Analysis of patterns of patient compliance after an abnormal Pap smear result: the influence of demographic characteristics on patient compliance.

OBJECTIVE: This study aimed to determine population characteristics that correlate to suboptimal follow-up after an abnormal cervical cytology result. MATERIALS AND METHODS: Nonpregnant women, ages 21 to 65 years, with newly diagnosed abnormal cervical cytology result between January 2009 and January 2012 at an urban clinic were eligible for inclusion in this retrospective chart review. Cervical cytology data and demographic characteristics such as age, ethnicity, employment, marital and smoking status, health insurance and number of pregnancies were abstracted from electronic medical record. A log-linear model was used to determine which factors influenced patient compliance. RESULTS: Of the total of 206 women, 78 (37.9%) had optimal follow-up and 128 (62.1%) had suboptimal follow-up. The 3 variables that were statistically significant in influencing patient follow-up after adjusted analyses included severity of cytology result (p = .0013), ethnicity (p = .02), and employment status (p = .0159). The risk ratio for optimal follow-up for those with severe cytology result was 1.81; for the non-whites, 1.77; and for the employed, 1.53. CONCLUSIONS: Ethnicity, severity of cervical cytology result, and employment status play an important role in patient follow-up after an abnormal cervical cytology result. Detecting trends in our patient population that influence adherence to follow-up will help health care providers formulate strategies that target this problem.

Clinical and laboratory characteristics of adolescents with platelet function disorders and heavy menstrual bleeding.

BACKGROUND: Platelet function disorders (PFDs) have emerged as an important etiology of heavy menstrual bleeding (HMB) in adolescents. However, neither clinical nor laboratory data have been methodically analyzed in this population subset. The objective of this study was to evaluate these parameters in order to distinguish characteristics of the disorder that in turn will lead to earlier diagnosis and therapy initiation. METHODS: Retrospective review of medical records from postmenarcheal adolescents with documented PFDs referred to a hemophilia treatment center and university faculty practices for bleeding diatheses with their clinical and laboratory data evaluated. RESULTS: Of 63 teens with documented PFDs, HMB was the most common clinical manifestation of PFD (43; 68.3%). Of these, 37 (86%) were diagnosed with PFD either at or after menarche with the diagnosis based on HMB symptoms alone. Only 6 (14%) were diagnosed with a PFD prior to menarche, based on associated bleeding, i.e., epistaxis, ecchymosis, and all developed HMB after menstruation onset. Interestingly, 20 girls were diagnosed with a PFD prior to menarche and of these, only 6 (30%) went on to develop HMB after pubertal transition, while the majority (14; 70%) did not. The average age-at-PFD diagnosis was 14.5yrs, significantly differing from the 10.9yrs average age-at-PFD diagnosis in their counterparts that, after menarche, did not develop HMB (P<.01) Blood type O occurred significantly more frequently (76%) than national norms (P <.037). Incidence of δ-Storage Pool deficiency (δ-SPD) was significantly higher (74%) than their non-HMB cohorts (45%) (P <.007). Coagulation and von Willebrand factor studies were all normal. Abnormal closure times and aggregation studies were observed in 42% and 60%, respectively, of tested girls. In 25.6% for whom standard platelet studies were normal, electron microscopy detected reduced platelet δ-granules numbers (δ-SPD). CONCLUSIONS: Adolescents with PFDs and HMB appear to be clinically distinct from their non-HMB counterparts. This group of girls is characterized by HMB the major bleeding symptom, significantly high incidences of blood group O and the δ-SPD with a PFD diagnosed well after menarche. High false negative standard platelet function study results indicate additional diagnostic strategies, particularly for δ-SPD, should be considered.

Human endometrial stromal stem cells differentiate into megakaryocytes with the ability to produce functional platelets.

