European consensus statement on expert colposcopy

BACKGROUND

Following the publication of the European consensus statement on standards for essential colposcopy in 2020, the need for standards relating to more complex and challenging colposcopy practice was recognised. These standards relate to colposcopy undertaken in patients identified through cervical screening and tertiary referrals from colposcopists who undertake standard colposcopy only. This set of recommendations provides a review of the current literature and agreement on care for recognised complex cases. With good uptake of human papillomavirus (HPV) immunisation, we anticipate a marked reduction in cervical disease over the next decade. Still, the expert colposcopist will continue to be vital in managing complex cases, including previous cervical intraepithelial neoplasia (CIN)/complex screening histories and multi-zonal disease.

AIMS

To provide expert guidance on complex colposcopy cases through published evidence and expert consensus.

MATERIAL & METHODS

Members of the EFC and ESGO formed a working group to identify topics considered to be the remit of the expert rather than the standard colposcopy service. These were presented at the EFC satellite meeting, Helsinki 2021, for broader discussion and finalisation of the topics.

RESULTS & DISCUSSION

The agreed standards included colposcopy in pregnancy and post-menopause, investigation and management of glandular abnormalities, persistent high-risk HPV+ with normal/low-grade cytology, colposcopy management of type 3 transformation zones (TZ), high-grade cytology and normal colposcopy, colposcopy adjuncts, follow-up after treatment with CIN next to TZ margins and follow-up after treatment with CIN with persistent HPV+, and more. These standards are under review to create a final paper of consensus standards for dissemination to all EFC and ESGO members.

Quality of life from cytoreductive surgery in advanced Ovarian cancer: investigating association with disease burden and surgical complexity in the international, prospective, SOCQER2 cohort study

OBJECTIVE

To investigate quality of life (QoL) and association with surgical complexity and disease burden after surgical resection for advanced ovarian cancer in centres with variation in surgical approach DESIGN: Prospective multicentre observational study SETTING: United Kingdom, Kolkata, India, and Melbourne, Australia gynaecological cancer surgery centres.

PARTICIPANTS

Patients undergoing surgical resection for late stage ovarian cancer. Exposure Low, intermediate or high Surgical Complexity Score (SCS) surgery MAIN OUTCOMES AND MEASURES: Primary: EORTC-QLQ-C30 Global score change. Secondary: EORTC OV28, progression free survival.

RESULTS

Patients' pre-operative disease burden and SCS varied between centres, confirming differences in surgical ethos. QoL response rates were 90% up to 18 months. Mean change from the pre-surgical baseline in the EORTC QLQ-C30 was 3.4 (SD 1.8, n=88) in the low, 4.0 (SD 2.1, n=55) in the intermediate and 4.3 (SD 2.1, n=52) in the high SCS group after 6 weeks (p=0.048) and 4.3 (SD 2.1, n=51), 5.1 (SD 2.2, n=41) and 5.1 (SD 2.2, n=35) respectively after 12 months (p=0.133). In a repeated measures model, there were no clinically or statistically meaningful differences in EORTC QLQ-C30 global scores between the three SCS groups, p= 0.840 but there was a small statistically significant improvement in all groups over time (p<0.001). The high SCS group experienced small to moderate decreases in physical (p=0.004), role (p=0.016) and emotional (p=0.001) function at 6 weeks post-surgery which resolved by 6-12 months.

CONCLUSIONS AND RELEVANCE

Global QoL of patients undergoing low, intermediate, and high SCS surgery improved at 12 months post operation and was no worse in patients undergoing extensive surgery.

Introducing human papillomavirus (HPV) primary testing in the age of HPV vaccination: projected impact on colposcopy services in Wales

OBJECTIVE

To determine the demand for colposcopy in the Cervical Screening Wales programme after the introduction of human papillomavirus (HPV) cervical screening, which coincided with the start of screening of women vaccinated against HPV types 16/18.

DESIGN

The study used a computational model that assigns screening and screening-related colposcopy events to birth cohorts in individual calendar years.

SETTING

Cervical Screening Wales.

POPULATION

Women aged 25-64 years from birth cohorts 1953-2007.

