Analytical Performance Specifications for Input Variables: Investigation of the Model of End-Stage Liver Disease

BACKGROUND

Artificial intelligence models constitute specific uses of analysis results and, therefore, necessitate evaluation of analytical performance specifications (APS) for this context specifically. The Model of End-stage Liver Disease (MELD) is a clinical prediction model based on measurements of bilirubin, creatinine, and the international normalized ratio (INR). This study evaluates the propagation of error through the MELD, to inform choice of APS for the MELD input variables.

METHODS

A total of 6093 consecutive MELD scores and underlying analysis results were retrospectively collected. "Desirable analytical variation" based on biological variation as well as current local analytical variation was simulated onto the data set as well as onto a constructed data set, representing a worst-case scenario. Resulting changes in MELD score and risk classification were calculated.

RESULTS

Biological variation-based APS in the worst-case scenario resulted in 3.26% of scores changing by ≥1 MELD point. In the patient-derived data set, the same variation resulted in 0.92% of samples changing by ≥1 MELD point, and 5.5% of samples changing risk category. Local analytical performance resulted in lower reclassification rates.

CONCLUSIONS

Error propagation through MELD is complex and includes population-dependent mechanisms. Biological variation-derived APS were acceptable for all uses of the MELD score. Other combinations of APS can yield equally acceptable results. This analysis exemplifies how error propagation through artificial intelligence models can become highly complex. This complexity will necessitate that both model suppliers and clinical laboratories address analytical performance specifications for the specific use case, as these may differ from performance specifications for traditional use of the analyses.

Heterogeneity in the perirenal region of humans suggests presence of dormant brown adipose tissue that contains brown fat precursor cells

Objective

Increasing the amounts of functionally competent brown adipose tissue (BAT) in adult humans has the potential to restore dysfunctional metabolism and counteract obesity. In this study, we aimed to characterize the human perirenal fat depot, and we hypothesized that there would be regional, within-depot differences in the adipose signature depending on local sympathetic activity.

Methods

We characterized fat specimens from four different perirenal regions of adult kidney donors, through a combination of qPCR mapping, immunohistochemical staining, RNA-sequencing, and pre-adipocyte isolation. Candidate gene signatures, separated by adipocyte morphology, were recapitulated in a murine model of unilocular brown fat induced by thermoneutrality and high fat diet.

Results

We identified widespread amounts of dormant brown adipose tissue throughout the perirenal depot, which was contrasted by multilocular BAT, primarily found near the adrenal gland. Dormant BAT was characterized by a unilocular morphology and a distinct gene expression profile, which partly overlapped with that of subcutaneous white adipose tissue (WAT). Brown fat precursor cells, which differentiated into functional brown adipocytes were present in the entire perirenal fat depot, regardless of state. We identified SPARC as a candidate adipokine contributing to a dormant BAT state, and CLSTN3 as a novel marker for multilocular BAT.

Conclusions

We propose that perirenal adipose tissue in adult humans consists mainly of dormant BAT and provide a data set for future research on factors which can reactivate dormant BAT into active BAT, a potential strategy for combatting obesity and metabolic disease.

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Dormant brown adipose tissue (BAT) dominates the perirenal adipose depot of adult humans.

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Multilocular BAT accumulates adjacent to local sympathetic sources.

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Dormant BAT displays a transcriptomic signature distinct from multilocular BAT and white adipose tissue.

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Brown fat precursor cells are present in human dormant perirenal BAT.

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SPARC is associated with a dormant BAT phenotype.

Incidental Coronary Artery Calcification Seen on Low-Dose Computed Tomography Is a Risk Factor for Obstructive Coronary Artery Disease in Patients Undergoing Liver Transplant

