Renal artery embolisation: indications and utilisation at Tygerberg Hospital.

BACKGROUND: To evaluate the indications, efficacy and outcomes of endovascular renal artery embolisation (RAE) in the management of renal haemorrhage, specifically in cases of non-iatrogenic origin. METHOD: This is a retrospective case note review of 92 patients who underwent RAE in the period from August 1999 to August 2014 at Tygerberg Hospital. RESULTS: Renal artery embolisation was performed in a total of 92 patients. The indication was traumatic renal injury in 60 patients (65.2%), with mean age 28.2 years. The mechanism of injury was stabbing (55.4%), blunt trauma (7.6%) and gunshot (2.2%). Digital subtraction angiography (DSA) showed pseudo-aneurysm in 32.6%, arteriovenous fistula in 19.6% and segmental artery injury in 13%. Embolisation success: 85% after one, 88.9% after a second attempt, with an overall success rate of 98.3% after two attempts. In 20 of the 92 patients (mean age 50.2 years) the indication was malignancy (21.7%). Other cases included iatrogenic haematuria (4.3%) and angiomyolipoma (3.3%). Embolisation was repeated in 16.3%, with eventual success rate of 93.8%. Post-embolisation syndrome was the most common complication, seen in 9.8% of all cases. Of the 9 patients who returned for follow-up with renogram imaging, 4 had a differential function of > 20% of the embolised kidney. CONCLUSION: Renal artery embolisation remains a very successful method of managing renal haemorrhage at this hospital, whether this results from trauma, malignancy, iatrogenic or other causes.

Response of Pemphigus betae (Hemiptera: Aphididae) and Beneficial Epigeal Arthropod Communities to Sugarbeet Plant Density and Seed-Applied Insecticide in Western Nebraska.

This study investigated the impact of a neonicotinoid seed-applied insecticide (Poncho Beta) and two plant densities (86,487 and 61,776 plants per hectare) on the sugarbeet root aphid (Pemphigus betae Doane), beneficial epigeal arthropods, and selected crop yield parameters in sugarbeet (Beta vulgaris L. var. vulgaris). Ground beetles and centipedes were the most commonly collected taxa during 2012 and 2013, respectively. Centipede, spider, and rove beetle activity densities were not affected by the seed-applied insecticide, whereas plant density had a marginal effect on centipede activity density during 2012. Ground beetle species richness, diversity, and evenness were also not impacted by the seed treatments. However, during 2013, ground beetle activity density was significantly higher in plots planted with untreated sugarbeet seeds due to the abundance of Bembidion quadrimaculatum oppositum Say. Sugarbeet root aphid populations were significantly higher in the untreated plots during both years. In 2012, sugarbeet tonnage and sugar yield were higher under the low plant density treatment, while higher sugar content was recorded from the seed-applied insecticide plots (2013). Seed-applied neonicotinoids and plant density had little impact on beneficial epigeal arthropod activity density. Seed treatment did result in decreased root aphid populations; however, these reductions were not sufficient to be considered as an adequate control. This limited aphid control likely contributed to inconsistent effects on yield parameters.

'Esprit de corps': Towards collaborative integration of pharmacists and nurses into antimicrobial stewardship programmes in South Africa.

With the global threat of antimicrobial resistance now more emergent than ever, there should be wider collaboration between members of the multidisciplinary healthcare team. This article proposes possible ways of engagement between the pharmacist, nurse and doctor. The pharmacist and nurse are placed in an ideal position through united efforts (camaraderie) to redirect healthcare towards improved patient outcomes while also reducing antimicrobial resistance.

Colposcopy.

