Nancy S. Hardt

Immunoglobulin E Importance in Parasitic Infections and Hypersensitivity Responses

I E (IgE) is one of the body’s 5 classes (isotypes) of immunoglobulins (antibodies). Like other immunoglobulins, IgE is produced by B cells and plasma cells.1,2 In contrast to other immunoglobulins, the concentration of IgE in the circulation is very low. Immunoglobulin E in cord blood usually measures less than 1 U/mL (1 U 5 2.4 ng). Generally, adult IgE levels are achieved by 5 to 7 years of age. Between the ages of 10 and 14 years, IgE levels may be higher than those in adults. After age 70 years, IgE levels may decline slightly and be lower than the levels observed in adults younger than 40 years. Circulating IgE concentrations are very low because mast cells have a very high affinity for IgE (1010 mol/L21) via their e-heavy-chain Fc receptors (FceR). The synthetic rate for IgE is also very low. Immunoglobulin E attaches to mast cells and to basophils and activated eosinophils. Immunoglobulin E on mast cells has a half-life (T1⁄2) of more than 10 days. In contrast to other immunoglobulins that bind to immunoglobulin Fc receptors only when antigen has been bound by an antibody, IgE will bind to FceR in the absence of antibody. Immunoglobulin E binding to mast cells ‘‘sensitizes’’ the mast cells to degranulate when multivalent antigens cross-link FceR-bound IgE (Figure). Intrinsically innocuous antigens that produce hypersensitivity responses are termed allergens.

Do Qualifiers of ASCUS Distinguish Between Low- and High-Risk Patients?

OBJECTIVE To evaluate the qualification of a Pap smear classified as atypical squamous cells of undetermined significance (ASCUS) favor reactive or neoplasia as recommended by the Bethesda System. STUDY DESIGN The smears from 105 concurrent patients with a cytologic diagnosis of ASCUS not otherwise qualified were reviewed and subclassified as ASCUS favor reactive, low grade squamous intraepithelial lesion (LSIL) or high grade squamous intraepithelial lesion (HSIL) based on the Bethesda System criteria. The cervical biopsy diagnoses were correlated. RESULTS Of the 105 cases classified as ASCUS, 37 were subclassified as favor reactive, 51 as favor LSIL and 17 as favor HSIL on cytologic review. In the ASCUS favor reactive group, 19 (51%) had reactive changes on biopsy, 17 (46%) had cervical intraepithelial neoplasia (CIN) 1, and 1 (2%) had CIN 3. A total of 48% patients had CIN. In the favor LSIL group, there was CIN 1 in 28 cases (55%), CIN 2 or 3 in 12 (23%) and benign changes in 11 (22%) on biopsy. Seventy-eight percent had CIN. In the 17 cases classified as ASCUS favor HSIL group, all had CIN. CONCLUSION Of the total 105 cases of ASCUS, 71% had CIN, 29% had reactive changes on follow-up biopsies, and 48% of patients in the ASCUS favor reactive group had CIN. Qualifiers of ASCUS have questionable utility in patient management.

Complications related to retained breast implant capsules

Citing evidence that breast implant-related capsules resolve uneventfully, surgeons have elected to leave the capsules in place when implants are removed because capsulectomy adds both morbidity and expense to the procedure. However, recent clinical and histopathologic evidence suggests that uneventful resolution is not always the case, and several potential problems may arise from retained capsules after removal of the implant. Retained implant capsules may result in a spiculated mass suspicious for carcinoma, dense calcifications that obscure neighboring breast tissue on subsequent imaging studies, and cystic masses due to persistent serous effusion, expansile hematoma, or encapsulated silicone filled cysts. Furthermore, retained capsules are a reservoir of implant-related foreign material in the case of silicone gel-filled implants and textured implants promoting tissue ingrowth. To avoid complications from retained capsules, total capsulectomy or postoperative surveillance should be offered to patients.

In vitro measurement of silicone bleed from breast implants.

