Protein prescription and delivery practices in critically ill adults: A survey of Australian and New Zealand intensive care dietitians.

BACKGROUND: Protein provision is thought to be integral to attenuating muscle wasting in critical illness, yet patients receive half of that prescribed. As international guidelines lack definitive evidence to support recommendations, understanding clinicians' views relating to protein practices is of importance. OBJECTIVES: The objective of this study was to describe Australia and New Zealand intensive care unit (ICU) dietitians' protein prescription and perceived delivery practices in critically ill adults, including common barriers and associations between ICU clinical experience and protein prescriptions for different clinical conditions. METHODS: A 42-item descriptive quantitative survey of Australian and New Zealand intensive care dietitians was disseminated through nutrition and ICU society e-mailing lists. Data were collected on respondent demographics and reported protein practices including questions related to a multitrauma case study. Data were analysed using descriptive and content analysis and reported as n (%). Fisher's exact tests were used to compare experience and protein prescriptions. RESULTS: Of the 67 responses received (one excluded due to >50% missing data), more than 80% of respondents stated they would prescribe 1.2-1.5 g protein/kg bodyweight/day for most critically ill patients, most commonly using European Society of Clinical Nutrition and Metabolism (ESPEN) guidelines to support prescriptions (n = 61/66, 92%). Most respondents (n = 49/66, 74%) thought their practice achieved 61-80% of protein prescriptions, with frequently reported barriers including fasting periods (n = 59/66, 89%), avoiding energy overfeeding (n = 50/66, 76%), and gastrointestinal intolerance (n = 47/66, 71%). No associations between years of ICU experience and protein prescriptions for 14 of the 15 predefined clinical conditions were present. CONCLUSIONS: Australian and New Zealand ICU dietitians use international guidelines to inform protein prescriptions of 1.2-1.5 g/kg/day for most clinical conditions, and protein prescriptions do not appear to be influenced by years of ICU experience. Key perceived barriers to protein delivery including avoidance of energy overfeeding and gastrointestinal intolerance could be explored to improve protein adequacy.

Diode laser assisted transcervical tubal sterilization: an in vivo study in rabbits.

BACKGROUND AND OBJECTIVE: To investigate the sterilization effectiveness of endoluminal tubal photocoagulation on tubal lumen obliteration. STUDY DESIGN/MATERIALS AND METHODS: Twenty-four female rabbits were subjected to laparotomy and hysterotomy. Endoluminal tubal photocoagulation was induced over a length of 3 cm in the proximal, extramural fallopian tube by using a cylindrical diffusing tip that emitted diode laser radiation at 805 and 980 nm wavelengths. Tubal patency was evaluated by observing patterns of injected methylene blue and/or breeding success rates. RESULTS: Postoperative recovery was uneventful in all animals. Evidence of occlusion of the tubal lumen included a negative methylene blue test in all 12 tubes treated (tubal occlusion rate 100%) and failure to conceive in 17 of 18 uteri (contraception rate 94.5%). Although identical power settings were used, distinctly lower tubal surface temperatures (about 10 degrees C) were obtained with the 805 nm diode laser as compared to the 980 nm diode laser. CONCLUSIONS: The described endoluminal tubal photocoagulation method using a diode laser emitting longer wavelengths (e.g., 980 nm) is suitable for safe and effective sterilization in rabbits and has potential as a new transcervical tubal sterilization method for humans.

Management of cervical intraepithelial neoplasia during pregnancy: a simplified and cost-effective approach.

OBJECTIVES: To determine the cost-effectiveness of managing an abnormal Papanicolaou (PAP) smear during pregnancy with a single colposcopic exam and biopsies, followed by Pap smears in each subsequent trimester of pregnancy and 8 weeks postpartum. MATERIALS AND METHODS: We reviewed 84 pregnant women with cervical intraepithelial neoplasia (CIN) between 1983 and 1991, testing the accuracy of an initial biopsy and subsequent Pap smears, to follow the progression (or regression) of disease as determined by postpartum biopsy or Pap smears. RESULTS: In 26 women with CIN1, 2 (8%) progressed to CIN3. In 29 women with CIN2, 5 (17%) progressed to CIN3. Of 29 patients with CIN3, 20 (69%) remained at CIN3 and 2 (6%) progressed to microinvasive carcinoma postpartum, confirmed by conization. No invasive carcinoma was missed. The cost of colposcopy with biopsies and Pap smear is $304, whereas cost of a Pap smear only is $30. CONCLUSIONS: Single colposcopy with biopsies at the beginning of pregnancy and Pap smears during subsequent trimesters and postpartum should be adequate follow-up to prevent progression to invasive cancer and represents a significant cost savings.

