Serial neuropsychological testing in MOG antibody-associated disease to improve understanding of outcomes.

Neurocognitive outcomes data in patients with myelin oligodendrocyte glycoprotein (MOG) antibody-associated disease are limited. Within MOG-positive cohorts, outcomes data typically utilize gross psychological, cognitive, or physical disability measures. Here, we report a pediatric patient who presented with two clinically heterogeneous events and was found to have MOG-associated encephalomyelitis. We administered detailed neuropsychological test batteries to obtain a robust understanding of the patient's neurocognitive profile over time. This case exemplifies the need to perform systematic and serial neuropsychological testing in patients with MOG-associated disease to better understand neurocognitive outcomes, facilitate multidisciplinary management, and improve recovery.

A Critical Review of All Known Published Records for Water Mite (Acari: Hydrachnidiae) and Mosquito (Diptera: Culicidae) Parasitic Associations From 1975 to Present.

All published records of water mite-mosquito parasitic associations since Gary R. Mullen's comprehensive review in the 1970s of the literature were critiqued to provide an up-to-date account on the identity of water mites parasitizing mosquitoes and their geographic distribution. In total, 321 records in 62 sources were identified, with each record representing an association specific to a state, province, or region within a country. The greatest number of records were from the United States (120), followed by India (106) and Canada (40). In all, 105 species of mosquitoes were parasitized, with the majority belonging to the genera Aedes sensu lato (30), Anopheles (30), and Culex (21). Records were biased toward mosquito genera with the greatest number of freshwater species and medical importance. Most water mites belonged to the genus Arrenurus, or were Parathyas barbigera (Viets 1908). Arrenurus water mites were often not identified to species, but 15 different Arrenurus species were determined in 119 records. All but one of the species (i.e., Arrenurus madaraszi Daday 1898) were only reported from Canada, Germany, or the United States. Although a greater proportion of sources reviewed by us compared with Mullen's review identified water mites down to the level of genus, to better understand the biological significance of mite and mosquito interactions, more of an effort is needed to identify the species of water mites. The availability of molecular techniques such as DNA barcoding will make this goal more attainable.

Seasonal Activity, Density, and Collection Efficiency of the Blacklegged Tick (Ixodes scapularis) (Acari: Ixodidae) in Mid-Western Pennsylvania.

Although Pennsylvania has recently reported the greatest number of Lyme disease cases in the United States, with the largest increase for PA occurring in its western region, the population biology of the blacklegged tick (Ixodes scapularis Say) has not been adequately characterized in western PA. We studied the seasonal activity of host-seeking I. scapularis larvae, nymphs, and adults in mid-western PA over the course of a year, including a severe winter, and determined their absolute densities and collection efficiencies using replicated mark-release-recapture or removal methods. Our results are compared to those from similar studies conducted in the highly Lyme disease endemic Hudson Valley region of southeastern New York State. The seasonal activity of I. scapularis was intermediate between patterns observed in the coastal northeastern and upper Midwestern United States. Only one peak of larval activity was observed, which was later than the major peak in the Midwest, but earlier than in the northeast. Seasonal synchrony of larvae and nymphs was similar to the northeast, but the activity peaks were much closer together, although not completely overlapping as in the Midwest. Pre- and postwinter relative densities of questing adult I. scapularis were not significantly different from one another. The absolute densities and collection efficiencies of larvae, nymphs, and adults were comparable to results from classic research conducted at the Louis Calder Center in Westchester County, NY. We conclude that the population biology of I. scapularis in mid-western PA is similar to southeastern NYS contributing to a high acarological Lyme disease risk.

Prevalence Rates of Borrelia burgdorferi (Spirochaetales: Spirochaetaceae), Anaplasma phagocytophilum (Rickettsiales: Anaplasmataceae), and Babesia microti (Piroplasmida: Babesiidae) in Host-Seeking Ixodes scapularis (Acari: Ixodidae) from Pennsylvania.

