Clinical and economic impact of school-based nonavalent human papillomavirus vaccine on women in Singapore: a transmission dynamic mathematical model analysis

OBJECTIVE

To examine the epidemiological and economic impact of a nine-valent (nonavalent) human papillomavirus (HPV) 6/11/16/18/31/33/45/52/58 vaccine programme for young teenagers in Singapore.

DESIGN

Mathematical modelling.

SETTING

Pharmaco-economic simulation projection.

POPULATION

Singapore demography.

METHODS

Clinical, epidemiological and financial data from Singapore were used in a validated HPV transmission dynamic mathematical model to analyse the impact of nonavalent HPV vaccination over quadrivalent and bivalent vaccines in a school-based 2-dose vaccination for 11- to 12-year-old girls in the country. The model assumed routine cytology screening in the current rate (50%) and vaccine coverage rate of 80%.

MAIN OUTCOME MEASURES

Changes over a 100-year time period in the incidence and mortality rates of cervical cancer, case load of genital warts, and incremental cost-effectiveness ratio (ICER).

RESULTS

Compared with bivalent and quadrivalent HPV vaccination programmes, nonavalent HPV universal vaccination resulted in an additional reduction of HPV31/33/45/52/58 related CIN1 of 40.5%, CIN 2/3 of 35.4%, cervical cancer of 23.5%, and cervical cancer mortality of 20.2%. Compared with bivalent HPV vaccination, there was an additional reduction in HPV-6/11 related CIN1 of 75.7%, and genital warts of 78.9% in women and 73.4% in men. Over the 100 years, after applying a discount of 3%, disease management cost will be reduced by 32.5% (versus bivalent) and 7.5% (versus quadrivalent). The incremental cost-effectiveness ratio (ICER) per quality-adjusted life-year gained was SGD 929 compared with bivalent vaccination and SGD 9864 compared with quadrivalent vaccination.

CONCLUSION

Universal two-dose nonavalent HPV vaccination for 11- to 12-year-old adolescent women is very cost-effective in Singapore.

TWEETABLE ABSTRACT

Nonavalent HPV vaccination of 11- to 12-year-old girls is cost-effective in Singapore.

Vaccine Misconceptions and Low HPV Vaccination Take-up Rates in Singapore

BACKGROUND

HPV vaccination in Singapore is voluntary and physician prescription-based. This study investigated the current status and intention for HPV vaccination among Singapore nurses.

MATERIALS AND METHODS

All female nurses in a general hospital were given an anonymous questionnaire on HPV vaccination experience and intention of vaccinating their daughters. The influence of age, knowledge and perceived-risk of cervical cancer, and cultural background on mother's intention of vaccinating their daughters was analyzed.

RESULTS

Of 2,000 nurses, 1,622 (81.1%) responded and analysis was performed on 1,611 with valid data. They showed good awareness on association of cervical cancer with multiple sexual partners (81.9%), history of sexually transmissible diseases (78.2%), and history of genital warts/HPV infection (73.5%), and on cervical cancer preventive effects of HPV vaccination (54.6%). The prevailing misconceptions of the vaccines were: investigational nature (38.9%), side effects (27.9%) and indicated for women at high risk for cervical cancer (20.5%).

CONCLUSIONS

Misconceptions on the nature, role and safety of HPV vaccines low vaccine up-take rates and daughters. Dissemination of adequate and accurate HPV vaccine information and a review for school-based vaccination are needed for optimal delivery of HPV vaccines in Singapore.

Application of legal principles and medical ethics: multifetal pregnancy and fetal reduction

In the management of complex medical cases such as a multifetal pregnancy, knowledge of the ethical and legal implications is important, alongside having competent medical skills. This article reviews these principles and applies them to scenarios of multifetal pregnancy and fetal reduction. Such a discussion is not solely theoretical, but is also relevant to clinical practice. The importance of topics such as bioethical principles and informed consent are also herein addressed.

First-line gemcitabine and carboplatin in advanced ovarian carcinoma: a phase II study

OBJECTIVES

To evaluate tumour response rate and toxicities of gemcitabine and carboplatin in chemonaive subjects with advanced epithelial ovarian cancer.

DESIGN

A phase II study.

SETTING

Gynaecologic oncologic unit.

POPULATION

Twenty chemonaive International Federation of Gynecology and Obstetrics (FIGO) stage IIIc and stage IV subjects with ovarian cancer.

MAIN OUTCOME MEASURES

Tumour response, disease free and overall survival and toxicity.

METHODS

Intravenous gemcitabine 1000 mg/m2 on day 1 and day 8 and carboplatin at area under centre (AUC) = 5 on day 1 were administered three weekly for six cycles. Subjects who received more than three cycles of chemotherapy were eligible for assessment of tumour response, while all the cycles of chemotherapy were assessed for toxicities.

RESULTS

The mean age of the subjects was 57.3 years, and the median follow up was 38.7 months. Of the 18 eligible subjects analysed, 11 (61.1%) showed a complete clinical response, and the overall response rate was 83.3% (15/18). The median overall survival was 29.2 [95% (confidence interval) CI 22.8-35.6] months, and the median progression-free survival was 11.6 (95% CI 4.7-18.5) months. WHO grade 3 anaemia, neutropenia and thrombocytopenia was 7.6, 9.5 and 0%, respectively, on day 8, and 15.5, 12.2 and 15.5%, respectively, on day 15. Two subjects required a total of three hospital admissions for neutropenic sepsis, and two required five hospital admissions for platelet transfusion for severe thrombocytopenia.

CONCLUSION

Chemonaive advanced ovarian cancer showed a high response rate to combined gemcitabine and carboplatin chemotherapy. The subjects developed moderate adverse reactions. Phase III study to evaluate the role of combined gemcitabine and carboplatin as first-line chemotherapy in ovarian cancer is warranted.

Silencing expression of UO-44 (CUZD1) using small interfering RNA sensitizes human ovarian cancer cells to cisplatin in vitro

Ovarian cancer is currently the second leading cause of gynecological malignancy and cisplatin or cisplatin-based regimens have been the standard of care for the treatment of advance epithelial ovarian cancers. However, the efficacy of cisplatin treatment is often limited by the development of drug resistance either through the inhibition of apoptotic genes or activation of antiapoptotic genes. We have previously reported the overexpression of human UO-44 (HuUO-44) in ovarian cancers and the HuUO-44 antisera markedly inhibited NIH-OVCAR3 ovarian cancer cell attachment and proliferation (Oncogene 23: 5707-5718, 2004). In the present study, we observed through the cancer cell line profiling array that the expression of HuUO-44 was suppressed in the ovarian cancer cell line (SKOV-3) after treatment with several chemotherapeutic drugs. Similarly, this suppression in HuUO-44 expression was also correlated to the cisplatin sensitivity in two other ovarian cancer cell lines NIH-OVCAR3 and OV-90 in a dose-dependent manner. To elucidate the function of HuUO-44 in cisplatin chemoresistance in ovarian cancer cell, small interfering RNAs (siRNAs) were employed to mediate HuUO-44 silencing in ovarian cancer cell line, NIH-OVCAR3. HuUO-44 RNA interference (RNAi) resulted in the inhibition of cell growth and proliferation. Importantly, HuUO-44 RNAi significantly increased sensitivity of NIH-OVCAR3 to cytotoxic stress induced by cisplatin (P<0.01). Strikingly, we have also demonstrated that overexpression of HuUO-44 significantly conferred cisplatin resistance in NIH-OVCAR3 cells (P<0.05). Taken together, UO-44 is involved in conferring cisplatin resistance; the described HuUO-44-specific siRNA oligonucleotides that can potently silence HuUO-44 gene expression may prove to be valuable pretreatment targets for antitumor therapy or other pathological conditions that involves aberrant HuUO-44 expression.

