Michelle Garcia Discacciati

Clinical diagnosis of bacterial vaginosis

Objective: To evaluate the accuracy of Amsels criteria individually or in combinations of two for the clinical diagnosis of bacterial vaginosis. Methods: This cross‐sectional study enrolled 135 women at UNICAMP, and evaluated Amsels four clinical criteria. Sensitivity, specificity, positive and negative predictive values were calculated for each criterion individually, in combinations of two, and for the classic test with at least three criteria present. The Nugent method was used as gold standard. Results: The most sensitive individual criteria were pH and vaginal discharge (97%), the latter having lowest specificity (26%). The criterion with highest specificity was the presence of clue cells (86%). The combination of two criteria showed sensitivity of 83% to 93%, and specificity of 82% to 94%. Conclusion: The accuracy of Amsels clinical criteria individually or in combinations of two was as accurate as the presence of at least three criteria for the diagnosis of bacterial vaginosis.

Outcome of expectant management of cervical intraepithelial neoplasia grade 2 in women followed for 12 months.

OBJECTIVE To evaluate the outcome of CIN 2 diagnosed by colposcopy-directed biopsy in women followed without treatment for 12 months and to verify whether the regression and progression of this lesion are associated with the womans age at diagnosis and age at first sexual intercourse. STUDY DESIGN Women diagnosed with CIN 2 by biopsy and with previous cervical smear showing LSIL were included in this cohort study and followed up for one year with cervical smear and colposcopy every three months. The rates of progression, persistence and regression of the CIN 2 were evaluated. The Kruskal-Wallis test was used to analyze the womans age at diagnosis, age at first sexual intercourse and interval since the first sexual intercourse according to the CIN 2 outcome, assuming a significance level of 5%. RESULTS At the end of 12 months of follow-up the CIN 2 regression rate was 74% (31/42), progression rate to CIN 3 was 24% (10/42) and in one case CIN 2 persisted (2%). Among women who had regression, this event was detected in the first six months of follow-up in 26 of the 31 cases. There was no statistically significant association between the evolution of CIN 2 and the womans age at diagnosis, age at first sexual intercourse and interval since first sexual intercourse. Women whose lesions were restricted to one quadrant were more likely to have CIN 2 regression at three-month follow-up compared with women with a lesion extending to one or more quadrants (OR: 6.50; 95% CI: 1.20-35.23). CONCLUSIONS The results of this study indicate that the majority of CIN 2 diagnosed by biopsy in women with previous Pap smear showing LSIL will regress in 12 months and therefore an expectant approach could be considered in these cases, not only for young women. Nevertheless these findings are not conclusive, and larger studies are required in order to certify when it is safe to adopt expectant management for CIN 2.

Microbiological characteristics and inflammatory cytokines associated with preterm labor

PurposeTo evaluate vaginal microflora and interleukin-1β (IL-β), interleukin-6 (IL-6), interleukin-8 (IL-8) and tumor necrosis factor-alpha (TNF-α) concentrations in the cervicovaginal fluid of a group of pregnant women in preterm labor when compared with a group of full-term pregnant women not yet in labor.MethodCase–control study performed in a University tertiary referral maternity in Campinas, Brazil with 45 pregnant women in preterm labor and 45 full-term pregnant women not in labor. All patients underwent speculum examination for the collection of cervicovaginal fluid. Bacterial vaginosis (BV) was diagnosed according to the criteria of Amsel and Nugent. Culture was performed for group B streptococcus (GBS) and lactobacilli, and hybrid capture assay for screening for chlamydial and gonococcal infection. Cytokine concentrations were measured using ELISA technique. Statistical analysis was performed using χ2, Fisher’s exact, and crude and adjusted odds ratios. Significance level was defined at 5%. The main outcome measures were cervicovaginal cytokines in preterm labor.ResultsIL-6 and IL-8 were significantly associated with preterm labor. The changes in vaginal microflora, as well as BV and GBS, were more frequent in women in preterm labor, although BV and GBS showed no statistical significance. The presence of Candida sp., absence of lactobacilli, positive screening for chlamydial and gonococcal infection and the presence of IL-1β and TNF-α were not associated with preterm labor.ConclusionsIL-6 and IL-8 and the presence of any type of vaginal infection were the factors that were significantly associated with preterm labor.

