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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. [ABSTRACT FROM AUTHOR]

Objective It is widely understood that a key means of improving health systems and patient outcomes is through research - accessing, understanding, generating and applying research evidence-based practice. To promote more targeted and strategic research in Allied Health practice, this study sought to establish the principles, areas and priorities for clinical research as perceived by Allied Health leaders in the South Australian public health system. Methods The study used a mixed-methods design (full, sequential and equal model). Participants were recruited from theSouth Australian Department of Health and Wellbeing employment lists for Allied Health senior leaders. Consenting participants attended face-to-face focus groups; after an overview presentation, they discussed the principles for Allied Health research, followed by areas and priorities for research. Summaries of the responses were themed descriptively and circulated electronically so participants could confirm the research areas and ascribe priority ratings, clinical populations and services. Results A total of 28 people attended the stakeholder forum (5 online); 20 responded to the second-round electronic summary. Nine principles of research action were agreed. Fourteen research areas were identified and prioritised. There was a relatively consistent prioritisation of measuring Allied Health value, Allied Health workforce, hospital avoidance and closing the gap for Aboriginal health outcomes - whether the individuals were thinking about their own service or the state as a whole. Conclusions Allied Health leadership identified key principles and priorities for research to improve service delivery and patient outcomes. These priorities should generate further discussion and interest for novice and experienced researchers and leaders and can be used to inform granting and project plans.

Background: Malnutrition rates for critically ill patients being admitted to the intensive care unit (ICU) are reported to range from 38% to 78%. Malnutrition in the ICU is associated with increased mortality, morbidity, length of hospital admission, and ICU readmission rates. The high volume of ICU admissions means that efficient screening processes to identify patients at nutritional or malnutrition risk are imperative to appropriately prioritise nutrition intervention. As the proportion of noninvasively mechanically ventilated patients in the ICU increases, the feasibility of using nutrition risk screening tools in this population needs to be established., Objectives: The aim of this study was to compare the feasibility of using the Malnutrition Universal Screening Tool (MUST) with the modified NUtriTion Risk In the Critically ill (mNUTRIC) score for identifying patients at nutritional or malnutrition risk in this population., Methods: A single-centre, prospective, descriptive, feasibility study was conducted. The MUST and mNUTRIC tool were completed within 24 h of ICU admission in a convenience sample of noninvasively mechanically ventilated adult patients (≥18 years) by a trained allied health assistant. The number (n) of eligible patients screened, time to complete screening (minutes), and barriers to completion were documented. Data are presented as mean (standard deviation), and the independent samples t-test was used for comparisons between tools., Results: Twenty patients were included (60% men; aged 65.3 [13.9] years). Screening using the MUST took a significantly shorter time to complete than screening using the mNUTRIC tool (8.1 [2.8] vs 22.1 [5.6] minutes; p = 0.001). Barriers to completion included obtaining accurate weight history for the MUST and time taken for collection of information and overall training requirements to perform mNUTRIC., Conclusions: The MUST took less time and had fewer barriers to completion than mNUTRIC. The MUST may be the more feasible nutrition risk screening tool for use in noninvasively mechanically ventilated critically ill adults., Competing Interests: Conflict of Interest None of the authors have a conflict of interest to declare., (Crown Copyright © 2021. Published by Elsevier Ltd. All rights reserved.)

Background: Gastrointestinal (GI) dysmotility impedes nutrient delivery in critically ill patients with major burns. We aimed to quantify the incidence, timing, and factors associated with GI dysmotility and subsequent nutrition delivery., Methods: A 10-year retrospective observational study included mechanically ventilated, adult, critically ill patients with ≥15% total body surface area (TBSA) burns receiving nutrition support. Patients with a single gastric residual volume ≥250 mL were categorized as having GI dysmotility. Daily medical and nutrition data were extracted for ≤14 days in the intensive care unit (ICU). Data are mean (SD) or median (interquartile range). Factors associated with GI dysmotility and the effect on nutrition and clinical outcomes were assessed., Results: Fifty-nine patients were eligible; 51% (n = 30) with GI dysmotility and 49% (n = 29) without. Baseline characteristics (dysmotility vs no dysmotility) were age (48 [33-60] vs 34 [26-46] years); Acute Physiology and Chronic Health Evaluation II score (16 [12-17] vs 13 [10-16]); sex ([men] 80% vs 86%); and TBSA (49% [35%-59%] vs 38% [26%-55%]). Older age was associated with increased probability of dysmotility (P = .049). GI dysmotility occurred 32 (19-63) hours after ICU admission but was not associated with reduced nutrient delivery. Postpyloric tube insertions were attempted in 83% (n = 25) of patients, with 72% (n = 18) being successful. Postpyloric feeding achieved higher nutrition adequacy than gastric feeding (energy: 82% [95% CI, 70-94] vs 68% [95% CI, 63-74], P = .036; protein: 75% [95% CI, 65-86] vs 61% [95% CI, 56-65], P = .009)., Conclusion: GI dysmotility occurs early in critically ill burn patients, and postpyloric feeding improves nutrition delivery., (© 2020 American Society for Parenteral and Enteral Nutrition.)