The use of intradepartmental audit to contain cesarean section rate

In one department practicing critical review of indications for cesarean delivery, the overall LSCS rate was maintained at 12.3%, 11.1%, 11.2% and 11.4% for 1987, 1988, 1989 and 1990, respectively. A highly significant (P = 0.0013) reduction of 26.8% was observed in the LSCS rate for cephalo-pelvic disproportion between 1987 and 1990. Perinatal mortality rate per 1000 births remained low at 8.25, 7.05, 9.39 and 5.83 for infants weighing 500 g or more.

Metastatic carcinoma of the cervix presenting as a psoas abscess in an HIV-negative woman

A case of advanced carcinoma of the cervix presenting as a psoas abscess is described. This unusual presentation has been reported in association with AIDS but is extremely rare in HIV-negative women. This case report emphasises the importance of awareness of unusual causes of the psoas abscess in an era when the classical tuberculous abscess is fast disappearing.

Sperm segregation patterns by fluorescence in situ hybridization studies of a 46,XY,t(2;6) heterozygote giving rise to a rare triploid product of conception with a 69,XXY,t(2;6)(p12;q24)der(6)t(2;6)(p12;q24)pat karyotype

A blighted ovum diagnosed initially by ultrasound was determined to be a partial hydatidiform mole with a 69,XXY,t(2;6)(p12;q24)der(6)t(2;6)(p12;q24)pat karyotype by cytogenetic analysis. The triploid state arose through dispermy in which both spermatozoa carried rearranged chromosomes, one carrying a balanced translocation through alternate segregation and the other an unbalanced derivative chromosome 6 through adjacent 1 segregation. Segregation analysis of 7,000 spermatozoa from the father was performed with a three-color fluorescence in situ hybridization (FISH) protocol using alpha-satellite 6, telomeric 2p, and telomeric 6q probes. Segregation frequencies of normal and balanced products (alternate segregation), adjacent 1, adjacent 2, and 3:1 were 49.9%, 42.4%, 2.5%, and 4.2%, respectively. The high percentage of alternate segregation is consistent with the knowledge of their preferential outcome. However, the high incidence of adjacent 1 sperm highlights the abnormality risk. Alternate and adjacent 1 segregations (92.3%) accounted for the observed rearranged chromosomes in the triploid. The most viable imbalanced combination would be the one carrying the der(6) chromosome, but since the unbalanced segment comprises 3.6% of the haploid autosomal length (HAL), no risk of a viable imbalanced offspring is indicated. However, an increased likelihood of recurrent miscarriages is likely, and this is confirmed by the couple's two earlier miscarriages. Sperm segregation patterns of translocation carriers determined by FISH can help in ascertaining expected and unexpected karyotypes. The high frequency of adjacent 1 products shows that the presence of the additional derivative chromosome in the partial mole, though rare in occurrence, should be less surprising.

Pregnancy after renal transplantation: experience in Singapore General Hospital

INTRODUCTION

Renal transplantation offers the best hope for those women with end-stage renal disease who wish to have children. However, pregnancy after renal transplantation is associated with increased maternal and fetal morbidity. The aim of this retrospective study was to review the outcome of pregnancy in renal transplant patients in Singapore General Hospital.

MATERIALS AND METHODS

Forty-two pregnancies, occurring between December 1986 and December 2000, in 25 out of 141 renal transplant women in their reproductive age group (18 to 45 years old) were identified from our high-risk pregnancy record and retrospectively analysed.

RESULTS

Thirteen (31%) pregnancies were unsuccessful; 10 abortions, 2 ectopic pregnancies and 1 stillbirth. The remaining 29(69%) successful pregnancies were complicated by maternal anaemia (65.5%), superimposed hypertension (44.8%), premature rupture of membranes (27.6%), urinary (17.2%) and lower genital tract (13.8%) infections, abnormal glucose tolerance test (13.8%), premature delivery (44.8%), low-birth-weight babies (44.8%), small-for-gestational-age babies (20.7%) and intrauterine growth restriction (20.7%). There were no documented cases of multiple pregnancies, congenital anomalies or deterioration of renal function. The outcome of pregnancy was not statistically influenced by preconception renal function and transplant-conception interval.

CONCLUSIONS

Successful pregnancy is possible in women after renal transplantation. Such pregnancy is often associated with increased maternal and fetal complications and should be managed by a multidisciplinary approach in a tertiary centre. The function and survival of renal allograft was not adversely affected by pregnancy.

Identification and characterization of genes involved in the carcinogenesis of human squamous cell cervical carcinoma

We utilized RT-PCR differential display and cDNA microarrays to identify cellular genes involved in the multi-step carcinogenesis of squamous cell cervical carcinoma. Thirty-eight cervical cancer patients in various stages of the disease and 5 non-cervical cancer patients were studied. Twenty-five cDNA clones were identified and these were subsequently demonstrated to be consistently over-expressed in squamous cell cervical carcinoma biopsies of various FIGO stages. To further evaluate the possible role that these genes may play in the progression of disease, we performed Northern blot analysis and RNA-RNA in situ hybridization studies using cervical cancer biopsies of various FIGO stages. Of particular interest are the 2 clones G32C4B and G30CC that have been identified to be the NADH dehydrogenase 4 gene and the gene that encodes ribosomal protein S12 respectively when compared to sequences available in the GenBank database. Increased expression of these 2 genes were detected in the matched normal tissues collected together with the late FIGO stages of cervical cancer biopsies. In comparison, upregulation of these 2 genes was not detected in cervical squamous epithelium collected from patients admitted for surgery for non-malignant conditions, suggesting that expression of these 2 genes may have altered in the adjacent histopathologically "normal" cervical squamous epithelial tissue from cervical cancer patients. The ribosomal protein S12 and the NADH dehydrogenase 4 genes may therefore be potentially useful as early pre-transformation diagnostic markers for human cervical cancer.

Laparoscopically-assisted vaginal hysterectomy (LAVH)--an alternative to abdominal hysterectomy

AIM

To study the outcomes of 42 consecutive patients who were scheduled for a laparoscopically-assisted vaginal hysterectomy (LAVH) between I January 1994 to 31 December 1999.

METHOD

Retrospective study

RESULTS

Two patients required conversion to an abdominal hysterectomy. The range of uteri removed was from six to 16 weeks' size. Menorrhagia was the commonest presenting complaint and uterine fibroids was the commonest diagnosis. The mean duration of surgery (+/- SD) was 131.0 +/- 31.7 minutes. Mean blood loss (+/- SD) was estimated at 417 +/- 169 mls. Six percent of patients required a perioperative blood transfusion. Fifty-five percent of patients did not require any injectable analgesics and 45% were able to ambulate on the day of surgery. The mean duration of hospital stay (+/- SD) was 4.2 +/- 2.3 days;The commonest complication was post-operative fever.

