Detection of high-grade cervical dysplasia: impact of age and Bethesda system terminology.

Pap smear, colposcopy, and biopsy results were collected from 1988-1993 at a group of family planning clinics. Positive predictive values and likelihood ratios were calculated for diagnosis of high-grade lesions based on age and Pap smear results. One thousand and forty-seven colposcopies were logged; 771 had a biopsy or endocervical curettage. Seventy-nine (10%) were high-grade lesions. If only human papillomavirus (HPV) was reported on the Pap smear, the likelihood of a high-grade biopsy was lowest (positive predictive value, 4.5%; likelihood ratio, 0.4). Women under age 25 were less likely to have high-grade biopsies (positive predictive value, 7.3%; likelihood ratio 0.7). Repeat Pap smears for atypical cells of undetermined significance (ASCUS) and low grade squamous intra-epithelial lesion (LGSIL) showing only HPV in women under age 30 would have reduced the immediate colposcopy rate by 60% and delayed diagnosis by 23% of high-grade lesions. Consideration of patient age and whether HPV is the only Pap smear finding may reduce referral for immediate colposcopy.

Effect of a transportation incentive on compliance with the first prenatal appointment: a randomized trial.

OBJECTIVE: To evaluate the effectiveness of incentives for improving compliance with the first prenatal appointment. METHODS: One hundred four low-income women, intending to enroll for prenatal care in a system of Northern California family planning clinics, were recruited for a randomized trial. Study subjects were assigned randomly to one of three groups, receiving a taxicab voucher or a baby-blanket coupon or an appointment slip (controls). Intention-to-treat analysis was used to compare compliance with the first prenatal appointment between the three groups. RESULTS: Subjects receiving the taxi voucher had a compliance rate of 82% for the first prenatal appointment, 22% higher than mean appointment compliance in the other groups. The odds ratio for missing the first appointment was 0.32 (95% confidence interval 0.12, 0.88) in the taxi voucher group. This was not affected by controlling for possible confounders. Despite better appointment compliance, only one of 34 taxi vouchers distributed was actually used. CONCLUSION: A taxi voucher incentive was effective in improving compliance with the first prenatal appointment, despite the fact that only one subject actually used the voucher.

Is cervicography a useful diagnostic test? A systematic overview of the literature.

BACKGROUND: The appropriate approach to women with mild dyskaryotic changes on Papanicolaou smear is subject to controversy. Our aim was to assess the usefulness of cervicography as a diagnostic test in detecting cervical cancer or its precursors. METHODS: We undertook an extensive literature search looking for pertinent studies of cervicography published between 1966 and 1996. Eligible studies included those in which the reference standard (colposcopy) was done on all patients. The following information was calculated: sensitivity, specificity, positive predictive value, negative predictive value, disease prevalence, and likelihood ratios. RESULTS: Cervicography has a high false-positive rate. This rate ranged from 8.2 to 61.0 percent (median 42.1 percent) for any dysplasia and 9.8 to 63.4 percent (median 50.6 percent) for high-grade cervical lesions. Likelihood ratios for a positive test result ranged from 1.0 to 10.6. Likelihood ratios for a negative result ranged from 0.02 to 1.0. CONCLUSIONS: The usefulness of cervicography is heavily dependent on the approach used to evaluate abnormal findings on a Papanicolaou smear. If a provider typically offers colposcopy to all patients with low-grade cytologic findings on a Papanicolaou smear, cervicography will decrease colposcopy use and allow for detection of cases of high-grade dysplasia missed by the index Papanicolaou smear. If a provider typically uses watchful waiting with repeat Papanicolaou smears for all patients who have low-grade cytologic findings, cervicography will substantially increase the use of colposcopy. Many of these colposcopies will be done as a result of false-positive cervigrams.

Management choices for patients with "squamous atypia" on Papanicolaou smear. A toss up?

