The clinical relevance of human papillomavirus negative status in unsatisfactory cervical cytology.

PURPOSE: The aim of this study was to evaluate the clinical relevance of high-risk human papillomavirus (HR-HPV) negativity at the time of unsatisfactory cervical cytology. METHODS: In this retrospective observational study, records were reviewed for patients who had unsatisfactory cervical cytology with HR-HPV testing performed from January 2015 through September 2019 at a large teaching hospital. Pathology results of follow-up cervical cytology and biopsies were assessed. RESULTS: Of 1282 patients with unsatisfactory cervical cytology and negative HR-HPV testing, repeat cytology was negative for intraepithelial lesion (NIL) in 952 (75%) patients, unsatisfactory in 273 (22%) patients, and abnormal in 41 (3%) patients. Median follow-up time was 91 days. The concordance of HR-HPV status between initial unsatisfactory cervical cytology and subsequent satisfactory cervical cytology was 96.3% for HR-HPV negative patients and 68.8% for HR-HPV positive patients. Compared to women who were HR-HPV negative, women who were HR-HPV positive on initial unsatisfactory cytology were at higher risk of subsequent cervical intraepithelial neoplasia (CIN) 2 or greater (odds ratio = 4.91, 95% confidence interval: 1.34-18.03 for E6/E7 mRNA positivity alone; odds ratio = 46.13, 95% confidence interval: 13.45-158.01 for HR-HPV genotype 16 or 18/45 positivity). CONCLUSION: In the 3 month follow-up of patients with unsatisfactory cervical cytology and negative HR-HPV testing, approximately 3% had abnormal cytology but no cases of HPV related pathology of CIN 2 or greater were found. There was high concordance of negative HR-HPV testing results with those on follow-up satisfactory cervical cytology.

Assessing the efficacy of magnesium oxide and riboflavin as preventative treatment of migraines in pregnancy.

PURPOSE: The purpose of this study is to assess the efficacy of magnesium oxide (MgO) alone and, secondarily, MgO plus riboflavin as preventive treatment of migraines in pregnancy. We hypothesize that MgO alone will be effective for the majority of patients and, when clinically indicated, the addition of riboflavin will result in further benefit. METHODS: This was a retrospective cohort study of pregnant patients treated for migraines between 2015 and 2020. We evaluated pre-/post-differences in the following primary outcomes: migraine frequency, severity, and duration. Secondary outcomes included associated migraine symptoms. RESULTS: Of 203 total patients, 117 received MgO alone and 86 received MgO plus riboflavin. There were no significant differences in baseline demographics between the two groups. There was a statistically significant decrease in migraine frequency, severity, and duration in the groups receiving MgO alone and MgO plus riboflavin (p < 0.01 for all). In total, 154 patients reported migraine-associated symptoms, of which 119 (77%) improved after treatment, 18 (12%) did not improve, and 17 (11%) patients' data were missing. The MgO plus riboflavin group had a lower gestational age at treatment initiation and was more likely to receive treatment prior to pregnancy (p < 0.01). Significant differences were observed for several baseline migraine symptoms, including photophobia, phonophobia, nausea, and vomiting, which were more common in the group receiving MgO plus riboflavin (p < 0.05 for all). CONCLUSION: Migraine frequency, severity, and duration all decreased with MgO alone and MgO plus riboflavin in this pregnancy cohort. Associated symptoms also significantly decreased for both groups.

Hematometrocolpos following Low Transverse Cesarean Delivery Complicated by Uterine Dehiscence.

BACKGROUND: Hematometrocolpos is a rare complication following procedures performed on the female genital tract. While usually seen in adolescents with congenital anomalies including imperforate hymen and vaginal stenosis, it has also been described following obstetric vaginal lacerations. The incidence following cesarean delivery is unknown. CASE: This is a 43-year-old multigravida who underwent a low transverse cesarean delivery complicated by uterine dehiscence, as well as cervical and vaginal lacerations. The repair resulted in lower genital tract obstruction. She presented seven months afterwards with severe abdominopelvic pain and secondary amenorrhea, which resolved after vaginal dilation and excision of the vaginal scar. CONCLUSION: Systematic inspection of the upper vagina should be undertaken following complicated cesarean delivery with vaginal extension. Hematometrocolpos after cesarean delivery should be managed similar to a transverse vaginal septum.