Prognostic Value of DNA and mRNA E6/E7 of Human Papillomavirus in the Evolution of Cervical Intraepithelial Neoplasia Grade 2

Objective This study aimed at evaluating whether human papillomavirus (HPV) groups and E6/E7 mRNA of HPV 16, 18, 31, 33, and 45 are prognostic of cervical intraepithelial neoplasia (CIN) 2 outcome in women with a cervical smear showing a low-grade squamous intraepithelial lesion (LSIL). Methods This cohort study included women with biopsy-confirmed CIN 2 who were followed up for 12 months, with cervical smear and colposcopy performed every three months. Results Women with a negative or low-risk HPV status showed 100% CIN 2 regression. The CIN 2 regression rates at the 12-month follow-up were 69.4% for women with alpha-9 HPV versus 91.7% for other HPV species or HPV-negative status (P < 0.05). For women with HPV 16, the CIN 2 regression rate at the 12-month follow-up was 61.4% versus 89.5% for other HPV types or HPV-negative status (P < 0.05). The CIN 2 regression rate was 68.3% for women who tested positive for HPV E6/E7 mRNA versus 82.0% for the negative results, but this difference was not statistically significant. Conclusions The expectant management for women with biopsy-confirmed CIN 2 and previous cytological tests showing LSIL exhibited a very high rate of spontaneous regression. HPV 16 is associated with a higher CIN 2 progression rate than other HPV infections. HPV E6/E7 mRNA is not a prognostic marker of the CIN 2 clinical outcome, although this analysis cannot be considered conclusive. Given the small sample size, this study could be considered a pilot for future larger studies on the role of predictive markers of CIN 2 evolution.

Increased detection of clue cells in smears from cervical intraepithelial lesions with reduced expression of COX-2

The relation between the detection of clue cells in cervical smears of women with CIN and the expression of COX‐2 in these lesions were determined. Samples from 228 women, treated due to CIN and who underwent cervical conization, were obtained. Hybrid Capture II and Pap smear samples were collected immediately before performing conization. Pathological diagnoses were 11 (5%) normal cervix, 35 (15%) CIN1, 31 (14%) CIN2, and 151 (66%) CIN3. COX‐2 immunoreactivity grading on the pathological specimens was based on the German ImmunoReactive score. In cervical smears, 20 fields (40x) were examined, each of them with a minimum count of 10 epithelial cells. When 20% or more of clue cells were detected the sample was considered positive for clue cells. The prevalence of clue cells was similar across histological strata (P = 0.42). Although the expression of COX‐2 did not differ in lesions with varying severities (P = 0.24), there was a negative association between the expression of COX‐2 and the presence of clue cells in Pap smear (OR = 0.4; 95% CI = 0.2–0.9): only 12% of women with moderate and strong expression of COX‐2 had clue cells in their smears, contrasted to 22% of those with negative and weak expression of COX‐2. HPV infection was associated in a borderline manner to the expression of COX‐2 (P = 0.04; OR = 2.3 95% CI = 1.0–5.4). The reduced expression of COX‐2 in CIN specimens may suggest that clue cells interfere with the inflammatory component of the carcinogenic process that lead to CIN. Diagn. Cytopathol. 2008;36:705–709.

Influência do conteúdo vaginal de gestantes sobre a recuperação do estreptococo do grupo B nos meios de transporte Stuart e Amies

PURPOSE: to evaluate the influence of vaginal environment of pregnant women on group B streptococcus (GBS) survival after 8, 24 e 48 h in Amies and Stuart transport media. METHODS: Three vaginal samples were collected from 30 pregnant women attending the Prenatal Care Outpatient Clinic of the Centro de Atencao Integral a Saude da Mulher (CAISM), Universidade Estadual de Campinas (UNICAMP). The first sample was placed directly onto Todd-Hewitt selective medium; the second was used to perform a gram-stained microscopy, and the third swab was placed in 2 mL physiological saline to which 200 µL of a suspension with 1-2 x 108 colony-forming units of GBS was added. After homogenization, six swabs were collected from this suspension (3 from Amie medium and 3 from Stuart medium). These six swabs were kept at room temperature for 8, 24 and 48 h and then incubated on blood agar. Bacterial growth at 37oC was observed after a 24-h incubation period and it was semiquantitatively graded (0-3+) according to the number of colonies. Statistical analysis was performed by the exact Fisher test and the level of significance was set at 0.05. RESULTS: the recovery of GBS after 48-h storage in Amie and Stuart media was 97 e 87%, respectively. In one of the four cases where no GBS recovery was possible after 48 h of storage, vaginal pH was higher than 4.5, and in two of those cases cytolytic vaginosis was found. CONCLUSIONS: both transport media showed to be appropriate for GBS recovery up to 48 h after sampling. Characteristics of the vaginal enviroment did not influence GBS recovery as observed in this study.