The etiological agents responsible for Lyme disease (Borrelia burgdorferi), human granulocytic anaplasmosis (Anaplasma phagocytophilum), and babesiosis (Babesia microti) are primarily transmitted by the blacklegged tick, Ixodes scapularis Say. Despite Pennsylvania having in recent years reported the highest number of Lyme disease cases in the United States, relatively little is known regarding the geographic distribution of the vector and its pathogens in the state. Previous attempts at climate-based predictive modeling of I. scapularis occurrence have not coincided with the high human incidence rates in parts of the state. To elucidate the distribution and pathogen infection rates of I. scapularis, we collected and tested 1,855 adult ticks statewide from 2012 to 2014. The presence of I. scapularis and B. burgdorferi was confirmed from all 67 Pennsylvania counties. Analyses were performed on 1,363 ticks collected in the fall of 2013 to avoid temporal bias across years. Infection rates were highest for B. burgdorferi (47.4%), followed by Ba. microti (3.5%) and A. phagocytophilum (3.3%). Coinfections included B. burgdorferi+Ba. microti (2.0%), B. burgdorferi+A. phagocytophilum (1.5%) and one tick positive for A. phagocytophilum+Ba. microti. Infection rates for B. burgdorferi were lower in the western region of the state. Our findings substantiate that Lyme disease risk is high throughout Pennsylvania.

Human leukocyte antigen class I and II alleles and risk of cervical neoplasia: results from a population-based study in Costa Rica.

To examine human leukocyte antigen (HLA) involvement in the development of all grades of cervical neoplasia, a nested case-control study of 10,077 women in Guanacaste, Costa Rica, was conducted. Participants had invasive cervical cancer, high-grade squamous intraepithelial lesions (HSILs; n=166), or low-grade squamous intraepithelial lesions (LSILs); were positive for human papillomavirus (HPV) with no evidence of cervical neoplasia (n=320); or were HPV negative with no evidence of cervical neoplasia but with a history of high-risk sexual behavior (n=173). Compared with women who were HPV negative, women with HLA-DRB1*1301 were associated with decreased risk for cancer/HSILs (odds ratio [OR], 0.4; 95% confidence interval [CI], 0.2-0.7) and for LSILs/HPV (OR, 0.6; 95% CI, 0.3-0.9). Women with both HLA-B*07 and HLA-DQB1*0302 had an 8.2-fold increased risk for cancer/HSILs (95% CI, 1.8-37.2) and a 5.3-fold increased risk for LSILs/HPV (95% CI, 1.2-23.7). These results support the hypothesis that multiple risk alleles are needed in order to increase risk for cervical neoplasia, but a single protective allele may be sufficient for protection.

An association of cervical inflammation with high-grade cervical neoplasia in women infected with oncogenic human papillomavirus (HPV).

Previous reports of genital conditions, such as nonspecific genital infection/sore or vaginal discharge associated with cervical cancer (L. A. Brinton et al., J. Natl. Cancer Inst. (Bethesda), 79: 23-30, 1987; C. J. Jones et al., Cancer Res., 50: 3657-3662, 1990), suggest a possible link between either genital tract inflammation or changes in bacteria flora consistent with bacterial vaginosis (BV) and cervical cancer. To test whether changes in vaginal bacterial flora or the degree of cervical inflammation are associated with women having a human papillomavirus (HPV) infection or with women infected with oncogenic HPV having high-grade cervical lesions (high-grade squamous intraepithelial lesions or cancer), we conducted a case-control study of women <50 years old enrolled in the Costa Rican natural history study of HPV and cervical neoplasia. To test whether BV and inflammation were associated with HPV DNA positivity, Analysis 1 was restricted to women with no or mild (low-grade or equivocal) cytological abnormalities, and the degree of inflammation and Nugent score (a measure of BV) were compared between women infected (n = 220) and not infected (n = 130) with HPV. To test whether BV and inflammation were associated with high-grade lesions, Analysis 2 was restricted to women infected with oncogenic HPV, and the degree of inflammation and Nugent score were compared between women with (n = 95) and without (n = 158) high-grade cervical lesions. In Analysis 1, BV and cervical inflammation were not associated with HPV infection. In Analysis 2, BV was not associated with high-grade lesions. However, we found a marginally significant positive trend of increasing cervical inflammation associated with high-grade lesions in oncogenic HPV-infected women, (P(trend) = 0.05). Overt cervicitis was associated with a 1.9-fold increase in risk of high-grade lesions (95% confidence interval, 0.90-4.1). The results of this study suggest that cervical inflammation may be associated with high-grade lesions and may be a cofactor for high-grade cervical lesions in women infected with oncogenic HPV.