METHODS AND MAIN OUTCOME MEASURES

We estimated the numbers of colposcopies and high-grade cervical intraepithelial lesions (CIN2+) within Cervical Screening Wales in 2018-32, using official population projections for Wales and published estimates of the effects of HPV screening and vaccination.

RESULTS

Vaccination will reduce the number of colposcopies by 10% within the first 3-4 years after the national roll-out of HPV screening, and by about 20% thereafter. The number of screening colposcopies is estimated to increase from 6100 in 2018 and peak at 8000 (+31%) in 2021, assuming current screening intervals are maintained. The numbers of CIN2+ lesions follow similar patterns, stabilising at around 1000 diagnoses per year by 2026, approximately 60% lower than at present. Extending the screening intervals to 5 years for all women shows similar trends but introduces peaks and troughs over the years.

CONCLUSIONS

Vaccination will not fully prevent an increase in colposcopies and detected CIN2+ lesions during the first 2-3 years of HPV-based screening but the numbers are expected to decrease substantially after 5-6 years.

TWEETABLE ABSTRACT

HPV-based cervical screening will initially increase colposcopy referral. In 6 years, this increase will be reversed, partly by HPV vaccination.

European consensus statement on essential colposcopy

This European consensus statement on essential colposcopy provides standards for the general colposcopist seeing women referred for colposcopy with an abnormal cervical screening test (including cytology and HPV tests) or with a clinically suspicious cervix. The article gives guidance regarding the aims and conduct of colposcopy. Recommendations are provided on colposcopy technique, the management of common colposcopy issues, treatment and follow-up of after treatment of CIN or early stage cervical. Colposcopists should make an informed decision on the management of each individual that is referred and organize appropriate follow-up. Cervical cancer is still a major health issue and the quality of care can only improve if there is a structured guidance for women with an abnormal smear or suspicious cervix.

Seasonal fluxes of carbon monoxide from an intensively grazed grassland in Scotland

Fluxes of carbon monoxide (CO) were measured using a fast-response quantum cascade laser absorption spectrometer and the eddy covariance method at a long-term intensively grazed grassland in southern Scotland. Measurements lasted 20 months from April 2016 to November 2017, during which normal agricultural activities continued. Observed fluxes followed a regular diurnal cycle, peaking at midday and returning to values near zero during the night, with occasional uptake observed. CO fluxes correlated well with the meteorological variables of solar radiation, soil temperature and soil moisture content. Using a general additive model (GAM) we were able to gap fill CO fluxes and estimate annual fluxes of 0.38 ± 0.046 and 0.35 ± 0.045 g C m^-2 y^-1g C m^-2 y^-1 for 2016 and 2017, respectively. If the CO fluxes reported in this study are representative of UK grasslands, then national annual emissions could be expected to be in the order of 61.91 (54.3-69.5) Gg, which equates to 3.8% (3.4-4.3%) of the current national inventory total.

Effects of fatty acid glyceride product SILOhealth 104 on the growth performance and carcass composition of broiler chickens

Butyric acid is the primary energy source for colonocytes, and has shown potential as an alternative to in-feed antibiotics, due to its antimicrobial activity and positive effects on production performance traits of broiler chickens. SILOhealth 104 (SILO S.P.A., Florence, Italy) is a commercial product mainly containing mono- and di-glycerides of butyrate with a small portion of propionic, caprylic, capric, and lauric acid mono- and di-glycerides. Its effects on broiler performance and carcass composition have yet to be evaluated. Four-hundred-eighty day-old male Ross 308 birds were divided into different dietary treatment groups with equal starting weights and fed a diet containing 0, 500, 1,000, 2,000, or 3,000 ppm of SILOhealth 104 for 35 days. There were no significant differences in overall average daily gain or feed: gain ratio with the addition of SILOhealth 104 to the diets (P > 0.05). At 5 wk of age, abdominal fat weight was reduced in birds supplemented with SILOhealth 104 in a dose-responsive manner (P < 0.05), while breast muscle weight increased with supplementation, with significant increases in 2,000 ppm and 3,000 ppm birds compared to controls (P < 0.05). A significant reduction in gene expression of both forkhead box protein O4 and myostatin, 2 factors that can inhibit protein synthesis, was found in the breast muscle of all SILOhealth 104 treated birds (P < 0.05). In addition, gene expression in the adipose tissue, including acetyl-CoA carboxylase alpha and lipoprotein lipase, which are associated with lipid metabolism, was significantly decreased and increased, respectively, by the supplementation of SILOhealth 104 (P < 0.05). These data suggest that the components of SILOhealth 104 can positively affect the deposition of muscle, while reducing abdominal fat deposition in broiler chickens.

