Prenatal nutrition: special considerations.

Awareness of the importance of nutrition during pregnancy has increased in recent years.Pregnancy outcomes vary by prepregnant weight as well as gestational weight gain. Inappropriate gain may have both short- and long-term consequences for mother and infant. This review article includes the newly released US Institute of Medicine prenatal weight gain guidelines, as well as the Dietary Reference Intakes for the US and selected European societies.Food safety topics are discussed including Listeria, Toxoplasma, peanuts, mercury and other contaminants. Preconceptual nutrition is discussed, as are specific at-risk prenatal nutrients, including folic acid, choline, vitamin B12, omega-3 fatty acids, iodine, calcium, vitamin D, and iron. Current controversies are discussed and practical suggestions are given to safely optimize nutrient intake. As part of the medical team, a local Registered Dietitian or other nutrition professional can give much more detailed guidance and support for a pregnant woman given her particular risk factors, including her pre-existing medical conditions and cultural concerns, and will emphasize nutritional quality rather than just pounds gained.

Extensive condyloma acuminata treated with imiquimod 5% cream: a case report.

Genital warts are one of the most common sexually transmitted infections, and are caused by human papillomavirus (HPV) types 6 and 11. Standard treatments for genital warts include cryotherapy, laser therapy, trichloroacetic acid and podophyllotoxin. We report the case of a 21-year-old female with extensive genital warts. A patient-applied, non-destructive therapy was considered to be the most appropriate treatment in this case, due to the extent of the disease and the resulting psychological distress experienced by the patient. She applied imiquimod 5% cream three times per week for a period of 5 weeks, which resulted in complete clearance of all the warts. Minor inflammatory changes were observed during treatment; however, no significant pain was by reported the patient. No recurrences were reported during 2 years of follow-up.

High-yield purification of lung surfactant proteins sp-b and sp-c and the effects on surface activity.

Several protocols for purification of milligram quantities of lung surfactant proteins (SP)-B and SP-C were studied for separation efficiency and surface activity of the isolated proteins recombined with synthetic phospholipids (SPL). SP-B and SP-C were obtained from calf lung surfactant extract by C8 chromatography with isocratic elution by either of three solvent systems: 7:1:0.4 MeOH/CHCl(3)/5% 0.1 M HCl (solvent A), 7:1 MeOH/CHCl(3)+ 0.1% TFA (solvent B), and 7:1:0.4 MeOH/CHCl(3)/H(2)O + 0.1% TFA (solvent C). Solvents A and C yielded pure apoprotein in a single pass, with estimated total protein recoveries of >85 and >90%, respectively. Solvent B was less effective in purifying SP-B and SP-C, had a lower recovery efficiency, and gave isolates with less surface activity. Mixtures of SPL plus SP-B eluted with solvents A and C adsorbed to equilibrium surface tensions of 21-22 mN/m and reached minimum surface tensions <1 mN/m during dynamic cycling. Mixtures of SPL with SP-C obtained with solvents A and C had equilibrium surface tensions of 26-27 mN/m and minimum dynamic values of 2-7 mN/m. The ability to obtain milligrams of virtually lipid-free SP-B and SP-C in a single column pass will facilitate research on their biological, structural, and biophysical properties.

Management of atypical squamous cells of undetermined significance and low-grade squamous intra-epithelial lesion by human papillomavirus testing.

Cervical cytological terminology varies from country to country. In the USA, the Pap smear is reported using the Bethesda system. The abnormal morphological changes described by this system include two very problematic categories: atypical squamous cells of undetermined significance (ASCUS) and atypical glandular cells of undetermined significance (AGUS). The management of ASCUS, which is similar to the British system 'borderline' smear, has been most problematic because the majority of women with this Pap result are normal, although approximately 5-11% have high-grade cervical intraepithelial neoplasia and 1 per 1000 has cervical cancer. Because AGUS is far less common and a significantly greater risk for high-grade cervical intraepithelial neoplasia, adenocarcinoma in situ and cancer, its management is far less controversial, but it is problematic because of clinical confusion with the ASCUS terminology. Low-grade squamous intraepithelial neoplasia is almost entirely related to human papillomavirus. Documentation that certain high-risk types of human papillomavirus are necessary in the aetiology of cervical cancer has led to investigations into the management of these equivocal and low-grade Pap smear abnormalities by testing for these human papillomavirus types.