Though in the 1980s, colposcopically-directed biopsy excluded over 90% of CIN 3 and cancer (CIN 3+), recent reviews found sensitivity of colposcopically-directed biopsy for CIN 3+ of 50-65%. Studies from China showed that the sensitivity of colposcopically-directed biopsy for CIN 3+ is higher for large CIN 3+ than for small CIN 3+ and higher for associated high-grade cervical cytology than for low-grade cervical cytology. Colposcopically-directed biopsy excluded over 90% of CIN 3+ in the 1980s because colposcopy clinics in the 1980s evaluated women with high-grade cytology that had large CIN 3+; it no longer excludes CIN 3+ well because current colposcopy clinics evaluate women with low-grade cytology that have small CIN 3+. When colposcopically-directed biopsy is used to exclude CIN 3+ our understanding of the natural history of CIN is skewed, errors occur in defining appropriate screening practice, and inaccurate diagnosis results in incorrect treatment. The impression that CIN is more common on the anterior lip of the cervix is an artifact introduced by the inaccuracy of colposcopy. An unjustified enthusiasm for screening with acetic acid aided visual inspection (VIA) occurred when the sensitivity of VIA for CIN 3+ was inflated by screening studies using colposcopically-directed biopsy as the gold-standard for CIN 3+. To limit the harm of inaccurate diagnosis associated with colposcopically-directed biopsy, at colposcopy we advise random biopsies at the squamocolumnar junction in cervical quadrants without visible lesions and, unless the woman is pregnant, endocervical curettage (ECC). As the diagnosis of CIN 3+ solely by ECC is uncommon in women under age 25, the ECC may be omitted in women under age 25 years. If multiple cervical biopsies are performed, to limit discomfort, a bronchoscopy biopsy instrument which obtains 2-mm biopsies should be used.

Influence of a rural background on a medical student's decision to specialize in family medicine.

INTRODUCTION: Minority populations, including those from rural areas, continue to be underrepresented in medical schools despite increased efforts to recruit them. Although family physicians are more highly represented in rural areas, and medical students from rural areas are more likely to return to rural areas, relatively few medical students enter the specialty of family medicine in the USA. Because family physicians are a smaller proportion of all practicing physicians--both urban and rural--in the east when compared with the remainder of the USA, this study examines the influence of a rural background on career decisions of medical students in an eastern state, New York. New York's social and political structure is additionally influenced by the presence of New York City, the largest city in the USA and one of the world's major financial centers. METHODS: A retrospective, case-control study comparing medical school graduates entering family medicine residencies with those entering residencies in other disciplines was conducted for a period of 16 years at a north-east medical school. The size of the town or city of the student's high school graduation was used to determine which students came from a rural background. RESULTS: Students graduating from rural high schools were more than twice as likely to enter family medicine (OR 2.27, p<0.01) than those from non-rural high schools. CONCLUSIONS: In order to alleviate health disparities and meet health manpower needs, admitting students to medical school who graduated from rural high schools will increase the rural workforce.

Educational games for health professionals.

BACKGROUND: The use of games as an educational strategy has the potential to improve health professionals' performance (e.g. adherence to standards of care) through improving their knowledge, skills and attitudes. OBJECTIVES: The objective was to assess the effect of educational games on health professionals' performance, knowledge, skills, attitude and satisfaction, and on patient outcomes. SEARCH STRATEGY: We used a comprehensive search strategy including an electronic search of the following databases: DARE, EPOC register, CENTRAL, MEDLINE, EMBASE, CINAHL, AMED, ERIC, and Dissertation Abstracts Online (search date: January 2007). We also screened the reference list of included studies and relevant reviews, contact authors of relevant papers and reviews, and searched ISI Web of Science for papers citing studies included in the review SELECTION CRITERIA: We included randomized controlled trials (RCT), controlled clinical trials (CCT), controlled before and after (CBA) and interrupted time-series analysis (ITS). Study participants were qualified health professionals or in postgraduate training. The intervention was an educational game with "a form of competitive activity or sport played according to rules". DATA COLLECTION AND ANALYSIS: Using a standardized data form we extracted data on methodological quality, participants, interventions and outcomes of interest that included patient outcomes, professional behaviour (process of care outcomes), and professional's knowledge, skills, attitude and satisfaction. MAIN RESULTS: The search strategy identified 1156 citations. Out of 55 potentially eligible citations, we included one RCT. The methodological quality was fair. The game, used as a reinforcement technique, was based on the television game show "Family Feud" and focused on infection control. The study did not assess any patient or process of care outcomes. The group that was randomized to the game had statistically higher scores on the knowledge test (P = 0.02). AUTHORS' CONCLUSIONS: The findings of this systematic review do not confirm nor refute the utility of games as a teaching strategy for health professionals. There is a need for additional high-quality research to explore the impact of educational games on patient and performance outcomes.

Shanxi Province cervical cancer screening study II: self-sampling for high-risk human papillomavirus compared to direct sampling for human papillomavirus and liquid based cervical cytology.