Atypical squamous metaplastic cells: reproducibility, outcome, and diagnostic features on ThinPrep Pap test.

BACKGROUND: Atypical squamous metaplastic (ASM) cells are associated with high-grade squamous intraepithelial lesions (HGSIL) in many cases. The reproducibility of the diagnosis and biopsy follow-up results of cases designated as ASM were studied at Women and Infants' Hospital of Rhode Island. METHODS: Of 180 patients with ASM who the authors examined from January 1, 1998 to September 30, 1998, 147 (81.7%) had subsequent biopsies. Results of the biopsies were tallied. Twenty cases were rescreened in a blinded fashion to determine intra- and interobserver agreement and to identify diagnostic features. RESULTS: Sixty-five (44.2%) cases of ASM had HGSIL on biopsy, 26 (17.7%) had low-grade squamous intraepithelial lesion, and 56 cases (38.1%) were benign. Overall individual consistency is 8 of 16 (50%), and overall agreement is 13 of 64 (20%). CONCLUSIONS: Sixty-two percent of cases designated as ASM cytologically were associated with SIL, primarily HGSIL, at biopsies. The findings underscore the importance of this subcategory of atypical squamous cells. However, poor reproducibility suggests the need for refined criteria and/or continuing education, and obtaining second opinion. Cancer (Cancer Cytopathol)

Sampling, sampling errors and specimen preparation.

To obtain an adequate cervical smear for making a correct cytologic diagnosis, smear taking, laboratory handling and interpretation must be optimal. Many people are involved, and only by a combined effort of all links can this target be seriously approached: the smear takers will have to be open minded about technical improvements and read the morphologic descriptions cautiously; in the laboratory, cytotechnicians and physicians will have to challenge themselves and each other. It is mandatory to discard specimens that do not meet general standards of adequacy. At present a host of new techniques are being implemented. It is not feasible for all laboratories to be engaged in testing these new methods, but we are all requested to follow the development the best we can and switch to new ways when justified. Our working conditions are very different; therefore, it is our professional responsibility and plight to respond at the right time. So far the conclusion is that the conventional Pap smear is the international standard of care for the diagnosis of cervical cancer precursers in cancer screening programs. Certainly, this may change within a very short time. Liquid-based techniques, and in particular HPV technologies, are just around the corner.

Clinical and cost implications of new technologies for cervical cancer screening: the impact of test sensitivity.

OBJECTIVE: To compare the available techniques for cervical cancer screening, including several new technologies, using actual program utilization patterns. STUDY DESIGN: Longitudinal cohort model. PATIENTS AND METHODS: The model followed a cohort of 100,000 women who underwent screening from age 20 through 65 years. The model was run with a weighted average of screening intervals to model the actual utilization of the cervical cancer screening program in the United States. RESULTS: The model demonstrated that new technologies with significantly increased test sensitivity have the potential to reduce the number of cancers by 45% to 60% depending on the screening frequency in fully compliant populations. At screening intervals of 2 years or more, these new technologies had cost-effectiveness ratios below $50,000 per life-year saved. Assuming existing utilization patterns, the model predicted there would be 13.2 cancers per year in the 100,000 women screened with the conventional Pap smear, and new technologies with increased test sensitivity could reduce the annual incidence to 9.5 cancers per 100,000 women screened. CONCLUSIONS: The model suggests that to achieve further dramatic reduction in cervical cancer mortality, significant improvements in test sensitivity, as reflected in the new screening technologies, may be the most realistic and cost-effective approach.

