Human papillomavirus testing in young women: clinical outcomes of human papillomavirus triage in a UK cervical screening program

BACKGROUND

In the United Kingdom, human papillomavirus (HPV) testing is used to triage women with borderline cytology or mild dyskaryosis; however, in young women, the value of triage is limited by the high HPV prevalence rate. The current study examined the impact of HPV triage on colposcopy referral, colposcopy procedures, and patient outcome in a cervical screening population that included women aged < 25 years.

METHODS

Women aged 18 to 65 years attending for cervical screening in Northern Ireland were tested for HPV if their cytology result demonstrated borderline cytology or mild dyskaryosis. Of the 866 women eligible for HPV triage, those who tested negative for HPV were returned to routine screening and women who tested positive were referred to colposcopy.

RESULTS

HPV prevalence was 82.07% in women aged < 25 years and 54.69% in women aged ≥ 25 years. Colposcopy referrals increased by 42.67%. The odds of undergoing a large loop excision of the transformation zone (LLETZ) compared with punch biopsy increased by 0.056 per year above the age of 31 years. LLETZ performed in women aged ≥ 25 years and those aged < 25 years yielded rates of cervical intraepithelial neoplasia of type 2 or higher (≥ CIN2) of 57.04% and 80.00%, respectively. The positive predictive value of HPV triage for detecting ≥ CIN2 was 29.92% in women aged < 25 years and 27.51% in the older age group.

CONCLUSIONS

HPV triage substantially increased colposcopy referrals. The positive predictive value of a positive HPV test to detect ≥ CIN2 was not affected by age. LLETZ performed in women aged < 25 years yielded higher rates of ≥ CIN2 compared with the older age group.

Improving the management and care of people with sepsis

Many hospitals struggle to implement the full sepsis care bundle, but research suggests that many patients with sepsis are transported to hospital by ambulance. In 2011, the Scottish Ambulance Service introduced a pre-hospital sepsis screening tool (PSST) to expedite sepsis identification and care delivery. However, ambulance clinicians have reported varying degrees of interest and enthusiasm from hospital staff during handover. Therefore, an online survey was set up to investigate medical and nursing staff perceptions and experiences of the introduction of a PSST. This article discusses the results, which show that participants perceive the PSST reduces time to treatment, improves continuity of care, benefits patients and is accurately applied by ambulance clinicians, but which also highlight problems with communication. The delivery of in-hospital and pre-hospital sepsis care is challenging, but simple measures such as improving and standardising communication and alert systems between ambulance services and receiving hospitals could improve the clinical effects of a PSST.

The pathogenic mechanism of the Mycobacterium ulcerans virulence factor, mycolactone, depends on blockade of protein translocation into the ER

Infection with Mycobacterium ulcerans is characterised by tissue necrosis and immunosuppression due to mycolactone, the necessary and sufficient virulence factor for Buruli ulcer disease pathology. Many of its effects are known to involve down-regulation of specific proteins implicated in important cellular processes, such as immune responses and cell adhesion. We have previously shown mycolactone completely blocks the production of LPS-dependent proinflammatory mediators post-transcriptionally. Using polysome profiling we now demonstrate conclusively that mycolactone does not prevent translation of TNF, IL-6 and Cox-2 mRNAs in macrophages. Instead, it inhibits the production of these, along with nearly all other (induced and constitutive) proteins that transit through the ER. This is due to a blockade of protein translocation and subsequent degradation of aberrantly located protein. Several lines of evidence support this transformative explanation of mycolactone function. First, cellular TNF and Cox-2 can be once more detected if the action of the 26S proteasome is inhibited concurrently. Second, restored protein is found in the cytosol, indicating an inability to translocate. Third, in vitro translation assays show mycolactone prevents the translocation of TNF and other proteins into the ER. This is specific as the insertion of tail-anchored proteins into the ER is unaffected showing that the ER remains structurally intact. Fourth, metabolic labelling reveals a near-complete loss of glycosylated and secreted proteins from treated cells, whereas cytosolic proteins are unaffected. Notably, the profound lack of glycosylated and secreted protein production is apparent in a range of different disease-relevant cell types. These studies provide a new mechanism underlying mycolactone's observed pathological activities both in vitro and in vivo. Mycolactone-dependent inhibition of protein translocation into the ER not only explains the deficit of innate cytokines, but also the loss of membrane receptors, adhesion molecules and T-cell cytokines that drive the aetiology of Buruli ulcer.

