Management of the minimally abnormal papanicolaou smear in pregnancy

OBJECTIVE

To evaluate the effectiveness of colposcopy of the uterine cervix in pregnant patients with minimally abnormal Papanicolaou smears.

METHODS

Two hundred, indigent, pregnant patients with atypical cells of undetermined significance (ASCUS) or low-grade squamous intraepithelial lesions (LGSIL) on Papanicolaou smear underwent colposcopy and endocervical evaluation. Directed biopsies were performed on 64 patients. One hundred thirty-five patients were compliant with postpartum Papanicolaou smears or colposcopy with endocervical evaluation.

RESULTS

One hundred eighty-seven pregnant patients had satisfactory prenatal Papanicolaou smears, colposcopy and endocervical brushings. High-grade intraepithelial lesions were found in 2.1% of prenatal endocervical brushings, 4.7% of prenatal biopsies, 0.8% of postpartum Papanicolaou smears, 2.2% of postpartum endocervical brushings, and 7.9% of postpartum biopsies. No invasive cervical cancer was detected.

CONCLUSION

Antepartum colposcopic evaluation did not add in the management of minimally abnormal Papnicolaou smears in this population of pregnant women.

Nitrogen fertiliser alleviates the disorder straighthead in Australian rice

Straighthead is a ‘physiological’ disorder of rice, the symptoms being floret sterility, deformed florets and panicles and reduced grain yield. Straighthead in rice is difficult to investigate because of its unpredictable occurrence under field conditions. An experiment was conducted in south-eastern Australia in 1996 to investigate the effect of rate and timing of N fertilisation on growth and yield of rice. The presence of straighthead at this location gave a unique opportunity to study the influence of crop N status. This paper reports the influence of N application on straighthead symptoms during this experiment. A significant reduction of straighthead occurred with higher rates of N application. Application of 250 kg N/ha pre-flood, improved plant growth and vigour with subsequent increased uptake and accumulation of S, P, K, Mg, Cu, Mn and Zn in the plant at panicle initiation. The reduction of straighthead at high nitrogen rates may be due to improved uptake of several essential nutrients, and Cu may be a critical nutrient. This study and earlier observations have shown the application of optimal levels of pre-flood nitrogen to achieve grain yields greater than 10 t/ha may reduce straighthead severity in the Australian rice-growing environment. The results in this paper are not presented as recommendations to growers but a contribution to the currently limited literature on straighthead in Australia.

DeLee suction. Does it have clinical significance?

OBJECTIVE

To evaluate the null hypothesis that there would be no difference in neonatal outcome in infants who underwent DeLee suction vs. those who underwent bulb suction when thick meconium was present. This difference was defined as a one-day difference in length of stay, two-point difference in the five-minute Apgar score or significant difference in blood gases.

STUDY DESIGN

A power calculation based on a one-day length of stay found that 115 patients would be needed in each arm. A cohort of 115 consecutive deliveries with the presence of thick meconium was reviewed during each time period when DeLee suction was utilized and then matched with deliveries that used bulb suction.

RESULTS

Two hundred thirty charts were reviewed. Length of stay, one-minute Apgar score, five-minute Apgar score, blood gases, gestational age and incidence of amnioinfusion were compared. There was no significant difference in any variable. Meconium aspiration syndrome in the period studied remained stable at < 1%.

CONCLUSION

There was no significant clinical change in neonatal outcome with the abandonment of nasopharyngeal DeLee suction on the perineum when meconium was present. We recommend the use of bulb suction as routine obstetric practice even in the presence of thick meconium.

Clinical pathway for evaluating women with abnormal uterine bleeding

OBJECTIVE

To devise a clinical pathway for evaluating women with abnormal uterine bleeding.

STUDY DESIGN

One thousand women with the complaint of abnormal uterine bleeding were enrolled. All would have undergone endometrial biopsy based on older recommendations. The patients followed a clinical pathway to determine if an endometrial biopsy was necessary. The pathway divided women into the categories of premenopausal, postmenopausal, low risk and high risk. If one risk factor was present, the patient underwent endometrial biopsy. If there were no risk factors, the patient continued down the pathway with medical therapy.