The false negative rate of cervical smears in high risk HIV seropositive and seronegative women.

We undertook a prospective study of cytology and concurrent colposcopically directed biopsies of both Human Immunodeficiencey Virus seronegative (HIV-) and seropositive (HIV +) women at high risk for cervical intraepithelial neoplasia (CIN) to determine the accuracy of Pap smears in this population. Women were recruited from a sexually transmitted disease clinic and a women's prison in eastern Massachusetts. All were interviewed, blood was tested for HIV with CD4 counts done in 101 of the 102 HIV + women, and all received a pelvic exam that included a conventional Pap smear, a Thinprep test, and colposcopy with directed biopsies and endocervical curettage. A total of 184 women volunteered. 82 were HIV- and 102 were HIV+. The prevalence of CIN in HIV+ women was 37%, more than twice the 17% prevalence of CIN in HIV-women (P = 0.002). When Atypical Squamous Cells of Undetermined Significance (ASCUS) findings were included with "negative" cytology, the conventional Pap smear false negative rates for HIV- and HIV+ women were 21% and 37%, respectively. When ASCUS was included with "positive" cytology, the false negative rates dropped to 14.3% for HIV- women and 10.5% for HIV+ women. We conclude that ASCUS diagnoses comprised the majority of false negatives in HIV+ women.

Preclinical feasibility study of NMP179, a nuclear matrix protein marker for cervical dysplasia.

OBJECTIVE: To evaluate, in a preclinical feasibility study, the efficacy of NMP179, a monoclonal antibody recognizing a cervical tumor-associated nuclear matrix antigen, for the early detection of high and low grade cervical intraepithelial neoplasia. STUDY DESIGN: In a blind study involving two clinical sites, NMP179 immunocytochemical staining data from 261 cervicovaginal Thin-Prep specimens were evaluated. Assay sensitivity and specificity were calculated based upon a positive threshold of > 10 immunostained cells per case, using cytologic diagnosis as an end point. RESULTS: Based upon the examination of squamous epithelial cells, NMP179 detected 96.7% of cases with cytologically diagnosed high grade squamous intraepithelial lesions (HSIL) and 70.5% of low grade squamous intraepithelial lesions. The antibody also reacted with 29.6% of normal (within normal limits or benign cellular changes) smears. CONCLUSION: The NMP179 assay detected HSIL with very high accuracy (96.7%). The assay was 79.3% sensitive for the detection of low and high grade cervical intraepithelial neoplasia (grades 1-3), with a specificity of 70.4%. NMP179 may be an effective marker for the early detection of preneoplastic squamous intraepithelial lesions of the cervix and may be useful as an adjunctive tool for better management of cervical intraepithelial neoplasia.

Utility of liquid-based cytology for cervical carcinoma screening: results of a population-based study conducted in a region of Costa Rica with a high incidence of cervical carcinoma.

BACKGROUND: In a study using a split-sample design, liquid-based cytology (ThinPrep Processor, Cytyc Corporation, Boxborough, MA) was compared with the conventional Papanicolaou (Pap) smear in Guanacaste, Costa Rica. The study provides the first population-based comparison of the ThinPrep screening technology and includes "gold standard" measures of diagnostic accuracy. METHODS: The population-based study was performed among over 8000 women residing in a Costa Rican province with a high incidence of cervical carcinoma. Conventional smears were prepared and diagnosed in Costa Rica, while the residual material on the sampling device was collected into a liquid preservative and shipped to the U.S., where ThinPrep cytologic slides were prepared and diagnosed. Cytologic diagnoses based on the two techniques, categorized according to the Bethesda System, were compared with a "gold standard" final case diagnosis for each patient, also based on Bethesda terminology, that reflected an integrated interpretation of all available data, including cytology, histology, and cervicography. Results were also compared with the results of HPV DNA detection (Hybrid Capture, Digene Corporation, Silver Spring, MD). RESULTS: ASCUS was the threshold for colposcopy referral. There were significantly more women referred according to this threshold with the ThinPrep slide (12.7%) than with the conventional smear (6.7%, P<0.001). Compared with the final case diagnosis, referral by ThinPrep slides detected 92.9% of cases with high grade squamous intraepithelial lesions (HSIL) and 100% of carcinoma cases. Smears detected 77.8% of HSIL and 90.9% of carcinomas. Thus, ThinPrep cytology was significantly more sensitive in the detection of HSIL and cancer (McNemar test, P<0.001). Adjudication of cases in which the ThinPrep and smear diagnoses disagreed, using the final case diagnoses and the HPV DNA test results as reference standards, suggested that the ThinPrep method was detecting additional true SIL as opposed to false-positives. CONCLUSIONS: In a population-based study of high risk women, ThinPrep cytology demonstrated significantly increased sensitivity for detecting HSIL and carcinoma, with a concurrent significant increase in colposcopy referrals.

