Large language models as assistance for glaucoma surgical cases: a ChatGPT vs. Google Gemini comparison

PURPOSE

The aim of this study was to define the capability of ChatGPT-4 and Google Gemini in analyzing detailed glaucoma case descriptions and suggesting an accurate surgical plan.

METHODS

Retrospective analysis of 60 medical records of surgical glaucoma was divided into "ordinary" (n = 40) and "challenging" (n = 20) scenarios. Case descriptions were entered into ChatGPT and Bard's interfaces with the question "What kind of surgery would you perform?" and repeated three times to analyze the answers' consistency. After collecting the answers, we assessed the level of agreement with the unified opinion of three glaucoma surgeons. Moreover, we graded the quality of the responses with scores from 1 (poor quality) to 5 (excellent quality), according to the Global Quality Score (GQS) and compared the results.

RESULTS

ChatGPT surgical choice was consistent with those of glaucoma specialists in 35/60 cases (58%), compared to 19/60 (32%) of Gemini (p = 0.0001). Gemini was not able to complete the task in 16 cases (27%). Trabeculectomy was the most frequent choice for both chatbots (53% and 50% for ChatGPT and Gemini, respectively). In "challenging" cases, ChatGPT agreed with specialists in 9/20 choices (45%), outperforming Google Gemini performances (4/20, 20%). Overall, GQS scores were 3.5 ± 1.2 and 2.1 ± 1.5 for ChatGPT and Gemini (p = 0.002). This difference was even more marked if focusing only on "challenging" cases (1.5 ± 1.4 vs. 3.0 ± 1.5, p = 0.001).

CONCLUSION

ChatGPT-4 showed a good analysis performance for glaucoma surgical cases, either ordinary or challenging. On the other side, Google Gemini showed strong limitations in this setting, presenting high rates of unprecise or missed answers.

Ocular Involvement in Systemic Sclerosis: Updated Review and New Insights on Microvascular Impairment

Systemic sclerosis (SSc) is a chronic multisystemic disease characterized by immunological activation, diffuse vasculopathy, and generalized fibrosis exhibiting a variety of symptoms. A recognized precursor of SSc is Raynaud's phenomenon, which is part of the very early disease of systemic sclerosis (VEDOSS) in combination with nailfold videocapillaroscopy (NVC) impairment. The pathophysiology of ocular involvement, alterations in internal organs, and body integumentary system involvement in SSc patients are complicated and poorly understood, with multiple mechanisms presumptively working together. The most prevalent ocular symptoms of SSc are abnormalities of the eyelids and conjunctiva as well as dry eye syndrome, due to fibroblasts' dysfunction and inflammation of the ocular surface. In particular, lagophthalmos, blepharophimosis limitation of eyelid motion, eyelid telangiectasia, and rigidity or tightening of the lids may affect up to two-third of the patients. In addition, reduction in central corneal thickness, iris defects and higher rates of glaucoma were reported. In the first reports based on retinography or fluorescein angiography, about 50% of SSc patients showed signs of vascular disease: peripheral artery occlusion, thinning of retinal pigment epithelium and choroidal capillaries, ischemic areas surrounded by intraretinal extravasation and microaneurysms, and peripheral capillary non-perfusion. Successively, thanks to the advent of optical coherence tomography angiography (OCTA), several studies highlighted significant impairment of either the choriocapillaris and retinal vascular plexuses, also correlating with NVC involvement and skin disease, even in VEDOSS disease. Given the sensitivity of this technique, ocular micro-vasculopathy may act as a tool for early SSc identification and discriminate between disease stages.

Exploring AI-chatbots' capability to suggest surgical planning in ophthalmology: ChatGPT versus Google Gemini analysis of retinal detachment cases

BACKGROUND

We aimed to define the capability of three different publicly available large language models, Chat Generative Pretrained Transformer (ChatGPT-3.5), ChatGPT-4 and Google Gemini in analysing retinal detachment cases and suggesting the best possible surgical planning.

METHODS

Analysis of 54 retinal detachments records entered into ChatGPT and Gemini's interfaces. After asking 'Specify what kind of surgical planning you would suggest and the eventual intraocular tamponade.' and collecting the given answers, we assessed the level of agreement with the common opinion of three expert vitreoretinal surgeons. Moreover, ChatGPT and Gemini answers were graded 1-5 (from poor to excellent quality), according to the Global Quality Score (GQS).

RESULTS

After excluding 4 controversial cases, 50 cases were included. Overall, ChatGPT-3.5, ChatGPT-4 and Google Gemini surgical choices agreed with those of vitreoretinal surgeons in 40/50 (80%), 42/50 (84%) and 35/50 (70%) of cases. Google Gemini was not able to respond in five cases. Contingency analysis showed significant differences between ChatGPT-4 and Gemini (p=0.03). ChatGPT's GQS were 3.9±0.8 and 4.2±0.7 for versions 3.5 and 4, while Gemini scored 3.5±1.1. There was no statistical difference between the two ChatGPTs (p=0.22), while both outperformed Gemini scores (p=0.03 and p=0.002, respectively). The main source of error was endotamponade choice (14% for ChatGPT-3.5 and 4, and 12% for Google Gemini). Only ChatGPT-4 was able to suggest a combined phacovitrectomy approach.

CONCLUSION

In conclusion, Google Gemini and ChatGPT evaluated vitreoretinal patients' records in a coherent manner, showing a good level of agreement with expert surgeons. According to the GQS, ChatGPT's recommendations were much more accurate and precise.

Inferior implant of XEN63 Gel stent in a refractory open-angle glaucoma due to silicone oil tamponade: A case report

BACKGROUND

To discuss the efficacy of an inferior implant of XEN 63 gel stent in a patient with refractory glaucoma after trabeculectomy failure and vitreoretinal surgery with silicone oil tamponade.

CASE DESCRIPTION

We report the case of a 73-year-old man with a history of refractory open glaucoma with trabeculectomy failure. He experienced recurrent retinal detachments with silicone oil tamponade, with uncontrolled intra-ocular pressure (IOP) after silicone oil removal. Due to the presence of oil emulsion in the anterior chamber, the chosen location for XEN 63 implantation was the infero-temporal quadrant. Mild hyphema and vitreous hemorrhage were seen post-operatively, but were self-limiting. At week 1, the intraocular pressure was 8 mmHg with a well-formed bleb seen in anterior segment optical coherence tomography (AS-OCT). At 6 month follow up, the patient maintained a IOP of 12 mmHg without topical hypotensive drugs. Slit lamp examination revealed a widespread, developed bleb with no signs of inflammation.

CONCLUSION

In this case of refractory glaucoma in a vitrectomized eye with previous oil tamponade, the inferior placement of the XEN 63 gel stent delivered an adequate intraocular pressure even at 6-months follow up, with a diffuse functional infero-nasal bleb seen with AS-OCT.

