COVID-19 Screening for Hospitalized Patients: The Role of Expanded Hospital Surveillance in a Low Prevalence Setting

Purpose

The COVID-19 pandemic poses a serious threat to healthcare workers and hospitalized patients. Early detection of COVID-19 cases is essential to control the spread in healthcare facilities. However, real-world data on the screening criteria for hospitalized patients remain scarce. We aimed to explore whether patients with negative results of pre-hospital screening for COVID-19 should be rescreened after admission in a low-prevalence (less than 3% of the world average) setting.

Patients and Methods

We retrospectively included patients in central Taiwan who were negative at the first screening but were newly diagnosed with pneumonia or had a body temperature above 38 degrees Celsius during their hospitalization. Each patient might be included as an eligible case several times, and the proportions of cases who were rescreened for COVID-19 and those diagnosed with COVID-19 were calculated. A logistic regression model was constructed to identify factors associated with rescreening. Reverse transcription-polymerase chain reaction tests were used to confirm the diagnosis of COVID-19.

Results

A total of 3549 cases eligible for COVID-19 rescreening were included. There were 242 cases (6.8%) who received rescreening. In the multivariable analysis, cases aged 75 years or older, those with potential exposure to SARS-CoV-2, or patients visiting specific departments, such as the Cardiovascular Center and Department of Neurology, were more likely to be rescreened. None was diagnosed with COVID-19 after rescreening. There was no known cluster infection outbreak in the hospital or in the local community during the study period and in the following two months.

Conclusion

In Taiwan, a country with a low COVID-19 prevalence, it was deemed safe to rescreen only high-risk hospitalized patients. This strategy was effective and reduced unnecessary costs.

Hospitalizations and mortality by severe acute respiratory syndrome: comparison between the pre-pandemic and pandemic periods

OBJECTIVE

To analyze the characteristics and the factors associated with mortality of cases hospitalized for severe acute respiratory syndrome in a health region, in pre-pandemic and pandemic periods.

METHODS

A retrospective documentary study of epidemiological surveillance carried out with secondary data from the Influenza Epidemiological Surveillance Information System, regarding the cases of patients belonging to a health region of Minas Gerais, Brazil.

RESULTS

During the pandemic period, there was an increase in the number of hospitalizations and deaths due to severe acute respiratory syndrome, in addition to differences between sociodemographic and clinical-epidemiological characteristics. In both periods, the age and the use of invasive ventilatory support were the predictors of hospital mortality. The mortality in the pandemic period was also associated with male gender, presence of risk factors, admission to an intensive care unit, use of non-invasive ventilatory support, and infection by COVID-19.

CONCLUSIONS

In 2020, the detection rate of severe acute respiratory syndrome was 21 times higher than in 2019 and new symptoms, such as anosmia and ageusia, were included in their investigation. In both periods evaluated, elderly patients and patients on invasive mechanical ventilation had a higher risk of mortality. With the pandemic, there was a greater number of hospitalizations and factors associated with mortality.

Expression analysis of p16 and TOP2A protein biomarkers in cervical cancer lesions and their correlation with clinico-histopathological characteristics in a referral hospital, Tanzania

Introduction

Biomarkers yield important information for early diagnosis of cervical cancer. However, they are rarely applied for prognosis of cervical cancer in Tanzania, where visual inspection assay with acetic acid or Lugol’s iodine and Pap test are being used as the standard screening/ diagnostic methods.

Methods

This was a retrospective hospital-based cross-sectional study that was conducted to assess cyclin-dependent kinase inhibitor (p16) and topoisomerase II-alpha (TOP2A) proteins expression among women seeking cervical cancer care at Kilimanjaro Christian Medical Centre, Tanzania between May 1, 2017 and May 10, 2018. Immunohistochemistry technique was used to detect the expressions of p16 and TOP2A proteins from the retrieved formalin-fixed and paraffin-embedded (FFPE) cervical biopsies.

Results

A total of 145 patients, with a mean age of 52.1 ± 12.9 years, were included in this study. Upon immunohistochemistry staining, 103 (71.0%) and 90 (62.1%) were p16 and TOP2A positive respectively. There was a strong association between histopathological class and p16/TOP2A expression levels (Fisher’s exact test, p<0.001). Moreover, there was a strong positive correlation between p16/TOP2A and cancerous cervical lesions (Spearman’s rank correlation coefficients = 0.833 and 0.687, p = 0.006 and 0.005, respectively). The age-adjusted odds ratio for predicting cervical cancer lesions were independently significant for p16/TOP2A biomarkers in FFPE cervical tissues [p16: OR = 1.142 (95% CI: 1.059–1.232, p<0.001) and TOP2A: OR = 1.046 (95% CI: 1.008–1.085, p = 0.015)]. Importantly, the diagnostic performance of p16 was higher than that of TOP2A in the diagnosis of cancerous lesions from non-cancerous cervical lesions (sensitivity: 97.2% versus 77.6%, accuracy: 92.8% versus 87.8%, respectively).