The objective of this study was to compare the sensitivity and specificity of a new method for self-sampling for high risk human papillomavirus (HPV) with direct sampling and liquid based cervical cytology. In Shanxi Province, China, 8,497 women (ages 27-56) underwent a self-sample for HPV using a conical-shaped brush placed into the upper vagina and rotated. Three to sixteen months later the women were screened with liquid-based cytology and direct HPV tests. Subjects with any abnormal test underwent colposcopy and multiple biopsies. Mean age was 40.9 years. 4.4 percent of subjects had >or=CIN II, 26% a positive self-sample and 24% a positive direct test for HPV. The sensitivity for detection of >or=CIN II was 87.5% for self-sampling, and 96.8% for the direct test (P < 0.001). The specificity was 77.2% for the self-sample and 79.7% for the direct test. With an abnormal Pap defined as ASCUS or greater the sensitivity of the Pap for the detection of >CIN II was 88.3% and the specificity was 81.2%. We conclude that self-sampling for HPV is less sensitive for >CIN II than the direct test, but similar to liquid based cytology.

Shanxi Province Cervical Cancer Screening Study: a cross-sectional comparative trial of multiple techniques to detect cervical neoplasia.

OBJECTIVE: The aim of this study was to design a cervical cancer screening algorithm for the developing world that is highly sensitive for cervical intraepithelial neoplasia (CIN) II, III, and cancer and highly specific for CIN II and III, making it possible to ablate the transformation zone without histologic confirmation. METHODS: In rural Shanxi Province, China, we examined 1997 women ages 35-45. Each subject underwent a self-test for intermediate and high-risk HPV (by HC-II assay), fluorescence spectroscopy, a liquid-based Pap (read manually and by computer and used as a direct test for HPV), a visual inspection (VIA) diagnosis, and colposcopy with multiple cervical biopsies. RESULTS: Mean age was 39.1 +/- 3.16 years, mean number of births was 2.6 +/- 0.93. Based on tests administered, 4.3% subjects had > or =CIN II. All subjects with > or =CIN II had either a ThinPrep Pap (> or =ASCUS) or a positive HPV direct test. The sensitivity and specificity for the detection of > or =CIN II were, respectively, 83 and 86% for the HPV self-test, 95 and 85% for the HPV direct test, 94 and 78% for the ThinPrep Pap (> or =ASCUS), 77 and 98% for the ThinPrep Pap (> or =HGSIL), 94 and 9% for fluorescence spectroscopy, 71 and 74% for VIA, and 81 and 77% for colposcopy. CONCLUSION: Based on these data and the existing healthcare infrastructure in China, we believe that further refinement of primary HPV screening using centralized labs is indicated. Self-testing in the local villages may be effective with improvements in the devices and techniques.

The colposcopic impression. Is it influenced by the colposcopist's knowledge of the findings on the referral Papanicolaou smear?

OBJECTIVE: To determine whether the colposcopic impression is influenced by the colposcopist's knowledge of the referral Papanicolaou smear. STUDY DESIGN: Using a community hospital database, the accuracy of the colposcopic impression (accuracy = proportion of women with histology greater than cervical intraepithelial neoplasia [CIN] 2 that have colposcopic impressions of greater than CIN 2) when referral smears were atypical squamous cells of uncertain significance (ASCUS), atypical glandular cells of uncertain significance (AGUS) or low grade squamous intraepithelial lesion (LSIL) was compared to that when smears showed high grade squamous intraepithelial lesion (HSIL) or cancer. The analysis was repeated with a screening study database in which colposcopic impression was assigned without knowledge of the Papanicolaou smear. Univariate and logistic regression analysis of the second database determined the relative importance of size and grade of lesion and Papanicolaou result to the accuracy of the colposcopic impression. RESULTS: In the community database, colposcopic accuracy was 60/510 (12%) when smears were ASCUS, AGUS or LSIL and 77/132 (58%) when smears were HSIL or cancer (P < .001); in the second database, it was 2/19 (11%) when smears subsequently were reported as negative, ASCUS, AGUS or LSIL and 33/65 (54%) when smears were HSIL or cancer (P < .005). An accurate colposcopic impression was seen in 5/39 (13%) women with one-quadrant lesions, 8/18 (44%) with two-quadrant lesions and 23/27 (85%) with three- or four-quadrant lesions (P < .005). None of 19 women with smears reported as negative, ASCUS, AGUS or LSIL had lesions involving three or four quadrants of the cervix, while 27/65 (42%) women with smears reported as HSIL or cancer had such lesions (P < .005). With logistic regression, the more quadrants of the cervix involved, the more accurate the colposcopic impression. Once controlled for lesion size, there was no improvement when worst histologic grade or Papanicolaou smear result was considered. CONCLUSION: Through lesions greater than CIN 2 were more often overlooked when referral smears were negative, ASCUS, AGUS or LSIL than when they were HSIL or cancer, the real reason that the lesions were not detected by colposcopy was that they were small.