CONCLUSIONS

LAVH patients have a quick postoperative recovery with less pain at the expense of a long duration of surgery. LAVH is a feasible option in a selected group of patients who would otherwise require an abdominal hysterectomy.

Identification of molecular markers for the early detection of human squamous cell carcinoma of the uterine cervix

To identify novel cellular genes that could potentially act as predictive molecular markers for human cervical cancer, we employed RT--PCR differential display, reverse Northern and Northern blot analysis to compare the gene expression profiles between squamous cell carcinoma biopsies and adjacent histo-pathological normal epithelium tissues. Twenty-eight cDNA clones were isolated that were demonstrated to be consistently over-expressed in squamous cell cervical cancer biopsies of FIGO stages 1B to 3B. Most importantly, it was observed that, in addition to their over-expression in cancer lesions, some of these genes are upregulated in the presumably histo-pathological normal adjacent tissues. Of particular interest is clone G30CC that has been identified to be the gene that encodes S12 ribosomal protein. When employed for RNA--RNA in situ hybridization experiments, expression of G30CC could be detected in the immature basal epithelial cells of histo-pathological normal tissues collected from cervical cancer patients of early FIGO stages. In comparison, the expression of G30CC was not detected in cervical tissues collected from patients admitted for surgery of non-malignant conditions. These results allow the distinct possibility of employing the ribosomal protein S12 gene as an early molecular diagnostic identifier for the screening of human cervical cancer and a potential target employed for cancer gene therapy trials.

Occupational risk for male infertility: a case-control study of 218 infertile and 227 fertile men

The aim of the study was to determine if certain occupations pose an increased risk for infertility (of no known cause) among a group of infertile men compared with a group of fertile men. A total of 640 consecutive men whose spouses were unable to conceive were recruited from an infertility clinic. Of these, 218 men (cases) were found to have no known cause for their infertility. A total of 227 men whose spouses were pregnant at the time of the study were recruited as controls. The Singapore Standard Occupational Classification was used to code the subjects' occupations. Semen parameters (density, total sperm counts, motility, viability, and normal morphology) in all of the cases were significantly poorer than those in the controls. The risk for infertility is associated with smoking adjusted odds ratio (OR) 2.85 and 95% confidence interval (CI) 1.91 to 4.24. Work, independently, is not a risk factor for infertility. Engineering technicians (adjusted OR, 2.75; 95% CI, 1.36 to 5.54), finance analysts (adjusted OR, 4.66; 95% CI, 1.90 to 11.40), corporate and computing managers (adjusted OR, 2.49; 95% CI, 1.04 to 5.98), and teachers (adjusted OR, 7.72; 95% CI, 1.86 to 32.10) were at a greater risk of infertility compared with "services and clerical workers." Using services and clerical workers as a reference group, certain occupations are at a higher risk for infertility. Higher work demands and possible electromagnetic field exposure could be contributory factors for infertility.

Diagnosing and prognosticating acute meningitis in young infants within 24 hours of admission

INTRODUCTION

The early diagnosis and prognosis of acute meningitis in young infants (infants 90 days old or younger) have not been well studied. We therefore investigated the diagnostic and prognostic factors for acute meningitis obtainable within 24 hours of admission.

METHODS

Data were obtained through a retrospective case review of 55 young infants from 1991 to 1999 inclusive.

RESULTS

The 3 commonest symptoms of acute meningitis were fever, abnormal activity and decreased feeding. The 3 commonest signs were temperature > 38.0 degrees C, irritability/crying and abnormal tone/reflexes. The best predictor of acute bacterial meningitis (ABM) was the cerebrospinal fluid (CSF)-to-blood glucose ratio. A glucose ratio of < or = 0.8 can be used to diagnose ABM with 100% sensitivity and 100% negative predictive value. Furthermore, a ratio < or = 0.3 can be used to diagnose ABM with 100% specificity and 100% positive predictive value. The best predictor of unfavourable neurological outcome (UFNO) was also the CSF-to-blood glucose ratio. A glucose ratio of < or = 0.3 again can be used to prognosticate for UFNO with 100% sensitivity and 100% negative predictive value.

CONCLUSIONS

Diagnosis of acute meningitis by history and physical examination alone is difficult. However, with the aid of laboratory tests, in particular the CSF-to-blood glucose ratio, one can diagnose ABM and prognosticate for unfavourable neurological outcome with high sensitivity and high negative predictive value within 24 hours of admission.

[Loop electrosurgical excision procedure: a valuable method for the treatment of cervical intraepithelial neoplasia]

OBJECTIVE

To determine the effectiveness and safety of loop electrosurgical excision procedure (LEEP) for the management of cervical intraepithelial neoplasia (CIN) and the significance of positive margins in cervical cone biopsy specimens with the relationship of prognosis.

METHODS

LEEP under local anesthesia and colposcopic guidance was performed in an outpatient of colposcopic clinic. Records of 135 patients treated between Feb 1992 and Jul 1999 were reviewed prospectively.

RESULTS

The median age of patients in this study was 42 years (range 18-67 years), parity 2.2 times (range 0-8 times). High-grade squamous intraepithelial lesion (HGSIL) accounted for majority of diagnosis according to pap smear (65.9%) and colposcopy (75.6%) respectively. The results of LEEP demonstrated negative histology in 7 patients (5.2%), human papilloma virus (HPV) infection in 2 patients (1.5%), CINI in 15 patients (11.1%), HGSIL in 108 patients (80.0%) which including 20 patients (14.8%) of CINII, 88 patients (65.2%) of CINIII, microinvasion in 3 patients (2.2%). Clear resection margin of lesion in cervix was noted in 78 (57.8%) patients. Unclear margins were appeared in 57 (42.2%) patients including 21 cases (15.6%) of resection margin positive and 36 cases(26.7%) of resection margin undetermined. HGSIL accounted for the majority (54 cases, 94.7%) in this kind of patients. The residual CIN occurred in 1 patient (4.8%) with the resection margin positive and 3 patients(8.3%) with the resection margin undetermined respectively. In 2 patients (2.6%) with the resection margin clear. Recurrence CIN occurred in 1 patient (4.8%) with the resection margin positive and 2 patients (5.6%) with the resection margin undetermined respectively, none of the patients (0.0%) with the resection margin clear. The overall cure rate in this study was 93.3% after first LEEP done. The residual CIN was identified in 6 (4.4%) patients. The recurrence CIN occurred in 3 (2.2%) patients. Complications of LEEP occurred in 14.1% (19/135) patients in this study.

CONCLUSIONS

LEEP is a kind of effective and safe method for the treatment of cervical intraepithelial neoplasia. The status of resection margin should be concerned. Margin involvement of specimen is the risk factor for residual and recurrence of CIN.

Total pelvic exenteration: results from a multispecialty team approach to complex cancer surgery

Total pelvic exenteration is often the only curative option for recurrent or locally advanced pelvic cancers, but it carries a high risk of mortality and morbidity. A dedicated multispecialty team operative approach may provide the expertise to perform this uncommon procedure with favorable outcomes. Data were analyzed from a prospectively collected computerized database. There were 14 patients (2 men; mean age, 54.6 +/- 3.6 years) with mainly cervical cancers, of which 71.4% were recurrent. Anesthetic time was 5 +/- 0.9 hours, intraoperative blood loss was 2.1 +/- 0.5 liters, and postoperative hospitalization was 22 +/- 9.9 days. An ileal conduit was performed in all patients, but intestinal continuity was restorable with colonic J-pouch in 71.4% of the patients. There was no mortality at 30 days or during hospitalization. Complication rates were 35.7%, accounting for reoperations in 28.6%. Recurrences were detected in 50% patients at a mean follow-up of 53.1 +/- 9.2 months. The mean time for cancer recurrence was 13.3 +/- 3.3 months. Fifty percent of those patients had otherwise survived to date. We conclude that a dedicated multispecialty team may perform total pelvic exenteration with minimum mortality and acceptable morbidity.