Conclusion

Our study has highlighted that over-expression of TOP2A is related to the grade of cervical intraepithelial neoplasia but does not predict prognosis in cervical cancer. Similarly, expression of p16 is related to degree of histological dysplasia and malignancy, suggesting its prognostic and predictive value in the management of cervical cancers. Further bigger studies are needed to validate their applications in the early diagnosis of cervical cancer.

Chagas disease and SARS-CoV-2 coinfection does not lead to worse in-hospital outcomes

Chagas disease (CD) continues to be a major public health burden in Latina America. Information on the interplay between COVID-19 and CD is lacking. Our aim was to assess clinical characteristics and in-hospital outcomes of patients with CD and COVID-19, and to compare it to non-CD patients. Consecutive patients with confirmed COVID-19 were included from March to September 2020. Genetic matching for sex, age, hypertension, diabetes mellitus and hospital was performed in a 4:1 ratio. Of the 7018 patients who had confirmed COVID-19, 31 patients with CD and 124 matched controls were included (median age 72 (64-80) years-old, 44.5% were male). At baseline, heart failure (25.8% vs. 9.7%) and atrial fibrillation (29.0% vs. 5.6%) were more frequent in CD patients than in the controls (p < 0.05). C-reactive protein levels were lower in CD patients compared with the controls (55.5 [35.7, 85.0] vs. 94.3 [50.7, 167.5] mg/dL). In-hospital management, outcomes and complications were similar between the groups. In this large Brazilian COVID-19 Registry, CD patients had a higher prevalence of atrial fibrillation and chronic heart failure compared with non-CD controls, with no differences in-hospital outcomes. The lower C-reactive protein levels in CD patients require further investigation.

Clinical characteristics and outcomes of hospitalized patients with SARS-CoV-2 infection in a Latin American country: Results from the ECCOVID multicenter prospective study

BACKGROUND

Clinical features and outcomes of SARS-CoV-2 infections diverge in different countries. The aim of this study was to describe clinical characteristics and outcomes in a cohort of patients hospitalized with SARS-CoV-2 in Argentina.

METHODS

Multicenter prospective cohort study of ≥18 years-old patients with confirmed SARS-CoV-2 infection consecutively admitted to 19 hospitals in Argentina. Multivariable logistic regression models were used to identify variables associated with 30-day mortality and admission to intensive care unit (ICU).

RESULTS

A total of 809 patients were analyzed. Median age was 53 years, 56% were males and 71% had at least one comorbidity. The most common comorbidities were hypertension (32%), obesity (23%) and diabetes (17%). Disease severity at admission was classified as mild 25%, moderate 51%, severe 17%, and critical 7%. Almost half of patients (49%) required supplemental oxygen, 18% ICU, and 12% invasive ventilation. Overall, 30-day mortality was 11%. Factors independently associated with ICU admission were male gender (OR 1.81; 95%CI 1.16-2.81), hypertension (OR 3.21; 95%CI 2.08-4.95), obesity (OR 2.38; 95%CI 1.51-3.7), oxygen saturation ≤93% (OR 6.45; 95%CI 4.20-9.92) and lymphopenia (OR 3.21; 95%CI 2.08-4.95). Factors independently associated with 30-day mortality included age ≥60 years-old (OR 2.68; 95% CI 1.63-4.43), oxygen saturation ≤93% (OR 3.19; 95%CI 1.97-5.16) and lymphopenia (OR 2.65; 95%CI 1.64-4.27).

CONCLUSIONS

This cohort validates crucial clinical data on patients hospitalized with SARS-CoV-2 in Argentina.

A snapshot of a pandemic: The interplay between social isolation and COVID-19 dynamics in Brazil

In response to the coronavirus pandemic, governments implemented social distancing, attempting to block the virus spread within territories. While it is well accepted that social isolation plays a role in epidemic control, the precise connections between mobility data indicators and epidemic dynamics are still a challenge. In this work, we investigate the dependency between a social isolation index and epidemiological metrics for several Brazilian cities. Classic statistical methods are employed to support the findings. As a first, initially surprising, result, we illustrate how there seems to be no apparent functional relationship between social isolation data and later effects on disease incidence. However, further investigations identified two regimes of successful employment of social isolation: as a preventive measure or as a remedy, albeit remedy measures require greater social isolation and bring higher burden to health systems. Additionally, we exhibit cases of successful strategies involving lockdowns and an indicator-based mobility restriction plan.

