The impact of HPV cervical screening on negative large loop excision of the transformation zone (LLETZ): A comparative cohort study.

OBJECTIVE: To determine the incidence and predictors of negative large loop excision of the transformation zone (LLETZ) following the introduction of Human Papillomavirus (HPV) cervical screening. METHOD: A retrospective cohort study. Two independent cohorts, who attended for a LLETZ procedure, before and after the introduction of HPV cervical screening were compared. For each cohort, 401 individuals were randomly selected from a colposcopy database. Clinical and colposcopic variables were extracted. The incidence of negative LLETZ was estimated in each cohort. Regression analysis was used to adjust for potential confounders and explore predictors of negative LLETZ. RESULTS: Eighty women (19.9%) from the pre-HPV testing cohort and 54 women (13.4%) from the post-HPV cohort were negative for cervical intraepithelial neoplasia (RR 0.75, CI: 0.55 to 0.93). In the post-HPV testing cohort, independent predictors of negative LLETZ were low grade cytology (RR 3.60, CI: 2.18-5.97) and a type 3 transformation zone (TZ) (RR 2.88, CI: 1.76-4.72). Women with both low grade cytology and a TZ type 3 were 10.4 times more likely to have a negative LLETZ (absolute risk 40%, 95% CI: 27-54%). CONCLUSIONS: Despite a 25% reduction in negative LLETZ following the introduction of HPV cervical screening, the incidence is still high. These results highlight the importance of continuing to improve the specificity of cervical intraepithelial neoplasia screening; this should include the use of biomarkers that detect HPV-transforming infections and techniques that sample an entirely endocervical transformation zone.

Long-term results of coronary bypass surgery. Analysis of 1698 patients followed 15 to 20 years.

Between 1968 and 1975, 1698 patients underwent coronary artery bypass with autogenous saphenous vein and were followed for up to 20 years. Age at operation was 53.9 +/- 8.4 years, and 1485 were men (88%). Angina was present in 1637 patients (96%). There was single-vessel disease in 306 patients (18%), double-vessel in 642 (38%), triple-vessel in 550 patients (32%) and left main stenosis in 200 (12%). Preoperative left ventricular quality was good in 1185 (70%), poor in 508 (30%), and unknown in five patients. Survival at 20 years was as follows: for single-vessel disease, 40%; double-vessel, 26%; triple-vessel, 20%; and left main, 25%. At 20 years of follow-up, 67% of surviving patients were asymptomatic and 26% were improved. Antianginal drug therapy consisted of nitrates in 49% of patients and beta-blockers in 26%. Graft patency at 0 to 5 years was 633 of 780 grafts (81%); at 6 to 10 years, 415 of 606 grafts (68%); at 11 to 15 years, 271 of 449 grafts (60%); and at 16 to 20 years, 65 of 140 grafts (46%). Coronary bypass reoperation was performed in 324 patients (19%) and survival of these patients was 62% compared to 37% for nonreoperation patients (p less than 0.05). Cox analysis demonstrated that the major determinants of survival related to age at operation, extent of coronary disease, quality of ventricle, history of stroke, and preoperative congestive heart failure. At 20 years of follow-up of this early experience with coronary bypass, 76% of surviving patients had one or more patent grafts and the probability of freedom from reoperation was 0.62.

Severe diabetic retinopathy at presentation in a young man.

A 22 year old man presented with a severe ischaemic diabetic retinopathy and, in spite of photocoagulation therapy, was blind in one eye 16 months after diagnosis. Four similar cases of aggressive diabetic retinopathy are reviewed. There is increasing evidence that a small group of young men with insulin dependent diabetes (IDD) may develop severe diabetic retinopathy at, or soon after, diagnosis.

Night sweats--presentation of an often forgotten diagnosis.

Night sweats are not uncommon complaints in the elderly and they are readily associated with disorders of catecholamine excess, solid malignancies and tuberculosis. We report night sweats as the presenting feature of giant cell arteritis.

Renovascular reconstruction: factors affecting long-term prognosis in 919 patients followed up to 31 years.