Vaginose bacteriana e DNA de papilomavírus humano de alto risco oncogênico em mulheres submetidas a conização com alça diatérmica para tratamento de neoplasia intra-epitelial cervical de alto grau

PURPOSE: to analyze the association between bacterial vaginosis (BV), high-risk HPV DNA, and Pap smear abnormalities in women submitted to diathermic conization for the treatment of high-grade cervical intraepithelial neoplasia (CIN 2 or 3). METHODS: a descriptive clinical study with 81 women submitted to diathermic conization for the treatment of CIN 2 or 3. Initial Pap smear was performed by the time of the biopsy and was also used to verify the presence of BV. Prior to conization, samples for the detection of high-risk HPV DNA through hybrid capture II (HC II) were collected. A control visit was scheduled for four months after the conization to repeat these tests. Twenty-seven women were found to have BV and 54 were not. Statistical analysis comprised odds ratios (OR) to assess the correlations between BV and HPV detection before and after diathermic conization and cytological abnormalities. All analyses were performed with a 95% confidence interval (95% CI). RESULTS: high-risk HPV DNA detection before conization was identical in both groups (89%). After conization, HPV DNA detection decreased to 26 and 18% in the groups with and without BV, respectively (OR=1.5; 95% CI 0.5 to 4.6). In addition, 41% of the women with BV and 20% without BV showed Pap smear abnormalities (OR=2.7; 95% CI 1.0 to 7.4). Regarding these 22 women with Pap smear abnormalities approximately four months after the diathermic conization, 83% of the BV group tested positive for HPV DNA compared with 50% in the group without BV (OR=5.0; IC 95% 0.5 a 52.9). CONCLUSION: women with BV presented more Pap smear abnormalities after conization when compared to the women without BV, although this was not statistically significant. This association was not related to high-risk HPV DNA.

Tinidazole versus cefazolin in antibiotic prophylaxis of vaginal and abdominal hysterectomy

PURPOSE to compare the efficacy of tinidazole and cephazolin on the febrile and infectious morbidity of post vaginal and abdominal hysterectomy antibiotic prophylaxis. METHODS randomized clinical study, where women admitted to hospital for hysterectomy were randomly allocated in one of the following antibiotic prophylaxis groups: Group C (2 g of IV cephazolin in the anesthetic induction); Group T (2 g of tinidazole orally, 12 hours before the surgery); or Group C+T (2 g of tinidazole orally 12 hours before the surgery and 2g of IV cephazolin in the anesthetic induction). Cervicovaginal smears were collected for specific cultures and the diagnosis of bacterial vaginosis (BV) was based in Amsel and Nugents criteria. The patients were reevaluated 7 and 30 days after the surgery for signs of febrile and/or infectious morbidity. The chi2 or the Fishers exact test was used to assess differences among the three groups, with a significance level of 5%. The sample power (1-beta) was calculated through the SAS program. RESULTS seven days after the hysterectomy, infectious morbidity was diagnosed in 6.6% of the women, but with no significant difference among the three groups studied (p=0.12). There was no febrile or infectious morbidity at the immediate post-surgical period or after 30 days from the surgery. BV ratio at the pre-surgical period was significantly higher among the women submitted to vaginal hysterectomy, rather than among the ones submitted to abdominal hysterectomy (27 versus 7%, p=0.02). BV ratio was also higher after 30 days, among the women submitted to vaginal hysterectomy (20 versus 8%), though without statistical significance (p=0.19). CONCLUSIONS the use of tinidazole, isolated or associated with cephazolin has not presented higher efficacy, than the use of cephazolin, alone to prevent febrile or infectious morbidity post hysterectomy. The high ratio of BV at the immediate pre-surgery period among the women submitted to vaginal hysterectomy suggests that this infection must be better investigated and properly treated before the surgery.