Incidental arterial calcification (Ca) on low-dose computed tomography (CT) prior to liver transplant (LT) may help identify those at risk for obstructive coronary artery disease (CAD). A single-center retrospective study of 358 consecutive patients who had undergone LT was performed. Of the 296 patients who met inclusion criteria, 193 patients (65.2%) had CT Ca. Aortic Ca was seen in 116 (39.2%), coronary Ca in 141 (47.6%), and peripheral Ca in 8 patients (2.7%). Patients with coronary Ca were assigned ordinal coronary artery Ca scores and classified as mild, moderate, and severe. All-cause mortality was higher in patients with Ca in any location (14.5% vs 6.8%, P = .05). Of the patients who underwent coronary angiography, those with obstructive CAD were more likely to have aortic and coronary Ca than patients with nonobstructive or no CAD (85.7% vs 50.0%, P = .02 and 92.9% vs 37.9%, P = < .001, respectively). Severe coronary artery Ca scores were more frequent in patients with obstructive CAD (35.7% vs 0%, P < .001). Any severity coronary Ca had an odds ratio of 11.57 (95% CI, 1.61-244.92; P = .04) for obstructive CAD. In conclusion, incidental coronary Ca seen on low-dose CT is a risk factor for obstructive CAD in patients undergoing LT.

Risk of all-type cancer, hepatocellular carcinoma, non-Hodgkin lymphoma and pancreatic cancer in patients infected with hepatitis B virus

The increased risk of hepatocellular carcinoma (HCC) among patients infected with hepatitis B virus (HBV) is well established; however, long-term risk estimates are needed. Recently, it has been suggested that HBV is associated with non-Hodgkin lymphoma (NHL) and pancreatic cancer (PC). The aim of this Danish nationwide cohort study was to evaluate the association between HBV infection and all-type cancer, HCC, NHL and PC. A cohort of patients infected with HBV (n = 4345) and an age- and sex-matched population-based comparison cohort of individuals (n = 26,070) without a positive test for HBV were linked to The Danish Cancer Registry to compare the risk of all-type cancer, HCC, NHL and PC among the two groups. The median observation period was 8.0 years. Overall, the incidence rate ratio (IRR) for all-type cancer among HBV-infected patients was 1.1 (95% confidence intervals (CI) 0.9-1.3). The IRR of HCC was 17.4 (CI 5.5-54.5), whereas the IRR of PC and NHL was 0.9 (CI 0.3-2.5) and 1.2 (CI 0.4-3.6), respectively. HBV-infected patients had a 10-year risk of 0.24% (Cl 0.12-0.44) for HCC, whereas the comparison cohort had a 10-year risk of 0.03% (Cl 0.02-0.07) for HCC. The risk of all-type cancer, NHL and PC was not higher in the HBV-infected cohort compared to non-HBV infected. We found a 17-fold higher risk of HCC for HBV-infected individuals.

Macrophage-related serum biomarkers soluble CD163 (sCD163) and soluble mannose receptor (sMR) to differentiate mild liver fibrosis from cirrhosis in patients with chronic hepatitis C: a pilot study

Macrophages regulate the fibrotic process in chronic liver disease. The aim of the present pilot study was to evaluate two new macrophage-specific serum biomarkers [soluble CD163 (sCD163) and soluble mannose receptor (sMR, sCD206)] as potential fibrosis markers in patients chronically infected with hepatitis C virus (HCV). Forty patients with chronic hepatitis C were included from two hospital clinics. On the day of inclusion, transient elastography (TE) was performed to assess the fibrosis stage, and blood samples were collected for the measurement of sCD163 and sMR. The plasma concentrations of both biomarkers were significantly higher in patients infected with HCV and with cirrhosis compared to those with no/mild liver fibrosis (5.77 mg/l vs. 2.49 mg/l and 0.44 mg/l vs. 0.30 mg/l for sCD163 and sMR, respectively). The best separation between groups was obtained by sCD163 [area under the receiver operating characteristic curve (AUC) 0.89 (95 % confidence interval [CI] 0.79-0.99)] as compared to sMR [AUC 0.75 (95 % CI 0.61-0.90)]. sCD163 and sMR correlated significantly (r (2) = 0.53, p < 0.0001). Interestingly, sCD163 also correlated significantly with TNF-α (presented in a previous publication), which is shed to serum by the same mechanism as sCD163 (r (2) = 0.40, p < 0.0001). In conclusion, the macrophage-related markers sCD163 and sMR are significantly higher in patients chronically infected with HCV and with cirrhosis than in those with no/mild fibrosis. sCD163 is a promising new fibrosis marker in patients infected with HCV.