Incidental Septostomy after Laser Surgery for Twin-Twin Transfusion Syndrome: Perinatal Outcomes and Antenatal Management.

INTRODUCTION: Incidental septostomy, or inadvertent perforation of the twins' dividing membranes, can create a functional monoamniotic twin pregnancy. Our aim was to describe the perinatal outcomes and antenatal management of patients with incidental septostomy after laser surgery for twin-twin transfusion syndrome (TTTS). MATERIALS AND METHODS: Monochorionic diamniotic multiple gestations with a gestational age (GA) between 16 and 26 weeks that underwent laser surgery from March 2006 to December 2015 were studied retrospectively. Perinatal outcomes were compared for patients with and without an incidental septostomy. A subgroup analysis was performed to evaluate antenatal management. RESULTS: Of 532 TTTS patients who underwent laser surgery, incidental septostomy occurred in 34 (6.4%). Compared to all others, patients with a septostomy had an earlier median (range) GA at delivery (30.8 [18.6-37.9] vs. 34.0 [19.3-40.4] weeks, p < 0.0001) and lower 30-day survival of at least one twin (85.3 vs. 94.6%, p = 0.0452). We found no evidence that inpatient fetal surveillance was protective. DISCUSSION: Incidental septostomy in TTTS patients treated via laser surgery appeared to be associated with lower GA at delivery and perinatal survival of at least one twin. Further study is required to determine the optimal antenatal surveillance strategy.

Plasma levels of intermedin (adrenomedullin-2) in healthy human volunteers and patients with heart failure.

Intermedin/adrenomedullin-2 (IMD) is a member of the adrenomedullin/CGRP peptide family. Less is known about the distribution of IMD than for other family members within the mammalian cardiovascular system, particularly in humans. The aim was to evaluate plasma IMD levels in healthy subjects and patients with chronic heart failure. IMD and its precursor fragments, preproIMD(25-56) and preproIMD(57-92), were measured by radioimmunoassay in 75 healthy subjects and levels of IMD were also compared to those of adrenomedullin (AM) and mid-region proadrenomedullin(45-92) (MRproAM(45-92)) in 19 patients with systolic heart failure (LVEF<45%). In healthy subjects, plasma levels (mean+SE) of IMD (6.3+0.6 pg ml(-1)) were lower than, but correlated with those of AM (25.8+1.8 pg ml(-1); r=0.49, p<0.001). Plasma preproIMD(25-56) (39.6+3.1 pg ml(-1)), preproIMD(57-92) (25.9+3.8 pg ml(-1)) and MRproAM(45-92) (200.2+6.7 pg ml(-1)) were greater than their respective bioactive peptides. IMD levels correlated positively with BMI but not age, and were elevated in heart failure (9.8+1.3 pg ml(-1), p<0.05), similarly to MRproAM(45-92) (329.5+41.9 pg ml(-1), p<0.001) and AM (56.8+10.9 pg ml(-1), p<0.01). IMD levels were greater in heart failure patients with concomitant renal impairment (11.3+1.8 pg ml(-1)) than those without (6.5+1.0 pg ml(-1); p<0.05). IMD and AM were greater in patients receiving submaximal compared with maximal heart failure drug therapy and were decreased after 6 months of cardiac resynchronization therapy. In conclusion, IMD is present in the plasma of healthy subjects less abundantly than AM, but is similarly correlated weakly with BMI. IMD levels are elevated in heart failure, especially with concomitant renal impairment, and tend to be reduced by high intensity drug or pacing therapy.

Pediatric Pulmonologists' Perceptions of Family Socioeconomic Status in Asthma Care.