Platelets in the perspective of COVID-19; pathophysiology of thrombocytopenia and its implication as prognostic and therapeutic opportunity

Despite endorsed and exponential research to improve diagnostic and therapeutic strategies, efforts have not yet converted into a better prospect for patients infected with the novel coronavirus (2019nCoV), and still, the name of SARS-CoV-2 is coupled with numerous unanswered questions. One of these questions is concerning how this respiratory virus reduces the number of platelets (PLTs)? The results of laboratory examinations showed that about a quarter of COVID-19 cases experience thrombocytopenia, and more remarkably, about half of these patients succumb to the infection due to coagulopathy. These findings have positioned PLTs as a pillar in the management as well as stratifying COVID-19 patients; however, not all the physicians came into a consensus about the prognostic value of these cells. The current review aims to unravel the contributory role of PLTs s in COVID-19; and alsoto summarize the original data obtained from international research laboratories on the association between COVID-19 and PLT production, activation, and clearance. In addition, we provide a special focus on the prognostic value of PLTs and their related parameters in COVID-19. Questions on how SARS-CoV-2 induces thrombocytopenia are also responded to. The last section provides a general overview of the most recent PLT- or thrombocytopenia-related therapeutic approaches. In conclusion, since SARS-CoV-2 reduces the number of PLTs by eliciting different mechanisms, treatment of thrombocytopenia in COVID-19 patients is not as simple as it appears and serious cautions should be considered to deal with the problem through scrutiny awareness of the causal mechanisms.

The COVID-19 Vaccination Strategy in Brazil-A Case Study

Brazil is among the countries which have faced two devastating infection waves of COVID-19 in the past year. Despite the fact the country has one of the world's leading immunization programs, Brazil only slowly established a national COVID-19 vaccination strategy and campaign. This case study is based on an integrative review of primary and secondary literature sources. Different search strategies on Medline and Google Scholar were performed for the case presentation, for the management and outcome of the COVID-19 outbreak and for the state of the COVID-19 vaccination program. Official documents from the Brazilian Ministry of Health, the website of the World Health Organization and pharmaceutical companies were also reviewed. Searches were limited to English, French, German, Portuguese and Spanish. This article describes the Brazilian COVID-19 vaccination campaign and the drivers and barriers to its implementation; and evaluates further investigations needed to have a conclusive overview over the constantly evolving situation. Healthcare inequalities, which were widened during the pandemic, a lack of coordination at the federal level, the absence of federal government support for scientific research and the lack of endorsement and commitment to the mitigation of the COVID-19 pandemic set the country's COVID-19 vaccination campaign off to a challenging start. However, Brazil had a well-developed primary care system and national vaccination program prior to the pandemic, which are both important facilitators. At the time of writing, six vaccines are currently available in the country, and the program is advancing. The scientific community needs to continue to investigate the country's vaccination strategy and its implementation to make sure that maximum effort is undertaken for the health of the Brazilian population.

Endocrinology in the Time of COVID-19: A Rapid Evolution of Knowledge and Care

American singer-writer and visual artist Bob Dylan produced the song "The Times They Are a-Changin" in the 1960s, which became a rallying cry for the civil rights and anti-war movements in that decade [...].

Characteristics, outcomes and global trends of respiratory support in patients hospitalized with COVID-19 pneumonia: a scoping review

INTRODUCTION

To date, a shared international consensus on treatment of Coronavirus disease 2019 (COVID-19) with invasive or non-invasive respiratory support is lacking. Patients' management and outcomes, especially in severe and critical cases, can vary depending on regional standard operating procedures and local guidance.

EVIDENCE ACQUISITION

Rapid review methodology was applied to include all the studies published on PubMed and Embase between December 15th, 2019 and February 28th, 2021, reporting in-hospital and respiratory support-related mortality in adult patients hospitalized with COVID-19 that underwent either continuous positive airway pressure (CPAP), non-invasive ventilation (NIV) or invasive mechanical ventilation (IMV). Only English language studies with ≥100 patients and reporting data on respiratory failure were included. Data on comorbidities, ventilatory parameters and hospital-related complications were registered.

EVIDENCE SYNTHESIS

Fifty-two studies (287,359 patients; 57.5% males, mean age 64 years, range 24-98 years) from 17 different countries were included in the final analysis. 33.3% of patients were hospitalized in intensive care units. 44.2% had hypertension, 26.1% had diabetes, and 7.1% a chronic respiratory disease. 55% of patients underwent respiratory support (36% IMV, 62% NIV and 2% CPAP). Without considering a study with the highest number of patients treated with NIV (N.=96,729), prevalence of NIV and CPAP use was 12.5% and 13.5% respectively. Globally, invasive and non-invasive approaches were heterogeneously applied. In-hospital mortality was 33.7%, and IMV-related mortality was 72.6% (range: 4.3-99%). Specific mortality in patients treated with CPAP or NIV was available for 53% of studies, and was 29% (range: 7.2-100%). The median length of hospital stay was 13 days (range: 6-63). The most frequent hospital-related complication was acute kidney injury being reported in up to 55.7% of enrolled patients.

