John F. Greene

Dysplasia associated with atypical glandular cells on cervical cytology

OBJECTIVES: To estimate the rates of and identify risk factors for disease in women with atypical glandular cells of undetermined significance (AGUS). METHODS: From 1998–2001, 477 Pap tests at Hartford Hospital were classified as AGUS and met the inclusion criteria of this study. Findings were evaluated for 2 years from the initial test. Disease was defined as histology results with a finding of high-grade squamous intraepithelial lesion or greater. RESULTS: Disease was diagnosed in 9% of the women, including malignancy in 3%. Women with malignant-appearing AGUS Pap tests had a higher rate of disease (29%) than women with benign-appearing (5%, P < .01) and unspecified AGUS Pap tests (13%, P < .03). Malignancies were associated with all subclassifications of AGUS Pap tests. Women aged less than 35 years were more likely to have disease than women aged 35 years or older (P < .02). Most women aged younger than 35 years had a squamous abnormality, whereas women aged 35 years or older had a greater diversity of squamous and glandular lesions and accounted for all cases of endometrial cancer, adenocarcinoma in situ, and cervical adenocarcinoma. Women with persistent AGUS Pap tests had a 31% rate of disease. The rate of disease among women with AGUS Pap tests collected by liquid-based cytology was 11%, compared with 6% among samples collected by the conventional method. CONCLUSION: These data suggest that women with atypical glandular cells are at substantial risk for dysplasia and malignancy. The rate of disease varies with the method of Pap test collection, age, presence of persistent AGUS Pap tests, and AGUS subclassification. LEVEL OF EVIDENCE: II-3

Lack of adherence to practice guidelines for women with atypical glandular cells on cervical cytology.

OBJECTIVE: We sought to estimate the rates and types of evaluation in women with atypical glandular cells of undetermined significance (AGC-US) on cervical cytology and to assess these findings on the basis of published management guidelines. METHODS: The rates of histologic sampling, comprehensive initial evaluations, and secondary evaluations were assessed in 477 women with an AGC-US Pap test from 1998 to 2001. A comprehensive evaluation was defined as a colposcopy and an endocervical curettage with or without a cervical biopsy. For women aged 35 or older, a comprehensive evaluation also included an endometrial biopsy. A secondary evaluation consisted of a diagnostic cone biopsy. RESULTS: Sixty-four percent of women with an AGC-US Pap test had histologic sampling; 36% were followed by repeat Pap test only. Thirty-six percent of women with an AGC-US Pap test had a comprehensive evaluation. Women with an AGC-US Pap test that was subclassified as malignant-appearing had higher rates of histologic and comprehensive evaluations than women with a benign-appearing or unspecified AGC-US Pap test (P < .01). Twenty-eight percent of women aged 35 or older had comprehensive evaluations compared with 57% of women younger than the age of 35 (P < .01). Secondary evaluations were performed in 8% of women with persistent AGC-US Pap tests and 2% of women with malignant-appearing AGC-US Pap tests after negative initial histologic evaluations. Twelve of the 42 cases of disease (29%) were diagnosed more than 1 year from the initial AGC-US Pap test. CONCLUSION: On the basis of accepted management guidelines, these data suggest that women with AGC-US Pap tests are undermanaged in both their initial and secondary evaluations. LEVEL OF EVIDENCE: III

Effectiveness of Reminder Systems on Appointment Adherence Rates

The aim of this study was to determine the impact of reminder systems on appointment nonadherence rates in an low-income inner-city clinic population. A total of 2,304 consenting patients were randomly assigned to one of three groups: (1) automated telephone reminder, (2) postcard reminder, or (3) no reminder. In contrast with research on other populations, the results of this study demonstrated no significant difference in appointment adherence rates among the three groups. To aid in the development of more effective interventions in the future, individuals not attending their scheduled appointments were interviewed by telephone to determine reason for nonadherence.

The onset of human labor: current theories.