Aim: To determine the prevalence of malnutrition on admission to the intensive care unit (ICU) and the relationship between nutritional status on admission and clinical outcomes in adult critically ill patients., Methods: This was a prospective study in an adult ICU. Patients with expected length of stay (LOS) >48 hours in ICU were assessed for nutritional status using the patient generated-subjective global assessment (PG-SGA) within 48 hours of admission to ICU., Results: Primary outcomes were ICU and hospital mortality, ICU and hospital LOS and length of mechanical ventilation. A total of 166 patients were enrolled in this study. Patients were aged 59 ± 17 years on average with a mean BMI of 29 ± 7 kg/m 2 and a mean Acute Physiology and Chronic Health Evaluation II score of 19 ± 7. The prevalence of malnutrition in critically ill patients was 36% (n = 60). Mortality rate of malnourished patients was 9% (n = 15) compared to 7.8% (n = 13) in well-nourished patients (adjusted odds ratio, 2.17; 95% confidence interval, 0.9-5.03, P = .069). There was no difference in hospital mortality between malnourished patients and well-nourished patients (10.2% vs 10.2% adjusted odds ratio, 1.93; 95% confidence interval, 0.89-4.19, P = .096). There was no relationship between nutritional status and length of mechanical ventilation (3.0 vs 1.0 days, P = .382)or ICU LOS (4.7 vs 4.8 days, P = .59). Malnourished patients had a longer LOS in hospital than well-nourished patients (24 vs 17 days, P = .03)., Conclusion: Malnutrition is an independent risk factor for increased hospital LOS., (© 2020 Dietitians Australia.)

Background: Critically ill patients who do not receive invasive mechanical ventilation (IMV) are a growing population, experiencing complex interventions that may impair dietary intake and nutrition-related outcomes., Objectives: The objectives of this study were to quantify intake and nutrition-related outcomes of non-IMV critically ill patients and to establish feasibility of methods to measure nutrition-related outcomes in this population., Methods: Non-IMV adult patients expected to remain in the intensive care unit (ICU) for ≥24 h were eligible. Nutrition-related outcomes were assessed at baseline by subjective global assessment (SGA); on alternate study days by mid-upper arm circumference (MUAC), calf circumference (CC), and ultrasound of quadriceps muscle layer thickness (QMLT); and daily by body weight and bioelectrical impedance analysis (BIA). Data were censored at day 5 or ICU discharge. Dietary intake from all sources, including oral intake via investigator-led weighed food records, was quantified on days 1-3. Feasibility was defined as data completion rate ≥70%. Data are expressed as mean (standard deviation) or median [interquartile range (IQR)]., Results: Twenty-three patients consented (50% male; 53 [42-64] y; ICU stay: 2.8 [1.9-4.0] d). Nutrition-related outcomes at baseline and ICU discharge were as follows: MUAC: 33.2 (8.6) cm (n = 18) and 29.3 (5.4) cm (n = 6); CC: 39.5 (7.4) cm (n = 16) and 37.5 (6.2) cm (n = 6); body weight: 95.3 (34.8) kg (n = 19) and 95.6 (41.0) kg (n = 10); and QMLT: 2.6 (0.8) cm (n = 15) and 2.5 (0.3) cm (n = 5), respectively. Oral intake provided 3155 [1942-5580] kJ and 32 [20-53] g protein, with poor appetite identified as a major barrier. MUAC, CC, QMLT, and SGA were feasible, while BIA and body weight were not., Conclusions: Oral intake in critically ill patients not requiring IMV is below estimated requirements, largely because of poor appetite. The small sample and short study duration were not sufficient to quantify changes in nutrition-related outcomes. MUAC, CC, QMLT, and SGA are feasible methods to assess nutrition-related outcomes at a single time point in this population., Competing Interests: Conflict of interest None of the authors have a conflict of interest to declare., (Crown Copyright © 2020. Published by Elsevier Ltd. All rights reserved.)