CONCLUSIONS

Global employment of respiratory supports and related outcomes are very heterogeneous. The most frequent respiratory support in patients with COVID-19 pneumonia is IMV, while NIV and CPAP are less frequently and equally applied, the latter especially in Europe, while data on NIV/CPAP-related mortality is often under-reported. Integrated and comprehensive reporting is desirable and needed to construct evidence-based recommendations.

ABC2-SPH risk score for in-hospital mortality in COVID-19 patients: development, external validation and comparison with other available scores

OBJECTIVES

The majority of available scores to assess mortality risk of coronavirus disease 2019 (COVID-19) patients in the emergency department have high risk of bias. Therefore, this cohort aimed to develop and validate a score at hospital admission for predicting in-hospital mortality in COVID-19 patients and to compare this score with other existing ones.

METHODS

Consecutive patients (≥ 18 years) with confirmed COVID-19 admitted to the participating hospitals were included. Logistic regression analysis was performed to develop a prediction model for in-hospital mortality, based on the 3978 patients admitted between March-July, 2020. The model was validated in the 1054 patients admitted during August-September, as well as in an external cohort of 474 Spanish patients.

RESULTS

Median (25-75th percentile) age of the model-derivation cohort was 60 (48-72) years, and in-hospital mortality was 20.3%. The validation cohorts had similar age distribution and in-hospital mortality. Seven significant variables were included in the risk score: age, blood urea nitrogen, number of comorbidities, C-reactive protein, SpO₂/FiO₂ ratio, platelet count, and heart rate. The model had high discriminatory value (AUROC 0.844, 95% CI 0.829-0.859), which was confirmed in the Brazilian (0.859 [95% CI 0.833-0.885]) and Spanish (0.894 [95% CI 0.870-0.919]) validation cohorts, and displayed better discrimination ability than other existing scores. It is implemented in a freely available online risk calculator (https://abc2sph.com/).

CONCLUSIONS

An easy-to-use rapid scoring system based on characteristics of COVID-19 patients commonly available at hospital presentation was designed and validated for early stratification of in-hospital mortality risk of patients with COVID-19.

Trends in COVID-19 case-fatality rates in Brazilian public hospitals: A longitudinal cohort of 398,063 hospital admissions from 1st March to 3rd October 2020

BACKGROUND

Almost 200,000 deaths from COVID-19 were reported in Brazil in 2020. The case fatality rate of a new infectious disease can vary by different risk factors and over time. We analysed the trends and associated factors of COVID-19 case fatality rates in Brazilian public hospital admissions during the first wave of the pandemic.

METHODS

A retrospective cohort of all COVID-19-related admissions between epidemiological weeks 10-40 in the Brazilian Public Health System (SUS) was delimited from available reimbursement records. Smoothing time series and survival analyses were conducted to evaluate the trends of hospital case fatality rates (CFR) and the probability of death according to factors such as sex, age, ethnicity, comorbidities, length of stay and ICU use.

RESULTS

With 398,063 admissions and 86,452 (21.7%) deaths, the overall age-standardized hospital CFR trend decreased throughout the period, varying from 31.8% (95%CI: 31.2 to 32.5%) in week 10 to 18.2% (95%CI: 17.6 to 18.8%) in week 40. This decreasing trend was observed in all sex, age, ethnic groups, length of stay and ICU admissions. Consistently, later admission (from July to September) was an independent protective factor. Patients 80+ year old had a hazard ratio of 8.18 (95% CI: 7.51 to 8.91). Ethnicity, comorbidities, and ICU need were also associated with the death risk. Although also decreasing, the CFR was always around 40-50% in people who needed an ICU admission.

CONCLUSIONS

The overall hospital CFR of COVID-19 has decreased in Brazilian public hospitals during the first wave of the pandemic in 2020. Nevertheless, during the entire period, the CFR was still very high, suggesting the need for improving COVID-19 hospital care in Brazil.

Efficacy of Photobiomodulation in the Treatment of Cancer Chemotherapy-Induced Oral Mucositis: A Meta-Analysis with Trial Sequential Analysis

