Acceptability of digital anal cancer screening examinations in HIV-positive homosexual men

OBJECTIVES

Anal cancer is more common in HIV-positive homosexual men than in HIV-negative homosexual men and the general population. Earlier diagnosis leads to improved prognosis. We aimed to determine if regular anal inspection and digital examination of asymptomatic homosexual men attending for routine HIV care were acceptable and to record the rate of referral for diagnosis of potentially malignant anal lesions.

METHODS

We offered anal examinations to consecutive homosexual men with HIV infection aged ≥ 35 years during their routine HIV clinic visits, aiming to complete three examinations over a 12-month period. Acceptability questionnaires were completed at baseline and after each examination and doctors recorded examination findings and all resulting interventions. Hospital referral outcomes were collected and interventions were costed using the Australian Medical Benefits Schedule.

RESULTS

Of 142 men who were offered enrolment in the study, 102 [72%; 95% confidence interval (CI) 64-79%] participated. Following the initial anal examinations, four men were referred to surgeons. Cancer was excluded in three men (3%; 95% CI 1-8%) and one was diagnosed with anal squamous cell carcinoma (SCC). Three men had anoscopy performed at the time and two were referred for colonoscopy. Ninety-eight per cent (95% CI 93-100%) of respondents said that they would probably have the examination next time. The intervention was estimated to cost approximately Australian $16 per examination.

CONCLUSIONS

Regular anal digital examinations are an acceptable and inexpensive addition to the routine care of homosexual men with HIV infection.

Epigallocatechin gallate sensitizes CAL-27 human oral squamous cell carcinoma cells to the anti-metastatic effects of gefitinib (Iressa) via synergistic suppression of epidermal growth factor receptor and matrix metalloproteinase-2

Human head and neck squamous cell carcinoma (HNSCC) is a major cause of cancer-related death during the last decade due to its related metastasis and poor treatment outcomes. Gefitinib (Iressa), a tyrosine kinase inhibitor has been reported to reduce the metastatic abilities of oral cancer. Previous studies have shown that epigallocatechin gallate (EGCG), a green tea polyphenol, possesses cancer chemopreventive and anticancer activity. However, the mechanisms involved in the suppression of invasion and metastasis of human oral cancer cells following co-incubation with gefitinib and EGCG remain poorly understood. In the present study, we attempted to investigate the synergistic effects of a combined treatment of gefitinib and EGCG in CAL-27 cells in vitro and to elucidate the underlying molecular mechanisms associated with the supression of cell migration and invasion. In the present study, we found that the individual treatments or the combined treatment of gefitinib and EGCG synergistically inhibited the invasion and migration of CAL-27 cells using Transwell invasion and wound-healing scratch assays, respectively. Similarly, gefitinib in combination with EGCG synergistically attenuated enzymatic activity and the protein expression of MMP-2 in CAL-27 cells. Furthermore, individual or combined treatment with EGCG and gefitinib suppressed the protein expression of p-EGFR and the phosphorylated protein levels of ERK, JNK, p38 and AKT and displayed inhibitory effects on metastatic ability of CAL-27 cells. Combined effects of EGCG and gefitinib-altered anti-metastatic actions for related gene expression were observed using DNA microarray analysis. Importantly, EGCG sensitizes CAL-27 cells to gefitinib-suppressed phosphorylation of epidermal growth factor receptor (EGFR in vitro. Taken together, our results suggest that the synergistic suppression of the metastatic ability of CAL-27 cells after EGCG and gefitinib individual or combined treatment are mediated through mitogen-activated protein kinase (MAPK) signaling. Our novel findings provide potential insights into the mechanism involved with synergistic responses of gefitinib and EGCG against the progression of oral cancer.