Seagull wings appearance on optical coherence tomography: A case of peripapillary detachment in pathologic myopia

PURPOSE

To report the case of a patient who presented with a peripapillary retinal detachment caused by pathological myopia.

OBSERVATIONS

A 73-year-old female with a clinical history of high myopia was admitted to our ophthalmic department complaining of vision loss in her right eye. Her best-corrected visual acuity was 20/25 in the right eye and 20/400 in the left eye. The refractive error was -9.00 D in both eyes. The anterior segment and pupillary reflex were normal. Dilated fundus examination revealed myopic retinopathy in both eyes and a yellow peripapillary lesion, distinct from the myopic conus and encircling almost the whole optic disc, in her right eye. The left eye displayed macular atrophy with macular pigmentation due to a previous myopic choroidal neovascularization. Optical coherence tomography showed a localized retinal detachment in the peripapillary area, adjacent to the inferior edge of the optic disc, giving a strange "seagull wings" appearance.

CONCLUSIONS AND IMPORTANCE

In case of peripapillary neuroepithelial detachment the presence of PDPM in high myopic patients should always be excluded. Further research is due in order to better understand this clinical entity's pathogenesis and prognosis.

Bilateral papilledema associated with retinal hemorrhagic appearance as earliest sign of spinal cord tumor

INTRODUCTION

To report a case of a 57-years-old female patient who presented with prominent bilateral proptosis and swollen disks.

CASE DESCRIPTION

A 57-year-old obese patient admitted to our ophthalmic department complaining of bilateral sense of eye swelling and mild blurring vision. The anterior segment and pupillary reflex were normal on ophthalmological testing. Likewise, eye movements were preserved and she did not report diplopia in any position of gaze. Dilated fundus examination revealed bilateral hemorrhagic papilledema, pre-retinal hemorrhages in both eyes, dot and blot hemorrhages in the peripheral retina. Visual acuity was 20/20 in both eyes. Routine hematological investigations revealed increased both Von Willebrand factor and ristocetin factor and LAC positivity. The lumbar puncture (LP) showed elevated cerebrospinal fluid (CSF) proteins. Magnetic resonance imaging (MRI) with contrast of brain and spinal cord showed signs of intracranial hypertension and the presence of two lesions in continuity with each other respectively located at T12-L1 and L1-L2. Radiologic features were compatible with the diagnosis of ependymoma. A surgical procedure was conducted and confirmed the diagnosis after anatomical pathology analysis.

CONCLUSION

Although rare, bilateral hemorrhagic swollen disks could be an early sign of spinal cord tumors, in particular ependymomas.

Ophthalmic Manifestations in Fabry Disease: Updated Review

Fabry disease (FD) is an X-linked lysosomal storage disorder, causing Gb-3 (globotriaosylceramide) buildup in cellular lysosomes throughout the body, in particular in blood vessel walls, neuronal cells, and smooth muscle. The gradual accumulation of this glycosphingolipid in numerous eye tissues causes conjunctival vascular abnormalities, corneal epithelial opacities (cornea verticillata), lens opacities, and retinal vascular abnormalities. Although a severe vision impairment is rare, these abnormalities are diagnostic indicators and prognostics for severity. Cornea verticillata is the most common ophthalmic feature in both hemizygous men and heterozygous females. Vessel tortuosity has been linked to a faster disease progression and may be useful in predicting systemic involvement. New technologies such as optical coherence tomography angiography (OCTA) are useful for monitoring retinal microvasculature alterations in FD patients. Along with OCTA, corneal topographic analysis, confocal microscopy, and electro-functional examinations, contributed to the recognition of ocular abnormalities and have been correlated with systemic involvement. We offer an update regarding FD ocular manifestations, focusing on findings derived from the most recent imaging modalities, to optimize the management of this pathology.

Early post-operative anterior segment parameters modifications induced by PreserFlo MicroShunt in primary open-angle glaucoma

PURPOSE

The aim this study is to determine anterior chamber parameters variations induced by PreserFlo MicroShunt implantation, in the early post-operative days.

METHODS

This is a prospective observational study on 48 eyes undergoing PreserFlo MicroShunt implantation alone (n = 30) or combined with phacoemulsification (n = 18). Anterior chamber depth (ACD) and volume (ACV), central corneal thickness (CCT) and total corneal astigmatism (TCA) were evaluated pre-operatively, post-operatively at day-1 and at 1 week with the Pentacam tomography.

RESULTS

Intraocular pressure decreased significantly from 20.9 ± 4.0 to 8.0 ± 2.8 mmHg (p < 0.0001) and to 10.8 ± 3.7 mmHg (p = 0.0001) at day-1 and week-1, respectively. TCA varied significantly from baseline (1.5 ± 1.2 D) to both day 1 follow up (2.7 ± 1.9 D, p = 0.0003) and week 1 follow up (2.2 ± 1.6 D, p = 0.02). Nevertheless, only K1 showed a transient flattening at day 1, while K2 value didn't show any statistical variation in the early post-operative period. CCT value rose significantly at day 1 (547 ± 49 vs. 529 ± 32 µm at baseline, p = 0.04), but then returned toward pre-operative values at week 1 (537 ± 39 µm, p = 0.57). In contrast, ACD values changed insignificantly from 3.3 ± 0.9 to 3.7 ± 1.0 mm at day 1 (p = 0.21), and then stabilized at 3.4 ± 0.9 mm (p = 0.82) at week 1 follow up. ACV changed from 150.0 ± 36.2 to 159.5 ± 42.1 mm³ at day 1 (p = 0.58), and successively to 153.9 ± 37.9 mm³ at week 1 follow up (p = 0.96). The subgroup analysis in eyes undergoing standalone PreserFlo implantation didn't show significant changes in both ACD and ACV.

CONCLUSION

PreserFlo implantation minimizes the anterior chamber modifications generated by traditional filtering surgery, inducing low and transient corneal and biometric changes only in the very early postoperative period and insignificant changes to ACD and ACV, label of its safety and minimal invasiveness.

Spontaneous ciliary body detachment in a Marfan patient: A case of personalized management

Purpose

We present a case of a patient with Marfan Syndrome who underwent a personalized approach to manage a spontaneous ciliary body detachment and degeneration of the ciliary processes, causing refractive ocular hypotony.