Human endometrium is a high dynamic tissue that contains endometrial stromal stem cells (hESSCs). The hESSCs have been differentiated into a number of cell lineages. However, differentiation of hESSCs into megakaryocytes (MKs) has not yet been investigated. The aim of this study was to investigate the feasibility of MK generation from hESSCs and subsequent production of functional platelets (PLTs). In our study, hESSCs were cultured from endometrial stromal cells as confirmed by positive stromal cell specific markers (CD90 and CD29) and negative hematopoietic stem cell markers (CD45 and CD34) expression. Then, hESSCs were differentiated in a medium supplemented with thrombopoietin (TPO) for 18 days. The MK differentiation was analyzed by flow cytometry and confocal microscopy. The differentiation medium was collected for PLT production analysis by flow cytometry, transmission electron microscopy and functional measurements. Our results show: 1) MKs were successfully generated from hESSCs as identified by expression of specific markers (CD41a: 1 ± 0.09% and 39 ± 3.0%; CD42b: 1.2 ± 0.06% and 28 ± 2.0%, control vs. differentiation) accompanied with reduction of pluripotent transcription factors (Oct4 and Sox2) expression; 2) The level of PLTs in the differentiation medium was 16 ± 1 number/µl as determined by size (2-4 µm) and CD41a expression (CD41a: 1 ± 0.4% and 90±2.0%, control vs. differentiation); 3) Generated PLTs were functional as evidenced by the up-regulation of CD62p expression and fibrinogen binding following thrombin stimulation; 4) Released PLTs showed similar ultra-structure characteristics (alpha granules, vacuoles and dense tubular system) as PLTs from peripheral blood determined by electron microscopic analysis. Data demonstrate the feasibility of generating MKs from hESSCs, and that the generated MKs release functional PLTs. Therefore, hESSCs could be a potential new stem cell source for in vitro MK/PLT production.

Peritoneal inclusion cysts in adolescent females: a clinicopathological characterization of four cases.

STUDY OBJECTIVE: To identify adolescent females with peritoneal inclusion cysts and characterize the clinicopathologic features. DESIGN: Observational and chart review along with immunohistochemical studies. SETTING: University pediatric and adolescent clinic. RESULTS: Medical records of all subjects, ages 10-18 years, diagnosed with peritoneal inclusion cysts over a 4-year period were retrospectively reviewed. Four patients, ages 11-16 years (mean, 13.8 yrs) were identified. Pelvic pain was the most common presenting symptom. No palpable abdominal or pelvic masses were detected. However, pelvic lesions were identified by radiographic studies in three of the four patients. Half experienced tenderness on examination. With one exception, all had a prior history of abdominal surgery. Twelve peritoneal inclusion cysts were identified, ranging from 1 cm to 7 cm in greatest diameter. Most were uninvolved in coexisting adhesions and non-adherent to pelvic or abdominal structures. Each had a well-defined pedicle connection to the peritoneum. No associated complications were identified. Their appearance conformed to established morphologic and immunohistochemical criteria, although accompanying mesothelial-associated changes occasionally reported in other populations were not detected. No recurrences were recorded. CONCLUSION: Young female adolescents with peritoneal inclusion cysts share presenting symptoms and histories of previous abdominal surgery similar to those reported in older female adolescents and adults. A palpable mass may not be detected on examination, but can often be identified using radiographic studies. Our cases differ from previous reports by smaller cyst size, presence of a pedicle, and uncomplicated gross and microscopic appearances. Additionally, local recurrences and associated complications occurred less than reported in adults.

Evaluation of Computer-aided Strategies for Teaching Medical Students Prenatal Ultrasound Diagnostic Skills.

OBJECTIVE: To evaluate whether computer-based learning (CBL) improves newly acquired knowledge and is an effective strategy for teaching prenatal ultrasound diagnostic skills to third-year medical students when compared with instruction by traditional paper-based methods (PBM). STUDY DESIGN: We conducted a randomized, prospective study involving volunteer junior (3(rd) year) medical students consecutively rotating through the Obstetrics and Gynecology clerkship during six months of the 2005-2006 academic year. The students were randomly assigned to permuted blocks and divided into two groups. Half of the participants received instruction in prenatal ultrasound diagnostics using an interactive CBL program; the other half received instruction using equivalent material by the traditional PBM. Outcomes were evaluated by comparing changes in pre-tutorial and post instruction examination scores. RESULTS: All 36 potential participants (100%) completed the study curriculum. Students were divided equally between the CBL (n = 18) and PBM (n = 18) groups. Pre-tutorial exam scores (mean+/-s.d.) were 44%+/-11.1% for the CBL group and 44%+/-10.8% for the PBL cohort, indicating no statistically significant differences (p>0.05) between the two groups. After instruction, post-tutorial exam scores (mean+/-s.d.) were increased from the pre-tutorial scores, 74%+/-11% and 67%+/-12%, for students in the CBL and the PBM groups, respectively. The improvement in post-tutorial exam scores from the pre-test scores was considered significant (p<0.05). When post-test scores for the tutorial groups were compared, the CBL subjects achieved a score that was, on average, 7 percentage points higher than their PBM counterparts, a statistically significant difference (p < 0.05). CONCLUSION: Instruction by either CBL or PBM strategies is associated with improvements in newly acquired knowledge as reflected by increased post-tutorial examination scores. Students that received CBL had significantlyhigher post-tutorial exam scores than those in the PBM group, indicating that CBL is an effective instruction strategy in this setting.

Oral contraceptives and DDAVP nasal spray: patterns of use in managing vWD-associated menorrhagia: a single-institution study.