Buruli ulcer is a progressive necrotic skin lesion caused by infection with the human pathogen Mycobacterium ulcerans. Mycolactone, a small compound produced by the mycobacterium, is the root cause of the disease pathology, but until now there has been no unifying mechanism explaining why. We have been using a model system to investigate the reason for the selective loss of protein that is a common feature of mycolactone exposure. Specifically, this involves identifying the point at which it stops immune cells making inflammatory mediators. In this work, we demonstrate that mycolactone inhibits production of such proteins by blocking the first step of protein export: translocation into a cellular compartment called the endoplasmic reticulum (ER). Proteins due for export are instead made in the cell cytosol where they are recognised as being in the wrong place and are rapidly degraded, causing a general cessation of the production of proteins that have to travel through the ER, including almost all secreted and surface proteins. This has a profound effect on basic cell functions such as growth, adhesion and survival. Therefore, we have identified the molecular basis underlying the key features of Buruli ulcer, and this will transform our understanding of disease progression.

Effect of glacial acetic acid treatment of cervical ThinPrep specimens on HPV DNA detection with the cobas 4800 HPV test

BACKGROUND

Cytology laboratories in the UK routinely treat unsatisfactory cervical liquid-based cytology (LBC) specimens with glacial acetic acid (GAA) to reduce the unsatisfactory rate. However, there is limited published data on the effect of GAA reprocessing on the molecular detection of human papillomavirus (HPV). The aim of this study was to assess the impact of GAA treatment of cervical ThinPrep(®) samples on HPV detection with the cobas(®) 4800 HPV Test (Roche Molecular Systems, Pleasanton, CA, USA).

METHODS

Residual ThinPrep samples (n = 121) were selected to provide a range of typical cytology results and enrich the study samples for HPV positivity. Specimens were equally split into two fractions: one part treated with 10% GAA and the other part left untreated. All samples were HPV tested using the cobas 4800 HPV Test, which simultaneously detects a total of 14 high-risk HPV (hrHPV) genotypes and individually identifies HPV16 and HPV18. The HPV positive/negative status of tested samples determined the level of agreement between treated and untreated fractions; one sample failed owing to detection of a clot by the instrument during pipetting, leaving 120 samples in the study. Statistical analysis was performed using an unweighted kappa.

RESULTS

Analysis of overall HPV positivity showed 97.5% (117/120) agreement between the treated and untreated fractions with a kappa value of 0.95. There were 63/65 (96.9%) concordant HPV positive and 54/55 (98.2%) concordant HPV negative results. In addition to the three discordant results for overall HPV positivity, there were three HPV type-specific discrepancies giving a total of 114/120 concordant HPV results (95% agreement).

CONCLUSIONS

Glacial acetic acid (GAA) treatment of cervical ThinPrep specimens does not have significant adverse affects on HPV detection with the cobas 4800 HPV Test.

Heart rate responses and technical comparison between small- vs. large-sided games in elite professional soccer