Observations

A 20-year-old MFS man, with a history of bilateral juvenile cataract surgery with failed IOL positioning due to subluxation and consequent explantation, was referred to our clinic after the discovery of persistent ocular hypotonia in his left eye for the past two months, non-responder to corticosteroids. Slit-lamp examination showed shallow anterior chamber and aphakia, with chorioretinal folds, optic disc swelling and mild peripheral retinal lifting. Intraocular pressure (IOP) was 4 mmHg. Ultrasound biomicroscopy (UBM) revealed the presence of a flat, annular ciliochoroidal detachment, posterior pole congestion and total ciliary body separation. One-month systemic therapy with corticosteroids revealed ineffective, and a newly performed UBM showed a significant reduction in the number and thickness of the ciliary processes. At this point, he underwent 23-gauge pars plana vitrectomy with silicone oil endotamponade, combined with a focal trans-scleral cryopexy of the ciliary body, 2 mm behind the limbus and one spot per quadrant, in order to favor ciliary body reattachment. Post-operative IOP was 28 mmHg and the choroidal detachment was resolved, with UBM highlighting ciliary body reattachment. Six months after, with good IOP control using topical therapy, silicone oil was removed. One year after, visual acuity had inccreased to 6/10 and a good IOP control was still maintained with eye drops.

Conclusion and Importance

A rare case of spontaneous ciliary body detachment in a long standing aphakic MFS patient was successfully managed with focal trans-scleral cryopexy of the ciliary body combined with pars plana vitrectomy and silicone oil endotamponade.

Brolucizumab For Wet Age-Related Macular Degeneration: One-Year Real-World Experience From A Tertiary Center

Introduction To explore the early efficacy and safety of treatment with intravitreal injections of brolucizumab in patients presenting neovascular age-related macular degeneration (nAMD) in a real-world setting. Methods This retrospective study included 194 eyes of 180 patients with nAMD treated with standard 6-mg intravitreal injections (IVTs) of brolucizumab in our clinic between 11 March 2021 and 15 June 2022. Both treatment-naive (33 eyes) and switch-therapy patients (161 eyes) were included in the study. Best corrected visual acuity (BCVA), central subfield thickness (CST), retinal fluid distribution (classified as intraretinal, IRF; subretinal, SRF; under the pigmented epithelium, sRPEF), treatment intervals and adverse event rates were collected for analysis. Results Average follow-up time was 37.2±16.6 weeks. Mean baseline BCVA were 38.1±4.5 and 41.9±6.7 letters in the treatment-naive and switch-therapy groups, with a final gain of 16.0±4.9 (p<0.0001) and 10.7±5.9 (p<0.0001) letters in the two groups, respectively. Throughout the study period, CST significantly decreased in both treatment-naïve (from 352.0±129.4 to 284.2±93.8 µm; p=0.0015) and switch-therapy (from 369.9±140.5 to 307.4±123.5 µm; p<0.0001). Significant fluid control rates were achieved at the end of the study period (45% and 27% eyes were completely free-of-fluid in naïve and switch groups, respectively). Five eyes (2.6%) developed adverse events with different grades of intraocular inflammation (IOI) and visual outcomes. Conclusion Brolucizumab IVTs showed a very good anatomical and functional outcomes in both naive and switch patients in this real-world experience. Nevertheless, even showing a favorable risk/benefit profile, clinicians should be aware of the possibility of a small rate of complications.

Sutureless scleral fixation Carlevale IOL: a review on the novel designed lens

Background: Complicated cataract surgery is the main cause of secondary lens implantation surgery. Several approaches have been introduced to face those circumstances. As it concerns scleral-fixated IOLs for the posterior chamber, many types of IOL can be implanted. The aim of article is to review the single piece sutureless scleral fixation Carlevale lens; Methods: Narrative review; Results: Several works described as safe the IOL implantation utilizing the handshake approach, without tactile manipulation, which allows for self-centration and lens firm fixation in uncomplicated surgery. This allows to reduce high order aberration such as astigmatism and coma, with a very good postoperative BCVA Conclusions: Carlevale lens is one of the best option to manage insufficient capsular support.

Radiological and clinical findings in uveal melanoma treated by plaque interventional radiotherapy (brachytherapy): Visual atlas and literature review on response assessment

Uveal melanoma (UM) is the most common intra-ocular tumor in Caucasian adults and may derive from melanocytes. Historically, the first therapeutic approach to treat UM has been surgical removal of the eye, with obvious consequences in terms of function, cosmesis, and psychological impact on patients. Collaborative Ocular Melanoma Study (COMS) introduced the first uniform approach to perform interventional radiotherapy (IRT - brachytherapy) procedure in a standardized way that allowed to demonstrate equivalence of IRT with enucleation in terms of overall survival. Since this milestone, several international guidelines have been issued with regard to several technical aspects of this procedure, which has become the mainstream therapy worldwide. However, nowadays, there is still a lack of consensus about the criteria to definitively assess UM response after IRT. We present a collection of paradigmatic cases treated in our institution, and then discuss in detail the latest available evidence on the topic.

Fluid Mechanics of Mosaic Ciliated Tissues

In tissues as diverse as amphibian skin and the human airway, the cilia that propel fluid are grouped in sparsely distributed multiciliated cells (MCCs). We investigate fluid transport in this "mosaic" architecture, with emphasis on the trade-offs that may have been responsible for its evolutionary selection. Live imaging of MCCs in embryos of the frog Xenopus laevis shows that cilia bundles behave as active vortices that produce a flow field accurately represented by a local force applied to the fluid. A coarse-grained model that self-consistently couples bundles to the ambient flow reveals that hydrodynamic interactions between MCCs limit their rate of work so that they best shear the tissue at a finite but low area coverage, a result that mirrors findings for other sparse distributions such as cell receptors and leaf stomata.

Blood Flow Limits Endothelial Cell Extrusion in the Zebrafish Dorsal Aorta

Blood flow modulates endothelial cell (EC) response during angiogenesis. Shear stress is known to control gene expression related to the endothelial-mesenchymal transition and endothelial-hematopoietic transition. However, the impact of blood flow on the cellular processes associated with EC extrusion is less well understood. To address this question, we dynamically record EC movements and use 3D quantitative methods to segregate the contributions of various cellular processes to the cellular trajectories in the zebrafish dorsal aorta. We find that ECs spread toward the cell extrusion area following the tissue deformation direction dictated by flow-derived mechanical forces. Cell extrusion increases when blood flow is impaired. Similarly, the mechanosensor polycystic kidney disease 2 (pkd2) limits cell extrusion, suggesting that ECs actively sense mechanical forces in the process. These findings identify pkd2 and flow as critical regulators of EC extrusion and suggest that mechanical forces coordinate this process by maintaining ECs within the endothelium.

CCDC61/VFL3 Is a Paralog of SAS6 and Promotes Ciliary Functions

Centrioles are cylindrical assemblies whose peripheral microtubule array displays a 9-fold rotational symmetry that is established by the scaffolding protein SAS6. Centriole symmetry can be broken by centriole-associated structures, such as the striated fibers in Chlamydomonas that are important for ciliary function. The conserved protein CCDC61/VFL3 is involved in this process, but its exact role is unclear. Here, we show that CCDC61 is a paralog of SAS6. Crystal structures of CCDC61 demonstrate that it contains two homodimerization interfaces that are similar to those found in SAS6, but result in the formation of linear filaments rather than rings. Furthermore, we show that CCDC61 binds microtubules and that residues involved in CCDC61 microtubule binding are important for ciliary function in Chlamydomonas. Together, our findings suggest that CCDC61 and SAS6 functionally diverged from a common ancestor while retaining the ability to scaffold the assembly of basal body-associated structures or centrioles, respectively.