Monthly variation in human semen quality in male partners of infertile women in the tropics

The aim of the study was to determine whether there were significant 'seasonal' variations in the rhythm of sperm parameters (i.e. semen volume and sperm density) of men who reside in the tropics. A total of 7656 semen analysis results from the department of obstetrics and gynaecology of a tertiary general hospital was analysed. These samples were obtained as part of an initial screening for male partners of couples with problems trying to conceive who were attending a fertility clinic from 1991 to 1995. The subjects' mean semen volume and sperm density of 2.9 ml and 26.9x10(6)/ml respectively were within the World Health Organization reference values. There were no significant month-to-month variations in the adjusted (for age of subject, year of test and technologist who performed the analysis by analysis of co-variance, ANCOVA) mean semen volume and sperm density over the 5 year period. Variations in semen volume and density observed in the temperate climates are not seen in this study, which was conducted in subjects staying in the tropics. This observation may be related to relative constant temperature and hours of light exposure among men who reside in the tropics. As this study is, so far, published data from only one country, Singapore, it may not truly reflect the actual situation for individuals who are residing in the tropics.

The use of vigabatrin in infantile spasms in Asian children

BACKGROUND

The use of adrenocorticotrophic hormone (ACTH) and prednisolone in the management of infantile spasms has been well established, but is associated with significant morbidity and cannot be used as long-term medication. Since the introduction of vigabatrin, results have been promising with suggestions currently that it should be used as first-line management of infantile spasms.

AIM

The aim of this study was to establish the efficacy, tolerability and problems associated with the use of vigabatrin, in Asian children with infantile spasms.

MATERIALS AND METHODS

Eighteen local Asian patients with infantile spasms were given vigabatrin, in 8 as first-line monotherapy and in 10 patients as add-on therapy to pre-existing anti-convulsants.

RESULTS

Thirty-nine per cent (7/18) showed 100% suppression of seizures at 2 weeks and 50% (9/18) showing complete suppression of seizures at 4 weeks after starting therapy. There was however, a high relapse rate (56%) in complete responders within the first 6 months of therapy. This was probably due to a lower maintenance dose in the patients, as those who relapsed were on an average dose of 59 mg/kg/day at the time of relapse and responded to a stepped up dose of 83 mg/kg/day. Vigabatrin was well tolerated and only 2 patients developed somnolence and irritability.

CONCLUSION

A dose of at least 70 mg/kg/day may be necessary to achieve adequate control and yet avoid the common adverse affects of vigabatrin.

Technical aspect of ThinPrep

AIM OF STUDY

To analyze the common technical problems encountered in ThinPrep preparations.

METHOD

A prospective and retrospective study of eight hundred and fifty (n = 850) conventional cervical smears with its corresponding paired ThinPrep specimens from July 1998 to December 1998.

RESULTS

139 ThinPreps were found to be technically suboptimal. Of these, 81 showed "patchy cells lost"; 18 showed "thick preparations"; 24 demonstrated "halo effect'" where the cellular material collected at the periphery of the cell circle, and 16 had "obscuring blood and amorphous debris", rendering the preparations "satisfactory for evaluation but limited" by the presence of the above artifacts.

CONCLUSION

Despite its many advantages in providing standardization of specimen preparation, superb cellular presentation, reduction in the number of unsatisfactory reports and increased lesion detection rate, ThinPrep has its own limitations in terms of technical problems, ease of operation and cost effectiveness.

Transaminitis in Duchenne's muscular dystrophy

BACKGROUND

Persistently raised transaminase levels often prompt the clinician to investigate for liver pathology. Previously, some of our patients with Duchenne's muscular dystrophy have had investigations to look for liver disorders when the alanine transaminases (ALTs) were found incidentally to be high.

AIM

The objective of the study was to ascertain the levels of the transaminases in patients with Duchenne's muscular dystrophy and to see if the levels of transaminases correlated with muscle enzymes such as creatine kinase (CK).

MATERIALS AND METHODS

This is a case series of 19 patients with Duchenne's muscular dystrophy. Alanine and aspartate transaminase (AST) levels and CK levels were measured in the serum of the patients.

RESULTS

In this series, ALT and AST levels were all found to be raised significantly in patients with biopsy-proven Duchenne's muscular dystrophy and Becker's muscular dystrophy. Alanine transaminase, in particular, was raised to a mean of 356 mmol/L, 9 times above the mean for normal. There was also good correlation between ALT and CK levels with a correlation coefficient of r = 0.80 and P value 0.01. Similar to CK, the transaminase levels were inversely proportional to mobility and to age.

CONCLUSION

The presence of hypertransaminasemia in patients with muscular dystrophy should be attributed to muscle breakdown rather than to liver pathology and such patients should not be over-investigated for liver disease. In the absence of liver pathology, raised transaminases may be an early sign of occult muscular dystrophy and such patients should have CK levels checked to look for evidence of muscular dystrophy.

Sandhoff disease--a case report of 3 siblings and a review of potential therapies

INTRODUCTION

Sandhoff disease is a GM2 gangliosidosis that may present within the first 6 months of life with developmental regression. This is the first report of a pedigree from Southeast Asia.

CLINICAL PICTURE

All the affected siblings presented in the first year of life with developmental regression, spasticity, seizures and loss of vision. The diagnosis was confirmed by an enzymatic deficiency in both beta-hexosaminidase A and B.

CONCLUSION

As the disorder is autosomal recessive, and no curative therapy is currently available, genetic counselling is necessary to prevent the burden of this devastating disease. We review the potential strategies of treatment for Sandhoff disease.

Comparison of zinc concentrations in blood and seminal plasma and the various sperm parameters between fertile and infertile men

The aim of the study was to examine the relationships between concentrations of zinc in blood and seminal plasma and sperm quality among infertile and fertile men. One hundred seven male (infertile group) partners of couples who were undergoing investigation for infertility with no known cause for the infertility and 103 men (fertile group) whose wives were pregnant at the time of the study were recruited. The subjects' blood and seminal plasma concentration of zinc were determined by atomic absorption spectroscopy. Except for semen volume, all the other semen parameters for the infertile men were significantly lower than those for the fertile group. The geometric means of the seminal plasma zinc concentration were significantly lower in the infertile group compared with those in the fertile group; 183.6 mg/L (range, 63-499) versus 274.6 mg/L (range, 55-420). There were no significant differences in the geometric means of the blood zinc concentration between the 2 groups. Seminal plasma zinc concentration was significantly correlated with sperm density (r = 0.341, P < .0001), motility (r = 0.253, P < .0001), and viability (r = 0.286, P < .0001). On the basis of the findings of this study and those of other reports, zinc may contribute to fertility through its positive effect on spermatogenesis.

