ARTISTIC: a randomised trial of human papillomavirus (HPV) testing in primary cervical screening

OBJECTIVES

Primary cervical screening uses cytology to detect cancer precursor lesions [cervical intraepithelial neoplasia stage 3 or beyond (CIN3+)]. Human papillomavirus (HPV) testing could add sensitivity as an adjunct to cytology or as a first test, reserving cytology for HPV-positive women. This study addresses the questions: Does the combination of cytology and HPV testing achieve a reduction in incident CIN3+?; Is HPV testing cost-effective in primary cervical screening?; Is its use associated with adverse psychosocial or psychosexual effects?; and How would it perform as an initial screening test followed by cytology for HPV positivity?

DESIGN

ARTISTIC was a randomised trial of cervical cytology versus cervical cytology plus HPV testing, evaluated over two screening rounds, 3 years apart. Round 1 would detect prevalent disease and round 2 a combination of incident and undetected disease from round 1.

SETTING

Women undergoing routine cervical screening in the NHS programme in Greater Manchester.

PARTICIPANTS

In total 24,510 women aged 20-64 years were enrolled between July 2001 and September 2003.

INTERVENTIONS

HPV testing was performed on the liquid-based cytology (LBC) sample obtained at screening. Women were randomised in a ratio of 3:1 to have the HPV test result revealed and acted upon if persistently positive in cytology-negative cases or concealed. A detailed health economic evaluation and a psychosocial and psychosexual assessment were also performed.

MAIN OUTCOME MEASURES

The primary outcome was CIN3+ in round 2. Secondary outcomes included an economic assessment and psychosocial effects. A large HPV genotyping study was also conducted.

RESULTS

In round 1 there were 313 CIN3+ lesions, representing a prevalence in the revealed and concealed arms of 1.27% and 1.31% respectively (p = 0.81). Round 2 (30-48 months) involved 14,230 (58.1%) of the women screened in round 1 and only 31 CIN3+ were detected; the CIN3 rate was not significantly different between the revealed and concealed arms. A less restrictive definition of round 2 (26-54 months) increased CIN3+ to 45 and CIN3+ incidence in the arms was significantly different (p = 0.05). There was no difference in CIN3+ between the arms when rounds 1 and 2 were combined. Prevalence of high-risk HPV types was age-dependent. Overall prevalence of HPV16/18 increased with severity of dyskaryosis. Mean costs per woman in round 1 were 72 pounds and 56 pounds for the revealed and concealed arms (p < 0.001); an age-adjustment reduced these mean costs to 65 pounds and 52 pounds. Incremental cost-effectiveness ratio for detecting additional CIN3+ by adding HPV testing to LBC screening in round 1 was 38,771 pounds. Age-adjusted mean cost for LBC primary screening with HPV triage was 39 pounds compared with 48 pounds for HPV primary screening with LBC triage. HPV testing did not appear to cause significant psychosocial distress.

CONCLUSIONS

Routine HPV testing did not add significantly to the effectiveness of LBC in this study. No significant adverse psychosocial effects were detected. It would not be cost-effective to screen with cytology and HPV combined but HPV testing, as either triage or initial test triaged by cytology, would be cheaper than cytology without HPV testing. LBC would not benefit from combination with HPV; it is highly effective as primary screening but HPV testing has twin advantages of high negative predictive value and automated platforms enabling high throughput. HPV primary screening would require major contraction and reconfiguration of laboratory services. Follow-up continues in ARTISTIC while maintaining concealment for a further 3-year round of screening, which will help in screening protocol development for the post-vaccination era.