Soluble interleukin 2 receptor levels and cervical neoplasia: results from a population-based case-control study in Costa Rica.

Progression from infection with human papillomavirus (HPV) to cervical cancer in some women is thought to involve a permissive host environment, one in which immune response is mobilized in an inappropriate manner. In a previous study (A. Hildesheim et al., Cancer Epidemiol. Biomark. Prev., 6: 807-813, 1997), increasing levels of soluble interleukin 2 receptor (sIL-2R), a known proxy for general immune activation, was found to be positively associated with increasing levels of cervical neoplasia. We attempted to confirm this finding by conducting a nested case-control study of 478 women within a 10,000-woman population-based cohort in Costa Rica. We selected for the study all of the women diagnosed (at enrollment into the cohort) with: (a) low-grade squamous intraepithelial lesions (LSIL, n = 191); (b) high-grade squamous intraepithelial lesions (HSIL, n = 130); or (c) cancer (n = 37). Controls were 120 cytologically normal, HPV-negative women selected from a random sample of the entire cohort. A questionnaire was administered to participants to elicit information on cervical cancer risk factors. All of the women received a pelvic examination during which cervical cells were collected and used for HPV DNA testing by PCR. Blood samples were also collected. Plasma obtained from the blood samples was tested for sIL-2R levels by ELISA. Results indicated that sIL-2R levels increased with age. Among controls, we observed that 44.3% of women over the age of 50 had high levels of sIL-2R (defined as >735 units/ml) compared with 15.8% of women <30 years of age (P = 0.008). When women with cervical disease (LSIL+) were compared with controls, women in the upper quartile of the sIL-2R distribution had an age-adjusted odds ratio (OR) of 2.1 [95% confidence interval (CI), 1.1-4.1]. Comparing each advancing state of neoplasia with its precursor, we found that women with LSIL had higher sIL-2R levels than controls (OR for upper quartile of sIL-2R, 2.3; 95% CI, 1.1-5.2; comparing LSIL cases with controls); women diagnosed with HSIL were similar to the LSIL group (OR for upper quartile of sIL-2R, 1.1; 95% CI, 0.5-2.4; comparing HSIL cases with LSIL cases); and those with cancer had higher sIL-2R levels than subjects with an HSIL diagnosis (OR for upper quartile of sIL-2R = 1.8; 95% CI, 0.5-7.1; comparing cancer cases with HSIL cases). These data suggest that among our study subjects, sIL-2R levels most likely rise as a response to the events of infection and cancerous invasion, but that sIL-2R levels are unlikely to be predictive of disease progression among women with LSIL.

Cervicography screening for cervical cancer among 8460 women in a high-risk population.