&NA; A method to measure gel bleed from intact silicone gel‐filled breast implants was developed. This nondestructive technique permits accurate and reproducible serial measurements of silicone bleed from smooth wall breast implants (n = 10) under simulated physiologic conditions in vitro. Gel bleed rates from new low bleed gel‐filled implants and intact explants (unbarriered, low bleed, double lumen) were determined. These results demonstrate the reliability of this method to quantify silicone gel bleed and may permit a meaningful comparison of bleed rates from implants in the future. (Plast. Reconstr. Surg. 97; 756, 1995.)

Benign cellular changes in Pap smears. Causes and significance.

Objective We reviewed consecutive cases classified as benign cellular changes (BCC) over a four-month period. Study design Cases classified as BCC were retrieved from the cytology files. A search was carried out to identify the previous Pap smears and concomitant cervical biopsies. Results One thousand one hundred three cases (23% of our gynecologic smears) were classified as BCC. Ninety-two patients (8.3%) underwent concurrent cervical biopsies. Specific infections accounted for 8% of BCC cases; reactive changes accounted for 92%. Of the biopsy specimens, 8.3% had no significant pathologic change. The most common biopsy diagnoses were cervicitis (31.5%), immature squamous metaplasia (16.3%) and reserve cell hyperplasia (10.8%). Miscellaneous benign diagnoses accounted for 21.7%. Cervical intraepithelial neoplasia (CIN) 1/human papillomavirus (HPV) was present in 14% of cases. All patients with biopsy diagnoses of CIN 1 had at least two previous abnormal Pap smears. Previous biopsy reports were available for review in 127 (12%) of the 1,103 patients. Of these 127 cases, 53.5% had a previous diagnosis of CIN/HPV; 9.4% had invasive carcinoma. A benign diagnosis was reported in 36.5%. Conclusion The majority of BCC cases are due to reactive and inflammatory processes. In patients with a previous history of CIN, BCC may be of some significance. In patients with no significant prior cervical abnormalities, a Pap smear classified as BCC represents a reactive process.

Financial Impact of Tertiary Care in an Academic Medical Center

OBJECTIVE To analyze the financial impact of three complex vascular surgical procedures to both an academic hospital and a department of surgery and to examine the potential impact of decreased reimbursements. SUMMARY BACKGROUND DATA The cost of providing tertiary care has been implicated as one potential cause of the financial difficulties affecting academic medical centers. METHODS Patients undergoing revascularization for chronic mesenteric ischemia, elective thoracoabdominal aortic aneurysm repair, and treatment of infected aortic grafts at the University of Florida were compared with those undergoing elective infrarenal aortic reconstruction and carotid endarterectomy. Hospital costs and profit summaries were obtained from the Clinical Resource Management Office. Departmental costs and profit summary were estimated based on the procedural relative value units (RVUs), the average clinical cost per RVU (

Squamous intraepithelial lesions of the cervix in a high-risk population.

33.12), surgeon charges, and the collection rate for the vascular surgery division (30.2%) obtained from the Faculty Group Practice. Surgeon work effort was analyzed using the procedural work RVUs and the estimated total care time. The analyses were performed for all payors and the subset of Medicare patients, and the potential impact of a 15% reduction in hospital and physician reimbursement was analyzed. RESULTS Net hospital income was positive for all but one of the tertiary care procedures, but net losses were sustained by the hospital for the mesenteric ischemia and infected aortic graft groups among the Medicare patients. In contrast, the estimated reimbursement to the department of surgery for all payors was insufficient to offset the clinical cost of providing the RVUs for all procedures, and the estimated losses were greater for the Medicare patients alone. The surgeon work effort was dramatically higher for the tertiary care procedures, whereas the reimbursement per work effort was lower. A 15% reduction in reimbursement would result in an estimated net loss to the hospital for each of the tertiary care procedures and would exacerbate the estimated losses to the department. CONCLUSIONS Caring for complex surgical problems is currently profitable to an academic hospital but is associated with marginal losses for a department of surgery. Economic forces resulting from further decreases in hospital and physician reimbursement may limit access to academic medical centers and surgeons for patients with complex surgical problems and may compromise the overall academic mission.

