Expansile Endocervical Crypt Involvement by CIN2 - 3 as a Risk Factor for High Grade Cytology Recurrence After Cold Coagulation Cervical Treatment.

Introduction To determine whether expansile endocervical crypt involvement (ECI) on pretreatment cervical punch biopsies is a risk factor for high grade cytology recurrence in women following cold coagulation for cervical intraepithelial neoplasia (CIN). Materials and Methods This was a secondary analysis on the results of an observational study of women who had a single cold coagulation cervical treatment between 2001 - 2011 and who were followed up for cytology recurrence. Women with a previous cervical treatment were excluded. Results 559 women were identified with a mean age of 28.7 ± 6.2 years. Expansile and non-expansile ECI were identified in 5.4 and 4.3% of women, respectively. The proportion of women with high grade cytology recurrence was 10% for those with expansile ECI and 2.3% for those without. Multivariate analysis showed that women with expansile ECI when compared to those without, had a four-fold greater risk for high grade cytology recurrence (HR = 4.22; 95% CI: 1.10 - 16.29, p = 0.036). There was no significant association found between non-expansile ECI and overall or high grade cytology recurrence. The increased biopsy depth and the CIN3 grade of pretreatment cervical punch biopsies were significantly associated with greater odds for the detection of expansile ECI. We calculated that the optimal-cut off of pretreatment cervical punch biopsy depth for the detection of expansile ECI was 4 mm (sensitivity: 73.3%; specificity: 55.1%). Conclusions Expansile ECI is a risk factor that increases the likelihood of high grade cytology recurrence following cold coagulation. Deeper pretreatment cervical punch biopsies need to be taken so as not to miss expansile ECI prior to ablative treatment.

Early and late pregnancy outcomes in women treated with cold-coagulation versus LLETZ cervical treatment for cervical intraepithelial neoplasia; a retrospective cohort study.

PURPOSE: To compare the pregnancy outcomes between women who were treated with cold-coagulation versus large loop excision of the transformation zone (LLETZ) for cervical intraepithelial neoplasia. METHODS: This was a retrospective cohort study of women who had a single cervical treatment between 2010 and 2011. We identified those women who had a singleton pregnancy subsequent to their cervical treatment until September 2017. Women with previous cervical treatment, previous miscarriage or preterm delivery were excluded. RESULTS: We identified 86 women with a pregnancy after LLETZ treatment and 75 women after cold coagulation. Those who had LLETZ when compared to cold coagulation miscarried more often in the first trimester (33.7 vs 17.3%; p = 0.01) than in the second trimester. In women with LLETZ this effect of increased early miscarriage was shown to be prolonged and to persist up to 17 months after excision. Women with LLETZ when compared to cold coagulation had higher spontaneous preterm birth rates (8.9 vs 6.7%) even though the difference was non significant, with the earliest spontaneous preterm birth occurring at 32 weeks and 34 weeks, respectively. CONCLUSION: We found that women who received LLETZ treatment when compared to cold coagulation had higher spontaneous preterm birth rates in their subsequent pregnancy and miscarried more frequently in the first trimester, and demonstrated an increased early miscarriage risk that persisted for more than a year after excisional treatment.

Comparison of cure rates in women treated with cold-coagulation versus LLETZ cervical treatment for CIN2-3 on pretreatment cervical punch biopsies: a retrospective cohort study.

PURPOSE: To compare the cure rates between women who were treated with cold-coagulation versus large loop excision of the transformation zone (LLETZ) for cervical intraepithelial neoplasia grade 2 (CIN2) or 3 (CIN3) on pretreatment cervical punch biopsies. METHODS: This was a retrospective cohort study of women having had a single cervical treatment for CIN2 or CIN3 on pretreatment cervical punch biopsies between 2010 and 2011. The cure rates were defined as the absence of any dyskaryosis (mild/moderate/severe) on cytology tests during follow-up and were determined at 6 and 12 months after treatment. RESULTS: We identified 411 women having had cervical treatment with 178 cases of cold-coagulation and 233 cases of LLETZ. The cure rates at 6 months following cold-coagulation and LLETZ treatment were 91.6 versus 97.1% (p = 0.02), whereas at 12 months, they were 96.5 versus 97.3% (p = 0.76). Multivariable analysis showed that after adjusting for confounding factors, there was a fourfold higher cure rate with LLETZ in comparison with cold-coagulation at 6 months after treatment (adjusted OR 4.50, 95% CI 1.20-16.83; p = 0.026), with this difference disappearing at 12 months. The lower cure rates with cold-coagulation were due to its higher rates of mild dyskaryosis cytology tests at 6 months. The rates of moderate/severe dyskaryosis cytology tests were similar between the two treatment methods at 6 and 12 months. CONCLUSION: We found that women with CIN2 or CIN3 on pretreatment cervical punch biopsies, after adjusting for multiple confounding factors, had higher cure rates when treated with LLETZ versus cold-coagulation at 6 months, with this difference disappearing at 12 months.