Cervical cancer screening by simple visual inspection after acetic acid.

OBJECTIVE: To estimate the sensitivity and specificity of visual inspection using acetic acid as a primary screen for cervical intraepithelial neoplasia (CIN). METHODS: Visual inspection was done on 1997 women aged 35-45 years in a screening trial in rural China. Each women had colposcopy and at least five cervical biopsies (directed biopsy of lesions, one biopsy at 2, 4, 8, or 10 o'clock at the squamocolumnar junction in each normal quadrant, and an endocervical curettage). RESULTS: Forty-three women had biopsy-proven CIN II, 31 had CIN III, and 12 had invasive cancer. In two women only the endocervix was positive (one with CIN II and one with CIN III). Visual inspection yielded normal results in 1445 women (72%), low-grade intraepithelial neoplasia in 525 (26%), high-grade in 21 (1%), and cancer in six (0.3%). With abnormal visual inspection defined as low-grade intraepithelial neoplasia or worse, the sensitivity for detecting biopsy proven CIN II or worse was 71% (61 of 86, 95% confidence interval [CI] 60%, 80%); the specificity was 74% (1420 of 1911, 95% CI 72%, 76%); the sensitivity was 65% for smaller lesions (37 of 57, 95% CI 51%, 77%), and 89% for larger lesions (24 of 27, 95% CI 71%, 98%) (P =.03). CONCLUSION: The sensitivity of visual inspection equaled or exceeded reported rates for conventional cervical cytology. Visual inspection and colposcopy have similar specificity profiles for CIN II and greater. The benefit of an inexpensive point-of-care diagnosis and treatment algorithm will be a powerful incentive to pursue visual inspection for cervical cancer screening in developing countries.

Prescription medication costs: a study of physician familiarity.

BACKGROUND: Studies in the past 25 years have suggested that physicians are not familiar with the costs of common prescription medications. OBJECTIVES: To determine physician familiarity with the cost of common prescription medications and to determine the value physicians place on knowing information regarding the cost of medications. DESIGN: Survey. SETTING: Seven community-based family medicine residency teaching clinics in Iowa. PARTICIPANTS: Two hundred five practicing resident and faculty physicians. INTERVENTIONS: From a series of $10 price intervals (range, $0.01-$80.00), physicians were asked to select the interval containing the cash price of the medication to an uninsured patient for 50 medications commonly prescribed in outpatient family medicine clinics. Physicians were also questioned about the value of medication cost information to their practice. MAIN OUTCOME MEASURES: The percentage of correct responses and the mean pricing scores were calculated for each respondent and for all medications. RESULTS: One hundred seventy-eight physicians responded (86.8%). Only 22.9% of the responses correctly identified the cost of the medication. More than two thirds (68.3%) of the responses underestimated the correct price interval. Branded drugs were underestimated in 89.9% of responses, while generic drugs were overestimated in 90.2% of responses. Overall, 64.4% of physicians believed they did not receive sufficient information in their practices regarding prescription drug costs, and nearly all (93.6%) reported that regular information on prescription medication costs would help them prescribe more cost-effectively. CONCLUSIONS: Physicians are unfamiliar with the costs of medications they commonly prescribe, and they report that regular access to information on prescription medication costs would help them prescribe more cost-effectively. Arch Fam Med. 2000;9:1002-1007

Prevalence of cervical cancer and feasibility of screening in rural China: a pilot study for the Shanxi Province Cervical Cancer Screening Study.

For cervical cancer screening to be feasible in developing countries, it must be accurate, inexpensive, and easy to administer. We conducted a pilot study in rural Shanxi Province, People's Republic of China, to determine disease prevalence and study feasibility in preparation for a large-scale comparative trial of 6 screening tests. One-hundred and thirty-six nonpregnant women with no history of hysterectomy, pelvic radiation, or Papanicolaou tests were screened in a rural clinic. Ten percent of the women enrolled reported abnormal vaginal bleeding and 45% reported abnormal vaginal discharge. The tests were the Papanicolaou test (both conventional and ThinPrep), a self-administered swab test by Hybrid Capture II for high-risk human papillomavirus (HPV), a test for high-risk HPV from residual PreservCyt medium, fluorescence spectroscopy, and visual inspection of the cervix by a clinician. All women also underwent colposcopy and biopsies as the reference standard. Biopsies showed 12 of 136 women had >/= high-grade squamous intraepithelial lesions (HGSIL). Screening was completed in 5 half-day sessions, the procedures went smoothly, and local cooperation was enthusiastic. Disease prevalence in Xiangyuan and Yangcheng Counties, Shanxi Province, can be estimated at 8.8% (95% CI, 4.5% to 15.0%). Screening 1000-2000 patients would be sufficient to detect a 10% difference in accuracy between diagnostic tests. The proposed large-scale trial is feasible.