Background: Physicians' assumptions about patients' socioeconomic status (SES) have been shown to influence clinical decision making in adult patients. The goal of this study is to assess the factors associated with pediatric pulmonologists' (PPs') subjective ratings of their patients' SES, and whether these factors differ by patient race/ethnicity. Methods: Parents of children with asthma (n=171) presenting for pulmonary care reported their SES using the MacArthur Subjective SES 10-rung ladder. The PPs (n=7) also estimated each family's SES. Two-level linear regression models with random intercepts (level 1: PP's SES ratings; level 2: PPs) were used to assess the predictors of PP-estimated family SES. The analyses were then stratified by race/ethnicity. Results: Parental educational, insurance type, age, and race/ethnic background were associated with PPs' SES ratings. Black/African American families were rated lower than white families, accounting for other demographic factors (b=-0.60, p<0.01), but families of other races/ethnicities were not (b=-0.10, p=0.29). Even when comparing families with the same level of parental education, black/African American families, but not families of other backgrounds, were judged to have lower SES than white families (from 0.77 rungs lower among parents with some college, to 1.2 rungs lower among parents with high school or less; both p<0.05). Conclusions: Racial differences in PPs' ability to estimate families' subjective SES in asthma care may be a function of unconscious societal biases about race and class. Collecting subjective SES from families and PPs during the office visit could facilitate discussions about material and psychosocial needs and resources that influence treatment effectiveness.

A method to determine the orientation of the upper arm about its longitudinal axis during dynamic motions.

Inaccuracy in determining the orientation of the upper arm about its longitudinal axis (twist orientation) has been a pervasive problem in sport biomechanics research. The purpose of this study was to develop a method to improve the calculation of the upper arm twist orientation in dynamic sports activities. The twist orientation of the upper arm is defined by the orientation of its mediolateral axis. The basis for the new method is that at any angle in the flexion/extension range of an individual's elbow, it is possible to define a true mediolateral axis and also a surrogate mediolateral axis perpendicular to the plane containing the shoulder, elbow and wrist joints. The difference between the twist orientations indicated by these two versions of the mediolateral axis will vary from one elbow angle to another, but if the elbow joint deforms equally in different activities, for any given subject the difference should be constant at any given value of the elbow angle. Application of the new method required individuals to execute sedate elbow extension trials prior to the dynamic trials. Three-dimensional motion analysis of the sedate extension trials allowed quantification of the difference between the true and surrogate mediolateral axes for all angles in the entire flexion/extension range of an individual's elbow. This made it possible to calculate in any dynamic trial the twist orientation defined by the true mediolateral axis from the twist orientation defined by the surrogate mediolateral axis. The method was tested on a wooden model of the arm.

Contributions of joint rotations to racquet speed in the tennis serve.

The purpose of this study was to measure the contributions of the motions of body segments and joints to racquet head speed during the tennis serve. Nine experienced male players were studied using three-dimensional film analysis. Upper arm twist orientations were calculated with two alternative methods using joint centres and skin-attached markers. The results showed that skin-attached markers could not be used to calculate accurate upper arm twist orientations due to skin movement, and that the use of joint centres produced errors of more than 20 degrees in the upper arm twist orientation when the computed elbow flexion/extension angle exceeded 135 degrees in the final 0.03 s before impact. When there were large errors in the upper arm twist orientation, it was impossible to obtain accurate data for shoulder or elbow joint rotations about any axis. Considering only the contributors that could be measured within our standards of acceptable error, the approximate sequential order of main contributors to racquet speed between maximum knee flexion and impact was: shoulder external rotation, wrist extension, twist rotation of the lower trunk, twist rotation of the upper trunk relative to the lower trunk, shoulder abduction, elbow extension, ulnar deviation rotation, a second twist rotation of the upper trunk relative to the lower trunk, and wrist flexion. The elbow extension and wrist flexion contributions were especially large. Forearm pronation made a brief negative contribution. Computed contributions of shoulder internal rotation, elbow extension and forearm pronation within the final 0.03 s before impact were questionable due to the large degree of elbow extension. Near impact, the combined contribution of shoulder flexion/extension and abduction/adduction rotations to racquet speed was negligible.