Factors associated with male infertility: a case-control study of 218 infertile and 240 fertile men

OBJECTIVE

To determine the likely risk factors, such as smoking and drinking habits, and occupational groups, for infertility in a group of infertile men with no known cause, compared with a group of fertile men; and to examine the effects of the semen parameters, such as volume, density, motility, viability and normal morphology, on fertility.

DESIGN

A case-control study.

SETTING

The department of obstetric and gynaecology of a tertiary general hospital.

PARTICIPANTS

Six hundred and forty consecutive male partners of couples trying to conceive were recruited from an infertility clinic. Of these, the cases comprised 218 men who had no known cause for their infertility. Two hundred and forty men whose wives were pregnant at the time of the study were recruited as controls.

RESULTS

The semen parameters (e.g. density, total sperm counts, motility, viability and normal morphology) of all cases were significantly poorer than that of the controls. The risk of infertility is associated with smoking (crude OR 2 x 82, 95% CI 1 x 93-4 x 13; adjusted OR 2 x 96; 95% CI 1 x 98-4 x 42). Technicians (adjusted OR 2 x 81; 95% CI 1 x 51-4 x 24) and professional, senior officials and managers were also at a greater risk of infertility (adjusted OR 2 x 36; 95% CI 1 x 26-4 x 40), compared with service and clerical workers. The significant factors predicting infertility were smoking, density of sperm, and viability of sperm. Smoking increased the odds of being infertile. Higher sperm counts and larger percentage of viable sperm decrease the odds of infertility. Based on the multiple logistic regression model, the odds ratio for infertility = (94 x 70) x (2 x 88(smoking)) X (0 x 29(logdensity)) X (0 x 95(viability)).

CONCLUSION

Smoking, density of sperm and the viability of sperm are significant predictors for infertility among men.

Two dosing regimens for preinduction cervical priming with intravaginal dinoprostone pessary: a randomised clinical trial

OBJECTIVE

To compare the efficacy within 24 hours of a three-times-a-day intensive dosing regimen with a standard once daily dosing regimen using dinoprostone vaginal pessary in preinduction cervical priming.

DESIGN

Randomised controlled trial.

SETTING

Department of Obstetrics and Gynaecology, Singapore General Hospital.

PARTICIPANTS

One hundred singleton term primigravidae with cephalic presentation with unfavourable cervical scores (Bishop score < or = 5) requiring induction of labour.

METHODS

Eligible women were randomly assigned the standard regimen (3000 microg dinoprostone [Prostin, Upjohn, Crawley, UK] once daily) or an intensive regimen (3000 microg dinoprostone given sequentially three times daily four hours apart) for cervical priming until successful priming (Bishop score of > or = 6) or the onset of active labour occurred.

MAIN OUTCOME MEASURES

Number of women whose cervices were ripened successfully or who entered active labour within 24 hours of starting cervical priming, priming to induction interval, and priming to delivery interval.

RESULTS

Forty-nine women were assigned to the standard regimen and 51 to the intensive regimen. The median number (range) of dinoprostone pessaries used was two (one to seven) in the standard regimen and three (one to nine) in the intensive regimen. Forty-two women (82.4%) who underwent the intensive regimen achieved successful cervical ripening or active labour within 24 hours, compared with 21 assigned to standard regimen (OR 6.2, 95% CI 2.3-17.4). This difference was statistically significant. The median intervals from priming to induction, and from priming to delivery, were also statistically significantly shorter in women treated with the intensive regimen. Thirty-five women (68.63%) assigned the intensive regimen experienced pain, compared with 21 (42.86%) in the standard regimen (OR 2.92, 95% CI 1.19-7.21), with two and one women in the respective regimens requiring opiate analgesics. Five women with oligohydramnios had transient cardiotocographic abnormalities during priming with the intensive regimen, none of which required immediate intervention, and the babies were born in good condition. There were no cases of uterine hypertonus and the outcomes of labour were similar for women from both regimens.

CONCLUSIONS

Preinduction cervical priming with the intensive dosing regimen improves the chances of successful ripening within 24 hours for primigravidae with unfavourable cervical scores at full term singleton pregnancies, and shortens the interval from priming to induction, and priming to delivery. This regimen may be more cost effective by shortening the period of hospital stay. The overall incidence of adverse reactions to the mother and fetus during priming was low. However, close fetal surveillance must be maintained, particularly in pregnancies complicated with oligohydramnios.

Is routine procaine spirit application necessary in the care of episiotomy wound?

BACKGROUND

A randomised controlled trial to investigate the usefulness of local application of procaine spirit versus cleansing with water for care of episiotomy wound after normal vaginal delivery was conducted in 100 women.

PATIENTS

Fifty women entered the study arm and 50 entered the control arm of the study. Women in the two arms were similar in their demographic and obstetric characteristics.

RESULTS

The pain scores on a verbal analogue scale was highest (score = 2.5) on Day 1 of the delivery. This was the same in women in both arms. The number of paracetamol tablets consumed was also low and was similar in both groups of women. By the fourteenth day of delivery, all the women were pain-free and the wound had healed well. It was noted that all the women maintained a high standard of perineal hygiene with a mean of 5 washes a day.

CONCLUSION

It is concluded that in a woman with normal vaginal delivery, local application of procaine spirit is unnecessary in the care of a routine episiotomy wound.

What constitutes a normal seminal analysis? Semen parameters of 243 fertile men

A cross-sectional study was conducted to determine the semen parameters (i.e. volume, concentration, motility, viability and normal morphology) of proven fertile males in Singapore and compare it with the World Health Organization (WHO) recommended normal values and to examine some factors that may affect spermatogenesis. A total of 243 men, whose wives were pregnant at the time of collection of semen, provided a semen sample each after sexual abstinence for 3 days. A questionnaire was used to elicit occupational exposure, alcoholic consumption, smoking history and past significant medical history. Most subjects had normal sperm volume (56.4%), concentration (79.8%), motility (69.5%) and viability (53.5%) based on WHO criteria. However, fertile men had a low mean percentage of normal sperm morphology (20.0%), although they were normally distributed. Cigarette smoking was associated with significantly lower semen volumes even after adjusting for alcohol consumption. The sperm parameters (i.e. volume, density, motility, viability and normal morphology) were not significantly associated with ethnic differences. The WHO criterion for normal sperm morphology is too stringent, and should be adopted with caution. Normal sperm morphology is but one of many parameters for assessment of fertility. Social alcohol consumption, cigarette smoking, and 'recent fever' did not appear to affect sperm quality in this group of fertile men.