Three-dimensional microscopy and image analysis methodology for mapping and quantification of nuclear positions in tissues with approximate cylindrical geometry

Organogenesis involves extensive and dynamic changes of tissue shape during development. It is associated with complex morphogenetic events that require enormous tissue plasticity and generate a large variety of transient three-dimensional geometries that are achieved by global tissue responses. Nevertheless, such global responses are driven by tight spatio-temporal regulation of the behaviours of individual cells composing these tissues. Therefore, the development of image analysis tools that allow for extraction of quantitative data concerning individual cell behaviours is central to study tissue morphogenesis. There are many image analysis tools available that permit extraction of cell parameters. Unfortunately, the majority are developed for tissues with relatively simple geometries such as flat epithelia. Problems arise when the tissue of interest assumes a more complex three-dimensional geometry. Here, we use the endothelium of the developing zebrafish dorsal aorta as an example of a tissue with cylindrical geometry and describe the image analysis routines developed to extract quantitative data on individual cells in such tissues, as well as the image acquisition and sample preparation methodology.This article is part of the Theo Murphy meeting issue 'Mechanics of development'.

Following Endocardial Tissue Movements via Cell Photoconversion in the Zebrafish Embryo

During embryogenesis, cells undergo dynamic changes in cell behavior, and deciphering the cellular logic behind these changes is a fundamental goal in the field of developmental biology. The discovery and development of photoconvertible proteins have greatly aided our understanding of these dynamic changes by providing a method to optically highlight cells and tissues. However, while photoconversion, time-lapse microscopy, and subsequent image analysis have proven to be very successful in uncovering cellular dynamics in organs such as the brain or the eye, this approach is generally not used in the developing heart due to challenges posed by the rapid movement of the heart during the cardiac cycle. This protocol consists of two parts. The first part describes a method for photoconverting and subsequently tracking endocardial cells (EdCs) during zebrafish atrioventricular canal (AVC) and atrioventricular heart valve development. The method involves temporally stopping the heart with a drug in order for accurate photoconversion to take place. Hearts are allowed to resume beating upon removal of the drug and embryonic development continues normally until the heart is stopped again for high-resolution imaging of photoconverted EdCs at a later developmental time point. The second part of the protocol describes an image analysis method to quantify the length of a photoconverted or non-photoconverted region in the AVC in young embryos by mapping the fluorescent signal from the three-dimensional structure onto a two-dimensional map. Together, the two parts of the protocol allows one to examine the origin and behavior of cells that make up the zebrafish AVC and atrioventricular heart valve, and can potentially be applied for studying mutants, morphants, or embryos that have been treated with reagents that disrupt AVC and/or valve development.

Anisotropic shear stress patterns predict the orientation of convergent tissue movements in the embryonic heart

Myocardial contractility and blood flow provide essential mechanical cues for the morphogenesis of the heart. In general, endothelial cells change their migratory behavior in response to shear stress patterns, according to flow directionality. Here, we assessed the impact of shear stress patterns and flow directionality on the behavior of endocardial cells, the specialized endothelial cells of the heart. At the early stages of zebrafish heart valve formation, we show that endocardial cells are converging to the valve-forming area and that this behavior depends upon mechanical forces. Quantitative live imaging and mathematical modeling allow us to correlate this tissue convergence with the underlying flow forces. We predict that tissue convergence is associated with the direction of the mean wall shear stress and of the gradient of harmonic phase-averaged shear stresses, which surprisingly do not match the overall direction of the flow. This contrasts with the usual role of flow directionality in vascular development and suggests that the full spatial and temporal complexity of the wall shear stress should be taken into account when studying endothelial cell responses to flow in vivo.

Summary: Blood flow modeling shows that dynamic shear stress patterns, rather than mean flow direction, predict the stereotypical behavior of endocardial cells during the early steps of heart valve formation.

Colposcopic patterns of vaginal intraepithelial neoplasia: a focus on low-grade lesions

OBJECTIVE

The aim of this study was to evaluate the colposcopic patterns observed in women with a histopathological diagnosis of vaginal intraepithelial neoplasia, with a particular interest in analyzing the colposcopic characteristics of low-grade squamous intraepithelial lesions (LSIL).

PATIENTS AND METHODS

Medical charts and colposcopy records of women diagnosed with vaginal intraepithelial neoplasia from January 1995 to December 2015, were analyzed in a multicenter retrospective case series. The abnormal colposcopic patterns observed in women with vaginal LSIL and vaginal high-grade SIL (HSIL) were compared. The vascular patterns and micropapillary pattern were considered separately.

RESULTS

Regardless the histopathological grading, in women with vaginal SIL, the grade I abnormal colposcopic findings were more frequent than grade II abnormalities. However, a grade I colposcopy was more commonly observed in women with a biopsy diagnosis of LSIL rather than HSIL (p<0.0001). Similarly, the micropapillary pattern was more frequently observed in women with LSIL (p=0.004), while vascular patterns were observed more frequently in women diagnosed with vaginal HSIL (p<0.0001). In women with grade I colposcopy, the menopausal status and a previous hysterectomy appeared to be associated with the diagnosis of vaginal HSIL.

CONCLUSIONS

Grade I abnormal colposcopic findings were more commonly observed in women with vaginal LSIL, as well as the micropapillary pattern. On the other hand, grade II abnormal colposcopy and the presence of vascular patterns were more frequently observed in women with vaginal HSIL.

High-grade vaginal intraepithelial neoplasia and risk of progression to vaginal cancer: a multicentre study of the Italian Society of Colposcopy and Cervico-Vaginal Pathology (SICPCV)

OBJECTIVE

The aim of this study was to analyse the women with high grade vaginal intraepithelial neoplasia (HG-VaIN), in order to identify a subset of women at higher risk of progression to invasive vaginal cancer.

MATERIALS AND METHODS

The medical records of all the women diagnosed with HG-VaIN, and subsequently treated, from January 1995 to December 2013 were analyzed in a multicentre retrospective case series. The rate of progression to invasive vaginal cancer and the potential risk factors were evaluated.

RESULTS

205 women with biopsy diagnosis of HG-VaIN were considered, with a mean follow up of 57 months (range 4-254 months). 12 cases of progression to vaginal squamocellular cancer were observed (5.8%), with a mean time interval from treatment to progression of 54.6 months (range 4-146 months). The rate of progression was significantly higher in women diagnosed with VaIN3 compared with VaIN2 (15.4% vs. 1.4%, p < 0.0001). Women with HG-VaIN and with previous hysterectomy showed a significantly higher rate of progression to invasive vaginal cancer compared to non-hysterectomised women (16.7% vs. 1.4%, p < 0.0001). A higher risk of progression for women with VaIN3 and for women with previous hysterectomy for cervical HPV-related disease was confirmed by multivariable logistic regression analysis.