OBJECTIVE: Cervicography was evaluated as a primary screening method for cervical cancer. STUDY DESIGN: Cervigrams of 8460 women were taken on enrollment into a population-based study of cervical neoplasia. Cervicography results were compared with a referent diagnosis determined by histologic analysis and 3 cytologic tests, and with the performance of conventional cytologic evaluation. RESULTS: Cervicography identified all 11 cancers, whereas cytologic testing missed 1. Cervicography yielded sensitivities for detecting high-grade squamous intraepithelial lesions or cancer of 49.3% overall (specificity, 95.0%), 54.6% in women younger than 50 years of age, and 26.9% in women 50 years of age and older. Cytologic testing yielded sensitivities for detecting high-grade squamous intraepithelial lesions or cancer of 77.2% overall (specificity, 94. 2%), 75.5% in women younger than 50 years of age, and 84.6% in women 50 years of age and older. CONCLUSIONS: Cytologic testing performed better than cervicography for the detection of high-grade squamous intraepithelial lesions. Cervicography performed marginally better than cytologic testing for the detection of invasive cervical cancer. Cervicography is not recommended for postmenopausal women.

Performance of a semiautomated Papanicolaou smear screening system: results of a population-based study conducted in Guanacaste, Costa Rica.

BACKGROUND: Automated cytology devices have utility in quality assurance applications, but the effectiveness of these devices in primary screening is unknown. METHODS: Enrollment smears obtained from 7323 women participating in a population-based study sponsored by the National Cancer Institute were screened manually in Costa Rica and then evaluated independently in the U.S. with the PAPNET system (Neuromedical Systems, Inc., Suffern, NY), a semiautomated, neural network-based device. Smears with abnormal PAPNET images were microscopically rescreened and then diagnosed by a U.S. cytopathologist. ThinPrep slides (Cytyc Corporation, Boxborough, MA), prepared from rinses of the cytologic sampler, and cervigrams (National Testing Laboratories, Fenton, MO) were also evaluated. Women with any abnormal cytologic diagnosis or a positive cervigram were referred for colposcopy with biopsy and definitive therapy if indicated. RESULTS: Based on the U.S. cytotechnologist's review of the PAPNET images, 1017 (13.9%) of 7323 smears were selected for manual screening, resulting in the selection of 492 (6.7%) possibly abnormal slides for referral to the U.S. pathologist. Ultimately, 312 smears (4.3% of the total) were diagnosed as containing squamous cells of undetermined significance or a more severe abnormality (> or =ASCUS), resulting, hypothetically, in the referral of 66.5% of women with a final diagnosis of a squamous intraepithelial lesion or a more severe abnormality (> or =SIL) and 86.0% of patients with > or =high grade SIL. Conventional microscopic screening performed in Costa Rica resulted in the hypothetical referral of 6.5% of patients with > or =ASCUS for colposcopy, including 69.5% of patients with > or =SIL and 79.8% of those with > or =high grade SIL. CONCLUSIONS: In this study, PAPNET-assisted cytologic screening accurately identified smears obtained from women with high grade SIL or carcinoma. Determination of the clinical cost-effectiveness of PAPNET-assisted screening in routine practice awaits future study.

Cell preparation methods and criteria for sample adequacy. International Academy of Cytology Task Force summary. Diagnostic Cytology Towards the 21st Century: An International Expert Conference and Tutorial.