Reporting the potential benefits of new technologies for cervical cancer screening.

The AHCPR released its evidence-based report, "Evaluation of Cervical Cytology" in early 1999. This report represents the most comprehensive analysis available to date of Pap smears and new technologies designed to improve cervical cancer screening. Both the ACOG and the AHCPR have released simplified summaries of the results of the evidence report that may lead to misunderstandings of the potential clinical impact of these new technologies. This report reviews the 4 major statements in these summaries and discusses how they are either incorrect based on the full AHCPR report or may be misinterpreted because their ramifications are not fully discussed. New screening technology has the potential to finally bring the sensitivity of a new Pap test to an acceptable level. The increased sensitivity afforded by these new technologies can reduce negative outcomes at reasonable cost-effectiveness ratios and at an equivalent or superior specificity compared to the conventional Pap smear.

Evaluation of abnormal cervical cytology.

The introduction of widespread cervical cytologic screening in the United States and in many other developed countries is clearly one of the most dramatic preventive health measures in history. This article provides a history of cervical cancer screening and a comprehensive review of management options and techniques.

Management of cervical intraepithelial neoplasia.

PIP: Three outpatient therapies--cryotherapy, laser vaporization, and loop electrosurgical excision procedure (LEEP)--are used in the US for the treatment of cervical intraepithelial neoplasia (CIN). There has been considerable controversy, however, about the relative safety, efficacy, and costs of these methods. A rigorous study (Mitchell et al.) in which patients were stratified by key prognostic variables provided irrefutable evidence of the similarity of efficacy of the three methods. This suggests that only cost and concern over the small risk of missing adenocarcinoma-in-situ or microinvasive cancer need influence decisions about CIN treatment. Women with lesions affecting more than two-thirds of the surface of the cervix are more than 19 times more likely to have persistent disease than women with smaller lesions, regardless of therapy type. The amount of tissue removed by laser, cryotherapy, and LEEP is small, so these techniques have no adverse affect on pregnancy. The issue of whether low-grade lesions should be treated, even though most are self-limiting, continues to be debated.^ieng

Colposcopy Quality Control: Establishing Colposcopy Criterion Standards for the National Cancer Institute ALTS Trial Using Cervigrams.

OBJECTIVES: The colposcopy quality control (QC) group of the Atypical Squamous Cells of Undetermined Significance-Low-Grade Squamous Intraepithelial Lesions (ASCUS/ LSIL) Triage Study (ALTS) monitors colposcopists at four clinical centers by direct observation and indirectly by assessment of digitized computer colposcopic images transferred nightly by modem. The purpose of this preclinical study was to determine the agreement among colposcopy QC monitors' colposcopic impressions and biopsy site placement through evaluation of cervical photographic images. MATERIALS AND METHODS: A nonparticipant selected 100 Cervigram slides representing four pathologically confirmed categories: cervical intraepihelial neoplasia 1(CIN), CIN2 and CIN3, normal, and cancer. our colposcopy QC monitors and two certified Cervigram evaluators independently interpreted the images for colpocopic impression on two separate occasions. Measures of agreement were calculated for intraobserver, pairwise interobserver, and observer versus histological diagnoses. Participants also indicated the most severe biopsy site by marking an χ on a 4 × 6-inch color print duplication. Mean distances between biopsy site annotations for each pair of evaluators were calculated. RESULTS: The ALTS observer agreement with histology ranged from 75.3% (K = .66) to 47.4% (K = .36) for the first evaluation and 71.1 % (K = .63) to 50.5% (K = .38) for the second evaluation. ALTS interobserver agreement varied between 71 % and 57% for the first interpretation and 76% and I2% for the second evaluation. ALTS intraobserver agreement varied from 86% (K = .86) to 68.0% (K = .60). The mean listances between biopsy site annotations for each pair of ALTS observers varied from 0.99 ± 0.93 mm to 1.44 ± 1.19 nm. CONCLUSIONS: The ALTS colposcopy QC monitors achieved poor to good observer agreement with histology, fair to excellent interobserver agreement, and good to excellent intraobserver agreement in assessing the severity of cervical images. These levels of agreement are similar to many reported by pathologists for cervical cytology and histology interpretations. Monitors also demonstrated a very narrow variation of distance (< 2 mm) for ideal biopsy site placement.