CONCLUSIONS

A higher rate of progression to vaginal cancer was reported in women diagnosed with VaIN3 on biopsy and in women with previous hysterectomy for HPV-related cervical disease. These patients should be considered at higher risk, thus a long lasting and accurate follow up is recommended.

Gynaecological Screening for Cervical and Vulvar Malignancies in a Cohort of Systemic Sclerosis Patients: Our Experience and Review of the Literature

Background. Increased incidence of cancer was frequently reported in scleroderma (SSc), but no association with gynaecological malignancies was described in literature. Objectives. To investigate gynaecological neoplasms in SSc patients. Methods. In this cross-sectional analysis, we evaluated 80 SSc patients, living in the same geographical area. We considered all patients undergoing gynaecological evaluation, including pap test as screening for cervical cancer, between January 2008 and December 2014. Results. 55 (68.7%) patients were negative and 20 (25%) presented inflammatory alterations, while cancer or precancerous lesions were found in 5 (6.2%) cases (2 showed cervical cancer (one of them in situ), 1 vulvar melanoma, 1 vulvar intraepithelial neoplasia, and 1 endocervical polyp with immature squamous metaplasia). The frequency of cervical cancer in our series seems higher in comparison to the incidence registered in the same geographical area. The presence of atypical cytological findings correlated with anti-Scl70 autoantibodies (p = 0.022); moreover, the patients with these alterations tended to be older (median 65, range 46-67), if compared to the whole series (p = 0.052). Conclusions. A relatively high frequency of gynaecological malignancies was found in our SSc series. In general, gynaecological evaluation for SSc women needs to be included in the routine patients' surveillance.

Live imaging and modeling for shear stress quantification in the embryonic zebrafish heart

Hemodynamic shear stress is sensed by the endocardial cells composing the inner cell layer of the heart, and plays a major role in cardiac morphogenesis. Yet, the underlying hemodynamics and the associated mechanical stimuli experienced by endocardial cells remains poorly understood. Progress in the field has been hampered by the need for high temporal resolution imaging allowing the flow profiles generated in the beating heart to be resolved. To fill this gap, we propose a method to analyze the wall dynamics, the flow field, and the wall shear stress of the developing zebrafish heart. This method combines live confocal imaging and computational fluid dynamics to overcome difficulties related to live imaging of blood flow in the developing heart. To provide an example of the applicability of the method, we discuss the hemodynamic frequency content sensed by endocardial cells at the onset of valve formation, and how the fundamental frequency of the wall shear stress represents a unique mechanical cue to endocardial, heart-valve precursors.

Developmental Alterations in Heart Biomechanics and Skeletal Muscle Function in Desmin Mutants Suggest an Early Pathological Root for Desminopathies

Desminopathies belong to a family of muscle disorders called myofibrillar myopathies that are caused by Desmin mutations and lead to protein aggregates in muscle fibers. To date, the initial pathological steps of desminopathies and the impact of desmin aggregates in the genesis of the disease are unclear. Using live, high-resolution microscopy, we show that Desmin loss of function and Desmin aggregates promote skeletal muscle defects and alter heart biomechanics. In addition, we show that the calcium dynamics associated with heart contraction are impaired and are associated with sarcoplasmic reticulum dilatation as well as abnormal subcellular distribution of Ryanodine receptors. Our results demonstrate that desminopathies are associated with perturbed excitation-contraction coupling machinery and that aggregates are more detrimental than Desmin loss of function. Additionally, we show that pharmacological inhibition of aggregate formation and Desmin knockdown revert these phenotypes. Our data suggest alternative therapeutic approaches and further our understanding of the molecular determinants modulating Desmin aggregate formation.

Blood flow mechanics in cardiovascular development

Hemodynamic forces are fundamental to development. Indeed, much of cardiovascular morphogenesis reflects a two-way interaction between mechanical forces and the gene network activated in endothelial cells via mechanotransduction feedback loops. As these interactions are becoming better understood in different model organisms, it is possible to identify common mechanogenetic rules, which are strikingly conserved and shared in many tissues and species. Here, we discuss recent findings showing how hemodynamic forces potentially modulate cardiovascular development as well as the underlying fluid and tissue mechanics, with special attention given to the flow characteristics that are unique to the small scales of embryos.

Age-related changes in the diagnostic assessment of women with severe cervical lesions

OBJECTIVES

To evaluate the effect of age on the diagnostic assessment of women with severe cervical intraepithelial neoplasia (CIN).

METHODS

This retrospective observational study included 338 consecutive women with a diagnosis of CIN3 on cone specimen. Patients were divided into three groups according to age: < 35 years (Group A), 35-49 years (Group B), and ≥ 50 years (Group C). Clinical and colposcopic variables were compared, and human papillomavirus (HPV) genotype distribution was measured.

RESULTS

The most common HPV genotype was HPV-16 (63.65%), followed by HPV-33 (7%), HPV-18 (6.2%), and HPV-31 (5.4%). The rate of the following high-grade lesion predictors was lower in Group C than in Groups A and B: HPV-16 infections (55.9% vs. 75% vs. 70.9%, respectively, p = 0.022); high-grade colposcopic impression (29.4% vs. 51.8% vs. 51.7%, respectively, p < 0.0001); and high-grade cytological changes (30.9% vs. 56.2% vs. 45.4%, respectively, p = 0.025). An endocervical lesion location was more frequent in Group C than in Groups A and B (55.6% vs. 6.8% vs. 11.8%, respectively, p < 0.0001).

CONCLUSION

Women aged 50 years and older with CIN3 showed a significant reduction of high-grade lesion predictors along with physiological confounding cervical changes (transformation zone type 3 and endocervical lesion location). The diagnostic work-up of cervical lesions in older women should provide their potential consideration as a special population.

Diagnostic accuracy of endometrial thickness for the detection of intra-uterine pathologies and appropriateness of performed hysteroscopies among asymptomatic postmenopausal women

OBJECTIVE

To measure the diagnostic accuracy of endometrial thickness for the detection of intra-uterine pathologies among asymptomatic postmenopausal women, and to test the diagnostic accuracy and appropriateness of performed hysteroscopies.

STUDY DESIGN

Prospective study of 268 asymptomatic postmenopausal women with endometrial thickness ≥4 mm referred to diagnostic hysteroscopy. The diagnostic accuracy of various endometrial thickness cut-off values was tested. Histological and hysteroscopic results were compared to measure the diagnostic accuracy of outpatient hysteroscopies.