RESULTS

Five hundred seventy endometrial biopsies were performed. Five cases of endometrial cancer and three of complex atypical hyperplasia, both in the postmenopausal, high-risk group, were discovered. Subsequent reviews revealed that no cases of endometrial cancer were missed or developed in the two years following the initial complaint.

CONCLUSION

Utilization of a clinical pathway reduced the number of endometrial biopsies by 50%. The introduction of clinical pathways at our institution was done successfully in the evaluation of abnormal uterine bleeding.

Comparing endocervical curettage and endocervical brush at colposcopy

OBJECTIVE

To determine the sensitivity and specificity of the cytologic diagnosis obtained from the endocervical brushings (ECB) compared to the histologic information obtained from endocervical curettage (ECC).

MATERIALS AND METHODS

Of 369 patients referred for colposcopy, 105 nonpregnant women underwent conization and/or hysterectomy allowing analysis of tissue samples. The racially diverse, sociodemographically homogeneous population was 15 through 71 years old. Participants had repeat Papnicolaou smears, ECB, colposcopy (with/without directed biopsy), and ECC. The sensitivity, specificity, and positive and negative predictive values of ECB and ECC for diagnosing endocervical disease were compared.

RESULTS

No invasive cancers were missed by either ECB or ECC. The sensitivity of ECB was 93%, which exceeded that of ECC (62%) for detection of endocervical pathology. However, the negative predictive value of both ECB and ECC was excellent. The specificity of ECC (63%) exceeded that of ECB (25%) for detection of endocervical pathology. However, the positive predictive value of both ECC and ECB was poor.

CONCLUSION

This study suggests that ECB can replace ECC during colposcopic evaluation of an abnormal Papnicolaou smear.▪.

Hysterotomy for retained placenta in a term angular pregnancy. A case report

BACKGROUND

Angular placentation may be a cause of retained placenta and may require hysterotomy.

CASE

A 33-year-old woman with a prior cesarean section underwent an uncomplicated vaginal delivery, had a retained placenta with postpartum hemorrhage and required hysterotomy because the placenta was inaccessible due to its angular location.

CONCLUSION

Antepartum ultrasound diagnosis may be possible in some cases of angular placentation.

Antigenic cross-reactivity of human tracheal mucin with human sperm and trophoblasts correlates with the expression of mucin 8 gene messenger ribonucleic acid in reproductive tract tissues

OBJECTIVE

To test whether autoimmunity to sperm in men with cystic fibrosis (CF) is a result of cross-reactivity between sperm and carbohydrate sequences of the abnormal CF mucins, we investigated the possible epitope sharing between sperm surface antigens and CF mucin antigens using specific monoclonal antibodies (mAbs) directed to purified CF tracheobronchial mucin-1 (HTM-1) and the expression of tracheal mucin 8 gene (MUC8) mRNA in normal male and female reproductive tract tissues by Northern blot analysis.

DESIGN

A panel of mAbs directed to HTM-1 subspecies (types I to V) and polyclonal antibodies (pAb) to native and deglycosylated HTM-1 were tested for their ability to agglutinate motile sperm. An indirect immunofluorescence assay was used to detect expression of cross-reactive HTM-1 epitopes on sperm, term placenta (n = 3), and purified trophoblasts (n = 9). Northern blot analysis was used to detect MUC8 messenger RNA (mRNA) in male and female reproductive tract tissues.

SETTING

University of Oklahoma Health Sciences Center, a tertiary care referral center.

MAIN OUTCOME MEASURES

The demonstration of cross-reactive mucin at the protein and mRNA levels in reproductive tract tissues.

RESULTS

Of the five mucin subspecies, type II, IV, and V mucin-specific mAbs (21.3, 33.3, and 54.1) induced head-to-head agglutination of motile sperm; pAb to deglycosylated mucin had no effect. Sperm agglutination mediated by type IV mucin mAb 33.3 was abrogated completely by D-mannose. Within the term placental villi, type II mucin, was localized to fetal endothelium, type IV mucin was localized to syncytiotrophoblast, and type V mucin was localized to cytotrophoblasts. Immunologic studies correlated with the results of Northern blot analysis, which revealed strong MUC8 mRNA expression in the human testis, placenta, endometrium, and cervix and weak or undetectable levels in the human epididymis, seminal vesicle, ovary, fallopian tube, and uterus.