Previously unrecognized advanced liver disease unveiled by transient elastography in patients with Haemophilia and chronic hepatitis C

Before the introduction of viral inactivation procedures and viral screening of plasma-products, haemophiliacs were at high risk of infection with HCV. Those who acquired HCV infection in the 1980s, and are still alive today, may have developed significant liver fibrosis or cirrhosis. However, liver biopsy has not routinely been utilized in the evaluation of haemophiliacs with HCV in Denmark. The aim of this study was to investigate the prevalence of significant fibrosis/cirrhosis among haemophiliacs as evaluated by transient elastography (TE). Cross-sectional investigation of adult patients with haemophilia A or B. TE with liver stiffness measurements (LSM) ≥ 8 kPa were repeated after 4-6 weeks. Significant fibrosis and cirrhosis was defined as measurements ≥ 8 kPa or ≥ 12 kPa respectively. Among 307 patients with haemophilia A or B registered at the two Haemophilia centres, 141(46%) participate in this study. Forty (28.4%) had chronic hepatitis C, 33 (23.4%) past hepatitis C and 68 (48.2%) had never been infected, at screening LSM ≥ 8 kPa were found in 45.7%, 24.7% and 4.6% respectively. Among patients with chronic hepatitis C significant fibrosis was confirmed in 17.1% and cirrhosis in 2.9% by repeated LSM ≥ 8 and ≥ 12 kPa respectively. The median TE-value in never HCV-infected haemophiliacs was comparable with what has been found in healthy non-haemophiliacs. In Danish haemophiliacs where liver biopsy has not routinely been used for assessing severity of liver fibrosis, LSM identified advanced liver disease in one-fifth of cases that had not been recognized during clinical follow-up.

Improved survival of patients with ovarian cancer in Northern Denmark, 1985-2004

OBJECTIVE

Ovarian cancer is a serious disease with a high mortality. Our aim was to examine changes in the survival of patients with ovarian cancer in Northern Denmark.

STUDY DESIGN AND SETTING

Patients (no. = 3,719) with an incident discharge diagnosis of ovarian cancer (1985-2004) from any hospital in four Danish counties (population, 1.6 million) were included and tracked for mortality through the Danish Civil Registration System. We determined survival and mortality rates stratified by age, and used Cox proportional hazard regression analyses to assess changes over time.

RESULTS

Overall survival rate improved between 1985 and 2004. One-year survival increased from 61% to 73%, and five-year survival from 30% to 38%. Compared with the period 1985-1989 the age-adjusted one-year mortality rate ratio (MRR) was 0.65 (2000-2004) and the age-adjusted five-year MRR was 0.80 (1995-1999). The improvement was most pronounced in patients older than 40 years.

CONCLUSION

The survival of ovarian cancer patients has improved in Denmark in recent decades. This change may be the result of improved treatment.

Accuracy of ovarian cancer ICD-10 diagnosis in a Danish population-based hospital discharge registry

OBJECTIVE

We estimated the accuracy of ICD-10 diagnosis of ovarian cancer in a Danish discharge registry (HDR) by comparing it with Cancer Registry data (DCR).

STUDY DESIGN AND SETTING

Patients (N=489) living in North Jutland County, Denmark with ovarian cancer or borderline tumour registered in the HDR or the DCR. We estimated the completeness and positive predictive value (PPV) of ovarian cancer discharge diagnosis. Mortality rates were constructed for both registries.

RESULTS

The completeness in the HDR for ovarian cancer was 96% (95% confidence interval [CI]: 94%-98%) and PPV was 87% (95% CI: 85%-90%). 87 (18%) of the patients coded with ovarian cancer in the HDR had borderline tumours. When borderline tumours were excluded from the DCR, the PPV declined to 69% and the completeness did not change. The mortality rate ratio for ovarian cancer registered in the HDR compared to the DCR was 1.08 (95% CI: 0.90-1.29).

CONCLUSION

The discharge data (ICD-10) had some misclassification, but can be a valuable tool in assessment of the prognosis of ovarian cancer.

Evolutionary rate variation and RNA secondary structure prediction

Predicting RNA secondary structure using evolutionary history can be carried out by using an alignment of related RNA sequences with conserved structure. Accurately determining evolutionary substitution rates for base pairs and single stranded nucleotides is a concern for methods based on this type of approach. Determining these rates can be hard to do reliably without a large and accurate initial alignment, which ideally also has structural annotation. Hence, one must often apply rates extracted from other RNA families with trusted alignments and structures. Here, we investigate this problem by applying rates derived from tRNA and rRNA to the prediction of the much more rapidly evolving 5'-region of HIV-1. We find that the HIV-1 prediction is in agreement with experimental data, even though the relative evolutionary rate between A and G is significantly increased, both in stem and loop regions. In addition we obtained an alignment of the 5' HIV-1 region that is more consistent with the structure than that currently in the database. We added randomized noise to the original values of the rates to investigate the stability of predictions to rate matrix deviations. We find that changes within a fairly large range still produce reliable predictions and conclude that using rates from a limited set of RNA sequences is valid over a broader range of sequences.