114. HYPERTENSIVE DISORDERS OF PREGNANCY ARE ASSOCIATED WITH IMMUNOREGULATORY GENE POLYMORPHISMS

Pregnancy is a controlled state of inflammation. Deregulation of cytokine networks can lead to adverse pregnancy outcomes including preeclampsia (PE). We aimed to identify single nucleotide polymorphisms in immunoregulatory genes that signify an increased risk of the gestational hypertensive disorders PE and gestational hypertension (GH). 1169 nulliparous pregnant women and their partners were recruited prospectively for the Adelaide SCOPE study. PE and GH were classified using strict guidelines. Uncomplicated pregnancies served as controls. Peripheral blood from couples and cord blood from neonates were collected. DNA was extracted and genotyped for Interleukin (IL)-6 rs1800795, IL-4 rs2243250, IL-10 rs1800896 and rs1800871, mannose binding lectin (MBL) rs1800450, transforming growth factor beta 1 (TGFβ-1) rs1800469 and cyclooxygenase (COX)-2 rs20417 & rs5275 and inducible nitric oxide synthase (NOS2A) rs1137933 using the Sequenom MassARRAY system. Genotypes for Caucasian PE (n = 75) and GH (n = 102) were compared with controls (n = 422) and analysed using Chi-Square. In neonates IL-6 G allele carriage was associated with PE (P = 0.011, OR=2.0, 95% CI = 1.2–3.7) and the CC genotype associated with GH (P = 0.002). Neonatal IL-10 RS180071 AA genotype associated with PE (P = 0.041) and IL-10 RS1800896 AA associated with GH (P = 0.022). Paternal NOS2A C allele was more frequent in PE (P = 0.03, OR = 2.1, 95% CI = 1.1–4.5), and maternal NOS2A CC more frequent in GH (P = 0.018). Increased neonatal carriage of MBL rs1800450 AA+GA genotypes associated with GH (P = 0.03, OR = 2.2, 95% CI = 1.1–4.5). No associations were observed between TGFβ-1 or COX2 genotypes and PE or GH. Associations between neonatal IL-6 G, which confers high placental IL-6 expression, and PE suggest a possible mechanism by which PE is a pro-inflammatory exacerbation of placental origin. Since placental IL-10 is important for maternal tolerance of the fetus, genotypes predisposing to low IL-10 expression in the neonate which associate with both PE and GH, suggest a role for decreased placental IL-10 in these disorders.

The Health Behaviour in School-aged Children (HBSC) study: methodological developments and current tensions

OBJECTIVES

To describe the methodological development of the HBSC survey since its inception and explore methodological tensions that need to be addressed in the ongoing work on this and other large-scale cross-national surveys.

METHODS

Using archival data and conversations with members of the network, we collaboratively analysed our joint understandings of the survey's methodology.

RESULTS

We identified four tensions that are likely to be present in upcoming survey cycles: (1) maintaining quality standards against a background of rapid growth, (2) continuous improvement with limited financial resources, (3) accommodating analysis of trends with the need to improve and adapt questionnaire content, and (4) meeting the differing requirements of scientific and policy audiences.

CONCLUSIONS

While these challenges are not trivial, the structure of the HBSC network and its long-term experience in working through such challenges renders it likely that HBSC can provide a model of other similar studies facing these tensions.

Psychological impact of preimplantation genetic diagnosis: a review of the literature

Preimplantation genetic diagnosis (PGD) was first reported as successful in humans in the early 1990s and nearly two decades later the psychological impact of PGD has not yet been clearly defined. As PGD requires the use of IVF, this paper provides a brief summary of literature related to the various psychological aspects of IVF followed by a review of the literature related to the psychological and broader psychosocial impact of PGD. The current literature includes attitudinal studies of couples for whom PGD may be beneficial and results suggest that those with traumatic reproductive and genetic histories are more likely to find PGD an acceptable treatment option. A small number of studies have used samples of women and couples who have used PGD. Due to a general lack of homogeneity in scope, method and results, these studies have not provided a uniform understanding of the PGD experience. Promisingly, however, two studies on parents of children born after PGD that explored parental stress show no differences between PGD, IVF and natural conception couples. The paper concludes that the missing link in the literature is a prospective study of PGD using validated psychological scales. Suggestions for future research are provided.

Beneficial effects of a 3-week course of intramuscular glucocorticoid injections in patients with very early inflammatory polyarthritis: results of the STIVEA trial

Objective

To evaluate whether treating patients with very early inflammatory polyarthritis (IP) with a 3-week course of intramuscular (IM) methylprednisolone acetate may postpone the need for disease-modifying antirheumatic drugs (DMARDs) and prevent IP from evolving into rheumatoid arthritis (RA).

Methods

Patients with very early IP (4–10 weeks’ duration) were randomised to receive three injections of either 80 mg IM methylprednisolone acetate or placebo, given at weekly intervals. Assessments were monthly until 6 months after the first injection, and then concluded at 12 months. The primary outcome was the need to start DMARDs by the 6-month assessment. Secondary outcomes included disease activity and final clinical diagnosis by the rheumatologist at 12 months.

Results

Patients in the placebo group (76%) were more likely to need DMARDs during the first 6 months of the trial than patients in the glucocorticoid group (61%) (adjusted OR = 2.11, 95% CI 1.16 to 3.85, p = 0.015). Disease activity did not differ between the two groups at 12 months, probably because many patients in the placebo group started DMARDs early in the study. After 12 months, the arthritis had resolved without the need for DMARDs in 9.9% (11/111) of the patients in the placebo group and in 19.8% (22/111) in the glucocorticoid-treated group (adjusted OR = 0.42, 95% CI 0.18 to 0.99, p = 0.048).