CONCLUSIONS

Both male and female reproductive tract tissues synthesize tracheal MUC8 mucin. Monoclonal antibodies specific to human tracheal mucin subtypes induced "immune-type" agglutination of motile sperm. Therefore, expression of cross-reactive MUC8 mucin epitopes in reproductive tract tissues may contribute to the development of low affinity, carbohydrate-specific, agglutinating antisperm antibodies in the genital tract.

Preferential binding of cross-reactive group A streptococcal anti-DNA monoclonal antibodies to decondensed human sperm DNA

Four murine anti-streptococcal monoclonal antibodies (mAbs) that cross-react with human DNA were evaluated by immunofluorescence flow cytometry for their reactivity with condensed and decondensed human sperm nuclei. All 4 anti-DNA mAbs reacted with condensed sperm nuclei. The reactivity of 3 of these mAbs with decondensed sperm nuclei was 13 to 177 times higher than that found with condensed nuclei. Under identical conditions, mAbs to cytoskeletal/cytocontractile proteins lacked reactivity with decondensed sperm nuclei. Binding of monoclonal anti-DNA antibodies to decondensed sperm nuclei was abolished by preincubation with double-stranded DNA. The preferential binding of anti-DNA antibodies to decondensed sperm DNA suggests the utility of decondensed sperm nuclei as the antigenic substrate for screening anti-DNA antibodies by flow cytometry.

Ultrastructural observations on the redial tegument of Paramphistomum epiclitum from the planorbid snail, Indoplanorbis exustus

The morphology of the tegument in the redia of Paramphistomum epiclitum (Digenea: Paramphistomidae) resembles that shown by most larval and adult digeneans; an outer surface syncytium is in continuity with the cytoplasm of in-sunken, nucleated cytons. Although tegumental cytons usually contain a single nucleus, some display up to six nuclei. The tegumental syncytium lining the pharynx of P. epiclitum rediae lack underlying cytons. The apical membrane of the tegument is elaborated by folds and microvilli, which presumably facilitate uptake of nutrients and/or exchange of ions involved in osmoregulation. A single type of secretory body, resulting from the fusion of smaller vesicles produced at Golgi complexes in the cytons, occurs throughout the tegument. Uniciliate sensory receptors occur in the surface syncytium particularly around the oral opening.

Tegumental surface modulation in Schistosoma mansoni primary sporocysts in response to ligand binding

The clearance of host molecules from the surface of a parasite constitutes a potential immune evasive strategy. The possibility that certain ligands, when bound to the tegument of Schistosoma mansoni primary sporocysts, could induce such a modulating effect was investigated. Live, in vitro cultured primary sporocysts were first treated with either snail host Biomphalaria glabrata plasma, an anti-sporocyst monoclonal antibody (MoAb III-1), or concanavalin A (con A). The capacity of these primary ligands to produce a modulating effect alone, or when subsequently crosslinked by secondary or tertiary ligands, was measured using quantitative fluorescence microscopy. Snail plasma alone, or plasma crosslinked at the sporocyst surface with a mouse anti-plasma MoAb had little or no modulating effect. However, a tertiary level of ligand crosslinking with an anti-mouse IgG antibody produced an average 1.8-fold decrease in surface fluorescence within 1 h post-labelling. The anti-sporocyst MoAb III-1 also required secondary antibody reactivity to induce an average 1.5-fold decrease in MoAb III-1 recognized epitopes. Sporocysts labelled with con A crosslinked by secondary and tertiary ligands showed inconsistent modulation, with a 1.5-fold decrease in fluorescence in one out of three replicates. Overall, however, analysis of combined data revealed no significant effect of tertiary ligand level crosslinkage on modulation of con A-tegumental receptor complexes. In contrast, con A binding alone to tegumental determinants induced a small, but significant, reduction in surface con A complexes. Modulation of ligand-receptor complexes on the sporocyst tegumental membrane appears to be an energy-requiring event, since clearance of surface complexes was inhibited in the presence of sodium azide and/or sodium iodoacetate, or when larvae were incubated at 4 degrees C. It is concluded that alterations in sporocyst tegumental surface components may be triggered by specific (but as yet undefined) signals. Sporocysts are capable of exhibiting different responses depending on the nature of the binding signal and reactive tegumental receptor, and the degree of ligand crosslinkage.