ISSUES: Cell Preparation Methods Standardized fixation and optimal staining Sampling of cervix, sampling error, homogenization of sample, subsampling Assessment of liquid-based preparations: efficacy and economic impact Training and transitional procedures before full implementation of new technologies Criteria for Sample Adequacy Clinician responsibility for collecting and providing representative sample to laboratory Collection instruments, number of slides Cellular content of samples: evidence of transformation zone (TZ) sampling, number of squamous cells present, obscuring factors Screening issues CONSENSUS POSITION The conventional cervical smear remains the standard method of cervical cancer screening but has limitations in individual test sensitivity and specificity. Sample takers should: (1) receive appropriate training in sample collection, (2) be held responsible for providing the laboratory with appropriate samples, and (3) have their performance monitored. The instruments used for sampling should collect cells from both the ectocervix and endocervix; optimally, TZ sampling, represented by the presence of endocervical or squamous metaplastic cells, should be identifiable in samples other than atrophic specimens. The adequacy of a specimen (as judged microscopically) does not guarantee that it is representative of the cervix. Each cytology report should include a comment on cellular content/adequacy of the specimen. Liquid-based preparations may overcome many of the inherent problems with the conventional cervical smear. ONGOING ISSUES: We need further data on the cost-effectiveness of making two slides from cervical specimens and/or using two samplers rather than a single one. Do we have enough information to make recommendations as to the appropriate type of sampler to be used in particular situations, such as routine screening? What is the best method of screening for/detecting endocervical glandular neoplasia? How are such terms as unsatisfactory and inadequate defined in cervical cytology classifications other than the Bethesda System? What number and types of epithelial cells should be present (visualized) in a cervical smear or liquid-based preparation for it to be considered adequate? Do we need to have evidence of TZ sampling in specimens taken during the follow-up period after treatment of squamous intraepithelial lesion or after detection of endocervical glandular neoplasia? What criteria for obscuring factors, such as blood and inflammation, should be used in assessing adequacy? Cost-benefit analyses of utilizing liquid-based preparations are needed. Should we inform women about the technical details of the test methods available or chosen by the laboratory? Are women in a position to decide which method is the most appropriate to assess their cervical scrape sample? We need to obtain more information about the properties of proprietary liquid fixative/transport media with respect to inactivation of viral pathogens, tuberculosis and other bacterial pathogens and suitability for immunobiologic and molecular tests, etc. We need to obtain more information on the use of stoichiometric stains and the limitations of Papanicolaou stain for image analysis systems. The use of liquid-based preparations for nongynecologic cytopathology and ancillary tests must be considered, including criteria for adequacy. We need to obtain more information on the time required for and best methods of training experienced cytotechnologists to become competent at assessing liquid-based cervical preparations.

Computerized screening devices and performance assessment: development of a policy towards automation. International Academy of Cytology Task Force summary. Diagnostic Cytology Towards the 21st Century: An International Expert Conference and Tutorial.

ISSUES: The extension of automation to the diagnostic assessment of clinical materials raises issues of professional responsibility, on the part of both the medical professional and designer of the device. The International Academy of Cytology (IAC) and other professional cytology societies should develop a policy towards automation in the diagnostic assessment of clinical cytologic materials. CONSENSUS POSITION: The following summarizes the discussion of the initial position statement at the International Expert Conference on Diagnostic Cytology Towards the 21st Century, Hawaii, June 1997. 1. The professional in charge of a clinical cytopathology laboratory continues to bear the ultimate medical responsibility for diagnostic decisions made at the facility, whether automated devices are involved or not. 2. The introduction of automated procedures into clinical cytology should under no circumstances lead to a lowering of standards of performance. A prime objective of any guidelines should be to ensure that an automated procedure, in principle, does not expose any patient to new risks, nor should it increase already-existing, inherent risks. 3. Automated devices should provide capabilities for the medical professional to conduct periodic tests of the appropriate performance of the device. 4. Supervisory personnel should continue visual quality control screening of a certain percentage of slides dismissed at primary screening as within normal limits (WNL), even when automated procedures are employed in the laboratory. 5. Specifications for the design of primary screening devices for the detection of cervical cancer issued by the IAC in 1984 were reaffirmed. 6. The setting of numeric performance criteria is the proper charge of regulatory agencies, which also have the power of enforcement. 7. Human expert verification of results represents the "gold standard" at this time. Performance characteristics of computerized cytology devices should be determined by adherence to defined and well-considered protocols. Manufacturers should not claim a new standard of care; this is the responsibility of the medical community and professional groups. 8. Cytology professionals should support the development of procedures that bring about an improvement in diagnostic decision making. Advances in technology should be adopted if they can help solve problems in clinical cytology. The introduction of automated procedures into diagnostic decision making should take place strictly under the supervision and with the active participation and critical evaluation by the professional cytology community. ONGOING ISSUES: Guidelines should be developed for the communication of technical information about the performance of automated screening devices by the IAC to governmental agencies and national societies. Also, guidelines are necessary for the official communication of IAC concerns to industry, medicolegal entities and the media. Procedures and guidelines for the evaluation of studies pertaining to the performance of automated devices, performance metrics and definitions for evaluation criteria should be established.