Conclusion

Treatment of patients with very early IP with IM methylprednisolone acetate appears to postpone the prescription of DMARDs and prevent one in 10 patients from progressing into RA.

Neurological functional recovery after thymosin beta4 treatment in mice with experimental auto encephalomyelitis

In the present study, we hypothesized that thymosin beta 4 (Tbeta4) is a potential therapy of multiple sclerosis (MS). To test this hypothesis, SJL/J mice (n=21) were subjected to experimental autoimmune encephalomyelitis (EAE), an animal model of MS. EAE mice were treated with saline or Tbeta4 (6 mg/kg, n=10) every 3 days starting on the day of myelin proteolipid protein (PLP) immunization for total five doses. Neurological function, inflammatory infiltration, oligodendrocyte progenitor cells (OPCs) and mature oligodendrocytes were measured in the brain of EAE mice. Double immunohistochemical staining was used to detect proliferation and differentiation of OPCs. Tbeta4 was used to treat N20.1 cells (premature oligodendrocyte cell line) in vitro, and proliferation of N20.1 cells was measured by bromodeoxyuridine (BrdU) immunostaining. Tbeta4 treatment improved functional recovery after EAE. Inflammatory infiltrates were significantly reduced in the Tbeta4 treatment group compared to the saline groups (3.6+/-0.3/slide vs 5+/-0.5/slide, P<0.05). NG2(+) OPCs (447.7+/-41.9 vs 195.2+/-31/mm(2) in subventricular zone (SVZ), 75.1+/-4.7 vs 41.7+/-3.2/mm(2) in white matter), CNPase(+) mature oligodendrocytes (267.5+/-10.3 vs 141.4+/-22.9/mm(2)), BrdU(+) with NG2(+) OPCs (32.9+/-3.7 vs 17.9+/-3.6/mm(2)), BrdU(+) with CNPase(+) mature oligodendrocytes (18.2+/-1.7 vs 10.7+/-2.2/mm(2)) were significantly increased in the Tbeta4 treated mice compared to those of saline controls (P<0.05). These data indicate that Tbeta4 treatment improved functional recovery after EAE, possibly, via reducing inflammatory infiltrates, and stimulating oligodendrogenesis.

Thirst perception and arginine vasopressin production in a kindred with an activating mutation of the type 2 vasopressin receptor: the pathophysiology of nephrogenic syndrome of inappropriate antidiuresis

BACKGROUND

Activating mutations of the vasopressin receptor gene on the X chromosome cause the nephrogenic syndrome of inappropriate antidiuresis (NSIAD). We describe a male child who presented with persistent hyponatraemia and whose mother was also found to be hyponatraemic. She had learnt to avoid excess fluid consumption because of associated malaise. Both individuals had a subnormal ability to excrete a water load with mother also demonstrating a heightened sense of thirst at low serum osmolalities.

RESULTS

Mother and child were found to have the previously characterised activating mutation (p.Arg137Cys) of the arginine vasopressin receptor type 2 gene (AVPR2), but had measurable levels of AVP when hyponatraemic.

CONCLUSIONS

We conclude that female carriers of activating mutations of the vasopressin receptor are susceptible to hyponatraemia and therefore need to be provided with advice regarding fluid intake. An altered thirst perception may increase susceptibility to hyponatraemia. We confirm that the presence of measurable amounts of AVP in patients with hyponatraemia does not exclude the diagnosis of NSIAD.

Inactivation of animal and human prions by hydrogen peroxide gas plasma sterilization

Prions cause various transmissible spongiform encephalopathies. They are highly resistant to the chemical and physical decontamination and sterilization procedures routinely used in healthcare facilities. The decontamination procedures recommended for the inactivation of prions are often incompatible with the materials used in medical devices. In this study, we evaluated the use of low-temperature hydrogen peroxide gas plasma sterilization systems and other instrument-processing procedures for inactivating human and animal prions. We provide new data concerning the efficacy of hydrogen peroxide against prions from in vitro or in vivo tests, focusing on the following: the efficiency of hydrogen peroxide sterilization and possible interactions with enzymatic or alkaline detergents, differences in the efficiency of this treatment against different prion strains, and the influence of contaminating lipids. We found that gaseous hydrogen peroxide decreased the infectivity of prions and/or the level of the protease-resistant form of the prion protein on different surface materials. However, the efficiency of this treatment depended strongly on the concentration of hydrogen peroxide and the delivery system used in medical devices, because these effects were more pronounced for the new generation of Sterrad technology. The Sterrad NX sterilizer is 100% efficient (0% transmission and no protease-resistant form of the prion protein signal detected on the surface of the material for the mouse-adapted bovine spongiform encephalopathy 6PB1 strain and a variant Creutzfeldt-Jakob disease strain). Thus, gaseous or vaporized hydrogen peroxide efficiently inactivates prions on the surfaces of medical devices.