Innovative research has led to marked improvement in medical knowledge. Advances in technology have allowed us to attain a clearer understanding of many physiologic processes. Despite these impressive gains in knowledge, the cause of the initiation of the process of human labor remains unclear. Potential factors include changes in hormonal levels of estrogen and progesterone, increased production of prostaglandins, and elevation of levels of corticotropin-releasing hormone, as well as increased sensitivity of the myometrium to endogenous oxytocin. It is most likely that interactions between these factors play an essential role in the process of labor, but the precise mechanism of onset still eludes us.

Prevalence of the human papillomavirus in an inner-city indigent population with previously normal Pap tests.

Objective. To determine the prevalence of human papillomavirus (HPV) in our inner-city indigent population (clinic population) of women with previously normal Pap tests and to identify any associated risk factors. Materials and Methods. A prospective cohort of 187 women between the ages of 15 and 49 years, with previously normal Pap tests, was recruited from a university affiliated outpatient clinic. A demographic questionnaire of social and sexual history was elicited, and ThinPrep cytology (Cytyc, Marlborough, MA) and HPV Digene Hybrid Capture II results (Digine, Gaithersburg, MD) were obtained. Results. The prevalence of HPV in our primarily Hispanic clinic population was 21%. The mean age of women with HPV was 28.9 years and those without were 32.1 years (p <.046). In women with HPV, 24% had abnormal Pap tests, whereas in those without HPV, 5% had abnormal Pap tests (p <.001). Women who were older and parous were less likely to have HPV (7.5%; p <.024). The presence of HPV was not influenced by sexual behaviors, sexually transmitted diseases, smoking, race, or contraceptive use. Conclusions. The prevalence of HPV in an inner-city indigent population, despite previously normal cytology, was consistent with earlier reported rates of HPV. Our data suggest that younger, nulliparous women have a high prevalence of HPV.

Building an award-winning women's health ambulatory service and beyond.

&NA; Many barriers exist for the provision of high‐quality health care to inner‐city minority women. The barriers include access to care, compliance problems, financial concerns, system navigation issues, as well as language barriers. This article describes the transition of the Womens Ambulatory Health Services at Hartford Hospital from a traditional clinic model to a culturally sensitive private practice model. The road to transition was paved by valuable input from staff as well as patients. The final product was a much more efficient, inviting model that catered to the needs of the community.

Large myomatous uterus resulting in complete obstruction of the inferior vena cava during pregnancy

incidence is during the third or fourth decade of life. Leiomyomas occur in 2 – 4% of pregnancies, and their incidence in pregnancy may be increasing as women delay childbearing 2,3 . In addition, routine use of ultrasound during pregnancy has increased the detection of leiomyomas 3 . Leiomyomas in pregnancy may be associated with a variety of pregnancy complications, including miscarriage, preterm rupture of the membranes, preterm labour, placental abruption, painful degeneration, postpartum haemorrhage, fetal malpresentation, fetal growth restriction and the need for caesarean delivery, with or without hysterectomy 2 . Complications may be related to the size and location of the leiomyomas 4 . We describe the clinical course of a pregnant woman with a very large myomatous uterus resulting in complete obstruction of the inferior vena cava early in the second trimester of pregnancy. No previous report of complete obstruction of the inferior vena cava from a myoma during pregnancy was found during a Medline search of the English literature from 1966 to the present by using the keywords ‘leiomyoma’, ‘thrombosis’, ‘inferior vena cava’, ‘fibroid’, and ‘pregnancy’.

Bioterrorism and Obstetrics the Exposed Pregnant Patient

Publisher Summary This chapter focuses on the management of pregnant women in the setting of a bioterrorist attack. The chapter reviews “category A” agents—smallpox, anthrax, plague, botulism, tularemia, and viral hemorrhagic fevers—and “category B” agents—Q fever, brucellosis, typhus, and food and water safety threats. A pregnant woman is more susceptible to infection throughout pregnancy because of changes in the immune system. Their treatment considerations should take into account the potential effects on the fetus. Medications should be chosen to minimize the fetal risk. If a woman requires vaccination while breastfeeding, she should not breastfeed until the scab has separated from the vaccination site. Women attempting pregnancy should not be vaccinated within 4 weeks of planning to conceive. The chapter concludes by discussing the various biologic agents, their maternal and fetal effects, and management of the exposed gravida.