Oral mucositis is a debilitating complication of chemotherapy, characterized by erythema, ulcers and oedema of the oral mucosa. This review aimed to evaluate the efficacy of Photobiomodulation in the treatment of oral mucositis using meta-analysis and trial sequential analysis, and also to assess the quality of the results by Grading of Recommendations, Assessment, Development and Evaluation (GRADE). A comprehensive search of three databases, including Embase, Medline and Central, was performed to identify randomized controlled trials studying the efficacy of Photobiomodulation in the treatment of cancer chemotherapy-induced oral mucositis. The primary outcome was reduction in the severity of oral mucositis. Secondary outcomes were pain relief, duration of oral mucositis and adverse effects. The meta-analysis was performed using the random-effects model, and random errors of the meta-analyses were detected by trial sequential analysis. A total of 6 randomized controlled trials with 398 participants were included in our analysis. Photobiomodulation significantly reduced the severity of oral mucositis when compared to sham radiation (RR 0.43, 95% CI 0.20 to 0.93; p < 0.05). Sensitivity analysis by excluding trials with high risk of bias reiterated the robustness of our results (RR 0.28, 95% CI 0.16 to 0.48). Trial sequential analysis illustrated that the evidence from the meta-analysis was conclusive. The result of the meta-analyses with trial sequential analysis illustrated that Photobiomodulation is an effective therapeutic intervention for the treatment of oral mucositis, and the evidence gathered can be considered conclusive with a moderate level of certainty according to GRADE. Further trials are recommended to standardize the laser parameters required for the optimal effect.

Classification of oral salivary gland tumors based on texture features in optical coherence tomography images

Currently, the diagnoses of oral diseases primarily depend on the visual recognition of experienced clinicians. It has been proven that automatic recognition based on images can support clinical decision-making by extracting and analyzing objective hidden information. In recent years, optical coherence tomography (OCT) has become a powerful optical imaging technique with the advantages of high resolution and non-invasion. In our study, a dataset composed of four kinds of oral salivary gland tumors (SGTs) was obtained from a homemade swept-source OCT, including two benign and two malignant tumors. Seventy-six texture features were extracted from OCT images to create computational models of diseases. It was demonstrated that the artificial neural network (ANN) based on principal component analysis (PCA) can obtain high diagnostic sensitivity and specificity (higher than 99%) for these four kinds of tumors. The classification accuracy of each tumor is larger than 99%. In addition, the performances of two classifiers (ANN and support vector machine) were quantitatively evaluated based on SGTs. It was proven that the texture features in OCT images provided objective information to classify oral tumors.

Safety, Precautions, and Modalities in Cancer Rehabilitation: an Updated Review

PURPOSE OF REVIEW

Providing rehabilitation to patients with cancer can be challenging due to the medical complexity associated with the illness and its treatments. This article provides the reader with a summary of frequently encountered medical conditions in the cancer population and associated safety considerations and precautions. An update on treatment modalities commonly used for symptom management is also presented.

RECENT FINDINGS

Cancer and cancer treatments can cause changes in multiple organ systems. Special considerations and precautions are necessary to provide safe and effective rehabilitation. Physical modalities can be used as monotherapy or adjunct to treatment for common cancer-related side effects with recent studies noting benefit with a variety of modalities.

SUMMARY

Detailed assessment of the cancer patient is necessary before implementing a rehabilitation program. Understanding cancer and side effects of treatments, including newer options, are necessary to provide safe care.

Chemotherapy drugs and inflammatory cytokines enhance matrix metalloproteinases expression by oral mucosa cells

OBJECTIVE

Oral mucositis (OM), the most common side effect of cancer therapy, is associated with pro-inflammatory cytokines and matrix metalloproteinases (MMPs) increased expression. Although there are approaches for OM management, none is infallible, thus, elucidation of molecular events related to OM etiopathogenesis may improve current therapeutic strategies. This study assessed the influence of pro-inflammatory cytokines and chemotherapy drugs on MMPs expression and synthesis by oral mucosa cells.

DESIGN

Human gingival fibroblasts (HGF) were exposed to different concentrations of methotrexate (MTX) and 5-fluorouracil (5-FU); subsequentially, cell viability, nitric oxide and interleukin(IL)-6 production were evaluated to select the concentration of these drugs that could stimulate inflammatory phenotype without cytotoxic effects. Then, HGF and primary gingival keratinocytes (PGK) were subjected to different stimuli: culture medium (negative control), tumor necrosis factor-alpha (TNF-α - positive control), IL-6, IL-8, MTX, and 5-FU for 3, 6, 12, and 24 h. Next, gene expression and synthesis of MMP-2 and MMP-9 by HGF and MMP-3 by PGK were assessed.

RESULTS

At 6 h, MMP-2 synthesis increased 60 % after exposure to TNF-α and MTX, 40 % after IL-6, and 15 % after IL-8. At 12 h, MMP-9 synthesis increased 15 % after exposure to TNF-α, while MMP-3 synthesis increased 30 % after TNF-α, and 10 % after IL-8. TNF-α-treated groups presented increased gene expression of all MMPs evaluated. IL-8 and 5-FU increased MMP-2 and MMP-3 expression, while IL-6 and MTX augmented MMP-2 expression.

CONCLUSIONS

The chemotherapy drugs and cytokines investigated up-regulated MMPs expression by oral mucosa cells, which may lead to OM establishment and severity.