Cervical and vaginal cytologic smears suggestive of adenocarcinoma.

OBJECTIVE: To determine the appropriate evaluation of women with cervical cytologic smears suggestive of adenocareinoma. STUDY DESIGN: Of 1,192,972 smears obtained between July 1989 and March 1992, 57 (0.005%) were interpreted as adenocarcinoma, adenocarcinoma in situ or "rule out" adenocarcinoma. Review of medical records allowed the determination of pathologic diagnoses in 46 of 57 women. Thirty of the 46 cytologic smears were reviewed. RESULTS: Fifteen of the 46 women were premenopausal and < 50 years of age. Twenty-three were asymptomatic, 22 had abnormal vaginal bleeding, and 1 had increasing abdominal girth. Twenty-nine (63%) of the 46 women had cancer, 12 (26%) had cervical intraepithelial neoplasia 2 (CIN 2) or 3, and 5 (11%) had CIN 1, condyloma or no pathology. Of the 29 women with cancer, 11 had cervical cancer, 1 had vaginal cancer, 13 had uterine cancer, and 4 had extrauterine cancer. Nineteen of 22 women (86%) with abnormal vaginal bleeding had cancer; 9 of 23 asymptomatic women had cancer (39%) (chi 2 = 9.84, P < .01). DISCUSSION: Women with smears suggestive of adenocarcinoma require biopsy of cervical or vaginal masses, colposcopy with directed biopsy, endocervical curettage and endometrial biopsy. If cancer is not diagnosed, cervical conization with dilatation and curettage (D&C) is indicated. If conization with D&C is negative, laparoscopy is indicated to exclude extrauterine cancer.

Invasive cervical cancer following cryotherapy for cervical intraepithelial neoplasia or human papillomavirus infection.

OBJECTIVE: To determine the following: 1) the causes for the failure of cervical cryotherapy to prevent cervical cancer, and 2) whether cervical cryotherapy is associated with the development of cervical adenocarcinoma rather than squamous carcinoma. METHODS: We reviewed the medical charts of 327 women with cervical cancer. One hundred forty-seven for whom pertinent history was missing were contacted by telephone or at clinic visits. History obtained verbally was confirmed by outside medical records. Cervical biopsies (N = 16) and endocervical curettages (ECCs) (N = 15) performed before cryotherapy and biopsies at the diagnosis of cancer (N = 21) were reviewed. RESULTS: Twenty-one women with cervical cancer had a history of cryotherapy for cervical intraepithelial neoplasia (CIN) or human papillomavirus infection (HPV). The interval between cryotherapy and cancer was more than 2 years in 19 and more than 5 years in ten. Several categories of pre-treatment errors were identified. Evaluation before cryotherapy was appropriate in only nine cases. Interpretive errors were noted in three of 16 cervical biopsies and ten of 15 ECCs. After cryotherapy, 12% of women had appropriate follow-up. Of the invasive cancers that developed, 24% in the cryotherapy group and 21% in the non-cryotherapy group were adenocarcinomas. CONCLUSIONS: Careful evaluation before cryotherapy, accurate pathology reports, and consistent long-term follow-up are necessary if cryotherapy is to be used to treat CIN or HPV. We found no evidence that cryotherapy is associated with the development of cervical adenocarcinoma.

Clinical stage I adenocarcinoma of the endometrium--analysis of recurrences and the potential benefit of staging lymphadenectomy.