Appropriate management of borderline abnormalities on Papanicolaou (Pap smears is controversial. This decision analysis compared two strategies for management of women with the Pap smear result of "squamous atypia." A policy of immediate colposcopy and biopsy was compared with repeating the cervical smear at 6-month intervals. Relevant probabilities and ranges were extracted from published studies in the English language medical literature from 1966 to 1993. When no relevant studies could be located, probabilities with a plausible range were determined through consensus of a panel of experts. Outcome values were assigned for the analysis to contrast the time period (approximately 2 years) covered by the analysis. Using baseline estimates, either policy resulted in an essentially equivalent probability of invasive cervical cancer. The estimated likelihood of remaining free of invasive cervical cancer was .9974 for follow-up by repeat smear versus .9976 for immediate colposcopy and biopsy. In sensitivity analysis, very high probabilities of progression to invasive cervical cancer favored the policy of immediate colposcopy and biopsy. Follow-up of squamous atypia on cervical smear by repeating the smear at 6-month intervals is unlikely to result in a detectable increase in invasive cervical cancers.

Management of patients with atypical and low-grade Pap smear abnormalities.

Family physicians frequently encounter patients with atypical and low-grade Papanicolaou (Pap) smear findings. While near consensus exists regarding the evaluation and management of patients with high-grade dysplasia and carcinoma detected on Pap smear, the appropriate management of patients with atypical and low-grade abnormalities continues to be controversial. Recent guidelines from the National Cancer Institute propose consideration of a more conservative management approach, with repeat Pap smear as an alternative to immediate colposcopy. Conservative management, as an alternative to an ablative or excisional procedure, has also been proposed for women with histologic evidence of lowgrade dysplasia. It is unlikely that an approach including a conservative diagnostic strategy and careful follow-up will result in an increase in the number of missed cases of cervical cancer. This assumption needs to be assessed by prospective clinical trials.

Cost-effectiveness analysis of five different antibiotic regimens for the treatment of uncomplicated Chlamydia trachomatis cervicitis.

BACKGROUND: The new Centers for Disease Control and Prevention treatment guidelines for Chlamydia trachomatis include two recently available drugs, azithromycin and ofloxacin. The best choice for initial therapy remains controversial. OBJECTIVES: We wanted to perform a cost-effectiveness analysis of five different antibiotic regimens for the treatment of uncomplicated Chlamydia trachomatis cervicitis. METHODS: Using information gathered from a MEDLINE search of the English language literature from 1966 to 1994, employing the key words "cervicitis," "C. trachomatis," "erythromycin," "tetracycline," "doxycycline," "ofloxacin," and "azithromycin," we developed a decision analysis model specific for a nonpregnant woman with uncomplicated Chlamydia trachomatis cervicitis. Options in this model included an initially cured infection, a failed initial cure resulting in persistent cervicitis, or pelvic inflammatory disease treated either on an inpatient or outpatient basis. Probability estimates for each option were derived from previously published reports. A cost-effectiveness analysis was performed for three end points: cost per cure with initial therapy, cost per case of pelvic inflammatory disease averted, and cost per hospitalization averted. Sensitivity analyses were done by varying the cure rates for each antibiotic and the complication rates for failed therapy. The costs incurred for treatment were also varied. RESULTS: Using the high estimate for initial cure rates, doxycycline and tetracycline were the most cost-effective agents. Azithromycin was the next most cost-effective agent, followed by ofloxacin and erythromycin. To achieve an equivalent final cost, the probability of initial cure with azithromycin must exceed that of doxycycline by 3 percentage points. As the cost of azithromycin decreases, the difference in initial cure rates between the two drugs to achieve an equivalent final cost becomes smaller. CONCLUSIONS: Doxycycline remains the drug of choice in the treatment of Chlamydia trachomatis cervicitis. The results favor the use of azithromycin rather than doxycycline when there is concern for compliance to the standard doxycycline regimen. A lower cost for azithromycin could favor its use as the drug of choice.

Trends in maternity care by graduates and the effect of an intervention.