Effects of supplementation level and feeding schedule of butyrate glycerides on the growth performance and carcass composition of broiler chickens

Mixed mono- and tributyrate glycerides have been used for effective delivery of butyrate to the gut to benefit broilers. However, limited information is available on the efficacy of butyrate glycerides individually and in combination with different levels and feeding schedules. The present study has first investigated the effects of monobutyrin at inclusion levels of zero, 500, 1,000, 2,000, and 3,000 ppm on the performance of broilers, and second, the effects of its combination with tributyrin. In the monobutyrin trial, there were no overall significant differences in average daily gain or feed efficiency. However, 2,000 ppm birds had significantly decreased abdominal fat deposition compared to controls (P ≤ 0.05), and the breast muscle deposition increased in a dose-response manner to the supplementation of monobutyrin (P ≤ 0.05). The combination trial tested 5 treatment groups: control, 500 ppm tributyrin + 500 ppm monobutyrin (5T5M), 500 ppm tributyrin + 500 ppm monobutyrin staggered (5T5Ms), 500 ppm tryibutyrin + 2,000 ppm monobutyrin (5T20M), or 500 ppm tributyrin + 2,000 ppm monobutyrin staggered (5T20Ms). In staggered groups, birds were fed tributyrin for one wk followed by 2 wk of monobutyrin, after which the feed was butyrate glyceride free. The non-staggered groups had constant inclusions levels through the 5 weeks. There were no significant differences in average daily gain or feed efficiency among groups. At 5 wk of age, all treatment groups except for 5T5Ms had significantly lower relative abdominal fat weight compared to control birds (P ≤ 0.05), although 5T5Ms birds demonstrated a trend for a decrease (P = 0.095). Relative breast muscle weight was significantly increased only in 5T5M birds over control birds at 5 wk of age (P ≤ 0.05). Serum biochemistry revealed significant changes in factors relating to muscle growth and fat deposition (P ≤ 0.05). These results indicate a consistent shift in lipid metabolism with the addition of butyrate glycerides and that the deposition of breast muscle may be highest with the incorporation of butyrate glycerides at a moderate level for the duration of development.

Predictors of complications in gynaecological oncological surgery: a prospective multicentre study (UKGOSOC-UK gynaecological oncology surgical outcomes and complications)

BACKGROUND

There are limited data on surgical outcomes in gynaecological oncology. We report on predictors of complications in a multicentre prospective study.

METHODS

Data on surgical procedures and resulting complications were contemporaneously recorded on consented patients in 10 participating UK gynaecological cancer centres. Patients were sent follow-up letters to capture any further complications. Post-operative (Post-op) complications were graded (I-V) in increasing severity using the Clavien-Dindo system. Grade I complications were excluded from the analysis. Univariable and multivariable regression was used to identify predictors of complications using all surgery for intra-operative (Intra-op) and only those with both hospital and patient-reported data for Post-op complications.

RESULTS

Prospective data were available on 2948 major operations undertaken between April 2010 and February 2012. Median age was 62 years, with 35% obese and 20.4% ASA grade ⩾3. Consultant gynaecological oncologists performed 74.3% of operations. Intra-op complications were reported in 139 of 2948 and Grade II-V Post-op complications in 379 of 1462 surgeries. The predictors of risk were different for Intra-op and Post-op complications. For Intra-op complications, previous abdominal surgery, metabolic/endocrine disorders (excluding diabetes), surgical complexity and final diagnosis were significant in univariable and multivariable regression (P<0.05), with diabetes only in multivariable regression (P=0.006). For Post-op complications, age, comorbidity status, diabetes, surgical approach, duration of surgery, and final diagnosis were significant in both univariable and multivariable regression (P<0.05).