Speech errors in Alzheimer's disease: reevaluating morphosyntactic preservation

Researchers studying the speech of individuals with probable Alzheimer's disease (PAD) report that morphosyntax is preserved relative to lexical aspects of speech. The current study questions whether dividing all errors into only two categories, morphosyntactic and lexical, is warranted, given the theoretical controversies concerning the production and representation of pronouns and closed-class words in particular. Two experiments compare the speech output of 10 individuals with Alzheimer's disease to that of 15 healthy age- and education-matched speakers. Results of the first experiment indicate that the pattern of errors in the speech of participants with mild PAD reflects an across-the-board increase in the same types of errors made by healthy older speakers, including closed-class and morphosyntactic errors. In the second task, participants produced a grammatical sentence from written stimuli consisting of a transitive verb and two nouns. Only adults with Alzheimer's disease had difficulties with this task, producing many more closed-class word errors than did healthy older adults. Three of the participants with PAD produced nearly agrammatic speech in this task. These 3 people did not differ from the rest of the PAD group in age, education, working memory, or degree of semantic impairment. Further, error rates on the two tasks were highly correlated. We conclude that morphosyntax is not preserved in the speech output of individuals with PAD, but is vulnerable to errors along with all aspects of language that must be generated by the speaker. We suggest that these results best support a model of speech production in which all words are represented by semantic and grammatical features, both of which are vulnerable to failures of activation when there is damage or noise in the system as a result of pathology, trauma, or even divided attention.

Assessing working memory and language comprehension in Alzheimer's disease

Studies of language impairments in patients with Alzheimer's disease have often assumed that impairments in linguistic working memory underlie comprehension deficits. Assessment of this hypothesis has been hindered both by vagueness of key terms such as "working memory" and by limitations of available working memory tasks, in that many such tasks either seem to have little relationship to language comprehension or are too confusing or difficult for Alzheimer's patients. Four experiments investigated the usefulness of digit ordering, a new task assessing linguistic working memory and/or language processing skill, in normal adults and patients with probable Alzheimer's disease. The digit ordering task was shown to be strongly correlated with the degree of dementia in Alzheimer's patients. The task correlated with measures of language processing on which patients and normal controls performed differently. The results are interpreted as indicating that linguistic representations, linguistic processing, and linguistic working memory are intertwined, such that a deficit of one (e.g., working memory) cannot be said to "cause" a deficit in the other. The implications of this approach are explored in terms of task demands in comprehension and memory measures, and interpretation of previous results in the literature.

Why do Alzheimer patients have difficulty with pronouns? Working memory, semantics, and reference in comprehension and production in Alzheimer's disease

Three experiments investigated the extent to which semantic and working-memory deficits contribute to Alzheimer patients' impairments in producing and comprehending referring expressions. In Experiment 1, the spontaneous speech of 11 patients with Alzheimer's disease (AD) contained a greater ratio of pronouns to full noun phrases than did the spontaneous speech produced by 9 healthy controls. Experiments 2 and 3 used a cross-modal naming methodology to compare reference comprehension in another group of 10 patients and 10 age-matched controls. In Experiment 2, patients were less sensitive than healthy controls to the grammatical information necessary for processing pronouns. In Experiment 3, patients were better able to remember referent information in short paragraphs when reference was maintained with full noun phrases rather than pronouns, but healthy controls showed the reverse pattern. Performance in all three experiments was linked to working memory performance but not to word finding difficulty. We discuss these findings in terms of a theory of reference processing, the Informational Load Hypothesis, which views referential impairments in AD as the consequence of normal discourse processing in the context of a working memory impairment.