BACKGROUND AND OBJECTIVES: Only 24% of family physicians in the United States deliver babies, a figure that declined remarkably during the decade of the 1980s. This study examines the content of practice, with regard to maternity care, of graduates of the University of California, Davis Family Practice Residency Network over the past 20 years, and the effectiveness of residency training intervention designed to increase maternity care activity among graduates. METHODS: Using a mailed survey instrument, graduates of the UC Davis Family Practice Residency Network have been periodically surveyed on practice characteristics since 1978. Using data from these surveys, maternity care and other practice characteristics of all graduates were analyzed using descriptive statistics. Data on trends in maternity care of two groups of residents who graduated a decade apart were evaluated. A separate evaluation of the two most recent graduating classes was performed to evaluate an intervention at the Network's university-based program. The program had been designed to increase the number of graduates who provide maternity care. RESULTS: Survey responses from previous graduates of the six network programs showed that only 31% included maternity care in their practices at the time of the 1991 survey. Sixty-one percent of a cohort of graduates from a 3-year period from 1979 through 1981 included maternity care upon entering practice. The 3-year cohort of residents graduating a decade later, during the years 1988-1990, had an initial participation rate in maternity care of only 37% in 1991. However, only 11% of the graduates from the university-based program in the 1988-1990 cohort made an initial decision to include maternity care in their practice. For the graduates of this program from 1991 and 1992, a period following the specific intervention, participation in maternity care increased to 50%. CONCLUSIONS: This study documents the decrease in interest in providing obstetrical services by recent family practice residency graduates when compared to graduates a decade earlier. Further, it suggests that residency programs, even with very low rates of participation in maternity care, can increase the interest and participation of residents to include these services in their practices after graduation.

Prevalence rate of hypertension among recent Southeast Asian refugees to northern California.

BACKGROUND: Little is known regarding the prevalence rate of hypertension among recent Southeast Asian refugees to the United States. METHODS: In this randomized, prospective study, four northern California counties with large Southeast Asian refugee populations were screened for the prevalence rates of hypertension and borderline hypertension. A population density method based upon 1988 census data was used to screen a representative sample of subjects from each county. Criteria for hypertension came from the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. RESULTS: In all, 964 subjects were screened. We found a prevalence rate of 4.8 percent for hypertension and 10.9 percent for borderline hypertension. CONCLUSIONS: The relatively low prevalence rates of this disease can be explained by the youth of this refugee population, mean age 37.6 +/- 0.36 years, as the presence of hypertension increases with chronological age.

Acid phosphatase stimulation of the growth of Nocardia asteroides and its possible relationship to the modification of lysosomal enzymes in macrophages.

Lysosomal acid phosphatase levels are reduced in murine macrophages by virulent strains of Nocardia asteroides. At the same time, other lysosomal enzymes either remain unchanged or increase in activity, indicating that acid phosphatase is not lost because of degranulation or membrane leakage. This study shows that acid phosphatase was utilized as a sole carbon source by Nocardia asteroides and that acid phosphatase combined with glutamate as a carbon source enhanced nocardial growth. As a consequence, the inverse relationship that was observed between acid phosphatase activity and the bactericidal capacity of macrophages infected with N. asteroides appears to be due to the ability of N. asteroides to preferentially metabolize this lysosomal enzyme during growth within phagocytes.

Acidification of phagosomes in murine macrophages: blockage by Nocardia asteroides.

Most strains of Nocardia asteroides are susceptible to the detrimental effects of pH 5 when grown in buffered brain-heart infusion broth. Preventing phagosomal acidification may be a mechanism by which this organism survives the microbicidal activity of macrophages. Fluorescein isothiocyanate was conjugated to the surface of Nocardia and Saccharomyces to form pH-sensitive fluorescent probes. The fluorescent emission, and thus the pH, of this probe was quantitated within individual phagosomes by using a computerized cytospectrophotometer. When either live or dead cells of virulent N. asteroides strain GUH-2 were ingested, the phagosomal pH remained above pH 7 for 2 hr. A nonpathogenic soil isolate, N. asteroides strain 19247, only partially blocked acidification. In contrast, when Saccharomyces was used as a control for normal response, the pH decreased to approximately pH 5. Therefore, virulent N. asteroides blocks phagosomal acidification. Because killed Nocardia act in the same manner, this inhibition of acidification appears to be associated with cellular components. This capacity to prevent phagosomal acidification may be prerequisite to the survival of intracellular pathogens.

Modulation of lysosomal protease-esterase and lysozyme in Kupffer cells and peritoneal macrophages infected with Nocardia asteroides.

Virulent Nocardia asteroides reduces lysosomal acid phosphatase activity in murine macrophages. A computer-assisted imaging photometry system was used to quantitate lysozyme and nonspecific esterase-neutral protease levels within individual macrophages following ingestion of nocardiae. In contrast to acid phosphatase, lysozyme and esterase-neutral protease activity was either unchanged or increased following infection by increasing numbers of nocardial cells.