RESULTS

No endometrial thickness cut-off values had optimal diagnostic accuracy [positive likelihood ratio (LR+) >10 and negative likelihood ratio (LR-) <0.1]. The best endometrial thickness cut-off value for the detection of all intra-uterine pathologies was ≥8 mm (LR+ 10.05 and LR- 0.22). An endometrial thickness cut-off value ≥10 mm did not miss any cases of endometrial cancer. The success rate of diagnostic hysteroscopy was 89%, but 97% of these revealed a benign intra-uterine pathology. The diagnostic accuracy of hysteroscopy was optimal for all intra-uterine pathologies, except endometrial hyperplasia (LR- 0.52).

CONCLUSION

Using an endometrial thickness cut-off value ≥4 mm, only 3% of performed hysteroscopies were useful for the detection of pre-malignant or malignant lesions. Despite the finding that endometrial thickness did not show optimal diagnostic accuracy, using the best cut-off value (≥8 mm) may be helpful to decrease the number of false-positive results. No cases of endometrial cancer were diagnosed in asymptomatic postmenopausal women with endometrial thickness <10mm.

Endothelial cilia mediate low flow sensing during zebrafish vascular development

VIDEO ABSTRACT

The pattern of blood flow has long been thought to play a significant role in vascular morphogenesis, yet the flow-sensing mechanism that is involved at early embryonic stages, when flow forces are low, remains unclear. It has been proposed that endothelial cells use primary cilia to sense flow, but this has never been tested in vivo. Here we show, by noninvasive, high-resolution imaging of live zebrafish embryos, that endothelial cilia progressively deflect at the onset of blood flow and that the deflection angle correlates with calcium levels in endothelial cells. We demonstrate that alterations in shear stress, ciliogenesis, or expression of the calcium channel PKD2 impair the endothelial calcium level and both increase and perturb vascular morphogenesis. Altogether, these results demonstrate that endothelial cilia constitute a highly sensitive structure that permits the detection of low shear forces during vascular morphogenesis.

A meshless boundary method for Stokes flows with particles: application to canalithiasis

We propose to couple the method of fundamental solutions (MFS) to the force coupling method (FCM). The resulting method is an efficient, easy to program, meshless method for flows at low Reynolds numbers with finite-size particles. In such an approach, the flow domain is extended across the solid particle phase, and the flow is approximated by a superposition of singular Stokeslets positioned outside the flow domain and finite-size multipoles collocated with the particle. To improve the efficiency of the coupling, we propose new MFS quadratures for the computation of the volume integrals required for the FCM. These are exact and do not require the expensive evaluation of Stokeslets. The proposed method has been developed in the context of investigations of the fluid dynamics of canalithiasis, that is, a pathological condition of the semicircular canals of the inner ear. Numerical examples are presented to illustrate the applicability of the method.

Efficacy and tolerability of fitostimoline (vaginal cream, ovules, and vaginal washing) and of benzydamine hydrochloride (tantum rosa vaginal cream and vaginal washing) in the topical treatment of symptoms of bacterial vaginosis

Two hundred and 91 patients showing signs and symptoms of bacterial vaginosis (BV) were randomized to receive topical treatment with Fitostimoline (vaginal cream and vaginal ovules + vaginal washing) or benzydamine hydrochloride (vaginal cream + vaginal washing) for 7 days. Signs (leucorrhoea, erythema, oedema, and erosion) and symptoms (burning, pain, itching, vaginal dryness, dyspareunia, and dysuria) (scored 0–3) were evaluated at baseline and at the end of treatment; the total symptoms score (TSS) was also calculated. In 125 patients, a bacterial vaginosis was confirmed by vaginal swab test. The primary efficacy variable analysis, that is, the percentage of patients with therapeutic success (almost complete disappearance of signs and symptoms), demonstrated that Fitostimoline ovules and vaginal cream were therapeutically equivalent and that pooled Fitostimoline treatment was not inferior to benzydamine hydrochloride. All the treatments were well tolerated, with only minor local adverse events infrequently reported. The results of this study confirmed that gynaecological Fitostimoline is a safe and effective topical treatment for BV.

Teenagers' knowledge about HPV infection and HPV vaccination in the first year of the public vaccination programme

The aim of this study was to assess teens' knowledge of HPV infection and vaccination one year after the initiation of the public vaccination programme and information campaign on the disease and the opportunity of vaccination. Between 15 May and 15 June 2009, a survey was carried out on 1,105 teenagers attending high schools in a town in the northeast of Italy by means of an anonymous and unannounced questionnaire covering the knowledge of HPV infection, transmission, prevention, vaccination and post-vaccination behaviours. Only 75% of teens knew what HPV infection is (92% of girls vs 51% of boys, p < 0.001); only 70% knew that it is a sexually-transmitted infection. Only 69.3% associated condoms with HPV disease prevention (72.6% girls vs 61.5% boys, p = 0.002). About 18.8% of girls and 33.2% of boys believe that HPV can lead to AIDS (p < 0.001). Among teens aware of HPV vaccination, 7.6% of girls and 21.8% of boys believe that it can prevent AIDS (p < 0.001). Only 75.5% of girls and 51.1% of boys (p < 0.001) believe that condom use remains useful for HPV prevention after vaccination. The need for regular pap smears after vaccination is reported by 93.3% of girls. Teens' knowledge about HPV infection and vaccination remains insufficient, despite a broad information campaign. Erroneous information may increase risky sexual behaviours. Without complete information about HPV infection and vaccination and information about other sexually-transmitted diseases, the latter might become difficult to control among teenagers, while some misunderstandings about the usefulness of secondary prevention might linger.

Expression of estrogen receptor in hemangioma of the uterine cervix: reports of three cases and review of the literature

The occurrence of hemangioma in the female genital tract, particularly in uterine cervix, is rare. The majority of them show asymptomatic behavior. Surgical excision remains curative in most of the cases. Conservative therapies such as sclerosing agents, cryotherapy, and CO(2) laser excision may be alternatively applied. We present three cases of hemangiomas of the cervix in asymptomatic women, diagnosed as cavernous hemangioma in two cases and capillary hemangioma in one. All tumors were immunoreactive for CD31, CD34, factor-VIII-related antigen. Focal expression of estrogen receptors was detected. No positivity was obtained with progesterone receptor antibodies. The presence of estrogen receptor in the endothelial cells of the hemangioma of the cervix suggests a direct role of this hormone in the hemangioma development. A possible target therapy is discussed.

Treatment patterns and associated costs for genital warts in Italy

OBJECTIVE

Genital warts are caused by human papillomavirus (HPV), principally types 6 and 11, and are highly contagious. This study assessed treatment patterns and costs of management of genital warts in Italy.

RESEARCH DESIGN AND METHODS

This was a retrospective, observational study conducted among gynaecologists, dermatologists, and specialists at sexually transmitted disease clinics in Italy. Resource-use data related to genital warts were collected for patients at risk in the age range 14-64 years examined during 2005. Unit costs were assigned to resource use to provide estimates of the direct, indirect and total costs per case of genital warts.