AKT serine/threonine protein kinase modulates bufalin-triggered intrinsic pathway of apoptosis in CAL 27 human oral cancer cells

Bufalin has been reported to induce apoptosis in a variety of cancers but little is demonstrated in oral squamous cell carcinoma (OSCC) cells. The present study investigated the inhibition of proliferation, cell cycle arrest and apoptotic effects of bufalin in CAL 27 human oral cancer cells. Bufalin inhibited the growth of CAL 27 cells in a concentration-dependent manner and an IC50 value of bufalin was about 125 nM for 24 h treatment using the MTT assay. Moreover, the cell cycle distribution was arrested at the G0/G1 phase in CAL 27 cells after bufalin exposure. Upon bufalin stimulation, the expression of Bcl-2 was significantly decreased while that of cytochrome c, Apaf-1 and AIF was increased compared to the control group by western blot analysis. An increase in the expression of the active form of caspases was found in bufalin-treated cells, and the caspase activities were also elevated. Bufalin-triggered apoptosis was blocked by specific inhibitors of caspase-9 (z-LEHD-fmk) and caspase-3 (z-DEVD-fmk), respectively. In contrast, CAL 27 cells overexpressing constitutively active AKT (CAL 27/CA-AKT) were exposed to bufalin at different concentrations, and cell growth remained unchanged. Bufalin exhibited minimal apoptotic effects on CAL 27/CA-AKT cells. Taken together, bufalin induced G0/G1 phase arrest and provoked the intrinsic apoptotic pathway via AKT activation in CAL 27 cells. Our data suggest that bufalin could be potentially efficacious in the treatment of oral cancer in the future.

Lysyl oxidase and enhancement of cell proliferation and angiogenesis in oral squamous cell carcinoma

BACKGROUND

Lysyl oxidase (LOX) is a copper-dependent enzyme that cross-links collagen and elastin in the extracellular matrix. LOX overexpressed in various tumors. The manner in which LOX affects tumor growth remains controversial.

METHODS

Chemical treatment and gene transfection were used to induce LOX overexpression or inhibition in cell lines SAS and SVEC4-10. LOX mRNA, protein, and activity were confirmed before tube formation assay and tumorigenesis. The microvessels in the tumor section were detected by immunostaining CD31-positive endothelial cells.

RESULTS

LOX overexpression and copper induction of LOX activity increased SVEC4-10 tube formation. LOX silencing and β-aminopropionitrile inhibition of LOX activity had opposite effects. LOX overexpression increased proliferation and proliferating cell nuclear antigen expression. High LOX expression clones increased tumor size in a tumorigenesis model. The microvascular numbers were higher in LOX overexpression tumors than in control tumors.

CONCLUSION

LOX can induce cell proliferation and angiogenesis in oral squamous cell carcinoma.

HIV-testing of men who have sex with men: variable testing rates among clinicians

High HIV testing coverage of high-risk populations is required to reduce the number of HIV-infected individuals unaware of their status. The aim of this study was to determine HIV testing rates among men who have sex with men (MSM) attending a sexual health service, including the impact of the treating clinician on HIV testing rates. Factors associated with HIV testing of MSM attending the Melbourne Sexual Health Centre for the first time between 2003 and 2009 were determined, including testing rates for individual treating clinicians. Overall, 78% of 4425 men were tested for HIV. Clinician HIV testing rates were higher among nurses (median 89%; range 77–95%) than doctors (median 73%; range 45–88%) with significant differences between individual physicians ( P < 0.001). Lower testing among doctors was independent of reported sexual risk and time since the last HIV test. Substantial differences in HIV testing rates between clinicians were evident with low testing by some. Increasing HIV testing rates among high-risk groups require engagement not only of individuals at risk but also awareness among health-care providers who perform HIV testing.

Does MR perfusion imaging impact management decisions for patients with brain tumors? A prospective study

BACKGROUND AND PURPOSE

MR perfusion imaging can be used to help predict glial tumor grade and disease progression. Our purpose was to evaluate whether perfusion imaging has a diagnostic or therapeutic impact on clinical management planning in patients with glioma.

