The significance of ASCUS cytology in HIV-positive women

OBJECTIVE

The aim of this study was to determine the incidence and severity of dysplasia associated with a cytologic diagnosis of atypical cells of undetermined significance (ASCUS) in women infected with the human immunodeficiency virus (HIV).

METHODS

A cross-sectional analysis of cervical cytology, colposcopic impression, and cervical biopsy results was performed on 261 HIV-positive women diagnosed with ASCUS. The prevalence and grade of histologically documented cervical intraepithelial neoplasia (CIN) was determined. Patients with CD4 counts above and below 200 cells/mm(3) were compared using chi(2) analysis to determine any effect of worsening immunosuppression on the rates of associated dysplasia.

RESULTS

Seven hundred sixty-one Pap smears were performed during the study period. Two hundred nine (27%) were diagnosed as ASCUS. All patients (pts) received colposcopic evaluation. The incidence of human papilloma virus (HPV) effect, low-grade CIN (I), and high-grade CIN (II, III, and carcinoma in situ) documented by cervical biopsy, cervical conization or endocervical curettings was 40, 17, and 15%, respectively. No cases of invasive cancer were found. These results are similar to those of previous cytohistologic studies of ASCUS in HIV-untested populations. There was no significant difference in frequency or severity of CIN in pts with severe immunosuppression (P = 0.4).

CONCLUSION

A cytologic diagnosis of ASCUS in HIV-positive women identifies a group at significant risk for histologic abnormalities. The majority of pts will be diagnosed with HPV or low-grade CIN. HIV infection and severe immunosuppression do not appear to increase the frequency or severity of CIN associated with ASCUS. Given the 32% risk of associated CIN, all HIV-positive women with ASCUS cytology should undergo colposcopic evaluation.

The efficacy of cervical conization in the treatment of cervical intraepithelial neoplasia in HIV-positive women

OBJECTIVE

The aim of this study was to evaluate the efficacy of cervical conization in the treatment of CIN in HIV-positive women.

MATERIALS AND METHODS

Sixty-six HIV-positive women treated with cervical conization for CIN were stratified into four groups based on surgical margin and endocervical curetting (ECC) status (group 1: -margin/-ECC, group 2: +margin/-ECC, group 3: +margin/+ECC, group 4: -margin/+ECC). The rate of histologically proven recurrent CIN was calculated for each group and compared using chi(2) analysis. The effect of +margins, +ECC, degree of dysplasia, and CD4 count on the risk of recurrence was determined by logistic regression.

RESULTS

Forty-nine percent of patients with negative margins and negative ECC experienced recurrence, most within 36 months. There was no significant difference in recurrence rate for patients with positive margins (69.2%, P = 0.19), positive ECC (50%, P = 0.97), or positive margins and ECC (66.7%, P = 0.41) when compared to patients with complete excision of dysplasia. No significant difference in the mean CD4 count of patients with and without recurrent dysplasia (316 vs. 390 cells/mm3, P = 0.37) was observed. Logistic regression showed only degree of dysplasia in the cone specimen to have a marginally significant linear relationship with recurrence.

CONCLUSION

Cervical conization is not an effective method for eradicating CIN in HIV-positive women. Most patients will recur despite complete excision of dysplasia. Surgical margin status, ECC status, and CD4 count appear to have no effect on recurrence rate. Although multiple procedures were necessary in some patients, cone biopsy was effective in preventing progression to invasive cervical cancer in all cases.

Reflections on the medical deanship

In 35 years, being dean of a medical school has changed dramatically. Thirty years ago, the dean's world was still the medical school and its affiliated hospitals, but soon this world was transformed by new emphasis on research (and the resources to conduct it) and the increase of specialty medicine. The medical school became larger and the affiliated hospital more complex. They consolidated into the modern academic medical center, which then became more diverse and self-contained and eventually became an island of special expertise and achievement in medicine, the biomedical sciences, and clinical care. Fifteen years, ago, the academic medical center began to be transformed again, this time by its competition with or incorporation into managed care and other health care delivery systems. The medical school dean now operates in an environment far different from that of the 1960s. Deans spend 90% of their time on five major issues: too few resources, isolation and division of activity within the institution, poor management, excessive traditionalism, and too few people with too much to do. In addressing these issues, the dean has several powerful levers, including the appointment and promotion of faculty, appointments to committees and task forces, assignments of budget and space, and controlling the agenda and leading the debate in the institution. Another but less tangible issue is the dean's attitude. Another but less tangible issue is the dean's attitude, which has enormous impact on what happens at the medical school and in its programs. The deanship will continue but in the new context of a health care delivery system-with variations on the same five problems and with the same ten levers available to address them. The responsibility is old; only the context is new.