During the 31-year period from May 3, 1955, to May 12, 1986, renovascular reconstructions were performed on 919 patients. The mean age of the 529 men was 54 +/- 0.58 (SE) years and, of the 390 women, 48 +/- 0.7 years. Mean preoperative diastolic blood pressure was 110 +/- 0.6 mm Hg. The most common causes of renal artery stenosis were atherosclerosis in 647 patients, fibromuscular disease in 161 patients, and renal artery aneurysm in 51 patients. In the remaining 60 patients, other causes were present, including kinks and fibrous bands. The most common surgical procedures were Dacron bypass graft (780 arteries) and endarterectomy with or without a patch graft (329 arteries). Four hundred sixty-nine patients had associated operations, the most common of which were abdominal aortic aneurysmectomy in 231 and aortoiliofemoral reconstruction in 141 patients. The perioperative mortality rate was 5.5% (51 of 919 overall); for renal procedures alone, it was 1.7% (8 of 450) and for combined surgical procedures, 9.2% (43 of 469). The overall graft patency rate at a follow-up of 18.8 +/- 1.9 months was 88.6% (381 of 430) and at a second follow-up of 50 +/- 4.3 months, 86.7% (111 of 128). Analysis of long-term blood pressure response and factors affecting late survival indicated that patients with preoperative diastolic pressures of greater than 100 mm Hg and renal artery stenosis of greater than 70% had the best blood pressure responses and that male sex, increasing age, bilateral renal stenosis, and associated vascular operations lowered the survival rate whereas fibromuscular disease enhanced the duration of survival.(ABSTRACT TRUNCATED AT 250 WORDS)

The St. Jude valve prosthesis: analysis of the clinical results in 815 implants and the need for systemic anticoagulation.

Between July 1979 and December 1984, 785 patients received 815 St. Jude Medical valve prostheses. Valve-related mortality in the follow-up period was due to thromboembolism in seven cases, anticoagulant-related hemorrhage in three and perivalvular leak in two. Freedom from valve-related death or reoperation at 3 years was 96.4% for aortic valve replacement and 98.3% for mitral valve replacement. The overall rate of thromboembolism was 2.6%/patient-year with warfarin, 9.2%/patient-year with antiplatelet medication and 15.6%/patient-year in patients with no anticoagulant therapy. One episode of thrombotic obstruction of a mitral valve, in a patient receiving no anticoagulant therapy, resulted in an occurrence rate of such obstruction of 0.22%/patient-year. Valve replacement with the St. Jude valve produced excellent clinical results, but long-term anticoagulation with warfarin was required to minimize thromboembolic complications. The use of antiplatelet agents alone provided inadequate protection.

Determinants of survival 10 to 14 years after coronary bypass: analysis of preoperative variables in 1,448 patients.

To determine which preoperative variables were most predictive of long-term survival after coronary bypass surgery, the status of 1,448 consecutive patients was determined 10 to 14 years after operation. All patients were operated on at least 10 years ago and follow-up at 10 years was 93.8% complete. The overall 14-year survival probabilities were: for one-vessel disease, 73.3%; for two-vessel disease, 45.9%; for three-vessel disease, 34.2%; and for left main coronary artery disease, 41.9%. Patients with good left ventricular function had an overall survival rate of 53.3%, and patients with poor ventricular function had a survival rate of 31.9%. Preoperative variables predictive of greater risk of total mortality were: digoxin usage, multivessel disease, poor quality of left ventricular function, age at operation, electrocardiographic evidence of myocardial infarction, previous stroke, diabetes, heart failure, diuretic usage, cigarette smoking, and residual ungrafted coronary artery disease. The major determinants of long-term survival were variables associated with preoperative left ventricular function. Diabetes was the only important metabolic risk factor identified. This study suggests that unfavorable preoperative conventional risk factors should not be considered a contraindication to operation in patients with adequate coronary anatomy and left ventricular function.

Influence of diabetes mellitus on the results of coronary bypass surgery. Follow-up of 212 diabetic patients ten to 15 years after surgery.

To determine the long-term influence of the severity of preoperative diabetes mellitus on the results of coronary bypass, a review was made of 212 diabetics operated on between 1968 and 1973, of whom 87 patients (41%) were receiving no drugs, 108 patients (50.9%) were receiving oral hypoglycemic agents, and 17 patients (8%) were receiving insulin. They were compared with 1,222 nondiabetic patients operated on over the same period. Perioperative mortality was similar in the diabetics and nondiabetics: 7.1% vs 4.5%. Improvement in anginal symptoms was similar in all patient groups: 85.9% to 92.7%. Overall 15-year survival probability was .53 for the nondiabetic group, .43 for the diabetics not receiving drugs, .33 for those receiving oral agents, and .19 for the insulin-treated patients. Late graft patency ranged from 78% to 90% and was comparable in all groups. The preoperative blood glucose level was an important predictor of late mortality in all diabetic patients. Thus, coronary bypass surgery was effective in all groups of diabetic patients in long-term relief of anginal symptoms. Intermediate-term survival rates were good in all groups, but the initial severity of the diabetes was an important determinant of long-term survival rates.