Thrombolysis for stroke in pregnancy at 39 weeks gestation with a subsequent normal delivery.

Stroke during pregnancy is fortunately a rare event, however, it can have severe consequences, with 9.5% of all maternal deaths being related to stroke. The most common presentation is an ischaemic stroke. There has been much debate as to the correct treatment for such cases' and whether thrombolysis can be used safely in pregnancy. Our case describes a 28-year-old woman with a previous normal vaginal delivery presenting in her third trimester with a sudden onset of dense left hemiparesis. She was successfully treated with alteplase, an intravenous recombinant tissue-type plasminogen activator, and made a full recovery after normal delivery of a healthy infant. This case report highlights one of the first documented successful outcomes from thrombolysis for this condition in the UK and may help inform future management of these women.

Endocervical Crypt Involvement by CIN2-3 as a Predictor of Cytology Recurrence After Excisional Cervical Treatment.

OBJECTIVE: The primary objective was to determine whether endocervical crypt involvement (ECI) by cervical intraepithelial neoplasia (CIN) on the excised cervical tissue after large loop excision of the transformation zone (LLETZ) represents a predictor of cytology recurrence. Secondary objective was to identify the ability of a pretreatment cervical punch biopsy to predict cytology recurrence. MATERIALS AND METHODS: This was a case series study conducted in an NHS hospital. Women with LLETZ treatment performed over a 2-year period (2010-2011) were identified through our colposcopy database. Women with previous cervical treatment, cervical cancer on cone histopathology, or missing follow-up data were excluded. RESULTS: A group of 526 eligible women was identified over the study period. Crypt involvement was not a predictor of recurrence in the total sample. However, in the subgroup of women with CIN2-3 on pretreatment punch biopsy and with ECI on cone specimen in comparison to those without ECI, we identified an increased risk for overall cytology recurrence (HR, 3.1; 95% CI, 1.04-9.28; P = 0.043) and a trend for increased risk of high-grade cytology recurrence (HR, 4.62; 95% CI, 0.84-25.28; P = 0.07). A pretreatment punch biopsy showing crypt involvement by CIN2-3 was indicative of women at risk for abnormal cytology after excision. In women with CIN2-3 on pretreatment punch biopsy and ECI on excised tissue, the high-grade cytology recurrence was significantly reduced if more than 1.9 cm of cervix was removed. CONCLUSIONS: It seems that the presence of crypt involvement on the excised cervix in the subgroup of women with CIN2-3 on pretreatment punch biopsy is predictive of cytology recurrence.

Risk factors for treatment failure following cold coagulation cervical treatment for CIN pathology: a cohort-based study.

PURPOSE: To determine any risk factors for cytology recurrence in women after cold coagulation ablative treatment for cervical intraepithelial neoplasia (CIN). METHODS: This was a retrospective observational study of a cohort of women having had cold coagulation between 2001 and 2011 in the colposcopy unit of an NHS hospital. We retrospectively collected data from our colposcopy unit database. Women with previous cervical treatment were excluded. RESULTS: 559 eligible women were identified with a mean age of 28.7 ± 6.2 years. Nulliparous women were 66.3 % with smokers involving 35.3 %. Referral cytology, pretreatment cervical punch biopsies and colposcopy were high grade in 51.9, 71.9 and 45.8 % of women. Endocervical crypt involvement (ECI) on pretreatment cervical punch biopsy involved 9.7 % of women. Mean follow-up was 3.1 ± 2.4 years. Overall cytology recurrence (mild/moderate/severe dyskaryosis) at 6 and 12 months follow-up was 7.4 and 5 %. High-grade cytology recurrence (moderate/severe dyskaryosis) involved 2.7 % of women over the entire follow-up period. Multiple regression analysis showed that ECI on pretreatment cervical punch biopsy was a risk factor for high-grade cytology recurrence (HR 3.72; 95 %CI 1.18-11.71; p = 0.024). There were no risk factors identified for overall cytology recurrence. However, when cytology tests with borderline nuclear changes at follow-up were pooled with mild/moderate/severe dyskaryosis cytology tests, then parity ≥2 was a risk factor for abnormal cytology (HR 1.71; 95 %CI 1.08-2.69; p = 0.022). CONCLUSIONS: Endocervical crypt involvement on pretreatment cervical punch biopsy and multiparity ≥2 are risk factors that increase the likelihood of abnormal cytology following cold coagulation. These two risk factors should be taken in consideration when performing cold coagulation cervical treatment for CIN pathology.