A rare case of a necrotized urethral prolapse in a postmenopausal woman with acute urinary retention

CASE

Urethral prolapse (UP) is a rare condition with unknown etiology. We reported on an 86-year-old woman with a normal BMI and cystocele, presented with acute urinary retention and perineal pain. A residual urine of 950 mL was measured and released by an indwelling catheter. The physical examination revealed 2 × 3 cm severely sore and purple polyp around the urethral meatus with signs of necrosis. A diagnosis of a strangulated urethral prolapse was stated.

OUTCOME

The patient was admitted to the Department of Urology, and treated with surgical excision using the four-quadrant excisional technique. The histopathological examination revealed a non-keratinized, inflammatory squamous epithelium. At a follow-up visit, the patient remained asymptomatic and a complete anatomical resolution was achieved.

CONCLUSION

UP is an uncommon, sometimes misdiagnosed condition. The management is controversial and to date no consensus exists. This clinical picture is sufficient for diagnosis and surgical excision of the prolapsed urethral mucosa is reasonable if there are signs of strangulation.

The Economic Impact of COVID-19 Treatment at a Hospital-level: Investment and Financial Registers of Brazilian Hospitals

Background: The economic impact associated with the treatment strategies of coronavirus disease-2019 (COVID-19) patients by hospitals and health-care systems in Brazil is unknown and difficult to estimate. This research describes the investments made to absorb the demand for treatment and the changes in occupation rates and billing in Brazilian hospitals. Methods: This research covers the initial findings of "COVID-19 hospital costs and the proposition of a bundled reimbursement strategy for the health-care system," which includes 10 hospitals. The chief financial officer, the chief medical officer, and hospital executives of each participating hospital provided information regarding investments attributed to COVID-19 patient treatment. The analysis included variations in occupation rates and billing from 2019 to 2020 observed in each institution, and the investments for medical equipment, individual protection materials and building construction per patient treated. Results: The majority of hospitals registered a decrease in hospitalization rates and revenue from 2019 to 2020. For intensive care units (ICUs), the mean occupancy rate ranged from 88% to 83%, and for wards, it ranged from 85% to 73%. Monthly average revenue decreased by 10%. The mean hospital investment per COVID-19 inpatient was I$6800 (standard deviation 7664), with the purchase of ventilators as the most common investment. For this item, the mean, highest and lowest acquisition cost per ventilator were, respectively, I$31 468, I$48 881 and I$17 777. Conclusion: There was significant variability in acquisition costs and investments by institution for responding to the COVID-19 pandemic. These findings highlight the importance of continuing microeconomic studies for a comprehensive assessment of hospital costs. Only with more detailed analyses, will it be possible to define and drive sustainable strategies to manage and reimburse COVID-19 treatment in health-care systems.

Incidence and risk factors for oral mucositis in pediatric patients receiving chemotherapy

PURPOSE

To investigate the incidence and risk factors for oral mucositis (OM) in patients with childhood cancer undergoing chemotherapy.

METHODS

Eight hundred and twenty-nine cycles of chemotherapy were evaluated in 112 patients with childhood cancer undergoing chemotherapy. Chemotherapy protocol, hematological, hepatic, and renal function parameters were collected and compared to presence and severity of OM, as graded by the World Health Organization (WHO) scale. Patients received counseling on oral hygiene and those who presented with OM (grade ≥1) received photobiomodulation therapy (PBMT).

RESULTS

Age ranged from 0 to 17 years (mean/SD, 8.58 ± 5.05) and fifty-one patients (45.54%) were females. The most common baseline diseases were leukemia (51%) followed by sarcomas (23%) and lymphomas (18%). Eight hundred and twenty-nine cycles of chemotherapy were evaluated, and OM was diagnosed in 527 cycles (63.57%). Higher incidence and severity of OM was observed in protocols using high-dose methotrexate (MTX-HD), MTX-HD cyclophosphamide/doxorubicin combination, and MTX-HD combined with cyclophosphamide (p <0.001). Patients with severe OM had lower levels of leukocytes (p = 0.003), hemoglobin (p = 0.005), platelets (p = 0.034), and higher levels of total bilirubin (p = 0.027), alanine aminotransferase (ALT) (p = 0.001), and creatinine (p = 0.007).

CONCLUSION

The study contributes to the elucidation of the risk factors for OM in pediatric cancer patients. Chemotherapy protocols using MTX-HD, MTX-HD associated with doxorubicin and cyclophosphamide, and MTX-HD and cyclophosphamide a have higher incidence of severe grades of OM. Other toxicities such as hematological, hepatic, and renal also developed in patients with OM.

Oral mucositis in childhood cancer patients receiving high-dose methotrexate: Prevalence, relationship with other toxicities and methotrexate elimination

BACKGROUND

Oral mucositis (OM) is one of the main adverse effects of the chemotherapeutic agent methotrexate (MTX).