Single agent paclitaxel in resistant and relapsed epithelial ovarian cancer after first-line platinum-based chemotherapy--experience in an Asian population

The efficacy and toxicity profile of paclitaxel (Taxol) was studied in 33 Singaporean women with epithelial ovarian carcinoma who had either failed to respond or relapsed after an initial response to first-line chemotherapy with combined platinum and cyclophosphamide. Paclitaxel was given intravenously as a single agent at a dose of 200 mg/m2 over 3 hours, with standard pre-medication, at 4 weekly intervals. A total of 102 cycles were administered. The median number of cycles was 3 (range 1 to 8) per patient. Twenty-six patients were eligible for response evaluation. Six (23.2%) patients showed a complete response and 4 (15.4%) showed a partial response. Two (7.7%) patients had stable disease and 14 (53.8%) patients had progressive disease. The response rate was 22.2% (2 of 9 patients) for patients with progressive disease while on the first-line platinum-based chemotherapy, 37.5% (3 of 8 patients) for patients with response-relapse interval of less than 6 months, 40.0% (2 of 5 patients) for patients with response-relapse interval of 6 to 12 months, and 75% (3 of 4 patients) for patients with response-relapse interval of more than 12 months. The median duration of survival was 10 months for the entire cohort of patients, but all complete responders and 75% of partial responders survived the duration of the study period of 24 months, compared to 50% of patients with stable disease and 7% of patients with progressive disease. Toxicity of paclitaxel treatment was evaluated in 102 cycles. Grade 3 or 4 alopecia, grade 1 or 2 sensory peripheral neuropathy and mild facial flush occurred in all patients. Haematological toxicity was mild, with 9.8% of the cycles complicated by grade 3 or 4 neutropenia. Bone marrow suppression was of short duration. No treatment delay or dose modification was needed. It is concluded that the effectiveness of paclitaxel for salvage treatment of patients with resistant or relapsed epithelial ovarian carcinoma after first-line platinum-based chemotherapy among Asian patients is comparable to that reported in Western populations. The treatment was well tolerated by our patients. It should be considered the chemotherapy of choice for patients with relapsed ovarian cancer after prior platinum-based chemotherapy.

Outcome of obstructive uropathy after pelvic irradiation in patients with carcinoma of the uterine cervix

The natural history and outcome of intervention for obstructive uropathy were studied retrospectively in 20 patients managed at the Department of Urology, Singapore General Hospital between 1991 and 1997. The diagnoses of these strictures were made between 10 months and 21 years after the initial treatment. There were 9 (45%) malignant and 11 (55%) benign strictures. The site of ureteric obstruction was in the lower ureter in 15 patients, in the middle ureter in 3 patients and in the upper ureter in 2 patients. Comparisons between malignant and benign strictures showed that patients with higher original stage of tumour were more likely to have malignant strictures. Besides latency period between primary treatment of the tumour and diagnosis of uropathy, bilaterality and site of strictures showed no discernible difference between benign and malignant strictures. Ureteric stenting provided good outcome in 5 patients with benign strictures and in 3 patients with malignant strictures. Open surgical reconstruction was performed on 2 patients with benign strictures and 2 patients with malignant strictures. All these four patients showed good outcome. Ureteric stenting is an acceptable treatment of benign ureteric stricture and for selected patients with malignant strictures. Open surgery is recommended in patients with benign strictures who could not be treated successfully on stenting.

Outcome of early cervical carcinoma treated by Wertheim hysterectomy with selective postoperative radiotherapy

Seventy-five consecutive patients with histologically confirmed FIGO stage IB-IIA cervical carcinoma who underwent Wertheim hysterectomy were studied retrospectively. Poor prognostic factors were found in 42 (56%) patients in whom postoperative adjuvant pelvic irradiation was given. The overall disease-free survival rate was 78% at 5 years and 75% at 9 years. The tumour recurrence rate was 12.1% in the low-risk patients and 35.7% in the high-risk patients. Tumour recurrences occurred significantly more frequently in patients with tumours with high grade squamous cell carcinomas and adenosquamous carcinoma. No recurrences occurred in patients with adenocarcinomas. After adjuvant radiotherapy, there was no statistically significant difference in the recurrence rates between lymph node positive and negative patients (26.7% and 19.6% respectively), however extrapelvic recurrences were more common in those with diseased lymph nodes. The recurrence rate was 40% in patients with involved resection margins compared to 16.7% of patients with clear margins. The recurrence rates were similar for patients with and without tumour embolisation of vascular/lymphatic channels. Wertheim hysterectomy with postoperative pelvic irradiation for selected high-risk patients was an effective treatment for FIGO stage IB-IIA cervical carcinoma. Despite radiotherapy, the high-risk patients still experienced a high tumour recurrence rate.

Adrenal hemangioma: two cases report

Adrenal hemangiomas are rare, nonfunctioning benign tumors. They are well circumscribed and comprise of closely adjacent vascular channels of varying sizes that are lined with a single layer of endothelium. When they occur, they are frequently located in the skin and liver. There are no characteristic symptoms of adrenal hemangioma unless the tumor reaches a size large enough to exert pressure. To our knowledge, there have been 14 clinical cases of adrenal hemangiomas reported, all with similar pathologic features. We present 2 additional cases, which were identified incidentally after non-urologic complaints (epigastric fullness and low back pain in patient 1 and patient 2, respectively). In these 2 patients, the tumors were surgically removed and diagnosed postoperatively as adrenal hemangiomas. Preoperative radiologic findings on plain film and abdominal computerized tomography showed the characteristic round calcifications with translucent centers, typical of phleboliths, to be pathognomonic of adrenal gland hemangiomas. Unfortunately, this characteristic feature of adrenal hemangioma existed in only one case report. In conclusion, the preoperative diagnosis of adrenal hemangioma is difficult but should be kept in mind as being part of the differential diagnosis of adrenal tumors.

Recurrent immature teratoma: lack of correlation between serum level and immunohistochemical detection of serum alpha-fetoprotein

We present the clinicopathologic and immunohistochemical features of a pure immature ovarian teratoma that had arisen in a 15-year-old girl. At original diagnosis immature extra ovarian implants were noted (grade 3) accompanied by moderately elevated serum alpha-fetoprotein (AFP) levels. AFP was immunohistochemically demonstrable in immature endodermal elements. The immature neural tissue present was negative for AFP, and no other tumor elements were recognisable. Serum AFP fell post-operatively to within normal limits. Despite five courses of chemotherapy and asymptomatic status, the patient re-presented 15 months after original diagnosis with a massive abdominal and pelvic tumor recurrence with predominantly mature glial tissue, but some persistent immature foci. There was no associated increase in serum AFP at this time. AFP was, however, persistently detectable immunohistochemically in immature endodermal components only. Immature neural elements were no longer identified. Disappearance of immature neural tissue in the tumor recurrence may have been related to chemotherapy. This case demonstrates the lack of correlative ability of serum AFP levels with both clinical behaviour and immunohistochemical demonstration of AFP expression in the tumor recurrence.

Outcome of hysterectomy for pelvic pain in premenopausal women

The outcome of abdominal hysterectomy for pelvic pain in premenopausal women was studied retrospectively in 228 women. In 17 women, pelvic pain was the sole indication while in the others, pelvic pain was one of the contributory indications for hysterectomy. The most common surgical histopathological diagnoses were uterine leiomyoma (73.9%), uterine adenomyosis (40.4%), benign ovarian cyst (19.3%) and endometriosis (7.9%); 118 (51.8%) patients had single pathology and 48.2% had multiple pathologies. The agreement between operative clinical diagnosis and histopathological diagnosis was 66.1% for leiomyoma, 57.1% for uterine adenomyosis and 30% for endometriosis. The incidence of early postoperative complication was 20.6%, mainly minor morbidities including urinary tract infection (3.9%), wound infection (3.1%) and unexplained fever (6.0%). These complications significantly prolonged the duration of hospital stay from an average of 7 days to 9-17 days. Of 98 patients with pain as the sole or the most predominant indication for hysterectomy, 72% responded to an outcome survey 12 or more months after hysterectomy. Of these, 62 (87%) were satisfied with the operation, 8 were unsure and 1 was dissatisfied; 68 (95.8%) patients reported relief of their symptoms. Relief of symptoms did not correlate with the patient's report of her satisfaction with hysterectomy. Pain in the abdominal wound a year or more after surgery was one of the commonest reasons cited for dissatisfaction with hysterectomy. We conclude that in well-selected cases, hysterectomy is an appropriate and satisfactory treatment for premenopausal women with pelvic pain irrespective of clinical evidence of associated pathology. Effective measures to reduce postoperative complications and wound pain are needed to further improve the outcome of abdominal hysterectomy.