This study aims to examine the difference in heart rate (HR) responses and technical activities placed upon European elite players when exposed to 2-sided games differing in the number of players and playing area. Fifteen male soccer players from a Scottish Premier League team (26.3 ± 4.85 years, 182.4 ± 6.99 cm, 79.5 ± 8.05 kg, VO2max of 54.36 ± 5.45 ml·kg(-1)·min(-1)) performed both small (3 vs. 3 plus goalkeepers) and large (9 vs. 9 plus goalkeepers) sided games each lasting for 3 × 5 minutes interspersed with 4-minute passive recovery during the 2009-2010 season. The HR responses and players' technical actions were recorded throughout all sided games. Results show that small-sided games (SSG) induced significantly (p < 0.05, large effect) higher HR responses as compared to large-sided games. Furthermore, during SSGs, players spent significantly longer time in the >85% maximal HR zone (p < 0.05, large effect) as compared to large-sided games. Technical analysis revealed a large practical difference (effect size ranged from 1.5 to 21.2) between small- and large-sided games: less number of blocks, headers, interceptions, passes, and receives but more dribbles, shots, and tackles in SSG. Furthermore, SSG induced significantly lesser total ball contacts per game (p < 0.05, large effect) but significantly greater ball contacts per individual (p < 0.05, large effect) when compared to larger-sided games. The different technical requirements also enable coaches to carry out training games more suitable to specific playing positions such as SSG for midfielders (more dribbles, tackles, and ball contacts per player) strikers (more shots), and large-sided games for defender (more blocks, headers, and interceptions).

Primary malignant gastric PEComa - Diagnostic and technical dilemmas

INTRODUCTION

The World Health Organisation defines PEComa's as "a mesenchymal tumour composed of histologically and immunohistochemically distinctive perivascular cells".(1) These ubiquitous tumours show distinctive perivascular epithelioid cell differentiation and arise most commonly at visceral and abdominopelvic sites.

PRESENTATION OF CASE

We present a case of a forty-two year old man presenting to accident and emergency department with upper gastro-intestinal bleeding. He had a palpable epigatric mass on examination. He underwent a CT Scan Abdomen which displayed a tumour arising from the gastric wall. Upper GI endoscopy and biopsy was carried out and biopsied were taken for histological analysis. A primary gastric PEComa was diagnosed and the patient underwent distal polya gastrectomy and gastrojejunostomy. This is believed to be the first reported case of a Primary malignant gastric PEComa.

DISCUSSION

Perivascular epithelioid carcinomas were first described in 1943 as an abnormal myoblast in a case of renal angiomyolipoma. PEComas display a strong female predominance with a typical benign course. There are approximately 100 reported cases of PEComa to date, with 55 of which were malignant. PEComa's may be subdivided into benign, uncertain malignant potential and malignant. Their natural history can be very aggressive leading to multiple metastases and death as expected with a high-grade sarcoma.

CONCLUSION

This case depicts the aggressive nature of malignant gastric PEComa's. The majority of PEComa's are benign in nature and have a better prognosis. We display here the challenges in ascertaining a definitive diagnosis and management of such patients due to limited clinical studies.

The effect of high altitude on the visual system

Increased ultraviolet light exposure and hypoxia at altitude along with the body's physiological adaptation to altitude can lead to problems with the visual system. The problems that occur can be at the time of the exposure or delayed. The article provides an overview of the ways which the different components of the visual system can be affected following such exposure.

Multiple sclerosis prevalence in Ireland: relationship to vitamin D status and HLA genotype

BACKGROUND

The relationship between prevalence of multiple sclerosis (MS) and latitude may be due to both genetic and environmental factors. The hypothesis that, in Ireland, MS prevalence is increasing and that north-south differences relate to variation in serum 25-hydroxyvitamin D (25(OH)D) levels was tested in this study.

PATIENTS AND METHODS

Patients and matched control subjects were identified in counties Donegal, Wexford and South Dublin through multiple sources. Prevalence was determined. Blood samples were taken for serum 25(OH)D and serum intact parathyroid hormone measurement, and DNA was extracted.

RESULTS

Prevalence in 2007 was significantly greater in Donegal (northwest) (290.3/105, 95% CI 262.3 to 321.7) compared with 2001 (184.6/105; 162 to 209.5). In Wexford (southeast), there was a non-significant increase in prevalence in 2007 compared with 2001. Prevalence was significantly higher in Donegal than in Wexford (144.8/105; 126.7 to 167.8, p<0.0001) and South Dublin (127.8/105; 111.3 to 148.2, p<0.0001). Overall, mean 25(OH)D levels were low and did not differ between patients (38.6 nmol/l) and controls (36.4 nmol/l) However, significantly more patients than controls had 25(OH)D levels <25 nmol/l (deficiency) (p=0.004). Levels of 25(OH)D (mean 50.74 nmol/l) were significantly higher in South Dublin (area with lowest prevalence) (p<0.0001) than in Donegal or Wexford. HLA DRB1*15 occurred most frequently in Donegal (greatest MS prevalence) and least frequently in South Dublin.