Success rate of cold coagulation for the treatment of cervical intraepithelial neoplasia: a retrospective analysis of a series of cases.

OBJECTIVE: To establish the cure rate at 1 year of patients who have undergone cold coagulation for the treatment of cervical intraepithelial neoplasia (CIN). DESIGN: Retrospective review of data for all patients at Shrewsbury and Telford NHS Trust who had undergone cold coagulation as part of their treatment for CIN between 2001 and 2011. Follow-up data up to December 2012 were analyzed. SETTING: Colposcopy Department, Shrewsbury and Telford NHS Trust, United Kingdom. POPULATION: Women undergoing cold coagulation for the treatment of CIN between 2001 and 2011, with cytologic follow-up until December 2012. METHODS: Patients were identified using a local colposcopy database. Data were obtained via the local histopathology reporting systems. Statistical analyses were performed using Stata/IC 10.1 software. MAIN OUTCOME MEASURES: Posttreatment cytology and whether subsequent treatment was required, with histology results. RESULTS: Data on 557 patients were collected and analyzed. Pre-cold coagulation treatment histologic findings were CIN 1 in 156 patients (28.01%), CIN 2 in 260 patients (46.68%), and CIN 3 in 141 patients (25.31%). The median length of time between cold coagulation treatment and first follow-up smear, used to calculate cure rates at around 1 year, was 406 days (interquartile range 123 days, range 169-3,116 days). The cure rate after cold coagulation was 95.7% at around 1 year. CONCLUSIONS: Cold coagulation has a cure rate comparable to that of excisional treatments such as large loop excision of the transformation zone and should be considered more widely in patients undergoing primary treatment for CIN, where there is no suspicion of invasive disease on history, examination and cytologic results.

Relation between inheritance of cyanotic congenital heart disease and persistent foramen ovale.

Cyanotic congenital heart disease (CCHD) usually occurs sporadically, but occasionally it is familial without evidence of Mendelian inheritance. The investigators previously reported an association between dominant inheritance of clinically significant atrial shunts (large persistent foramina ovale and small atrial septal defects) and migraine with aura in some families. In 1 family, 4 patients with CCHD were linked by relatives with atrial shunts. The presence of atrial shunts and migraine symptoms was investigated in another family in which 3 members had CCHD. Contrast echocardiography was used to detect whether atrial right-to-left shunts were present in family members. A consultant neurologist, who was blinded to cardiac findings, diagnosed and categorized migraine symptoms. In this family, relatives with atrial right-to-left shunts linked 3 members who had CCHD. There appears to be dominant inheritance of atrial shunts, which is linked to inheritance of CCHD in some families. In conclusion, it is possible that the gene responsible most often causes an atrial shunt but sometimes causes more complex heart disease.

Outpatient hysteroscopy: an observational study of patient acceptability.

OBJECTIVE: To assess the patient acceptability of outpatient hysteroscopy when Prilocaine is used as analgesia and to determine if our practice of using Prilocaine only if indicated by pain is appropriate. MATERIAL AND METHODS: Prospective observational study of 100 consecutive patients undergoing outpatient hysteroscopy. RESULTS: One hundred consecutive women attending for outpatient hysteroscopy, completed questionnaires after the procedure, indicating the level of pain experienced on an analogue scale. Prilocaine hydrochloride (40 mg/ml) had been administered as an intracervical block only if a patient experienced pain or if cervical dilatation was required. Patients expressed significantly more pain during hysteroscopy than after hysteroscopy whether Prilocaine was used or not. The median pain score was significantly higher in the group that required local anesthetic. There was a greater desire to have the procedure done under general anesthesia when Prilocaine was used than when it was not used. CONCLUSION: Pain is a determining factor in patient acceptability of outpatient hysteroscopy and is a likely reason for some women to opt to have a hysteroscopy under general anesthesia. The practice of administering Prilocaine only if needed is inappropriate. Future studies should now aim to determine the optimal drug, dose, and timing of administration of analgesia in pre-selected women who are likely to experience pain and hence benefit from analgesia.