Clinical role of HPV testing.

The subjectivity of morphologic methods contributes to a "swamping" of colposcopic services, excessive costs, overdiagnosis, and overtreatment. HPV DNA testing provides the objectivity required to clarify difficult patient management issues, including follow-up, for low-grade cytologic abnormalities (ASCUS and LSIL), noncorrelating (nonconfirmed) Pap smears, evaluation of nondiagnostic lower genital tract lesions, and cytology and histology laboratory quality assurance. Additionally, favorable preliminary data on HPV testing as a primary screen raise the exciting prospect of potentially lowering costs of cervical cancer-screening programs, while further decreasing the incidence of cervical cancer.

Differentiating normal and abnormal findings of the vulva.

Proper evaluation of the vulva required background in general dermatology and an understanding of the special nature of many vulvar conditions. A firm understanding of normal vulvar findings is necessary to guard against overdiagnosis and unnecessary treatment. In the past few years, the most common overdiagnosis has been that of micropapillae of the inner labia minora, or acetowhite changes of the vulva, secondary to human papillomavirus (HPV) infection. Differentiating normal variants and minor nonspecific findings from well-developed disease is not always easy. Vulvar biopsy should be performed if a diagnosis cannot be made confidently by visual inspection alone. Vulvar intraepithelial neoplasia is a precancerous lesion of squamous origin associated with HPV infection. It usually occurs in younger patients. Vulvar intraepithelial neoplasia in older women is associated with chronic inflammation, especially in areas of hyperplasia and atrophy. The older patient with vulvar intraepithelial neoplasia has a higher risk of developing invasive vulvar cancer.

Human papillomavirus testing by hybrid capture appears to be useful in triaging women with a cytologic diagnosis of atypical squamous cells of undetermined significance.

OBJECTIVE: Our purpose was to determine the clinical value of human papillomavirus deoxyribonucleic acid testing with the hybrid capture test, specifically to examine whether human papillomavirus testing could identify which women with Papanicolaou smears read as atypical squamous cells of undetermined significance were most likely to have histologically confirmed cervical intraepithelial neoplasia. STUDY DESIGN: Hybrid capture testing for 14 human papillomavirus types, repeat Papanicolaou smears, and colposcopically directed biopsies were performed concurrently on 217 women referred to a student health colposcopy clinic with a previous Papanicolaou smear read as atypical squamous cells of undetermined significance. RESULTS: Human papillomavirus deoxyribonucleic acid positivity was associated with an eightfold increased likelihood of histologic confirmation of cervical intraepithelial neoplasia. The sensitivity of hybrid capture for any cervical intraepithelial neoplasia was 86% (43/50) and for grade 2 or 3 was 93% (14/15), whereas the corresponding values for the repeat Papanicolaou smear were 60% (30/50) and 73% (11/15), respectively. Moreover, high viral levels of human papillomavirus types known to be associated with cervical cancer were strongly predictive of high-grade cervical intraepithelial neoplasia. CONCLUSIONS: Testing for human papillomavirus deoxyribonucleic acid with hybrid capture appears to offer an effective means by which patients whose cervical Papanicolaou smears have been read as atypical squamous cells of undetermined significance could be triaged for colposcopy. In particular, sensitivity for high-grade cervical intraepithelial neoplasia could be maintained and specificity markedly improved by referring only those patients who had elevated levels of human papillomavirus deoxyribonucleic acid of cancer-associated viral types.