Outpatient loop electrosurgical excision procedure for cervical intraepithelial neoplasia. Can it replace cold knife conization?

OBJECTIVE: To determine if loop electrosurgical excision procedure (LEEP) can replace cold knife conization. STUDY DESIGN: In a population at high risk for invasive carcinoma, 163 cases of LEEP conization were performed with the same indications as cold knife for cervical conization. RESULTS: Seventy-five percent of LEEP surgical specimens were positive for dysplasia. Six cases showed invasive squamous cell carcinoma. No complications were seen. CONCLUSION: LEEP conization is a quick, simple and economical procedure that can safely replace most cases of cold knife conization.

Avoiding conization for inadequate colposcopy. Suggestions for conservative therapy.

OBJECTIVE: To determine if conservative treatment can safely be offered to patients with cervical intraepithelial neoplasia (CIN) and inadequate colposcopic examination. STUDY DESIGN: We reviewed the charts of 733 evaluable cone biopsies of the cervix performed for CIN at the University of Texas Medical Branch at Galveston from January 1981 to September 1990. RESULTS: Of 371 conizations that indicated inadequate colposcopy, there were 62 cases that fulfilled all the following conditions: cytologic smear suggesting CIN 2 or less, negative endocervical curettage (ECC) and cervical colposcopic biopsy showing CIN 2 or less. Pathologic examination of the cone biopsy specimen in these 62 cases revealed no dysplasia in 29.0%, CIN 1 in 16.%, CIN 2 in 37.0%, 3 in 17.7%, and no microinvasive or invasive lesions. Pathologic examination of the cone specimens of 309 patients with any high-risk factor--smear suggesting CIN 3 or invasive disease, colposcopic biopsy showing CIN 3 or positive ECC--revealed no dysplasia in 11.9%, CIN 1 in 11.3%, CIN 2 in 16.8%, CIN 3 in 49.8%, microinvasive carcinoma in 5.5% and frankly invasive carcinoma in 4.5%. CONCLUSION: Conservative therapy may be offered to patients with inadequate colposcopy, CIN 1-2 on both biopsy and cytology, and negative ECC without over-looking either invasive or microinvasive carcinoma. With these criteria, 16.7% of patients with an inadequate colposcopy in our study could have avoided cone biopsy.

Interleukin-10 messenger ribonucleic acid in human placenta: implications of a role for interleukin-10 in fetal allograft protection.

OBJECTIVE: Our purpose was to determine whether interleukin-10 is expressed in human placental tissue, which might imply a role for it in fetal allograft protection. STUDY DESIGN: Detection of interleukin-10 messenger ribonucleic acid in human placental tissue and in human placental JAR cells by reverse transcription-coupled polymerase chain reaction was studied. RESULTS: Interleukin-10 messenger ribonucleic acid was detected in human placental tissue from term mothers and in human placental JAR cells. Sequence analysis of the expected interleukin-10 complementary deoxyribonucleic acid fragment revealed 100% homology to authentic interleukin-10 complementary deoxyribonucleic acid. CONCLUSION: Our results indicated that human placental tissue from term mothers expressed high levels of interleukin-10 messenger ribonucleic acid, suggesting that cells that produce interleukin-10 and that are associated with the placenta may play a role in preventing rejection of the fetal allograft by the mother.

Management of patients with positive margins after cervical conization.

OBJECTIVE: To evaluate conservative management of patients undergoing cervical conization with cone margins positive for dysplasia. METHODS: The outcomes of 93 patients with cone biopsies that had margins positive for dysplasia were tabulated. RESULTS: Thirty of 47 patients (64%) undergoing conization only and followed by cytology had negative Papanicolaou smears for at least 2 years. Twenty-one of 37 women (57%) with conization and immediate hysterectomy had no residual disease in the cervix. Three of nine women (33%) with conization and delayed hysterectomy had no detectable dysplasia in the remaining cervix. There was no case of progression to invasive disease. The overall resolution rate was 58%. Persistence of disease was found most often at the endocervical margins associated with cervical intraepithelial neoplasia grade III. CONCLUSION: Patients with cone margins positive for dysplasia can be followed appropriately with cytology. In cases of recurrent abnormal Papanicolaou smears, colposcopy, biopsies, and endocervical curettage should be repeated.

Enterobius vermicularis salpingitis: a distant episode from precipitating appendicitis.

Chronic pelvic inflammatory disease is a common gynecologic diagnosis in women with chronic pelvic pain. When standard antimicrobial therapy does not improve the clinical status, uncommon diagnoses such as Enterobius vermicularis should be considered. In this case, E vermicularis presented as acute and chronic salpingitis in a patient who had had E vermicularis-related appendicitis 5 years earlier.