Cost and clinical consequence of antibiotic non-adherence in acute exacerbations of chronic bronchitis

OBJECTIVE

To quantify the impact of non-adherence on the clinical effectiveness of antibiotics for acute exacerbations of chronic bronchitis (AECB) and to estimate the economic consequences for Spain, Italy and the United States.

METHODS

Standard systematic reviewing procedures were followed to identify randomised controlled clinical trials of antibiotic treatment for acute respiratory tract infection for which adherence was reported. A decision-analytic model was then constructed to evaluate the impact of non-adherence to antibiotic treatment on clinical effectiveness and costs per AECB episode. The model compared the total treatment costs, cure rates and incremental costs per cure for a poor compliance group (PCG) against a good compliance group (GCG). Clinical and resource use estimates were from the published literature and physician surveys.

RESULTS

Twenty-five articles met the criteria of the systematic review, although only one reported treatment success by adherence status. The relative risk of clinical effectiveness if non-adherent was 0.75 (95%CI 0.73-0.78). Based on this single study, the model predicted that 16-29% more patients would be cured in the GCG vs. the PCG, and payers would save up to euro122, euro179 and US$141 per AECB episode in Spain, Italy and the United States, respectively.

CONCLUSIONS

Non-adherence to antibiotics for AECB may have an impact on clinical effectiveness, which is associated with increased costs.

Clinical pathway for the evaluation of postmenopausal bleeding with an emphasis on endometrial cancer detection

Postmenopausal bleeding (PMB) accounts for about 5% of all office gynaecology visits. The causes of PMB are varied. Many women with endometrial cancer present with this symptom. Although many investigations are described, the most appropriate approach is often unclear. In a patient with no obvious local cause, the emphasis should be on uterine and adnexal evaluation. Based on a literature review, the evidence favours a conservative approach if the endometrial thickness (ET) is < 4mm, unless there are risk factors. All patients with ET 4 mm should have outpatient endometrial sampling. If this is unsuccessful, then outpatient hysteroscopy with directed biopsy or inpatient hysteroscopy is favoured. The role of ancillary investigations are described.

Knowledge of female genital mutilation among healthcare professionals

The World Health Organisation estimates that 2 million women undergo some form of female genital mutilation (FGM) annually. Because of increasing migration, clinicians in the UK are increasingly exposed to women who have suffered FGM. Recognising this trend, the RCOG has set standards for guidance of health professionals caring for women with FGM. As yet, no study has assessed levels of knowledge of FGM among relevant health professionals. An anonymous structured questionnaire based on the Royal College of Obstetricians and Gynaecologists' standards was circulated among staff at a University Teaching Hospital. A total of 45 participants completed the questionnaire. Only 40% were familiar with the regulations in the FGM Act of 2003; 58% were unable to list the different categories of FGM; 47% incorrectly thought that caesarean section is the best way of managing FGM if vaginal examination is not possible in the first stage of labour and 54% chose anterior episiotomy as the treatment of choice during the second stage. Our study found that there were significant gaps both in theoretical knowledge and practice.

Investigation into the effect of an alcohol-based hand product on infection rate in a nursing home setting

The study assessed the impact on nursing home (NH) resident infection rates of providing staff with a personal alcohol-based hand product (ABHP) with and without training on its use.

Fifteen North Wales NHs were recruited and randomly allocated into one of three groups. All monitored infection rates throughout the study period of 18 weeks (Phase I [weeks 1—9], Phase II [weeks 11—19]). NHs used liquid soap and water for hand washing throughout the study. Groups B and C introduced interventions during week ten: Group B were provided with personal ABHPs without training on use; Group C personal ABHPs with standard training from the sponsoring hand hygiene company. Infection rates between groups and pre- and post-intervention were compared.

Infection rates (per 1,000 bed days) for Phase I vs. Phase II of the study were: Group A: 6.99 vs. 7.16; Group B: 6.08 vs. 3.46; and Group C: 5.04 vs. 6.78 respectively. Change in infection rates in Groups B and C pre- and post-intervention did not reach statistical significance, p = 0.097 and p = 0.072 respectively.

Comparison of rates in non-intervention Group A with the intervention groups indicated a significantly lower rate after the intervention in Group B ( p = 0.035) but not Group C ( p = 0.765).