Sentence comprehension deficits in Alzheimer's disease: a comparison of off-line vs. on-line sentence processing

Two studies explored whether sentence comprehension impairments in Alzheimer's disease (AD) are due to deficits in syntactic processing or memory. Study 1 used a picture-pointing sentence comprehension task to measure the final outcome of comprehension in an off-line fashion. It showed the comprehension of 30 patients with AD to be impaired, but suggested that the deficits could not be attributed solely to syntactic impairments. Study 2 investigated the effects of memory on sentence comprehension by comparing off-line (grammaticality judgment) with on-line (cross-modal naming) language processing in 11 AD and 9 control subjects. The results revealed impaired performance in the off-line task but normal performance in the on-line task using the same sentences. Performance on the off-line task correlated with independent measures of verbal working memory. These data are used to argue that sentence comprehension impairments are related to verbal working memory deficits in AD.

Combination laser conization as treatment of microinvasive carcinoma of the uterine cervix

During the period June 1985 to August 1992 combination laser conization was considered definite therapy in 41 patients with microinvasive carcinoma of the cervix. Selection criteria for conservative, fertility-saving therapy were: invasion 3 mm or less, no lymphovascular involvement and horizontal spread of 7 mm or less. After treatment patients were followed for 5 to 12 years, mean follow-up 81 months, and mean number of examination was 10. In one cases, adenocarcinoma in situ was diagnosed during follow-up. In all other cases persistent or recurrent disease was not diagnosed during follow-up. By thorough histopathologic evaluation and strict criteria for selection of patients, it was possible to perform conservative treatment with no observed risk of undertreatment. Combination laser conization was a useful treatment modality. A follow-up regimen based on colposcopy and cytology proved sufficient.

Category-specific semantic deficits in focal and widespread brain damage: a computational account

Category-specific semantic impairments have been explained in terms of preferential damage to different types of features (e.g., perceptual vs. functional). This account is compatible with cases in which the impairments were the result of relatively focal lesions, as in herpes encephalitis. Recently, however, there have been reports of category-specific impairments associated with Alzheimer's disease, in which there is more widespread, patchy damage. We present experiments with a connectionist model that show how "category-specific" impairments can arise in cases of both localized and widespread damage; in this model, types of features are topographically organized, but specific categories are not. These effects mainly depend on differences between categories in the distribution of correlated features. The model's predictions about degree of impairment on natural kinds and artifacts over the course of semantic deterioration are shown to be consistent with existing patient data. The model shows how the probabilistic nature of damage in Alzheimer's disease interacts with the structure of semantic memory to yield different patterns of impairment between patients and categories over time.

Double dissociation of semantic categories in Alzheimer's disease

Data that demonstrate distinct patterns of semantic impairment in Alzheimer's disease (AD) are presented. Findings suggest that while groups of mild-moderate patients may not display category specific impairments, some individual patients do show selective impairment of either natural kinds or artifacts. We present a model of semantic organization in which category specific impairments arise from damage to distributed features underlying different types of categories. We incorporate the crucial notions of intercorrelations and distinguishing features, allowing us to demonstrate (1) how category specific impairments can result from widespread damage and (2) how selective deficits in AD reflect different points in the progression of impairment. The different patterns of impairment arise from an interaction between the nature of the semantic categories and the progression of damage.

The reliability of preconization diagnostic evaluation in patients with cervical intraepithelial neoplasia and microinvasive carcinoma

The accuracy of preconization cytology and histology was evaluated in 536 patients undergoing combination laser conization. Exact agreement between cytology and cone diagnosis was observed in 41.8% of the patients. The lowest agreement, 13.6% was demonstrated in cytologic cervical intraepithelial neoplasia (CIN) I, the highest in cytologic CIN III, 64.3%. Concerning microinvasive disease, the positive predictive value of cytology was only 27.3%; the negative predictive value 94.6%. When cytology showed CIN II or worse, the cone biopsy showed CIN or invasive disease in 92.8%. Exact agreement between preconization histology and the cone biopsy was found in 59.5%. Highest agreement was observed in CIN III lesions, 67.1%, and the lowest agreement in CIN II lesions, 42.7%. When preconization showed CIN II, a higher grade of lesion was found in the cone biopsy in 29.1%. Cone biopsy revealed invasive disease in 38 cases. In 24 cases, invasive disease was not demonstrated prior to conization, corresponding totally to 4.7% of patients not suspected to have invasive disease prior to conization. Regarding invasive disease, the sensitivity of preconization histology was 36.8%, the positive predictive value 58.3%, and the negative predictive value 95.3%. Kappa statistics demonstrated rather low agreement between cone diagnoses and preconization diagnoses. These results confirm the potential risk of overlooking invasive disease by conventional preconization evaluation and demonstrate the need for excisional methods in the management of cervical intraepithelial neoplasia to provide a sufficient specimen for diagnostic purposes. Combined with the therapeutic results, combination laser conization was a reliable diagnostic and therapeutic method in the management of patients with CIN and microinvasive cancer of the cervix.