CONCLUSIONS

This multicentre prospective audit benchmarks the considerable morbidity associated with gynaecological oncology surgery. There are significant patient and surgical factors that influence this risk.

The effect of dietary alterations during rearing on feather condition in broiler breeder females

In commercial production, broiler breeders are severely feed restricted to maintain healthy BW. This restriction can induce stereotypic behavior, including feather pecking, which has negative welfare implications for both the victim and performer. It has been suggested that the problem may be symptomatic of chronic hunger or the frustration of feeding motivation. In this study, we determined whether feather condition, as an indirect measure of feather pecking, could be improved via dietary manipulation. Six dietary treatments were tested, each with 5 replicate pens of 9 to 12 birds. Control diets (C) were fed on a daily or skip-a-day (SAD) basis. Alternative diets included soybean hulls as a bulking ingredient and calcium propionate (CaP) as an appetite suppressant of either a feed grade (F) or purified (P) quality. Both alternative diets were fed on either a daily or SAD basis. Five or 6 birds were randomly chosen from each pen and feather scored at 10, 14, 20, 26, and 36 wk of age. Six body parts (neck, back, wings, legs, vent area, tail) were given a score from 0 to 5 (0 = no feather damage, and 5 ≥ 50% feather loss with tissue damage). Scores were summed for each bird and averaged for each pen. Data were analyzed with room and feeding frequency as main factors and diet as the subfactor with repeated measures. There was an interaction between diet and time (P < 0.01) with the feather condition of the C birds worsening more quickly in comparison with the F and P birds. There was an interaction between feeding frequency and time (P = 0.015), with SAD-fed birds scoring better than daily-fed birds at 20, 26, and 36 wk. This interaction could indicate that SAD feeding increased satiety after the birds became accustomed to the schedule. Because feather condition was better with the alternative diets, this may indicate a reduction in stereotyped feather pecking with these diets. This suggests that the alternative diets increase satiety compared with the control diets.

The effect of dietary alterations during rearing on growth, productivity, and behavior in broiler breeder females

Parent stocks of meat birds are severely feed restricted to avoid obesity-related health and fertility problems. This restriction often leads to chronic hunger, accompanied by stereotypic behavior. Research based in the United Kingdom has shown that using diets containing fiber and appetite suppressants may relieve some of the symptoms of hunger. However, few data are available regarding North American-sourced ingredients or nondaily feeding regimens. This study investigated the effects of 2 alternative diets, in combination with 2 feeding frequencies on growth, productivity, and behavior in broiler breeders. Six dietary treatments were tested, each with 5 replicate pens of 12 or 13 birds. Control diets consisted of a commercial crumble, fed on a daily or skip-a-day (SAD) basis. Alternative diets included soybean hulls as a fiber source, and calcium propionate as an appetite suppressant of either a feed-grade or purified quality, fed on either a daily or SAD basis. Birds were weighed weekly and egg production was recorded daily. Video cameras were used to record behavior during and following the morning feeding bout every 2 wk from 11 to 28 wk. Data were analyzed with a mixed model ANOVA, with repeated measures. Diet, feeding frequency, time, or an interaction of the 3 had significant effects on all observed behavior during rearing. These differences appeared to diminish during lay, with most stereotypic behavior no longer present. Very little object pecking and aggression was observed during and immediately following feeding bouts; however, daily-fed control birds still displayed this behavior more often, especially during rearing (P = 0.015). During feeding bouts, SAD birds feather pecked (P = 0.003) and rested more (P = 0.0002) than daily-fed birds. Control birds feather pecked most often (P = 0.033) after feeding bouts. Overall, the feed-grade diet appeared most effective at reducing hunger-related behavior, and the control diet appeared the least effective. There was little conclusive evidence to show that daily feeding was more effective at reducing hunger.

Patient-reporting improves estimates of postoperative complication rates: a prospective cohort study in gynaecological oncology

Background:

Most studies use hospital data to calculate postoperative complication rates (PCRs). We report on improving PCR estimates through use of patient-reporting.

Methods:

A prospective cohort study of major surgery performed at 10 UK gynaecological cancer centres was undertaken. Hospitals entered the data contemporaneously into an online database. Patients were sent follow-up letters to capture postoperative complications. Grade II–V (Clavien–Dindo classification) patient-reported postoperative complications were verified from hospital records. Postoperative complication rate was defined as the proportion of surgeries with a Grade II–V postoperative complication.