In vitro excystment of the metacercariae of Gynaecotyla adunca and Probolocoryphe uca (Microphallidae) from the fiddler crab, Uca pugilator

A high rate and percentage of excystment of Probolocoryphe uca metacercariae occur at 40 °C in a low salt medium, in the absence of exogenous enzymes, indicating a largely active form of excystment. Exogenous trypsin is required for excystment of Gynaecotyla adunca metacercariae and it is presumed that excystment is largely a passive process. Saturated CO2 conditions promote excystment in this species, whereas high concentrations of pepsin, bile salts (especially deoxycholate), and extreme pH conditions have adverse effects on the process. Physicochemical factors operating in the in vitro excystment of the two microphallids are correlated with conditions presumed to prevail in the avian gut. Excysted metacercariae of both species begin egg production in vitro within several days. Such rapid development may be related to diverse definitive host capacities.

Schistosoma mansoni: origin and expression of a tegumental surface antigen on the miracidium and primary sporocyst

A monoclonal antibody, recognizing a carbohydrate epitope associated with several tegumental surface components on Schistosoma mansoni primary sporocysts, was used to follow tegumental formation during transformation of the miracidium to sporocyst and its subsequent development in vitro and in vivo. Indirect fluorescent antibody and direct immunogold labeling methods confirm a structural connection between the intercellular ridges and a submuscular, multinucleate syncytium in the miracidium. Immunoreactive vesicles within this latter system directly contribute to elaboration of the tegumental surface membrane, through the process of membrane fusion. Lateral expansion of intercellular ridges by vesicular fusion ultimately result in fully transformed sporocysts exhibiting vesicular membrane epitopes as prominent tegumental surface components. Light microscopical and ultrastructural observations, together with Western immunoblot analyses, suggest a gradual depletion of intracellular and surface immunoreactive material of vesicular origin in primary sporocysts grown in culture for up to 12 days. In contrast, similar immunoreactive vesicles appear to be continuously synthesized throughout in vivo primary sporocyst development. Monoclonal antibody reactive epitopes appear to be uniquely expressed in the miracidium/primary sporocyst since similar molecules are absent from daughter sporocysts, cercariae, adults, and snail tissues.

Schistosoma mansoni: relationship between cercarial production levels and snail host susceptibility

Two populations of Biomphalaria glabrata snails differing slightly in their susceptibility to Schistosoma mansoni infection showed dramatic differences in cercarial output per snail. Exposed to five or more miracidia, snails from a group with a 90-100% susceptibility rate (Group A) produced nearly twice the number of cercariae as those from a group with a 70-80% susceptibility rate (Group B). Exposure of individual snails to known numbers of miracidia resulted in higher numbers of primary (mother) sporocysts in Group A snails than in Group B snails. However, monomiracidial exposure of snails from both groups resulted in equivalent numbers of cercariae produced per positive snail, indicating that, once established, all primary sporocysts possess a similar reproductive potential. Morphometric analysis of serially sectioned 9-day-old primary sporocysts supported this conclusion; the size of the primary sporocysts and the size and numbers of secondary (daughter) sporocysts within each primary sporocyst were comparable in snails from both groups. The data indicate cercarial production in this system is regulated prior to, and/or during, early development of the primary sporocyst.