Pigmented villonodular synovitis of the shoulder after anterior capsulolabral reconstruction

Pigmented villonodular synovitis (PVNS) is a proliferative disorder of the synovium affecting joints, bursae, or tendon sheaths. PVNS is further classified into diffuse and localized forms and rarely affects the shoulder. We report a case of nodular synovitis of the shoulder after arthroscopic and open anterior capsulolabral reconstruction. The histopathology and treatment of a nodular form of PVNS of the shoulder is discussed.

Variability in BPRS definitions of positive and negative symptoms

Reviewing Brief Psychiatric Rating Scale (BPRS) research indicates that combining items to form larger 'symptom factors' (e.g., depression, psychosis) has become the standard methodology. Unfortunately, a single symptom factor may be defined by different combinations of different BPRS items in different studies. To examine the potential impact of these differences, a number of different BPRS definitions of positive and negative symptoms in schizophrenia were culled from previous research. To compare these definitions, one hundred schizophrenics were interviewed with regard to current and recent symptomatology and rated on the BPRS, the Schedule for the Assessment of Negative Symptoms (SANS), and the Schedule for the Assessment of Positive Symptoms (SAPS). The four BPRS negative symptom definitions all correlated highly with one another and with the SANS. There were no differences in the amount that these different definitions of negative symptoms correlated with the SANS. Also, the nine definitions of positive symptoms all correlated highly with one another and with the SAPS. However, there were significant differences in how they correlated with the SAPS. Because of these differences, possible standard definitions for negative and positive symptoms of schizophrenia are proposed for future use of the BPRS in research.

Business and managerial education in the medical school curriculum

The need for medically related business and managerial training for medical students and physicians is an area of education that has been frequently discussed among physicians in private and academic practice. However, little has been done by physicians or in formal programs of medical or graduate medical education to address the need to introduce this type of training. This paper, based upon a survey of the medical students at Vanderbilt University, analyzes this need and proposes three new approaches in implementing medically related business and management education and training.

Combined paraesophageal and sliding hiatal hernia

We have reported a case of a large paraesophageal herniation with a small sliding component. Abnormal positioning of the esophagogastric junction or the necessity for mobilizing it during repair requires the addition of an antireflux procedure to the standard reduction and repair. Elective repair of a paraesophageal herniation, even in the absence of limiting symptoms, is warranted, since complications of nonsurgical treatment may be sudden and severe.

Repair of aneurysms of the thoracic aorta: 12-year experience in a high-risk population

We present our 12-year experience with surgical treatment of aneurysms of the thoracic aorta in a high-risk patient population. Of 52 patients with aneurysms, 36 patients, aged 19 to 80 years, had operation. In 24 of the 36, there were three or more associated major disease processes, such as chronic bronchitis, hypertensive cardiovascular disease, aortic valve disease, cerebrovascular disease, abdominal aortic aneurysm, and coronary artery disease. Eight patients with acute type A (ascending aorta) and seven with acute type B (descending aorta) aneurysms had emergency repair, with survival in four and seven, respectively. All patients with chronic type A or B aneurysms had elective repair, and all patients with acute or chronic type A aneurysms had surgical treatment. Four patients with acute type A and two with acute type B aneurysms had elective operation, with survival in three and one, respectively. Nine patients with chronic type A and six with chronic type B aneurysms had elective operation, and all survived. Twelve patients with chronic type B aneurysms did not have operation, and all were alive at early follow-up. Mortality for patients having acute type A aneurysms requiring emergency operation was greater than that after elective repair of acute or chronic type A aneurysms. Short-term survival for chronic type B aneurysms was similar whether the patient was treated medically or surgically.

Congenital absence of pericardium: an unusual cause of atypical angina

Congenital defects of the pericardium are unusual. Patients may experience exertional chest pain, cardiac arrhythmias, syncope, sudden death, or incarceration of myocardium, or they may be entirely asymptomatic. We describe the case of a symptomatic pericardial herniation diagnosed by echocardiography and confirmed by cineangiography. Successful repair was accomplished using a polytetrafluoroethylene soft-tissue prosthesis.