The purpose of this study was to examine patterns of use for oral contraceptive and desmopressin acetate nasal spray, both used in managing menorrhagia in adolescents with von Willebrand disease (vWD). Hospital records of adolescents with documented vWD and menorrhagia were reviewed retrospectively. Subjects with vWD type 1 (n = 36) administered either oral contraceptives (OC) or intranasal desmopressin acetate (DDAVP) and followed from 6 months to 4 years were selected for inclusion. Treatment outcomes were examined with respect to effectiveness and safety. Assessing menstrual blood loss using PBAC scores from pretreatment and treatment periods determined effectiveness. Safety was evaluated by monitoring reported adverse events. No significant differences were identified in treatment effectiveness for controlling menorrhagia in vWD adolescents in the OC and intranasal DDAVP group comparisons: 86% versus 77% (P > 0.05), respectively. When combining both treatment groups, the majority of vWD adolescents, 81% (P > 0.05), experienced alleviation of menorrhagia symptoms. Treatment failures were attributed to either the inability of a regimen to control bleeding or to adverse events, including severe headaches and flushing with DDAVP. Safety outcomes were not significantly greater in vWD patients with menorrhagia when OC were compared with intranasal DDAVP. Both medical approaches, OC and DDAVP nasal spray, used in managing menorrhagia in adolescents with documented type I vWD were well tolerated and showed equivalent effectiveness, and no serious adverse events were reported.

Expression of HOX gene products in normal and abnormal trophoblastic tissue.

OBJECTIVE: The expression pattern of three homeobox genes products, HOX A11, HOX B6, and HOX C6, was examined in normal human placental tissue and abnormal trophoblastic tissue derived from complete hydatidiform moles and choriocarcinoma tumors. We sought to determine whether expression of these gene products during different states of trophoblastic differentiation and proliferation is constant or demonstrates variation. Variation in expression of these respective homeobox genes may provide insight into predicting which molar tissues are likely to develop into choriocarcinoma tumors. METHODS: Tissue sections from a total of 12 samples were studied. Among these, six full-term human placentas, three complete hydatidiform moles, and three choriocarcinoma tumors were examined for expression of the homeobox HOX A11, HOX B6, and HOX C6 gene products, using immunohistochemistry staining methods. RESULTS: Expression of HOX homeobox gene products, HOX A11, HOX B6, and HOX C6, was detected in full-term human placenta and tissue from complete hydatiform moles. Abnormal trophoblasts from complete moles demonstrated an immunoreactivity expression pattern comparable to that of normal trophoblasts from term pregnancies. However, definitive expression of these respective homeobox genes was not identified in tissue obtained from choriocarcinoma tumors. CONCLUSION: Variation in expression of HOX homeobox gene products, HOX A11, HOX B6, and HOX C6, was established in trophoblast tissue obtained from full-term human placentas, complete hydatiform moles, and choriocarcinoma tumors. This finding indicates that normal full-term trophoblasts and abnormal molar trophoblasts may share similar fundamental regulatory control mechanisms. The absence of definitive expression of these HOX gene products in trophoblastic cells derived from choriocarcinoma tumors indicates that while HOX A11, HOX B6, and HOX C6 genes may be involved in maintenance of some trophoblastic cell states, they may be either downregulated or have alterations in their expression in trophoblasts from choriocarcinoma tumors.

Visualization of the epigastric vessels and bladder before laparoscopic trocar placement.

OBJECTIVE: Transillumination and laparoscopic visualization are two techniques recommended to minimize the risks of injury to abdominal wall structures during insertion of secondary trocars. This study was designed to determine the effectiveness of these techniques to locate the epigastric vessels and superior bladder margin. DESIGN: Prospective observational. SETTING: Academic medical centers. PATIENT(S): One hundred five women undergoing laparoscopy for tubal sterilization, infertility, pelvic masses, or pelvic pain. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): The ability to visualize the superficial and inferior epigastric vessels, and bladder margin; body mass index (BMI; in kilograms per meter squared); and skin color. RESULT(S): Transillumination successfully visualized 64% of superficial epigastric vessels and was less effective both as weight increased (BMI <25 kg/m(2): 86%; BMI = 25-30 kg/m(2): 61%; BMI >30 kg/m(2): 25%) and in dark-skinned women (69%) compared to those with lighter skin (42%). Laparoscopic visualization successfully identified 82% of inferior epigastric vessels and 46% of bladder margins, and was less effective as weight increased. CONCLUSION(S): Transillumination can successfully locate superficial epigastric vessels, and laparoscopic visualization can locate inferior epigastric vessels and the superior bladder margin in the majority of women undergoing laparoscopy. Transillumination is less effective in dark-skinned women, and both techniques are less effective with increasing body weight.