Background: Optimising nutrition support in critically ill patients with an open abdomen is challenging., Objectives: The aims of this study were to (i) quantify the amount and adequacy of nutrition support administered and (ii) determine any relationships that exist between mode of nutrition support delivery and clinical outcomes in critically ill patients with an open abdomen., Methods: A retrospective review of critically ill patients mechanically ventilated for at least 48 h with an open abdomen in a mixed quaternary referral intensive care unit. Enteral and parenteral nutrition (ml) administered daily to patients was recorded for up to 21 days. Length of stay in the intensive care unit and hospital and duration of mechanical ventilation (days) were reported., Results: Thirty patients were studied [14 male, 68 y (15-90 y), body mass index 25 kg/m 2 (11-51 kg/m 2 ), Acute Physiology and Chronic Health Evaluation II score 20 (7-41), energy goal 1860 kcal/d (1250-2712 kcal/d)]. Patients received 55% (0-117%) of energy goal and 56% (0-105%) protein goal from either enteral or parenteral nutrition. When enteral nutrition was delivered alone or in combination with parenteral nutrition, patients received 48% (0-146%) of their energy and 59% (19-105%) of their protein goal. Patients fed parenteral nutrition, either alone or as supplementary to enteral nutrition (n = 18), received more energy when compared with those who only received enteral nutrition (n = 9) [65 (27-117) vs 49 (15-89) % energy goal, P = 0.025]. Parenteral nutrition was associated with an increased length of stay in hospital [63 (45-156) vs 45 (17-93) d, P = 0.037]., Conclusion: Patients with an open abdomen receive about half of their nutrition requirements when fed exclusively via the enteral route. Providing combination enteral and parenteral nutrition to reach nutritional goals may not result in better clinical outcomes for patients with an open abdomen., (Crown Copyright © 2018. Published by Elsevier Ltd. All rights reserved.)

Aim: To determine whether the placement of a post-pyloric feeding tube (PPFT) can be taught safely and effectively to a critical care dietitian., Methods: This is a prospective observational study conducted in an adult intensive care unit (ICU). The intervention consisted of 19 attempts at post-pyloric intubation by the dietitian. The 10 'learning' attempts were performed by the dietitian under the direction of an experienced (having completed in excess of 50 successful tube placements) user. A subsequent nine 'consolidation' attempts were performed under the responsibility of the intensive care consultant on duty. The primary outcome measures were success (i.e. tip of the PPFT being visible in or distal to the duodenum on X-ray) and time (minutes) to PPFT placement. Patients were observed for adverse events per standard clinical practice., Results: A total of 19 post-pyloric tube placements were attempted in 18 patients (52 (23-70) years, ICU admission diagnoses: trauma n = 4; respiratory failure n = 3; and burns, pancreatitis and renal failure n = 2 each). No adverse events occurred. Most (75%) patients were sedated, and mechanically ventilated. Prokinetics were used to assist tube placement in 11% (2/19) of attempts, both of which were successful. Placement of PPFT was successful in 58% (11/19) of attempts. Whilst training, the success rate was 40% (4/10) compared with 78% (7/9) once training was consolidated (P = 0.17). In the successful attempts, the mean time to placement was 11.0 minutes (3.9-27.1 minutes)., Conclusions: A dietitian can be trained to safely and successfully place PPFT in critically ill patients., (© 2017 Dietitians Association of Australia.)

Malnutrition is associated with poor clinical outcomes among hospitalized patients. However, studies linking malnutrition with poor clinical outcomes in the intensive care unit (ICU) often have conflicting findings due in part to the inappropriate diagnosis of malnutrition. We primarily aimed to determine whether malnutrition diagnosed by validated nutrition assessment tools such as the Subjective Global Assessment (SGA) or Mini Nutritional Assessment (MNA) is independently associated with poorer clinical outcomes in the ICU and if the use of nutrition screening tools demonstrate a similar association. PubMed, CINAHL, Scopus, and Cochrane Library were systematically searched for eligible studies. Search terms included were synonyms of malnutrition, nutritional status, screening, assessment, and intensive care unit. Eligible studies were case-control or cohort studies that recruited adults in the ICU; conducted the SGA, MNA, or used nutrition screening tools before or within 48 hours of ICU admission; and reported the prevalence of malnutrition and relevant clinical outcomes including mortality, length of stay (LOS), and incidence of infection (IOI). Twenty of 1168 studies were eligible. The prevalence of malnutrition ranged from 38% to 78%. Malnutrition diagnosed by nutrition assessments was independently associated with increased ICU LOS, ICU readmission, IOI, and the risk of hospital mortality. The SGA clearly had better predictive validity than the MNA. The association between malnutrition risk determined by nutrition screening was less consistent. Malnutrition is independently associated with poorer clinical outcomes in the ICU. Compared with nutrition assessment tools, the predictive validity of nutrition screening tools were less consistent.

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.

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.

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.

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.

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 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.

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.

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%.

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.

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.

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.