The influence of intravenous solution content on ritodrine-induced metabolic changes

To examine the influence of intravenous (IV) solution content on ritodrine-induced metabolic changes, 25 patients treated with various IV solutions were studied before and after a bolus of fluid, and during IV drug therapy, for the effect of hematocrit, pH, lactate, glucose, and electrolyte concentrations. Results were viewed on a mg/kg/minute ritodrine dosage basis. Dextrose-containing fluids caused a significant elevation of glucose after bolus therapy, and 5% dextrose in water also significantly altered lactate and potassium levels. Dextrose enhanced drug-mediated changes in potassium, sodium, chloride, pH, and lactate. The CO2 content dropped in all patients, regardless of IV content. The best IV solution would appear to be plain lactated Ringer's, and the least desirable, 5% dextrose in water.

Analysis of tegumental surface proteins of Schistosoma mansoni primary sporocysts

Axenically transformed primary sporocysts of Schistosoma mansoni (NMRI strain) were labeled with 125I in an effort to identify sporocyst proteins exposed at the tegumental surface. Using the 125I activating reagent, 1,3,4,6-tetrachloro-3 alpha,6 alpha-diphenylglycoluril, in conjunction with SDS-PAGE and autoradiography, up to 12 bands were radiolabeled out of 60 components visualized by silver staining. Labeled proteins ranged in apparent Mr from greater than 200 to less than 12 kDa. Pronase treatment of living sporocysts after radioiodination removed all labeled material, suggesting that only surface proteins were being iodinated. Western blot analysis employing 5 monoclonal antibodies (MAB's) to sporocyst surface antigens revealed a wide range of reactivities which produced banding patterns closely reflecting autoradiograms of identical samples. The concomitant removal by Pronase of immunoreactive and radiolabeled surface proteins with identical Mr in the range of 90-130 kDa suggests that epitopes recognized by these antibodies are associated with these higher molecular weight surface proteins. However, although Pronase removes all labeled surface proteins, substantial nonradiolabeled, immunoreactive material with Mr less than 90 kDa still remains on enzyme-treated parasites. This indicates that MAB-reactive epitopes, in addition to their occurrence with surface proteins, are also associated with either unlabeled, protease-resistant surface components or internal antigens. The immunohistochemical localization of antibody-reactive material in gland-like structures within sporocysts supports an internal source for nonradiolabeled, immunoreactive components. Finally, the periodate sensitivity of the epitopes recognized by all tested MAB's suggests that carbohydrate moieties may represent a common and extremely immunogenic constituent of the sporocyst surface.(ABSTRACT TRUNCATED AT 250 WORDS)

Studies on the ultrastructure and histochemistry of the lymph system in three species of amphistome (Trematoda: Digenea) Gigantocotyle explanatum, Gastrothylax crumenifer and Srivastavaia indica from the Indian water buffalo Bubalus bubalis

The lymph system of three amphistome parasites from buffaloes, Gigantocotyle explanatum, Gastrothylax crumenifer and Srivastavaia indica was studied using light microscope histochemistry and electron microscopy. In each case the system comprised a single pair of main longitudinal vessels which gave rise to numerous sub-dividing lateral branches. Although the finer lymph channels associated with most internal systems, they did not penetrate the basement membrane of any organ. The lymph vessels were delimited by a unit membrane and separated from adjacent cells by interstitial material. The lymph fluid consisted of an amorphous proteinaceous, lipid-rich matrix, containing naked nuclei and granules of various sizes. Complexes of endoplasmic reticulum were frequently associated with the nuclei. No distinct Golgi bodies or mitochondria were evident. The granules noted throughout the lymph morphologically resembled autophagosomes and lysosomes. Autophagy within the lymph system presumably mobilizes amino acids for subsequent transport to tissues undergoing active protein synthesis. The lymph channels displayed an intimate relationship with the general parenchyma. In particular, numerous protrusions of lymph occurred into the cytoplasm of certain specialized parenchymal cells surrounding the pharynx. Within these 'juxtapharyngeal' cells autophagic degradation of sequestered lymph cytoplasm apparently occurred. In the three species of amphistome studied, the lymph system appears to function in storage and mobilization of amino acids and possibly lipids. It may also serve to distribute other small molecules throughout the body. The detection of haemoglobin in the lymph system of G. crumenifer and S. indica, but not in Gigantocotyle explanatum, suggests a further role in oxygen storage and transport.