Comparison of cryopreserved sperm in vaporous and liquid nitrogen.

OBJECTIVE: To evaluate the feasibility of using the vaporous phase of liquid nitrogen as a storage medium for human semen samples. STUDY DESIGN: Human semen samples were used in a 2-armed study. In the first arm, semen samples were rapidly frozen and randomly assigned to storage in either liquid nitrogen (-196 degrees C) or vapor-phase nitrogen (-189 degrees C). In the second arm, sperm specimens were frozen in a controlled, stepwise process and randomly assigned to storage in either the vaporous or liquid phase of liquid nitrogen. The samples were subsequently thawed and analyzed for sperm viability. RESULTS: The rapid freezing technique demonstrated no differences in the examined viability parameters between semen specimens stored in either liquid or vaporous nitrogen. Similarly, semen samples prepared by the slower, controlled freezing process also showed no differences in viability parameters after storage in either the liquid or vaporous phase of liquid nitrogen. The rapid freezing technique was equal to the slow, controlled freezing method in terms of preserving the integrity of the sperm when the specimens were subsequently stored in either liquid or vaporous nitrogen. CONCLUSION: Cryopreservation of human semen in the vapor phase of nitrogen is a viable alternative to storage in liquid-phase nitrogen.

Patient rotation and resolution of unilateral cornual obstruction during hysterosalpingography.

OBJECTIVE: Unilateral obstruction of the proximal fallopian tube is identified in 10-24% of patients undergoing hysterosalpingography for evaluation of infertility. Upon further testing, this obstruction spontaneously resolves 16-80% of the time. We hypothesized that patient rotation during hysterosalpingography might resolve proximal tubal obstruction in some cases by altering either the location of intrauterine air bubbles or the spatial relationship of the tube to the uterine fundus. METHODS: In patients in whom unilateral proximal tubal obstruction was detected during hysterosalpingography performed for standard clinical indications, the patient was rotated on her hip approximately 45 degrees such that the obstructed tube was first superior (ventral) to the patent tube, and dye was reinjected. If obstruction did not resolve, the patient was rotated in the opposite direction so that the obstructed tube was inferior (dorsal) to the patent tube and dye reinjected. RESULTS: Unilateral tubal obstruction was found in 15% of cases (24 of 156). Rotating the patient with obstructed tube superior to the patent tube never resulted in tubal patency, whereas rotating the patient with the obstructed tube inferior resulted in resolution of tubal patency in 63% of cases (15 of 24) CONCLUSION: . Unilateral cornual obstruction during hysterosalpingography is often resolved by rotating the patient such that the obstructed tube is more inferior. Although this observation may be the result of dislodging smaller air bubbles, from a fluid dynamics perspective a more likely explanation is unkinking of the more inferior tube.

Expression of homeobox gene transcripts in trophoblastic cells.

OBJECTIVE: This study was conducted to examine the dynamics of homeobox gene expression in the differentiation of trophoblasts as a key to the understanding of the regulatory mechanisms that are involved in placental development. STUDY DESIGN: Expression of homeobox genes was examined in primary trophoblastic cells and in the BeWo choriocarcinoma model cell lines by molecular and immunocytochemistry techniques. RESULTS: We demonstrated the expression of 3 homeobox genes (HOX B6, HOX C6, and HOX A11) in primary trophoblastic cells. BeWo cells showed an expression pattern similar to that of the primary cell lines. In both primary trophoblasts and BeWo cells, the HOX A11 gene, but not the HOX B6 or HOX C6 genes, were found to down-regulate with differentiation from single- to multinucleate giant cells. CONCLUSION: This study demonstrates a novel expression pattern for HOX A11 gene in trophoblastic differentiation and suggests that the down-regulation of HOX A11 may be necessary for the differentiation of cytotrophoblasts into syncytiotrophoblasts.

Protruding giant cervical polyp in a young adolescent with a previous rhabdomyosarcoma.

Giant cervical polyps are rare entities, with only 8 reported cases in the international literature (MEDLINE 1966-2002). Of these cases, only one has been described in the pediatric population. There has been no report of a giant cervical polyp occurring in the older, although early, adolescent period. The discovery of a giant cervical polyp in a young adolescent is a gynecological oddity. The immense size of giant cervical polyps, together with their menacing appearance and unusual presentation, can simulate a malignant neoplasm. Care must be taken in their diagnosis and management so that the patient's fertility is not compromised. We report on a young adolescent girl with a previous history of a rhabdomyosarcoma (RMS), who presented with a giant cervical polyp protruding from the vaginal introitus. The literature on this entity is reviewed.