Mixed müllerian tumors of the uterus: a clinicopathologic study.

Forty-seven cases of mixed müllerian tumors of the uterus were analyzed clinically and pathologically. All patients but one were postmenopausal. Vaginal bleeding was the most frequent presenting symptom, followed by abdominal mass and pelvic pain. Long-term survival was found only in those cases in which the tumor was localized to the uterus (surgical stage I), particularly if it arose from a benign endometrial polyp. No correlation could be established between survival and tumor size, depth of myometrial invasion, or histologic type of sarcoma. Tumors arising after previous irradiation had a poor prognosis. Treatment included surgery, radiation, and chemotherapy. The cumulative probability of 5-year survival was 35%.

Necessity for endocervical curettage in elderly women undergoing colposcopy.

A retrospective study of 164 women aged 45 and older undergoing colposcopy for abnormal Papanicolaou smears showed that 49% had adequate colposcopy and 51%, inadequate colposcopy. Of those with adequate colposcopy, 23% had positive endocervical curettage (ECC). That finding required conization, which detected one case of microinvasive and two of invasive cervical carcinoma. Of those with inadequate colposcopy, 64% had positive ECC. All patients with inadequate colposcopy underwent conization, which detected 4 cases of microinvasive and 11 of invasive carcinoma. Therefore, women with inadequate colposcopy had a higher risk of invasive disease. ECC is a necessary step in the colposcopic evaluation of elderly women.

The cytologist and bacterioses of the vaginal-ectocervical area. Clues, commas and confusion.

To evaluate the role of the cytologist in the diagnosis of bacterial vaginosis, the predominant bacterial patterns seen in 157 Papanicolaou-stained cervical smears were assessed and classified as large bacillus, anaerobic or scanty. A large bacillus pattern was found in 73 smears (46%), an anaerobic pattern in 77 (49%) and scanty bacteria in 7 (5%). Comma-shaped (curved) bacilli were found in 34 smears. The prevalence of clue cells in smears with anaerobic patterns was 73%. Gardnerella vaginalis was cultured from 89% of the cases with anaerobic-type smears containing clue cells and from 88% of those with anaerobic-type smears lacking clue cells. Mobiluncus sp. was cultured from 83% of the cases with anaerobic-type smears showing curved bacilli and 14% of those with anaerobic-type smears lacking curved bacilli. Papanicolaou-stained smears were found to be more sensitive and more specific for identifying clue cells than were wet preparations. A positive association was found between a positive KOH "whiff" test and the presence of curved bacilli on the Papanicolaou-stained smear. The clinical significance of these findings is discussed.

Mixed mesodermal tumors of the ovary: a clinicopathologic study of 14 cases.

Fourteen cases of mixed mesodermal tumor of the ovary are presented. The actuarial survival of patients with these tumors was 2.5 months. Eighty-six percent of patients were stage III or IV at the time of diagnosis. The stromal or carcinomatous component of the tumor could not be correlated with survival. Both our two longest survivors, 14 and 27 months, were treated with surgery and radiotherapy, one patient with and one without chemotherapy.

Simultaneously occurring condylomata acuminata, carcinoma in situ and verrucous carcinoma of the vulva and carcinoma in situ of the cervix in a young woman. A case report.

A case of simultaneously occurring condylomata acuminata, carcinoma in situ and verrucous carcinoma of the vulva and carcinoma in situ of the cervix was seen in a 26-year-old woman. In situ DNA hybridization on sections of the condyloma acuminata and verrucous carcinoma yielded DNA sequences for human papillomavirus 6.

Carcinoma in situ of the vulva. A clinicopathologic study of 50 cases.

The authors reviewed 50 cases of carcinoma in situ of the vulva treated at the University of Texas Medical Branch, Galveston, from 1975 to 1984. Sixty-two percent of the patients were premenopausal. The most frequent complaint was vulvar itching. Twenty-six percent of the patients were asymptomatic. Recurrences were frequent (25%) and were associated with multifocal lesions, involved surgical margins and the bowenoid histologic type. Superficially invasive carcinoma was detected in 8% of patients, mostly postmenopausal women with simplex histologic types. Immunohistochemical studies failed to detect papillomavirus- or herpesvirus-associated antigens in any of the cases. Follow-up of 48 patients from six months to ten years revealed no mortality from invasive cancer.

Necessity of endocervical curettage in colposcopy.

The use of endocervical curettage was evaluated in 200 patients undergoing colposcopy, biopsy, endocervical curettage, and conization. It is suggested that endocervical curettage be performed only in cases of satisfactory colposcopy, since patients with unsatisfactory colposcopy should undergo conization.