MATERIALS AND METHODS

Standard MR imaging protocols were interpreted by a group of 3 NRs in consensus, with each case being interpreted twice: first, including routine sequences; and second, with the addition of perfusion imaging. A multidisciplinary team of treating physicians assessed tumor status and created hypothetical management plans, on the basis of clinical presentation and routine MR imaging and then routine MR imaging plus perfusion MR imaging. Physicians' confidence in the tumor status assessment and management plan was measured by using Likert-type items.

RESULTS

Fifty-nine consecutive subjects with glial tumors were evaluated; 50 had known pathologic diagnoses. NRs and the treatment team agreed on tumor status in 45/50 cases (κ = 0.81). With the addition of perfusion, confidence in status assessment increased in 20 (40%) for NRs and in 28 (56%) for the treatment team. Of the 59 patient-care episodes, the addition of perfusion was associated with a change in management plan in 5 (8.5%) and an increase in the treatment team's confidence in their management plan in 34 (57.6%). NRs and the treatment team found perfusion useful in most episodes of care and wanted perfusion included in future MR images for >80% of these subjects.

CONCLUSIONS

Perfusion imaging appears to have a significant impact on clinical decision-making and subspecialist physicians' confidence in management plans for patients with brain tumor.

Age-related changes in kallikreins-kinins system in rat corpus cavernosum

Many factors, such as nitric oxide synthase, androgen and growth factors, can regulate the tone of corpus cavernosum (CC) smooth muscle with an age-related tendency. It has been shown that the active metabolites of kallikreins-kinins system (KKS), including bradykinin, Lys-BK and Met-Lys-BK, can also relax the CC smooth muscle significantly in vitro. Our aim was to evaluate the specific association between KKS and age in rat CC. CC and thoracic aorta were isolated from rats at postnatal weeks (PW) of 2, 8, 12, 20, 30, 40 and 60, respectively. Tissue kallikrein-I (KLKI) and kinin B2 receptor (B2R) mRNA in CC and thoracic aorta were detected by real-time polymerase chain reaction (PCR). Protein expression of KLKI and B2R were determined with immunofluorescence in situ and Western blot. Real-time PCR, immunofluorescence in situ and Western blot all demonstrated that the age-related changes in expression of KLKI were similar between the CC and thoracic aorta. It significantly increased with age from PW2 to PW30, reached the peak at PW30 and then declined gradually. However, there was no statistically significant difference among PW30, PW40 and PW60. Similarly, the expression of B2R increased gradually with age reached and remained at the peak during adult stages and no significant differences were found among PW20, PW30 and PW40; then, it decreased significantly at PW60. The changes in the expression of B2R in CC and age-matched aorta were similar except that it was significantly less than that in the aorta at PW60. The expression of KLKI and B2R changed in an age-dependent pattern in rat CC and have a tendency to decline during ageing, which is of the same tendency as reported for erection capacity in ageing males and suggests why ageing is an independent predictor of ED, to some extent.

Australian men who have sex with men prefer rapid oral HIV testing over conventional blood testing for HIV

This study examined the views of 172 community-based Australian men who have sex with men (MSM) on the acceptability and potential uptake of rapid oral testing for HIV in clinic and home-based settings. Men were asked to complete a questionnaire that sought their views on rapid testing for HIV. When asked about which HIV test they would prefer in a clinic setting, 64% indicated a preference for rapid oral HIV testing and 74% indicated that if rapid oral HIV testing was available at a clinic they would test for HIV more frequently. If rapid oral HIV testing was available for home testing, 63% of men indicated it would be likely they would test themselves for HIV and 61% indicated they would test more frequently. Overall, MSM expressed a preference for rapid oral HIV testing and would test more frequently if testing was available for clinic or home use in Australia.

Definitions of antiretroviral treatment failure for measuring quality outcomes

OBJECTIVES

Our aim was to compare three different definitions of treatment failure and discuss their use as quality outcome measures for a clinical service.