CONCLUSION

Vitamin D deficiency is common in Ireland. Latitudinal variation in MS probably relates to an interaction between genetic factors and environment (25(OH)D levels), and MS risk may be modified by vitamin D in genetically susceptible individuals.

Induction pegylated interferon alfa-2a and high dose ribavirin do not increase SVR in heavy patients with HCV genotype 1 and high viral loads

BACKGROUND & AIMS

Patients infected with hepatitis C virus (HCV) genotype 1, body weight ≥85 kg, and high baseline viral load respond poorly to standard doses of pegylated interferon (peginterferon) and ribavirin. We evaluated intensified therapy with peginterferon alfa-2a plus ribavirin.

METHODS

This double-blind randomized trial included HCV genotype 1-infected outpatients from hepatology clinics with body weight ≥85 kg and HCV RNA titer ≥400,000 IU/mL. Patients were randomized to 180 μg/wk peginterferon alfa-2a for 48 weeks plus 1200 mg/day ribavirin (standard of care) (group A, n = 191) or 1400/1600 mg/day ribavirin (group B, n = 189). Additional groups included 360 μg/wk peginterferon alfa-2a for 12 weeks then 180 μg/wk peginterferon alfa-2a for 36 weeks plus 1200 mg/day ribavirin (group C, n = 382) or 1400/1600 mg/day ribavirin (group D, n = 383). Follow-up lasted 24 weeks after treatment.

RESULTS

Sustained virologic response rates (HCV RNA level <15 IU/mL at end of follow-up) in groups A, B, C, and D were 38%, 43%, 44%, and 41%, respectively. There were no significant differences among the 4 groups or between pooled peginterferon alfa-2a regimens (A + B vs C + D: odds ratio [OR], 1.08; 95% confidence interval [CI], 0.83-1.39; P = .584) or pooled ribavirin regimens (A + C vs B + D: OR, 1.00; 95% CI, 0.79-1.28; P = .974).

CONCLUSIONS

In patients infected with HCV genotype 1 who are difficult to treat (high viral load, body weight ≥85 kg), a 12-week induction regimen of peginterferon alfa-2a and/or higher-dose ribavirin is not more effective than the standard regimen.

Radioprotection from radiation-induced lymphedema without tumor protection

Lymphedema or tissue swelling from impaired lymph drainage commonly occurs after regional nodal dissection and/or radiation therapy for cancer control. Treatment options for this disabling and life-altering complication involve long-term labor-intensive commitments. Sentinel node biopsy can forestall removal of negative regional nodes, offering some protection against lymphedema, however, most preventive measures are elusive, ineffective, or unproven. Our goal was to determine whether the radioprotectant amifostine could prevent or retard the development of lymphedema in a rodent radiation therapy-dependent model yet not offer tumor protection from the therapeutic effects of radiation therapy. We pre-treated rats after unilateral radical groin dissection with the organic thiophosphate radioprotectant amifostine or placebo prior to single dose post-operative groin radiation therapy and monitored hindlimb volumes, wound scores, and tissue lymphostasis. In addition, we determined whether amifostine protected human MCF7 breast cancer cells exposed to a range of radiation therapy doses in an in vitro clonogenic assay and an in vivo MCF7 tumor xenograft model. Our findings indicate that amifostine markedly reduced the volume of limb lymphedema and dramatically improved wound healing and tissue lymphostasis in the rodent lymphedema model. The in vivo and in vitro studies further demonstrated that amifostine offered no MCF7 tumor protection from radiation therapy. These pre-clinical findings provide proof-of-principle to further delineate specific mechanisms underlying amifostine's beneficial effects, determine optimal amifostine-radiation therapy dosing regimens, and thereby expedite translation into clinical trials to reduce lymphedema incidence and severity in cancer patients at high lymphedema risk in whom radiation therapy is the recommended therapy.