AIM

To evaluate the relationship of OM with MTX metabolism time and other toxicities in childhood, cancer patients receiving high-dose of methotrexate (HD-MTX).

DESIGN

Seventy-seven childhood patients receiving HD-MTX for treatment of leukaemia, osteosarcoma or lymphoma were evaluated. MTX serum level, hepatic and renal function parameters, and presence and intensity of OM were analysed.

RESULTS

The patients were submitted to 255 cycles of chemotherapy. OM was diagnosed in 191 (74.9%) cycles. Of these, 119 (46.6%) presented ulcerative lesions. Lymphoma was associated with severe OM (P = .01). OM was associated with higher serum levels of aspartate aminotransferase (P = .006), alanine aminotransferase (P = .04) and creatinine (P = .008). Increase of one unit of total bilirubin and indirect bilirubin associated, respectively, with 11% and 39% higher prevalence of OM. For each increase of one unit of creatinine serum level, it was observed a 37% higher prevalence of OM in patients with lymphoma. No association was found between delayed excretion of MTX and OM development.

CONCLUSIONS

OM is a prevalent complication of childhood cancer patients receiving HD-MTX. Renal and hepatic toxicity could be considered risk factors for OM, especially in patients with lymphoma.

Use of Lasers and Piezoelectric in Intraoral Surgery

Laser therapy has been delivering good results for more than 30 years. Therapeutic effects are seen due to its ability to stimulate cell proliferation, revascularization, cell regeneration, local microcirculation, and vascular permeability; leading to edema reduction and analgesic effects. The piezoelectric system has been used in several surgeries recently, following the trend of minimally invasive surgery. The system consists of crystals undergoing deformation when exposed to electric current, resulting in an oscillating movement with ultrasound frequency. In oral surgery it is used in orthognathic and temporomandibular joint procedures, alveolar corticotomies, tumor excision, bone grafts, third molars, and dental implants.

Phototherapy With LED as an Effective Treatment for Chemotherapy-Induced Oral Mucositis in Hamsters

Introduction: Oral mucositis (OM) has been considered one of the most feared collateral effects of oncological treatments. Some therapies have been used, such as light-emitting diode (LED), with promising results, but with no sufficient evidence in the literature. Objective: Our study aimed to evaluate, by clinical and histological analysis, the effect of LED on the treatment of chemotherapy-induced OM (CIOM) in an animal model. Methods: Twenty male hamsters were equally distributed to two groups: control (C), which received anesthesia and CIOM induction; and LED (L), which received anesthesia, CIOM induction, and LED treatment (635 nm, 120 mW, 0.48 J). The clinical analysis was performed through two specific scales for OM analysis on days 5, 7 and 10 of the experiment. In addition, the injured area of all hamsters check pouch mucosa was removed and processed for histological analysis on the last experimental day. Results: After statistical analysis, group L showed less severity of OM when compared with the C group (P <0.05); beyond that, both healed completely on day 10. Conclusion: Our results suggested that the phototherapy with LED had a positive effect on accelerating repair, reducing the severity of CIOM.

Therapeutic effects of andiroba (Carapa guianensis Aubl) oil, compared to low power laser, on oral mucositis in children underwent chemotherapy: A clinical study

ETHNO-PHARMACOLOGICAL RELEVANCE

The Carapa guianensis Aubl, popularly known as andiroba, is a large tree of the Meliaceae family, commonly found in the Amazon region. The oil extracted from its seeds is recognized in traditional medicine and has high anti-inflammatory and analgesic potential, which are the basic prerequisites for a therapeutic agent that can be used in the treatment of oral mucositis (OM). Moreover, the aforementioned oil has antimicrobial, antiallergic, and parasiticidal actions and is effective in the management of cutaneous and muscular dysfunctions.

AIM OF THE STUDY

To evaluate the therapeutic effects of andiroba gel (Carapa guianensis Aubl) on the symptomatology and evolution of OM in children with leukemia who underwent chemotherapy and to compare it to the effects of low power laser.

MATERIALS AND METHODS

This randomized, double-blind clinical trial involved 60 patients of both genders with leukemia, with age ranging from six to twelve years. The patients were divided into two study groups: the andiroba group (n = 30) and the laser group (n = 30). The level of pain experienced by the patients was assessed using the Wong-Baker visual analog scale and the degree of severity of OM was assessed using a table, recommended by the World Health Organization, that depicts the degrees of severity of OM. The data obtained were analyzed using the Mann-Whitney test, with statistical significance indicated by a P value less than or equal to 0.05.

RESULTS

A statistically significant reduction in the degree of OM was observed on the fourth, fifth, and sixth days and in the pain scores on the second, third, and fourth days in the andiroba group after the manifestation of OM, compared to the laser group.