METHODS

Data for treatment-naïve patients who attended the Melbourne Sexual Health Centre (MSHC) between 1 January 2000 and 31 December 2008 were analysed. Definition 1 was the strict Food and Drug Administration (FDA) definition of treatment failure as determined using the time to loss of virological response (TLOVR) algorithm. Definition 2 defined treatment failure as occurring in those whose viral load never fell to <400 HIV-1 RNA copies/mL or who developed two consecutive viral loads > or =400 copies/mL on any treatment (switching or stopping treatment with a viral load <400 copies/mL was permitted). Definition 3 was the same as definition 2 except that individuals were also deemed to have failed if they stopped treatment for 6 months or longer.

RESULTS

There were 310 antiretroviral-naïve patients who started treatment in the study period. Of these, 156 [50.3%; 95% confidence interval (CI) 42.1-53.3%] experienced treatment failure under definition 1, 10 (3.2%; 95% CI 1.5-5.8%) experienced treatment failure under definition 2, and 16 (4.5%; 95% CI 2.5-7.4%) experienced treatment failure under definition 3 over the 108 months of follow-up. The probability of failing definition 1 was statistically different from the probability of failing definition 2 or 3 (P=0.01).

CONCLUSION

There were significant differences in treatment failure for the three definitions. If definition 1 were used, the outcomes would be sufficiently common to enable clinics to be compared but would be less meaningful. If definition 2 or 3 were used, the events would be too rare to enable clinics to be compared, but it would be possible to set a benchmark level of success that clinics could aim to reach.

Rapid decline in presentations of genital warts after the implementation of a national quadrivalent human papillomavirus vaccination programme for young women

OBJECTIVE

This study aimed to determine if the Australian human papillomavirus (HPV) vaccination programme has had a population impact on presentations of genital warts.

METHODS

Retrospective study comparing the proportion of new clients with genital warts attending Melbourne Sexual Health Centre (MSHC) from January 2004 to December 2008. Australia provided free quadrivalent HPV vaccine to 12-18-year-old girls in a school-based programme from April 2007, and to women 26 years and younger through general practices from July 2007.

RESULTS

36,055 new clients attended MSHC between 2004 and 2008 and genital warts were diagnosed in 3826 (10.6%; 95% CI 10.3 to 10.9). The proportion of women under 28 years with warts diagnosed decreased by 25.1% (95% CI 30.5% to 19.3%) per quarter in 2008. Comparing this to a negligible increase of 1.8% (95% CI 0.2% to 3.4%) per quarter from the start of 2004 to the end of 2007 also in women under 28 years generates strong evidence of a difference in these two trends (p<0.001). There was no evidence of a difference in trend for the quarterly proportions before and after the end of 2007 for any other subgroup, and on only one occasion was there strong evidence of a trend different to zero, for heterosexual men in 2008 in whom the average quarterly change was a decrease of 5% (95% CI 0.5% to 9.4%; p = 0.031).

CONCLUSIONS

The data suggest that a rapid and marked reduction in the incidence of genital warts among vaccinated women may be achievable through an HPV vaccination programme targeting women, and supports some benefit being conferred to heterosexual men.

Delay in the diagnosis of early syphilis among men who have sex with men: need for greater community and health provider education

The objective of this study was to determine the duration between onset of symptoms of early symptomatic syphilis and diagnosis among men who have sex with men (MSM). A review of cases of primary and secondary syphilis among MSM presented to the Melbourne Sexual Health Centre between January 2003 and August 2007. The mean age of the 123 MSM included was 37 years. Fifty-two percent (n = 64) presented with primary syphilis and 48% (n = 59) with secondary syphilis. Twenty-five percent were HIV-positive. The median rapid plasma reagin titre was 1:32. Of the 34 men referred by general practitioners, referring practitioners did not consider the diagnosis of syphilis in 10 cases of primary syphilis and 20 cases of secondary syphilis. For primary and secondary cases combined, the median duration between onset of symptoms and diagnosis, and onset of symptoms and treatment, was 15 (3-56) and 20 (1-57) days, respectively. The respective durations for secondary syphilis (17 and 23 days) was longer than for primary syphilis (13 and 15 days) (P < 0.05). The mean number of sex partners reported for the prior three months was 8.8 (range 1-15). If early detection and treatment of syphilis is to be optimized in order to improve syphilis control, greater awareness of its symptoms and signs of syphilis need to be promoted among both health-care providers and affected communities.