Results:

Patient replies were received for 1462 (68%) of 2152 surgeries undertaken between April 2010 and February 2012. Overall, 452 Grade II–V (402 II, 50 III–V) complications were reported in 379 of the 1462 surgeries. This included 172 surgeries with 200 hospital-reported complications and 231 with 280 patient-reported complications. All (100% concordance) 36 Grade III–V and 158 of 280 (56.4% concordance) Grade II patient-reported complications were verified on hospital case-note review. The PCR using hospital-reported data was 11.8% (172 out of 1462; 95% CI 11–14), patient-reported was 15.8% (231 out of 1462; 95% CI 14–17.8), hospital and verified patient-reported was 19.4% (283 out of 1462; 95% CI 17.4–21.4) and all data were 25.9% (379 out of 1462; 95% CI 24–28). After excluding Grade II complications, the hospital and patient verified Grade III–V PCR was 3.3% (48 out of 1462; 95% CI 2.5–4.3).

Conclusion:

This is the first prospective study of postoperative complications we are aware of in gynaecological oncology to include the patient-reported data. Patient-reporting is invaluable for obtaining complete information on postoperative complications. Primary care case-note review is likely to improve verification rates of patient-reported Grade II complications.

Risk of epithelial ovarian cancer in asymptomatic women with ultrasound-detected ovarian masses: a prospective cohort study within the UK collaborative trial of ovarian cancer screening (UKCTOCS)

OBJECTIVE

To estimate the risk of primary epithelial ovarian cancer (EOC) and slow growing borderline or Type I and aggressive Type II EOC in postmenopausal women with adnexal abnormalities on ultrasound.

METHODS

This was a prospective cohort study in the ultrasound group of the UK Collaborative Trial of Ovarian Cancer Screening of postmenopausal women with ultrasound-detected abnormal adnexal (unilocular, multilocular, unilocular solid and multilocular solid, solid) morphology on their first scan. Women were followed up through the national cancer registries and by postal questionnaires. Absolute risks of EOC and borderline, Type I and Type II EOC within 3 years of initial scan were calculated.

RESULTS

Of 48 053 women who underwent ultrasound examination and had complete scan data, 4367 (9.1% (95% CI, 8.8-9.3%)) had abnormal adnexal morphology. Median follow-up was 7.09 (25(th) -75(th) centiles, 6.03-7.92) years. Forty-seven (32 borderline or Type I, 15 Type II) were diagnosed with EOC. The overall absolute risk of EOC associated with abnormal adnexal morphology was 1.08% (95% CI, 0.79-1.43%); for borderline and Type I it was 0.73% (95% CI, 0.5-1.03%); and for Type II it was 0.34% (95% CI, 0.33-0.79%). In the subgroup (n = 741) with solid elements (unilocular solid, multilocular solid and solid) overall absolute risk was 4.45% (95% CI, 3.08-6.20%), for borderline and Type I it was 3.1% (95% CI, 1.9-4.6%) and for Type II it was 1.3% (95% CI, 0.6-2.4%). 11 982 women had both ovaries visualized and normal annual scans throughout the 3-year follow-up period. In this group, no borderline or Type I and eight Type II cancers were diagnosed.

CONCLUSION

Asymptomatic postmenopausal women with ultrasound-detected adnexal abnormalities with solid elements have a 1 in 22 risk for EOC. Despite the higher prevalence of Type II EOC, the risk of borderline or Type I cancer in women with ultrasound abnormalities seems to be higher than does the risk of Type II cancer. This has important immediate implications for patients with incidental adnexal findings as well as for any future ultrasound-based screening.

Future considerations in poultry nutrition

Following is invited commentary on the symposium "A Crystal Ball Look into the Future of…" delivered July 16, 2011, at the Poultry Science Association's 100th annual meeting, St. Louis, Missouri. The symposium examined various aspects that will impact the future of poultry production over the next 10 to 20 yr. Topics included genetics, nutrition, incubation, and bird health. This paper deals with various aspects of future issues affecting global feeding and nutrition of poultry.