Findings are limited due to sample size; introduction of personal ABHPs with training did not reduce infection rates. This conflicts with other studies examining education and improvement of hand hygiene compliance. However, infection rates fell in NHs not receiving training, possibly mediated through a sense of `ownership' of the intervention.

Mumps outbreak on the island of Anglesey, North Wales, December 2008-January 2009

Twenty-three cases of clinical mumps in young people have been reported in North Wales over a five-week period since late December 2008. All cases have social links, and most of them have received two doses of mumps-containing vaccine.

Role of endothelial nitric oxide synthetase in arteriogenesis after stroke in mice

Arteriogenesis supports restored perfusion in the ischemic brain and improves long-term functional outcome after stroke. We investigate the role of endothelial nitric oxide synthetase (eNOS) and a nitric oxide (NO) donor, (Z)-1-[N-(2-aminoethyl)-N-(2-ammonioethyl) amino] diazen-1-ium-1, 2-diolate (DETA-NONOate), in promoting arteriogenesis after stroke. Adult wild-type (WT, n=18) and eNOS-knockout (eNOS(-/-), n=36) mice were subjected to transient (2.5 h) right middle cerebral artery occlusion (MCAo) and were treated with or without DETA-NONOate (0.4 mg/kg) 24 h after MCAo. Functional evaluation was performed. Animals were sacrificed 3 days after MCAo for arterial cell culture studies, or 14 days for immunohistochemical analysis. Consistent with previous studies, eNOS(-/-) mice exhibited a higher mortality rate (P<0.05, n=18/group) and more severe neurological functional deficit after MCAo than WT mice (P<0.05, n=12/group). Decreased arteriogenesis, was evident in eNOS(-/-) mice compared with WT mice, as demonstrated by reduced vascular smooth muscle cell (VSMC) proliferation, arterial density and diameter in the ischemic brain. eNOS(-/-) mice treated with DETA-NONOate had a significantly decreased mortality rate and improved functional recovery, and exhibited enhanced arteriogenesis identified by increased VSMC proliferation, and upregulated arterial density and diameter compared to eNOS(-/-) mice after stroke (P<0.05, n=12/group). To elucidate the mechanisms underlying eNOS/NO mediated arteriogenesis, VSMC migration was measured in vitro. Arterial cell migration significantly decreased in the cultured common carotid artery (CCA) derived from eNOS(-/-) mice 3 days after MCAo compared to WT arterial cells. DETA-NONOate-treatment significantly attenuated eNOS(-/-)-induced decrease of arterial cell migration compared to eNOS(-/-) control artery (P<0.05; n=6/group). Using VSMC culture, DETA-NONOate significantly increased VSMC migration, while inhibition of NOS significantly decreased VSMC migration (P<0.05; n=6/group). Our data indicated that eNOS not only promotes vascular dilation but also increases VSMC proliferation and migration, and thereby enhances arteriogenesis after stroke. Therefore, increase eNOS may play an important role in regulating of arteriogenesis after stroke.

Cluster randomized trial of a parent-based intervention to support early development of children in a low-income country

BACKGROUND

Programmes that promote early psychological development of children in the developed world have been found to be beneficial. However, such programmes are rare in underprivileged parts of the developing world. We adapted one such parent-based programme (Learning Through Play) for a rural Pakistani population and aimed to study if: (1) it was acceptable to community health workers; (2) the programme led to an improvement, after a period of 6 months, in mothers' knowledge and attitudes about early infant development; (3) it led to a reduction in the levels of maternal mental distress in the post-natal period.

METHODS

Using a cluster randomized design with villages as unit of randomization, 163 mothers from 24 villages in a rural sub-district of Rawalpindi, Pakistan, received the 'Learning Through Play' programme, whereas 146 mothers from 24 villages acted as controls. Twenty-four community health workers were trained to carry out the programme. Assessments were conducted using a specially developed 15-item Infant Development Questionnaire and the 20-item Self-Reporting Questionnaire (SRQ).

RESULTS

Over 80% of the community health workers trained found the programme to be relevant and were able to integrate it into their routine work. There was a significant increase in mothers' knowledge and positive attitudes about infant development in the intervention group, compared with the control group. Women in the intervention group answered correctly 4.3 (95% CI 3.7-14.9, P < 0.001) more questions than the control group. There was no difference in levels of mental distress measured by the SRQ.

CONCLUSIONS

The 'Learning Through Play' programme was successfully integrated into the existing health system and accepted by community health workers. The programme succeeded in improving the knowledge and attitudes of mothers about infant development.