What female patients feel about the offer of a chaperone by a male sexual health practitioner

The aim of this study was to determine the experience and views of female patients when they were offered a chaperone by a male sexual health practitioner for a genital examination. Between November 2007 and January 2008, an anonymous survey was administered to female patients seen by male practitioners at Melbourne Sexual Health Centre. None of the 79 (95% CI 0-5%) patients who were offered a chaperone and declined one reported that they were uncomfortable declining the offer. The qualitative analysis showed that some participants appreciated being offered the option of a chaperone even if they did not want one and that the professional attributes of the practitioner influenced their decision not to have a chaperone. Only 8% (95%CI 4-15%) felt uncomfortable when asked if they would like a chaperone. The results reassure that when a female patient declines the offer of a chaperone within a sexual health clinic, the male practitioner can feel confident that this is the expression of the patient's wish.

Risk profile of walk-in triage compared with an appointment-based phone-triage evening clinic

The aim of this study is to compare risk factors in new clients attending the walk-in triage-based day clinic (WITS) to those attending a telephone-triage appointment-based evening clinic of a sexual health service. The method involves an audit of computerized medical records of new clients attending between July 2002 and December 2007. There were 37,833 new clients of which 37,223 (98.4%) attended WITS and 610 (1.6%) attended the evening clinic. WITS clients were significantly older (31% vs. 30%, P < 0.041), more likely to be male (58% vs. 43%, P < 0.001), sex workers (6% vs. 3%, P < 0.001), not employed (34% vs. 10%, P < 0.001), diagnosed with gonorrhoea (1.7% vs. 0.7%, P < 0.041), herpes (4% vs. 2%, P < 0.000), non-specific urethritis (6% vs. 2%, P < 0.000) and less likely asymptomatic (35.1% vs. 53.4%, P < 0.001). Men attending WITS had significantly more female partners in the 12 months (3.9 vs. 3.0, P < 0.001), but other risks were similar in both clinics. A telephone-triage appointment-based evening clinic is important for asymptomatic high-risk individuals.

Factors associated with traumatic fluoroscopy-guided lumbar punctures: a retrospective review

BACKGROUND AND PURPOSE

To minimize diagnostic confusion, a CSF specimen should be free from traumatically introduced red blood cells (RBCs). The purpose of this research is to determine if patient age, sex, gauge of the lumbar puncture (LP) needle, or the level of LP is associated with an increased risk for traumatic fluoroscopy-guided LP.

MATERIALS AND METHODS

Data were collected retrospectively for consecutive male and female patients of all ages (n = 756) who underwent a fluoroscopy-guided LP for a 2-year period. We defined traumatic LP as a CSF sample with an RBC count more than 500 cells/mm(3) without xanthochromia.

RESULTS

Rate of traumatic LP was 13.3%. The rate of traumatic LP at the L4-L5 level (19%) was significantly higher than at the L2-L3 (9%) or L3-L4 level (10%). Patients older than 80 years had higher traumatic LP rates (25.9%) compared with patients between ages 11 and 80 years (12.4%). Sex and gauge of the spinal needle were not associated with increased rate of traumatic LP. Patients younger than 1 year had failed LP rate of 58.8% compared with 3.2% failure rate in older patients.

CONCLUSIONS

Fluoroscopy-guided LP at the L4-L5 level is associated with nearly twice the risk for traumatic puncture compared with the L2-L3 or L3-L4 level. Rates of traumatic result are twice as high in adults older than 80 years compared with younger patients. Failure rates for fluoroscopy-guided LP are low except in children younger than 1 year, in whom failure occurs in most cases.