Evaluation of costs and benefits of advances in cytologic technology. International Academy of Cytology Task Force summary. Diagnostic Cytology Towards the 21st Century: An International Expert Conference and Tutorial.

ISSUES: Uterine cervical cytology smears are among the most cost-effective cancer prevention interventions available, but they are not infallible, and new or modified technologies have been and will be proposed to improve diagnostic accuracy. Before these new technologies are accepted, their performance attributes will be carefully studied and defined. Equally important in this era of fiscal constraints are cost/benefit analyses, for which we review certain guidelines. CONSENSUS POSITION: In an effort to control rising costs in the health care sector, there has been a strong incentive to move toward a market system, and a variety of forces are acting to drive down expenditures. These same pressures will continue to be brought to bear on the providers of cervical cytology services. It must be emphasized that the technical knowledge required to define cost-effective medical practice lies within the medical profession itself, which must recognize the following: (a) Resources are finite; (b) Elimination of fraud, abuse and waste is not enough to bring health care expenditures down to levels considered acceptable to government and business; (c) The medical profession must take the responsibility to identify the health and economic consequences of the services it provides and make wise recommendations for allocation of resources to optimize health consequences. The analysis of costs and benefits must be viewed from a societal perspective and presented in terms of the marginal impact on current practice. This does not mean that new technologies must reduce cost; on the contrary, improvements in health can be expected to come at a price, but at a price commensurate with value gained in lives saved or in added quality adjusted life years. To be of value, a new technology for cervical cytology must be more effective in preventing cervical carcinoma. Dysplasia is considered a precursor of carcinoma, and detection of dysplasia has been a surrogate for prevention of cervical carcinoma, but dysplasia does not always lead to carcinoma, least of all mild dysplasia, and policy makers ultimately will insist that a favorable change in health outcome be effected by new technology before it is allocated resources. Alternatively, new technologies may lower cost, perhaps by modifying screening or rescreening procedures according to known risk; by improved cytopreparatory techniques that simplify, improve or speed screening; or by monitoring devices that minimize screening error. In each case the performance attributes of the instrument or human instrument process should be evaluated in the intended use environment. ONGOING ISSUES: While current cervical cytology methodology is one of the most effective means of cancer prevention, there continues to be development of new techniques to increase the sensitivity and specificity of this test. With present fiscal constraints, these will be subject to stringent cost/benefit analyses in which the medical profession must play a key role. Such analyses can be quite complicated, considering the additional costs or cost savings of clinical follow-up procedures and the reliability of dysplasias detected by cytology as a surrogate for cervical carcinoma in calculating quality of life years saved.

Improved Accuracy for Cervical Cytology with the ThinPrep Method and the Endocervical Brush-Spatula Collection Procedure.

OBJECTIVE: Our objective was to assess the sensitivity of a fluid-based, thin-layer slide preparation system (ThinPrep; Cytyc Corporation, Boxborough, MA), as compared to conventional Papanicolaou smears obtained with the endocervical brush and spatula sampling devices. PATIENTS AND METHODS: Two groups totaling 1,583 patients, all of whom were attending Planned Parenthood of the Rocky Mountains clinics, were included in the study. Cervical cell samples taken with the endocervical brush and plastic spatula were used first to make a conventional smear. Then the residual cells were rinsed into a vial containing preservative fluid, from which a ThinPrep slide was made. Screening and diagnosis of ThinPrep and conventional slides were blinded. RESULTS: The ThinPrep method demonstrated 110% greater detection of low-grade squamous intraepithelial lesions and more severe diagnoses as compared to the conventional smear. The ThinPrep method yielded 54% more high-grade squamous intraepithelial lesions than did the conventional smears. Review by an independent pathologist confirmed the significant increase in detection of low-grade squamous intraepithelial lesions and more severe diagnoses. CONCLUSION: The data from more than 1,500 patients indicate improved sensitivity for the detection of disease with the ThinPrep cervical slide preparation method.