RESULTS

Twenty-eight investigators enrolled 341 patients aged 15-64 years, including 194 (56.9%), 81 (23.7%) and 66 (19.4%) patients with newly diagnosed, recurrent and resistant genital warts, respectively. Most patients (333/341; 97.7%) had at least one outpatient visit, while 43 (12.6%) patients were hospitalised, including 39 patients without an overnight stay (day-hospital cases, 11.4%). Self-applied medication was prescribed for 124 (36.4%) patients. Most outpatient cases (267/333; 80.2%) underwent an office-based procedure. Mean annual direct medical costs per patient, which were funded predominantly by the Italian National Health Service (there was some patient co-payment), were €242 for men and €332 for women. When productivity losses were included, mean total annual costs were €325 for men and €464 for women.

CONCLUSIONS

This is the first study of treatment patterns and costs for genital warts in Italy. Treatment patterns differ in some respects from those observed in other European countries, but costs generally appear similar. Despite the limitations of physician selection bias and over-representation of North Italy in the patient sample, the findings of this study may be useful in estimating the cost-effectiveness of introducing a quadrivalent HPV vaccination programme in Italy.

[Preoperative platelet count as index of the grading in endometrial carcinoma]

AIM

To investigate a possible relationship between preoperative platelet count and following clinicopathological variables of the endometrial carcinoma: age, stage, histological type, histological grading (G), myometrial invasion, lymphovascular space involvement, cervical involvement, lymph node metastasis. In particular the existence of a possible relationship between elevated preoperative platelet count (=or>300 000 microL) and negative prognostic factors.

METHODS

The authors analyzed retrospectively 120 patients with endometrial carcinoma underwent to surgery as the initial treatment. All the patients were subjected to radical surgical procedure: peritoneal cytology, total abdominal hysterectomy, bilateral salpingo-oophorectomy, systematic pelvic lymphadenectomy and omentectomy. Blood platelet count was taken from the patients three days prior to the surgery.

RESULTS

The patients with platelet count<300000/microL whom they had a G1, G2, G3 they were respectively the 23.1%, 44.2% and 32.7% versus the 0%, 12.5% and 87.5%, respectively for G1, G2, G3, of the patients with platelet count>300000/microL (P=0.024). Only considering the patients to the stage I of the Federazione Internazionale dei Ginecologi ed Ostetrici (FIGO). The patients with platelet count<300000/microL whom they had a G1, G2, G3 they were respectively the 27.3%, 43.2% and 29.5% versus the 0%, 0% and 100%, respectively for G1, G2, G3, of the patients with platelet count=or>300000/microL (P=0.008). There were no differences respect to age, stage, histological type, myometrial invasion, lymphovascular space involvement and cervical involvement.

CONCLUSION

Elevated preoperative platelet count, in the patients with endometrial carcinoma, may reflect poor prognostic factor such as higher histological grade. This study allowed to observe: a significant correlation between elevated preoperative platelet count (=or>300000/microL) and tumoral grading (G3) of general population submitted to study; for the patients to the stage I FIGO a more significant correlation between elevated preoperative platelet count (=or>300000/microL) and tumoral grading: the 100% of the patients with platelet count=or>300 000/microL had a histological grading G3.

[Preliminary results of the Italian epidemiological study on vulvo-vaginitis]

AIM

The aim of this work was to evaluate the prevalence of symptomatic vulvo-vaginal infections among the Italian female population and the diagnostic approach of 158 Italian gynaecologists.

METHODS

A total of 1644 patients were enrolled in this survey. A presumed diagnosis of vulvovaginal infection was made according to specific clinical and laboratory criteria (pH e sniff test) in 902 (55.4%) cases, whereas a definitive diagnosis was made in 1439 (87.5%) cases. The definitive diagnoses were as follows: 844 (51.3%) vulvovaginal mycosis, 327 (19.9%) bacterial vaginosis, 110 (6.7%) trichomonal infection, 100 (6.1%) aspecific bacterial vaginitis, 58 (3.5%) non-infectious vaginitis. As assessed by typing, mycosis were mainly due to Candida albicans infections in 459 cases (78%).

CONCLUSION

From the survey it is possible to infer that: 1) only thanks to the employed microbiological diagnostic tests a definitive diagnosis was made in 702 patients without a previous presumed diagnosis; 2) mycotic infections were underestimated; 3) Candida albicans was the most common species causing female low genital tract mycotic infections. In conclusion, these data underline the importance of laboratory examinations in the diagnosis of low genital tract infections for the ambulatory gynaecological practice.

Sclerosing stromal tumor of the ovary: US, CT, and MRI findings

We present the sonographic, computed tomographic, and magnetic resonance imaging findings in a case of a sclerosing stromal tumor of the ovary with pathologic correlations.

Patients' perspectives on the burden of recurrent genital herpes

The purpose of this study was to quantify the impact of recurrent genital herpes (RGH) on health-related quality of life, healthcare resource and workplace productivity. This was a cross-sectional survey conducted in 5 countries (Australia, Denmark, Italy, The Netherlands and UK). Patients with a confirmed history of RGH completed the MOS 36-Item Short Form Health Survey (SF-36) and the Recurrent Genital Herpes Quality of Life questionnaire (RGHQoL). Questionnaires addressing frequency of access to healthcare services and workplace productivity were also completed and patients' medical history was obtained. Scores for 6 of the 8 domains of the SF-36 were significantly lower (P<0.001) i.e. worse, compared with scores for the normal population. The RGHQoL score was significantly lower in patients experiencing more frequent or more severe recurrences. Forty-five per cent of patients estimated that their work effectiveness was reduced by between 25% and 50% due to genital herpes symptoms.

The Italian experience of a Pap test and speculoscopy based screening programme

OBJECTIVES

The main objective of the study was to evaluate if speculoscopy, a magnified chemiluminescent examination, combined with a Pap smear, could improve the detection of early cervical lesions compared with the Pap smear alone.

SETTING

Pap tests and speculoscopies were performed in two family planning centres located in the surrounding areas of Modena. Colposcopic investigations and biopsies of the uterine cervix were performed in a second level centre (Gynaecological Prevention Centre of Modena Policlinico). Histological specimens were analysed at the Section of Pathological Anatomy of Modena Policlinico.

SUBJECTS

The study population comprised 1000 women aged 25-64 years, invited to undergo a Pap smear every three years in accordance with the screening programme for cervical cancer started in Modena in 1997.

METHODS

Midwives performed the Pap smear and speculoscopy in succession. Women with a positive Pap test and/or positive speculoscopy underwent colposcopy and, if colposcopic findings were positive, targeted punch biopsies were performed.