Phase I study of immunotherapy of cutaneous metastases of human carcinoma using allogeneic and xenogeneic MHC DNA-liposome complexes

The generation of strong tumor-specific immunity by in situ gene therapy is an attractive approach for the eradication of human cancer lesions. The objectives of this study were to examine the toxicities of employing the human HLA-A2, HLA-B13 and the murine H-2K genes to generate tumor regression in patients with different cancer types via DC-Chol/DOPE cationic liposomes. The study was composed of two phaseI/II trials involving a total of 19 late-stage cancer patients. The patients were given four weekly injections of a DNA-liposome mixture directly into a cutaneous nodule. These procedures resulted in no significant clinical side-effects. The HLA-A2 gene gave the highest level of expression in situ. Although all patients treated had progressive systemic disease and eventually succumbed to their disease, strong local responses were generated in the treated nodules. Of the eight patients whose cutaneous nodules received HLA-A2 DNA, two completely regressed while four tumor nodules gave a partial local response. All but one of the patients who received HLA-A2-liposome mixtures and had a subsequent local response were either cervical or ovarian carcinoma patients. This local response, seen in a group of patients who had relapsed stage IV systemic metastatic disease and were refractory to all available therapies, demonstrates the generation of a strong local immune response following our in situ gene therapy protocol. Further studies to investigate the use of HLA-A2 DC-Chol/DOPE cationic liposomes for immunotherapy of cervical and ovarian cancers are warranted.

Visual effect of partogram designs on the management and outcome of labour

A prospective study of 3 partogram designs was performed in 990 women in labour with singleton pregnancy. Partogram A, B and C showed a progressively flatter steepness of the curve of labour progression. Oxytocin was administered in 35.1% of partogram-A users, 45.9% of partogram-B users (p = 0.001) and 44.1% of partogram-C users (p = 0.035). Significantly fewer patients among the partogram-A users (10.2%) were administered oxytocin too early compared to 18.6% of partogram-B users and 20.5% of partogram-C users. Of those with spontaneous onset of labour, a significantly smaller total dose of oxytocin was administered to the partogram-A users compared to the other 2 groups. Ominous electrocardiotocographic fetal heart patterns were detected less frequently during the first stage of labour in partogram A users (0.4%) compare to partogram-B users (1.1%) and partogram-C users (3.0%). Significantly fewer infants born to partogram-A users had depressed Apgar scores at 1 and 5 minutes. Partograms displaying a flat graph, compared to a steep graph, were more often considered to have a slow progress of labour. Adoption of partograms showing a steep graph of progress of cervical dilatation is recommended.

Laparoscopic treatment of ectopic pregnancies--a study of 100 cases

The experience of laparoscopic treatment of ectopic pregnancies (EPs) in a single institution was studied. Of the 358 cases of EPs treated between January 1990 and December 1995, 100 (27.9%) were treated laparoscopically. The mean age of these patients was 27.6 years and 65% were parous. The preoperative haemoglobin levels ranged between 7.1 and 13.2 g/dl. Haemoperitoneum was present in 83% of these cases and ectopic gestation was sited within the ampullary region in 66% of cases. Of the 100 cases of laparoscopically-treated EPs, 63 were treated by salpingectomy and 37 by linear salpingostomy. The mean operative time was 58 min (range 30 to 90 min). Except one patient with deteriorating vital signs in the immediate postoperative period needing a repeat laparoscopy, no other intra or postoperative morbidity was encountered. Majority of patients were ambulant within 12 hours of surgery and 84% were discharged home within 36 hours of their surgery. Laparoscopic treatment of EPs is safe and effective. Resident specialists in Obstetrics and Gynaecology should be trained in therapeutic laparoscopy early in their career so that more patients with EP can benefit from this minimally invasive surgery.

Efficacy of inosine pranobex oral therapy in subclinical human papillomavirus infection of the vulva: a randomized double-blinded placebo controlled study

A randomized double-blind placebo controlled study was carried out to assess the efficacy of inosine pranobex (1 g orally 3 times a day for 6 weeks) in the treatment of symptomatic subclinical human papillomavirus infection of the vulva. In a series of 55 women, 22 patients in the inosine pranobex group and 24 patients in the placebo group were suitable for analysis. A total of 14 (63.5%) of the inosine pranobex treated patients and 4 (16.7%) of the placebo treated patients showed significant vulval epithelial morphological improvement (P = 0.005) at 2 months after initiation of treatment. Whereas 13 (59.1%) and 9 (37.5%) patients in the respective groups showed significant improvement in the severity of pruritus vulvae (P = 0.435). Twelve (66.7%) of 18 patients with morphological improvement compared to 10 (35.7%) of 28 patients with no morphological improvement experienced significant symptomatic alleviation of pruritus vulvae (P = 0.041). Similar results were seen at the second assessment 4 months after the initiation of treatment. Adverse drug reactions were reported by 2 patients in the treatment group and by 2 patients (skin rash) in the placebo group. These adverse reactions were mild and self limiting. It is concluded that inosine pranobex demonstrated a significant pharmacological activity in subclinical HPV infection of the vulva and should be considered an alternative treatment for the condition.

Immunotherapy of human cancers

Advances in molecular biology technologies have significantly facilitated the identification of functional genes which cause, promote or control a variety of human diseases. Through recombinant DNA and polymerase chain reaction technologies, individual genes responsible for specific diseases have been identified, and consequently, the prospect that these diseases might be "cured" through replacement of the defective genes by their normal counterparts become distinct possibilities. Therefore, the goal of gene therapy is to apply this technology to the treatment of human diseases. In addition to its logical role for the correction of inherited diseases caused by a missing or defective gene product, gene therapy also holds promise for treatment of acquired disorders such as human cancer through the introduction of genes whose products have been implicated in controlling the growth of cancer. In this report, we present our results on the introduction of allogeneic major histocompatibility complex genes into cancer cells as an approach to increase the host's immune response against cancer. Various gene delivery strategies have been optimized for the introduction of DNA into various human tumour cells and these data are presented.

Genital oncogenic human papillomavirus infection: a short review on the mode of transmission

The most common oncogenic human papillomaviruses (HPVs) detected in the female lower genital tract are HPV types 16 and 18. They are ancient viruses which have evolved with mankind over the last 200 000 years. The identification of their roles in the development of carcinoma of the uterine cervix in the last decade fills the gap between the long-sought link between sexual behaviour and risk of cervical cancer. Indeed, epidemiological, clinical and sophisticated molecular studies employing the polymerase chain reaction (PCR) and DNA sequencing techniques have established the sexual transmissibility of these viruses. However, there is also compelling evidence indicating that these viruses can be transmitted through non-sexual routes. These include vertical transmission when an infant passes through the HPV-infected birth canal of the mother during vaginal delivery, and transmission by formites contaminated by HPV-infected cells. The long latent phase of HPV infection poses difficulties for accurate identification of the route of infection in an individual patient. Genital oncogenic HPV infection in a woman should not be treated as a venereal disease exclusively, and such patients should be counselled appropriately.