Two hundred forty-eight consecutive patients with clinical Stage I adenocarcinoma of the endometrium were seen between 8/77 and 8/88. Twenty-one were medically not operable and eleven others had papillary serous tumors. The remaining 216 were managed by a consistent operative protocol except that routine preoperative cesium was discontinued after 12/83. Patients received postoperative pelvic radiation on the basis of the depth of invasion, extrauterine pelvic disease, and/or cervix involvement. No patient underwent a pelvic lymphadenectomy. Only palpably suspicious nodes were removed. Twenty-one of these two hundred sixteen patients developed a recurrence. These 21 cases are analyzed for the probability of a staging lymphadenectomy having prevented their recurrence. Median follow-up of all 216 patients is 61 months with a mean time to recurrence of 26.5 months. No patient was lost to follow-up. Patients who recurred are analyzed by grade, depth of invasion, surgical stage, time to recurrence, site of recurrence, survival, protocol breaks, and frozen section discrepancies. No patient recurred on the pelvic side-wall. All patients found to have positive para-aortic nodes have died. No patient who received vaginal and/or pelvic radiation recurred in the pelvis. We conclude that staging lymphadenectomy would not have improved the outcome for these patients.

A randomized trial of three methods of obtaining Papanicolaou smears.

The relationship between technique of obtaining Papanicolaou smears, presence of endocervical cells, and rate of cervical neoplasia was studied by comparing an endocervical and ectocervical nylon brush (Bayne brush), Ayre spatula plus endocervical brush, and spatula plus cotton-tipped swab in a randomized, prospective trial involving 11,061 patients. Eligible patients had a cervix and were not pregnant. Clinic records of patients with abnormal cytology were reviewed to determine the pathologic diagnosis. Whether pathology was defined as including condyloma, dysplasia, and cancer; dysplasia and cancer; moderate dysplasia, severe dysplasia, and cancer; or just severe dysplasia and cancer, no significant difference was found in the rates of pathology between the three techniques. Endocervical cells were identified in 89.5% of smears obtained with the Bayne brush, in 91.5% with the spatula plus endocervical brush, and in 71.1% with the spatula plus cotton-tipped swab (P less than .001). Among smears obtained with the spatula plus swab, the rate of any pathology was higher in smears that contained endocervical cells than in smears in which endocervical cells were absent (2.0 versus 0.6%; P = .009). After correction for the influence of age, there remained predictive value with the presence of endocervical cells. Once corrected for the influence of age, the rate of pathology and abnormal cytology in smears obtained with the spatula plus brush or the Bayne brush was not dependent upon the presence of endocervical cells.(ABSTRACT TRUNCATED AT 250 WORDS)

Presentation of cervical cancer.

To determine how patients with invasive cervical cancer present and whether presentation affects disease-free survival (DFS), a review of 81 patients treated for cervical cancer by the Division of Gynecologic Oncology and Pelvic Surgery at the Southern California Permanente Medical Group between January 1, 1986, and December 31, 1986, was performed. Fifty-six percent of patients presented with abnormal vaginal bleeding, twenty-eight percent presented with abnormal Papanicolaou (Pap) smears, nine percent presented with pain, four percent presented with vaginal discharge, and four percent presented with other symptoms. Follow-up was 24 to 41 months. Patients presenting with abnormal Pap smears had DFS of 96%. Those presenting with abnormal vaginal bleeding had DFS of 51% and those presenting with pain had DFS of 29%. Presentation strongly influences DFS (chi 2 = 16.8, P less than 0.001). Of women presenting with abnormal Pap smears, 87% were Stage I and 13% were Stage II. Of women presenting with other than abnormal Pap smears, 40% were Stage I, 34% were Stage II, and 26% were Stage III or IV. Presentation with abnormal Pap smear and stage are significantly related (chi 2 = 14.8, P less than 0.001). Of women presenting with abnormal Pap smears, 89% had cancers 0 to 2 cm, 5% had cancers 2.1 to 4 cm, and 5% had cancers greater than 4 cm in diameter. Of women presenting with other than abnormal Pap smears, 21% had cancers 0 to 2 cm, 26% had cancers 2.1 to 4 cm, and 53% had cancers greater than 4 cm in diameter. Presentation with abnormal Pap smear is significantly associated with tumor size (chi 2 = 25.4, P less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Management of massive ovarian tumors.

Two patients with massive ovarian tumors, one with a 51 kilogram Stage IC mucinous cystadenocarcinoma and the other with a 34 kilogram mucinous cystadenoma, are presented. Problems associated with resection of massive ovarian tumors, including respiratory failure, intraoperative fluid shifts, adequate exposure, orthostatic hypotension and adynamic intestine, are identified. Guidelines for avoiding these pitfalls by the use of appropriate monitoring, controlled drainage of the cyst and transverse elliptic incision with abdominoplasty are suggested.