RESULTS

A total of 1000 patients were subjected to cytology and speculoscopy examinations. Among these women, 10 had abnormal Pap smear findings whereas 144 had an abnormal speculoscopic pattern. Only three of 59 patients with a histological diagnosis of cervical intraepithelial neoplasia grade I (CIN I)/human papillomavirus and only three of seven patients with CIN II/CIN III had a positive Pap test.

CONCLUSIONS

Speculoscopy combined with a Pap test can significantly increase the detection of cervical lesions when included in a screening programme.

Improvement of Pap smear sensitivity using a visual adjunctive procedure: a co-operative Italian study on speculoscopy (GISPE)

The present study evaluates whether speculoscopy, a magnified chemiluminescence examination, combined with Pap smear can improve the detection of cervical lesions, as compared with Pap smear alone. The investigation was a prospective practice-based research carried out as a multicentre cohort study throughout the Italian territory. The participants were 3,300 asymptomatic women age > or = 18 years undergoing routine pelvic and cytological screening. All participants were subjected to Pap smear, speculoscopy and colposcopy investigations in succession. The 646 women with positive colposcopy underwent biopsy. Of the 267 women with positive histology 25 were high-grade intraephitelial lesions (HGSIL) and 242 were low-grade intraephitelial lesions (LGSIL). The histological findings were correlated with the results of Pap smear and speculoscopy alone and combined (PPS). Pap smear alone detected 76% of HGSIL, speculoscopy alone identified 84% of HGSIL, and PPS indicated 100% HGSIL. Of the 242 women with LGSIL, Pap smear alone detected 37% of the cases, speculoscopy alone detected 54% of the cases, and PPS identified 91% of the cases. Together, the two tests missed 9% of the LGSIL. The combination PPS was found to increase sensitivity from 40% to 92%, but to lower specificity from 94% to 23%. Speculoscopy combined with Pap smear can yield a higher percentage of women with biopsy-confirmed cervical pathology than the use of Pap smear as a sole screening test. This is particularly true of patients with LGSIL. The mechanisms of pathological detection and the use of speculoscopy should be investigated further.

Efficacy of the association of 13-cis-retinoic acid (13cRA) and alpha-interferon 2a (alpha-IFN 2a) in moderate-severe cervical intraepithelial neoplasia (CIN II-III): a pilot study

Recent in vitro studies have suggested a possible therapeutic synergism between alpha-IFN 2a and 13cRA in certain neoplasias, while encouraging in vivo findings strongly support the enhanced effectiveness of the two agents when used in combination. The specific aim of our study was to evaluate the efficacy and the toxicity of the association of 13cRA and alpha-IFN 2a in patients with CIN II and CIN III who refused surgical treatment. Twenty-one patients (aged between 25 and 58 years), of which 14 were CIN II and 7 CIN III, entered the study. 13cRA (orally at 0.5-1 mg/Kg/day) and alpha-IFN 2a (intramuscular at 3x10(6) I.U./day for the first 15 days, then 3 times/week for the following four weeks) were administered simultaneously for eight consecutive weeks. 13/21 (62%) histologically verified objective responses (6 complete and 7 partial) were achieved. We also obtained 8 stable diseases. Compliance was generally good and no delays in therapy due to toxicity were recorded (except for two patients presenting WHO degree III cutaneous and mucosal toxicity which regressed one week after suspending treatment). Human Papilloma Virus (HPV) was initially detected in 16/21 (76%) patients, while HPV negativization after treatment was observed in 3/16 (19%). Although preliminary and requiring long-term assessment, the encouraging results of this study confirm the need for further investigation on the role of systemic medical therapy in the treatment of CINs.

Prevalence of different types of human papillomavirus in cervical infection of north Italian women

We investigated the prevalences of human papillomavirus (HPV) of type 6, 11, 16, 18, 31, 33, 35 and 42 in 276 cervical tissue samples biopsied from a group of North-Italian women in which a HPV infection of the cervix had been suspected. The specimens were evaluated by conventional histological examination and by HPV typing, using Southern blot hybridization on the extracted DNA. We related different degrees of squamous cervical dysplasia, showing or not viral cytopathic effects, with the HPV types harboured in the lesions. Significant rising of HPV 16 prevalences was observed proceeding from mild to moderate and to severe dysplasias both in presence (r = 0.9623, P less than 0.01) and in absence (r = 0.879, P less than 0.05) of koilocytosis, while an opposite trend was detected for HPV 6 and 11. In our sampling we did not find HPV 35 DNA sequences; in all occasions HPV 31 was associated with mild dysplasias. The absolute prevalences of types 18, 33 and 42 were generally low (from 2 to 3%); they did not show any association with specific histological damage of the cervix or with significant patterns related with the progression of cervical dysplasia.

Oral discomfort and hormone replacement therapy in the post-menopause

We evaluated the incidence of oral discomfort in post-menopausal women and the efficacy of hormone replacement therapy in patients complaining of such symptoms. Two studies were performed. In the first, we compared oral discomfort and oral mucosa smears in 47 patients receiving replacement therapy and in 40 untreated post-menopausal women. In the second, the efficacy of hormone replacement therapy with oestriol vaginal cream (22 patients) or conjugated oestrogens plus norethisterone acetate (10 patients) was evaluated. In the first study, oral exfoliative cytology showed a similar maturation index and volume in both groups. In the second, hormone replacement therapy improved subjective and objective symptoms in 12 out of 22 patients treated with oestriol and in 7 out of 10 patients treated with conjugated oestrogens plus norethisterone. These data suggest that oestrogen deficiency can be considered a possible cause of oral discomfort in some post-menopausal patients and that oestrogen replacement therapy may improve subjective symptoms.

Vulvar intraepithelial neoplasia. A clinicopathologic study of 60 cases

Sixty cases of vulvar intraepithelial neoplasia (VIN) were analyzed clinicopathologically (24 VIN I, 9 VIN II, 27 VIN III). The ages of the patients ranged from 21 to 83 years (mean, 53.7). Colposcopic examinations showed the presence of white areas in 29 cases, red areas in 9, acetowhite areas in 6 and other alterations in 13. One-third of the lesions were multifocal. Pruritus and burning were present in 65% of the cases. Fifty-one percent of the cases showed histologic changes suggestive of human papillomavirus (HPV) infection; the mean age of those patients was significantly lower than that of patients without HPV infection. In 15 cases of VIN, HPV DNA testing was performed with Southern blot hybridization; in three (20%) of those specimens HPV 16 episomal DNA was identified. Epithelial alterations surrounding the areas of VIN were found in 24 cases (40%)-23 squamous cellular hyperplasias and 1 lichen sclerosus. Different types of treatment were performed according to the different grades of VIN: medical therapy, diathermocoagulation, local excision, hemivulvectomy and total vulvectomy. Follow-up was possible in 52 cases, with a mean of 33 months (range, 3-98). Two cases of VIN I showed progression of disease over 12-24 months.