Laser conization: the results of treatment of cervical intraepithelial neoplasia

Combination laser conization was performed for the treatment of cervical intraepithelial neoplasia (CIN) in 473 patients, who were followed for a mean period of 70 months. In 16 cases (3.4%) CIN was demonstrated during follow up, and in 10 cases (2.1%) within the first year after treatment. The grade of CIN in the cone specimen was of no predictive value to recurrence. When excisional margins were involved recurrence was observed in 8.7% of cases, compared to 2.3% when margins were uninvolved. The risk of recurrence was significantly higher in patients with involvement of the endocervical cone margin. The only case of invasive disease during follow-up was observed more than 2 years after conization; cone biopsy was without involved margins. The results clearly demonstrate the method to be effective and justify an expectant management of all patients after conization by this method.

[Cryotherapy of cervical intraepithelial neoplasia. Long-term prognosis]

Cryotherapy for the treatment of cervical intraepithelial neoplasia (CIN) was performed in 261 patients and the patients were followed for five to 10 years. Cure rate fed significantly with inoeasing grade of CIN and with endocervical involvement. In pure exocervical lesions, 91% and 77.8% of patients with respectively CIN II and CIN III were cured. In patients with endocervical involvement, the grade of lesion was not significant. Life-table calculations showed an over-all risk of persisting CIN during the first year of observation of 8.8%, and a risk of 0.8% during years 6 to 10. Patients age was of no significance. Endocervical involvement should be a contraindication to cryotherapy, and a careful follow-up schedule is mandatory. A careful colposcopic examination especially concerning the lesion area might help to increase the cure rate in patients with exocervical CIN III lesions.

Cryosurgery for cervical intraepithelial neoplasia: 10-year follow-up

Cryotherapy was performed for the treatment of CIN in 261 patients, who were followed for 5 to 10 years after treatment. The overall cure rate was 83.5%. Increasing grade of CIN and enocervical involvement significantly reduced the cure rate. In pure exocervical lesions, a 91% cure rate in patients with CIN II lesions and a 77.8% cure rate in CIN III patients were observed. In patients with endocervical involvement, the influence of grade of lesion was of no significance. Life-table calculations demonstrated an overall risk of persisting CIN during the first year of observation of 8.8%, compared to a risk of 0.8% during Years 6 to 10. Log-rank test showed a risk of recurrence in patients with CIN III lesions significantly higher than that in patients with CIN II lesions and also a higher risk in patients with endocervical involvement. There was no significant influence of age on cure rates. Endocervical involvement should be considered a contraindication to cryotherapy, and a careful follow-up schedule is mandatory if cryotherapy is to keep its position as a recommendable therapy in patients with CIN.

[Acute fatty liver in pregnancy. Report of 2 cases]

We present the case histories of two patients showing the clinical and biochemical manifestations of acute fatty liver of pregnancy associated with disseminated intravascular coagulation. Both patients were young primiparae. One was admitted in the 39th week of pregnancy, the other immediately after spontaneous delivery at the 36th week. Both patients recovered. Laboratory investigations, treatment and differential diagnosis are discussed.

Laser conization: follow-up in patients with cervical intraepithelial neoplasia in the cone margin

Combination laser conization was performed in 469 patients for the treatment of cervical intraepithelial neoplasia (CIN). In 58 cases (12.4%), CIN was located in the margins of the cone. Fifty-one patients with involvement of the margins were evaluated by cytologic examination, using the Ayre spatula and the Cytobrush, and by cervical biopsy and endocervical curettage (ECC). In six cases, the histologic evaluation was positive, and in three of these cases, the cytology was positive too. Hysterectomy was performed in five cases, but in only one case was a significant lesion demonstrated in the uterus. These results justify expectant, conservative management of patients treated with combination laser conization. Follow-up based on colposcopy and cytology seems sufficient.

