squamous carcinoma, 8 (35%) demonstrated intracellular mucin to some degree and only 2 (25%) of those 8 were alive after 3 years compared with 13 of the other 15 (87%) who did not show any mucin staining (P less than 0.01).

Measurement of deeply virtual compton scattering beam-spin asymmetries

The beam-spin asymmetries in the hard exclusive electroproduction of photons on the proton (e p-->epgamma) were measured over a wide kinematic range and with high statistical accuracy. These asymmetries result from the interference of the Bethe-Heitler process and of deeply virtual Compton scattering. Over the whole kinematic range (x(B) from 0.11 to 0.58, Q2 from 1 to 4.8 GeV2, -t from 0.09 to 1.8 GeV2), the azimuthal dependence of the asymmetries is compatible with expectations from leading-twist dominance, A approximately a sinphi/(1+c cosphi). This extensive set of data can thus be used to constrain significantly the generalized parton distributions of the nucleon in the valence quark sector.

Is it time for a reconsideration of the criteria for cone biopsy?

Between August 1985 and November 1988, 475 laser cone biopsies were performed at the Regional Gynaecological Oncology Unit in Gateshead. Of these, 332 were performed for abnormal cervical cytology and unsatisfactory colposcopy. The negative cone rate in this group was 34%. In those with cytological abnormalities up to and including mild dyskaryosis the figure was 64% and there were no cases of invasive disease. In this group the authors have reconsidered the criteria for cone biopsy and suggested biopsy of the visible ectocervical lesion combined with endocervical curettage or brushing. Those with negative histology or cytological abnormalities less than moderate dyskaryosis should be managed conservatively.

Platelet-derived endothelial cell growth factor expression and angiogenesis in cervical intraepithelial neoplasia and squamous cell carcinoma of the cervix

Growth and metastatic spread of invasive carcinoma depends on angiogenesis, the formation of new blood vessels. Platelet-derived endothelial cell growth factor (PD-ECGF) is an angiogenic growth factor for a number of solid tumors, including lung, bladder, colorectal, and renal cell cancer. Cervical intraepithelial neoplasia (CIN) is the precursor to squamous cell cervical carcinoma (SCC). Mean vessel density (MVD) increases from normal cervical tissue, through low- and high-grade CIN to SCC. We evaluated PD-ECGF immunoreactivity and correlated its expression with MVD in normal, premalignant, and malignant cervical tissue. PD-ECGF expression was assessed visually within the epithelial tissues and scored on the extent and intensity of staining. MVD was calculated by counting the number of vessels positive for von Willebrand factor per unit area subtending normal or CIN epithelium or within tumor hotspots for SCC. Cytoplasmic and/or nuclear PD-ECGF immunoreactivity was seen in normal epithelium. PD-ECGF expression significantly increased with histologic grade from normal, through low- and high-grade CIN, to SCC (P < .02). A progressive significant increase in the microvessel density was also seen, ranging from a mean of 28 vessels for normal tissue to 57 for SCC (P < .0005). No correlation was found between PD-ECGF expression and MVD (P = .45). We conclude that PD-ECGF expression and MVD increase as the cervix transforms from a normal to a malignant phenotype. PD-ECGF is thymidine phosphorylase, a key enzyme in the activation of fluoropyrimidines, including 5-fluorouracil. Evaluation of PD-ECGF thymidine phosphorylase expression may be important in designing future chemotherapeutic trials in cervical cancer.

Aggressive angiomyxoma of the perineum

We report the case of perineal aggressive angiomyxoma in a 46-year-old woman presenting as left perineal swelling associated with superficial dyspareunia. Initial clinical examination revealed a 4- to 5-cm cystic mass in the posterior aspect of the left labia majora, not thought to be typical of a Bartholin cyst. A magnetic resonance imaging (MRI) scan revealed a well-defined 2- x 1.5- x 2-cm area posterolateral to the lower vagina on the left but anterolateral to the anal canal extending into the left ischiorectal fossa, with no obvious involvement of the anal sphincter complex. Excision biopsy was performed via an incision in the left labia majus under general anesthesia. Histologic findings were consistent with aggressive angiomyxoma of the vulva. This was confirmed by immunohistochemistry showing spindle cells positive for vimentin with strong nuclear staining for estrogen and progestogen receptors. Postoperative management following discussion at the multidisciplinary gynecological oncology meeting was to perform a repeat MRI scan 6 weeks postoperatively, and treatment with raloxifene was commenced for its antiestrogenic property.

Borderline malignant change in recurrent müllerian papilloma of the vagina

Malignant change occurred in a benign, recurrent vaginal müllerian polyp. The patient, a 49 year old woman with cerebral palsy, presented with a polypoid mass in the vagina. At four years of age she had presented with a haemorrhagic polyp, and over the following years she had recurrent irregular bleeding and regrowth of the polypoidal mass, requiring a total of 10 operations to excise the polyp. Histological examination of the specimen showed typical müllerian features with tubal, endometrioid, and endocervical cell types. There were significantly abnormal nuclei, indicating low grade or borderline malignancy. Review of previous biopsies showed similar müllerian features but no atypia. This is the first reported case of borderline malignant change in a previously benign recurrent müllerian papilloma of the vagina. Definitive radical surgery or radiotherapy is contraindicated in this patient and she remains under follow up.

Measurement of single- and double-spin asymmetries in deep inelastic pion electroproduction with a longitudinally polarized target

We report the first measurement of the transverse momentum dependence of double-spin asymmetries in semi-inclusive production of pions in deep-inelastic scattering off the longitudinally polarized proton. Data have been obtained using a polarized electron beam of 5.7 GeV with the CLAS detector at the Jefferson Lab (JLab). Modulations of single spin asymmetries over the azimuthal angle between lepton scattering and hadron production planes ϕ have been measured over a wide kinematic range in Bjorken x and virtual photon squared four-momentum Q2. A significant nonzero sin2ϕ single spin asymmetry was observed for the first time indicating strong spin-orbit correlations for transversely polarized quarks in the longitudinally polarized proton.

Should women with postcoital bleeding be referred for colposcopy?

This study was to determine the risk of finding significant cervical pathological abnormality in women referred to the colposcopy clinic primarily because of postcoital bleeding. We evaluated the cervical smear history of such women and correlated this with any colposcopic or pathological abnormality. There were 142 women seen over a period of 12 months. The age range of the study population was 16 - 61 years (mean age of 34.1 years). There was no case of lower genital tract invasive neoplasia. Out of the 142 cases, 56 women (39.4%) had normal findings at colposcopy and 44 (31%) were secondary to cervical ectopy. A total of 27 (19%) had cervical intraepithelial neoplasia (CIN) out of which there were 15 (10.6%) cases of high-grade disease (CIN II and CIN III); and, 20 (74%) out of the 27 women with CIN had a recently negative cervical smear (within the previous 36 months). Seven women (4.9%) had benign cervical polyps that were removed during colposcopy. The frequency of finding invasive lower genital tract neoplasia in women with postcoital bleeding is low. However, a good proportion of them would have a diagnosis of cervical intraepithelial neoplasia even with a recently negative cervical smear. Therefore, postcoital bleeding should remain an indication for referral to the colposcopy clinic for a detailed evaluation of the lower genital tract.