High long-term cure rate justifies routine treatment of cervical intraepithelial neoplasia grade I

The long-term clearance of cervical intraepithelial neoplasia (CIN) Grade 1 after one treatment was studied retrospectively in 105 patients. Treatment was by CO2 laser vaporization (74 patients), cone biopsy (8), loop electroexcision (LEEP) (7), electrodiathermy (1) and hysterectomy (2); 79 of the 92 treated patients (85.9%) had normal cervical cytology and colposcopy on a mean follow-up period of 36.7 months (95% confidence interval between 33.1-40.4 months). Life table analysis showed that the probability of the cervix remaining disease free was 81% at 72 months of follow-up. Of the 13 patients with a cervical abnormality after the initial treatment, 4 had persistent CIN 1, 3 persistent human papillomavirus (HPV) infection, 2 recurrent CIN 1 and 4 had recurrent HPV infection. In contrast, of the 13 untreated patients with CIN 1, 7 (53.8%) continued to demonstrate an abnormality on the cervix after a mean follow-up period of 27.5 months (95% confidence interval between 18.8 and 36.3 months). No significant perioperative morbidity was recorded in the treated patients. The results of this study suggest that CIN 1 can be effectively eradicated in more than 80% of women with 1 treatment alone. The treatment should be considered for all these patients to spare them the psychological and emotional trauma of having to face repeated abnormal cervical cytology on follow up.

Comparison of the usefulness of serum CA 125 level and a risk scoring system in detecting malignancy in ovarian cysts

A prospective study was carried out to compare the sensitivity, specificity, positive and negative predictive values, and the accuracy of serum CA 125 measurement with a clinical risk scoring system in the detection of malignant ovarian cysts. One hundred and three patients admitted to one department of obstetrics and gynaecology within a 12-month period were studied. There were 22 cases of malignant ovarian cysts. The sensitivity, specificity, positive and negative predictive values, and accuracy were 81.8%, 72.0%, 43.9%, 93.7% and 75.0% respectively for a raised serum CA 125 measurement (> or = 35 u/ml) alone, and 90.9%, 64.8%, 40.8%, 96.4% and 70.2% respectively for a high risk score system (> or = 7 scores) alone. The specificity and positive predictive value were both further improved to 93.9% by combining a raised CA 125 level and high risk score of 7 or more as the predictive test. When used alone, the clinical risk scoring system picked up more FIGO stage I ovarian cancer than the raised serum CA 125 level. The findings of this study indicated that the risk scoring system is a useful predictor of malignant ovarian cysts. It needs to be assessed further in populations with different prevalence of ovarian cysts of various pathological types and malignancy before it can be advocated for general application, particularly in selecting ovarian cysts for laparoscopic surgery.

APC mutation associated with late onset of familial adenomatous polyposis

Familial adenomatous polyposis is an autosomal dominantly inherited disorder. Mutation studies in the corresponding gene (APC) may provide information for predictive tests for persons at risk in affected families. We report here a new mutation in exon 6 (codon 233) of the APC gene and clinical data in a large family with late onset of the disease in most affected persons.

Continent pouch ileostomy

Continent pouch ileostomy is fashioned for patients who need a proctocolectomy. It is usually indicated for cases of ulcerative colitis and familial adenomatous polyposis where the anal sphincter can no longer maintain normal function or has to be removed. A case of familial adenomatous polyposis with features of Gardner's syndrome is reported. The patient presented with carcinoma of the rectum. Abdominoperineal resection followed by completion pancolectomy was performed. A continent pouch ileostomy was fashioned for him. He resumed work as a labourer within six months. The pouch was troublefree, needed to emptied four to six times a day and was fully continent of fluid, flatus and faeces until his demise three years later from liver secondaries. Continent pouch ileostomy is a better alternative than permanent end ileostomy. All care should be taken to rule out the existence of Crohn's disease. It is proposed that continent pouch ileostomy should be offered to patients needing permanent ileostomy if the expertise is available.

Primary lymphangiomyomatosis with chylous ascites

Primary lymphangiomyomatosis is a benign tumour of lymphatic channels and lymph nodes, clinically manifested by chylous ascites. This disease is usually progressive and unresponsive to surgery, chemotherapy or irradiation. A case of a 36-year-old lady with chylous ascites due to underlying primary lymphangiomyomatosis is reported.

Correlation of serum, urinary and salivary CA 125 levels in patients with adnexal masses

A prospective study was made of 105 consecutive patients admitted to one department of obstetrics and gynaecology for surgery for adnexal masses. The objective was to investigate if CA 125 level is measurable in the urine or saliva and to correlate these measurements with serum CA 125 level in patients presenting with adnexal masses. The final diagnosis and grouping of patients for analysis were based on histopathological examination of the adnexal masses. Serum, urine and salivary samples were collected simultaneously from all patients on the morning before surgery. CA 125 levels in each sample were determined in duplicate using Abbott CA 125-E1A monoclonal test kits (Abbott Laboratories, USA). The mean inter-assay variability was 10%. CA 125 was detectable in the serum, urine and saliva from all the patients and the concentration was highest in the saliva and lowest in urine. There were no discernible differences in the distributions of salivary CA 125 concentrations between patients with ovarian malignancies and those with benign ovarian cysts. In contrast, both serum and urinary CA 125 levels were significantly higher in the ovarian cancer group. There was no correlation in CA 125 concentrations between serum and urine, or between serum and saliva. For detection of ovarian malignancies, the sensitivity, specificity, and positive and negative predictive values for serum CA 125 measurement (> or = 35 U/mL) were 88.9%, 79.2%, 27.6% and 98.7 respectively. The corresponding figures for urinary CA 125 measurement (> or = 10 U/mL) were 88.9%, 66.7%, 19.5% and 98.4% respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Evolution of human papillomavirus type 18: an ancient phylogenetic root in Africa and intratype diversity reflect coevolution with human ethnic groups

Papillomaviruses are an ideal model system for the study of DNA virus evolution. On several levels, phylogenetic trees of papillomaviruses reflect the relationship of their hosts. Papillomaviruses isolated from remotely related vertebrates form major branches. One branch of human papillomaviruses (HPVs) includes an ape and two monkey papillomaviruses, possibly because the diversification of the viruses predated the separation of the infected-primate taxa. This hypothesis predicts that the root of the evolution of some if not all HPV types should point to Africa, since humans evolved from nonhuman primates in this continent. We tested this hypothesis and compared the genomic sequences of HPV type 18 (HPV-18) isolates from four continents. Diversity within HPV-18 correlates with patterns of the evolution and spread of Homo sapiens: HPV-18 variants, just like HPV-16 variants, are specific for the major human races, with maximal diversity in Africa. Outgroup rooting of the HPV-18 tree against HPV-45, which is closely related to HPV-18, identifies African HPV-18 variants at the root of the tree. The identification of an African HPV-45 isolate further reduces the evolutionary distance between HPV-18 and HPV-45. HPV-18 variants from Amazonian Indians are the closest relatives to those from Japanese and Chinese patients and suggest that a single point mutation in the phylogenetically evaluated genomic segment represents at least 12,000 years of evolution. We estimate that diversity within HPV-18 and probably within other HPV types evolved over a period of more than 200,000 years and that diversity between HPV types evolved over several million years.