Impaired induction of ornithine decarboxylase activity following nerve crush in the streptozotocin-diabetic rat

Ornithine decarboxylase activity was measured in the dorsal root ganglia from crushed and uncrushed contralateral sciatic nerve of control and streptozotocin-diabetic rats. A further group of diabetic rats was treated with insulin throughout the experiment. Ornithine decarboxylase activity in ganglia from uncrushed nerves was the same in diabetic and non-diabetic rats. A significant (greater than 4-fold) increase in mean levels of ornithine decarboxylase activity 72 h after crush injury was found in ganglia from crushed nerves in non-diabetic but not in diabetic rats. The enzyme activity in ganglia from diabetic rats treated with insulin resembled that in non-diabetic rats. Twenty-four hours after crush injury, ornithine decarboxylase activity in ganglia from crushed nerves was higher in non-diabetic than in diabetic animals. This may be responsible for the delayed and defective nerve regeneration known to occur in peripheral nerve of the streptozotocin-diabetic rat.

Angio and peritoneal access for endstage renal disease in the community hospital: a cost analysis

As the population requiring maintenance dialysis continues to grow, costs have become an important consideration to professionals dealing with this clinical problem. A four and one-half year experience with various methods of dialysis in a community hospital is reviewed. The overall base-level estimate for providing functional access of various types if $19,000 per patient per year.

Cerebral angioendotheliomatosis associated with hemispheric symptoms of carotid arterial origin

Cerebral angioendotheliomatosis may mimic classic hemispheric and nonhemispheric carotid arterial symptomatology and may even result in carotid arteriography and endarterectomy prior to its recognition. Diagnosis requires brain biopsy and the prognosis is poor.

The core curriculum in diagnostic radiology residency training

THE CONSTRUCTION of a core curriculum in diagnostic radiology, medical imaging and radiological sciences requires an understanding of the historical context in which the current technological advances of the last two decades are seen in the perspective of traditional radiology. The future trainee in this discipline will require an additional background in physics, engineer ing and computer sciences as well as in-depth clinical kills in the basics of diagnostic imaging. The formula tion of future training programmes must provide appropriate experience in the newer imaging modali ties, such as computed tomography, real time ultra sound, digital radiology, nuclear magnetic resonance and positron emission tomography by building on a broad and complete foundation of core subjects. This communication will discuss a suggested core curriculum from the aspect of the desired results of the prog ramme.

A simplified technique for the tunneling of extra-anatomic polytetrafluoroethylene grafts

A technique using the trocars from disposable thoracostomy sets as a tunneling instrument in vascular operations is described. A number of preselected and hand shaped trocars, with a single hole drilled in the puncture tip end, are kept sterile on the vascular surgical supply cart and can be used to construct perfectly calibrated tunnels for cross-subclavian and axillo-axillary graft procedures as well as other extra-anatomic graft procedures. They are especially useful in the construction of the tunnels for the loop forearm Gore-Tex arteriovenous fistula for angioaccess which can be used almost immediately. These otherwise disposable instruments can be resterilized and are, hence, quite cost-effective as well as convenient and easy to use.

The decision-making process: implications for the medical school organization

In this article, the authors make use of some contemporary models of decision-making to show how the process of decision-making can become more self-conscious, and thus both more enlightened and more assured. The approach is an examination of several models examined both from the perspective of the steps in the process itself, as well as general observations about the decision-making process. The practical focus is on the medical school organization with its unique characteristics. This article also examines the decision-making process through a comparison of two types of organizational structure (pyramidal and matrix) found in most medical schools. Certain constants emerge from this article that positively enhance good decision-making. These elements are: (1) the rapidity of change; (2) the critical need for a wide range of alternatives; (3) an understanding of both the organizational structure and human factors involved; and (4) the necessity of involving others in the decision-making process. By analyzing various modes of decision-making and presenting options, this article should be of real assistance to administrators.

Iliac-mesenteric-atrial shunt procedure for Budd-Chiari syndrome complicated by inferior vena caval thrombosis

A 33-year-old woman had a diagnosis of idiopathic Budd-Chiari syndrome complicated by inferior vena caval occlusion. Conservative medical therapy failed to control the symptoms of both portal hypertension and vena caval stasis. Therefore, a prosthetic shunt was placed from the right common iliac vein to the right atrium with a side-arm to the superior mesenteric vein. She exhibited almost complete relief of symptoms and the graft was documented to be patent two weeks postoperatively. In many instances aggressive surgical therapy may help these patients who, in the past, would have been relegated to symptomatic therapy.