Stage II endometrial carcinoma: prognostic factors and the results of treatment

Results of treatment and potential prognostic factors in 54 patients with clinical stage II endometrial carcinoma were analyzed. During the period analyzed, three different treatment techniques were used. The highest cure rate (70.6%) was observed in patients treated with simple hysterectomy and bilateral salpingo-oophorectomy followed by external pelvic irradiation and vaginal irradiation. Radiation therapy alone cured 50%. High tumor grade, deep myometrial invasion (greater than 50%), and invasion of the cervical stroma reduced the cure rates, but the only factor significantly reducing cure rate was patient age. Patients 59 years of age or older fared significantly more poorly than younger patients. Significant complications was observed in 9.3% of patients. Prospective studies of standardized treatment techniques in patients with stage II endometrial carcinoma are necessary to achieve better results and acquire more information.

Lymphocyte subpopulations in patients with cervical intraepithelial neoplasia

Quantitation of T-lymphocyte subsets and natural killer cells in peripheral blood of 16 patients with cervical intraepithelial neoplasia and 15 controls with normal cervical cytology was performed using specific monoclonal antibodies and flow cytometry. No differences were observed in T-helper lymphocytes, T-suppressor/cytotoxic lymphocytes, Th/Ts cell ratios, or natural killer cells. The results indicate that disturbances of the cell-mediated immune response, observed in patients with invasive cancer of the cervix, are secondary to the disease and of no significance in the initiation of cervical cancer.

Autoimmune associated recurrent abortions

A possible relationship between recurrent spontaneous abortions and autoimmune abnormalities was studied. Eight serological autoimmune or autoimmune-correlated parameters were investigated in 91 women with unexplained recurrent abortions (greater than or equal to 3 consecutive, spontaneous abortions) and 89 fertile control women. Five parameters were seen significantly more frequently in 19 women with at least one second trimester miscarriage which had been associated with severe intrauterine growth regardation (IUGR), than in controls. Seventeen of these 19 patients (89%) had at least one positive autoimmune parameter, compared to 15 of 72 patients (21%) with no second trimester abortions with IUGR (P less than 0.0001) and 14 (16%) of the controls (P less than 0.0001). No single autoantibody characterized patients who exhibited a significant accumulation of autoimmune parameters. These findings may suggest that women with recurrent abortions, in whom autoimmunity is thought to play a role, cannot be identified merely by one laboratory assay, such as that for cardiolipin antibodies, but must be defined by positivity of several criteria. Using our own test panel, preliminary clinical and serological criteria have been set up for the definition of an autoimmune-associated recurrent abortion condition. Twenty-three per cent of the patients in our material fulfilled these criteria, and seven out of nine of these women (78%) have to date been treated successfully with heparin/aspirin during pregnancy.

Adenocarcinoma in situ of the uterine cervix: a clinico-pathologic study of 36 cases

Thirty-six consecutive cases of adenocarcinoma in situ (ACIS) of the uterine cervix, including 8 cases of early stromal invasion to a depth not exceeding 5 mm, were revised with specific reference to detection rate and treatment. The final histologic diagnoses were based on 31 cone biopsies, 1 hysterectomy specimen, and 4 endocervical curettings/punch biopsies. ACIS was localized in the transformation zone of all cone biopsies/hysterectomy specimen, with a mostly superficial spread in the glands. The mucosal surface was involved in 34 cases. In 29 cone biopsies, ACIS was found unifocal. ACIS was associated with lesions of the squamous epithelium, mostly severe, in 25 cases. On review, all cervical smears were positive and ACIS could be specifically diagnosed in 24 cases. Pretreatment biopsies showed ACIS in 28 cases. Detection of early invasive adenocarcinoma required cone biopsy in most cases. Colposcopy showed no characteristics of ACIS. The detection of ACIS depended on the extension of the lesion. Conization with uninvolved margins was an adequate treatment. Residual ACIS was only found in cases with coexisting early invasive adenocarcinoma. No recurrences or frankly invasive adenocarcinomas have been observed during the observation period.