Atypical glandular cells of undetermined significance and other glandular cell abnormalities in a high-risk population.

Objectives We set out to examine our use of the squamous intraepithelial lesion (SIL) category, compare our SIL rate to rates reported by others, and determine the corre-lation between SIL and histologically proven cervical intraepithelial neoplasia (CIN) in our population. Materials and Methods Reports from all Papanicolaou smears and associated histological specimens interpreted by the University of Florida Department of Pathology between 1992 and 1996 were reviewed. Results Of 39,484 Papanicolaou smears, 2,101 (5.3%) were classified as low-grade squamous intraepithelial lesion (LGSIL) and 1,366 (3.5%) were classified as high-grade (HGSIL). Of the LGSIL cases, 972 (46.3%) underwent timely biopsy: Findings were benign in 29.9%; 41.7% had CIN1,20.9% had CIN2, and 7.5% had CIN3. Of the HGSIL cases, 932 (68.2%) underwent timely biopsy: Findings were benign in 12.3%; 17.1% had CIN1, 26.7% had CIN2, 42.2% had CIN3, and 1.6% showed squamous cell carcinoma. Condusions. Our LGSIL rate is similar to reported rates, but our HGSIL rate of 3.5% is higher. We found good correlation between SIL on Papanicolaou smear and CIN on biopsy (70.1% for LGSIL and 86% for HGSIL).

Youth Arrested for Trading Sex Have the Highest Rates of Childhood Adversity A Statewide Study of Juvenile Offenders

Objectives We set out to determine our rate of atypical glandular cells of undetermined significance (AGUS) classification, to compare our AGUS rate to rates reported by others, and to determine the correlation between AGUS and histological abnormalities in our population. Materials and Methods Reports from all Papanicolaou (Pap) smears and associated histological specimens interpreted by the University of Florida Department of Pathology between 1992 and 1996 were reviewed. Results A total of 462 (1.2%) of 39,484 Pap smears were classified as epithelial cell abnormality-glandular cell, with 328 (0.83%) AGUS, 102 (0.26%) endometrial cells out of phase or in a postmenopausal woman, and 32 (0.08%) adenocarcinoma. A total of 146 (45%) of the AGUS cases had timely biopsies: 95 (65.1%) had benign findings, 27 (18.5%) had cervical intraepithelial neoplasia, 14 (9.6%) had adenocarcinoma (10 endometrial, 2 endocervical, 2 extrauterine), 9 (6%) had endometrial hyperplasia, and 1 (0.7%) showed endocervical glandular cell dysplasia. Conclusions AGUS on Pap is associated with a clinically significant histological abnormality in a moderate percentage of patients. Both squamous and glandular lesions are seen, supporting the need for aggressive evaluation of the cervix, endocervix, and endometrium when AGUS is reported.

Animal cruelty as an indicator of family trauma: Using adverse childhood experiences to look beyond child abuse and domestic violence

A history of childhood adversity is associated with high-risk behaviors and criminal activity in both adolescents and adults. Furthermore, individuals with histories of child maltreatment are at higher risk for engaging in risky sexual behavior, experiencing re-victimization, and in some cases, becoming sexual offenders. The purpose of the current study was to examine the prevalence of individual and cumulative adverse childhood experiences (ACEs) reported by 102 offending youth who were arrested for trading sex and 64,227 offending youth who were arrested for various other crimes, using Florida’s Positive Achievement Change Tool. Youth with violations related to sex trafficking had higher rates for each ACE as well as number of ACEs, particularly sexual abuse and physical neglect. These findings have implications for identifying adverse experiences in both maltreated and offending youth as well as tailoring services to prevent re-victimization.