Primary carcinoma of the vagina: a study of 29 cases

Twenty-nine cases of primary carcinoma of the vagina were reviewed. Vaginal carcinoma produced symptoms in 26 cases and postmenopausal bleeding was the most frequently observed symptom. Squamous carcinoma was the dominating histologic type (83%). Twelve patients had previously been treated for invasive or preinvasive cervical disease. Six patients had previously received pelvic irradiation. The median time from cervical carcinoma to vaginal carcinoma was 20 years, and from pelvic irradiation to vaginal carcinoma, 25 years. Two factors significantly influenced the results of treatment: the mode of delivery of radiation therapy and the total tumor dose. Clinical staging did not significantly influence the results of treatment although stage I patients did better than stage II-IV patients. Combination of external pelvic irradiation and brachytherapy, with a total tumor dose of 7000 R or more, was necessary to prevent local recurrence.

Verrucous carcinoma of the female genital tract: report of a case and review of the literature

Verrucous carcinoma (VC) of the female genital tract is a rare lesion, primarily affecting postmenopausal women. A case of VC of the vulva is reported, bringing the total number of VC of the female genital tract to 89. VC is a slowly growing, locally "pushing" tumor with a rather benign histologic appearance, and the clinical and histologic characteristics are described on the basis of the present report and a review of the literature. The treatment of VC is still a matter of discussion. It seems logical to treat the tumor by wide local excision, taking the lack of proof of spontaneous metastasis into consideration. Radiation therapy should be contraindicated, and local application of podophyllin, bleomycin therapy, and cryosurgery are ineffective methods in the treatment of VC.

The results of cryosurgery for cervical intraepithelial neoplasia

During 4 years, 1980-1984, 197 patients were treated for CIN II and CIN III by cryosurgery. Included were 62 patients with endocervical involvement (positive ECC). The cure rates of a single cryosurgical treatment were lowered significantly by increasing grade of CIN and by endocervical involvement. The factors influencing the cure rates of cryosurgery are discussed in relation to the results obtained in the present study. The most important step in treatment of patients with CIN by conservative methods seems to be the pretreatment evaluation and not the method of treatment. Despite the fact that we achieved good results in treating patients with CIN II and endocervical involvement (cure rate: 88.9%) it is our opinion that endocervical involvement should contraindicate conservative procedures. The potential risk of overlooking invasive disease among these patients should always be kept in mind. Careful pretreatment evaluation in patients undergoing cryosurgery is mandatory, or else this excellent method would be brought into discredit.

Treatment of habitual abortions associated with autoimmune abnormalities. A report of two cases

In a study of the etiology of idiopathic habitual abortion, we have found 2 patients with a history of 5 and 4 spontaneous abortions respectively, possibly caused by autoimmune abnormalities. In the plasma of one of the patients we had found the presence of lupus anticoagulans and other lupus antibodies, whereas the other suffered from a latent autoimmune hepatitis. We describe the successful treatment of the 2 womens' subsequent pregnancies with subcutaneous heparin supplemented with acetylsalicylic acid.

Meningismus as main symptom in toxic shock syndrome

A case of toxic shock syndrome (TSS) with meningismus as main symptom is presented. The case illustrates that, in cases of rigidity of the neck and back, not directly explainable, TSS should be considered as a possible diagnosis. Toxic syndrome (TSS) is a severe, acute infectious disease with great variations in symptomatology (1,2). Its lethality is approximately 5% (3). The prognosis depends on early diagnosis and treatment.

Blind children's language: resolving some differences

Although the role of visual perception is central to many theories of language development, researchers have disagreed sharply on the effects of blindness on the acquisition process: some claim major differences between blind and sighted children; others find great similarities. With audio-and video-recorded longitudinal data from six children (with varying degrees of vision) aged 0; 9–3; 4, we show that there ARE basic differences in early language, which appear to reflect differences in cognitive development. We focus here on early lexical acquisition and on verbal role-play, demonstrating how previous analyses have failed to observe aspects of the blind child's language system because language was considered out of the context of use. While a comparison of early vocabularies does suggest surface similarities, we found that when sighted peers are actively forming hypotheses about word meanings, totally blind children are acquiring largely unanalysed ‘labels’. They are slow to extend words and rarely overextended any. Similarly, although verbal role-play appears early, attempts to incorporate this kind of language into conversations with others reveal clear problems with reversibility – specifically, the ability to understand the role of shifting perspectives in determining word meaning. Examination of language in context suggests that blind children have difficulties in just those areas of language acquisition where visual information can provide input about the world and be a stimulus for forming hypotheses about pertinent aspects of the linguistic system.