CONCLUSIONS

The use of andiroba oil effectively reduced the severity of OM and relieved pain, which resulted in a decrease in the severity of signs and symptoms in the patients in the andiroba group, compared to the laser group.

Expression of p16INK4a and human papillomavirus 16 with associated risk factors in cervical premalignant and malignant lesions

Introduction:

Human papilloma virus (HPV) which is causative factor for cervical cancer may interact with p16 leading to malignant transformation of cervical epithelial cells. The present study was conducted to assess the immunoexpression of p16 INK4a in premalignant and malignant lesions of cervix and to correlate it with HPV 16 expression. It was also intended to study the various risk factors which may be associated with cervical cancer in this north Himalayan region of India.

Material and Methods:

The study included 50 cases of premalignant and malignant cervical lesions and 50 controls diagnosed on histopathology over a period of one year. All the relevant clinical details were noted and both cases and controls were subjected to HPV 16 and p16 INK4a immunohistochemical staining.

Results:

67% of subjects (including cases and controls) and 94% of the cases were positive for HPV 16 expression. p16 INK4a expression was negative in all the controls, positive in 96% of invasive cancer, 66.6% in HSIL and 37.5% in LSIL.

Conclusion:

Cervical cancer is associated with low socio economic status, illiteracy, smoking, early age of marriage and conception in north Himalayan region of India. HPV 16 infection is positive in both cases and controls indicating high prevalence of HPV 16 in this region. Neoplastic transformation by HPV is identified by over expression of p16 INK4a in premalignant and malignant cases. The immunopositivity of p16 INK4a increases with the severity of cervical lesions and thus may play an important role in stratification of premalignant and malignant lesions.

Head and neck cancer therapy-related oral manifestation management in the COVID-19 pandemic: a critical review

With the onset of the new coronavirus disease (COVID-19) pandemic, the dental treatment of patients at risk of infection has become quite challenging. In view of this, patients with head and neck cancer may present with oral complications due to anticancer therapy, making dental assistance necessary. Thus, the objective of the study was to review the literature and critically discuss important concerns about the treatment of patients with head and neck cancer during the COVID-19 pandemic. Because dental professionals are in close contact with the main viral transmission routes, this study presents recommendations for management and protection during clinical dental care. The main characteristics and transmission routes of COVID-19 are also discussed. Dental professionals should control pain and the side effects of antineoplastic treatment and use preventive measures for infection control. During this pandemic, patients with head and neck cancer should not undergo elective procedures, even if they do not have symptoms or a history of COVID-19; therefore, in asymptomatic or painless cases, only preventive actions are recommended. In symptomatic or painful cases, precautions for safe interventional treatments must be implemented by following the hygiene measures recommended by health agencies and using personal protective equipment. During health crises, new protocols emerge for cancer treatment, and professionals must act with greater attention toward biosafety and updated knowledge. It is important to offer adequate individualized treatment based on the recommendations of preventative and interventional treatments so that patients can face this difficult period with optimized quality of life.

Photo-Biomodulation as a Prevention Modality of Oral Mucositis in Patients Undergoing Allogeneic Hematopoietic Stem Cell Transplantation

The aim of the study was to observe the effectiveness of a photo-biomodulation (PBM) protocol for the prevention of oral mucositis (OM) in patients undergoing allogeneic hematopoietic stem cell transplantation (aHSCT). A case-control study was conducted on 40 patients undergoing aHSCT. The patients were divided into two groups; the preventive group (PG) included 20 patients (7 females and 13 males) who were subjected to intra-oral PBM for five sessions a week, starting one day before the conditioning regimen and continuing until the 10th day after transplantation (D+10). In each session, ten points on the at-risk mucosal surfaces were irradiated using a double diode laser that emits two wavelengths simultaneously at 650 nm and at 904–910 nm with the following parameters at each point: energy of 4 J, and power of 88.9 mW. The control group (CG) included 20 patients (10 females and 10 males) who were not subjected to laser therapy and were selected retrospectively to compare the obtained results. For all patients, OM was assessed by the World Health Organization (WHO) grading scale. Eight patients in the PG did not experience OM during their hospitalization period (with grade 0). Severe OM was observed in 40% of the patients in the PG, while in the CG, severe OM was shown in 85% of the patients. The mean duration of OM in the PG was significantly lower than that of CG (4.7 days in the PG and 15 days in the CG) (p < 0.001). The study demonstrated that the preventive PBM protocol reduced the severity and duration of OM in patients undergoing aHSCT.

The Effect of Photobiomodulation on Nitrite and Inflammatory Activity in Radiotherapy-Induced Oral Mucositis: A Randomized Clinical Trial

BACKGROUND AND OBJECTIVES

To investigate pro- and anti-inflammatory cytokines and nitrite salivary levels in patients with head and neck cancer receiving photobiomodulation therapy (PBMT) associated with a Preventive Oral Care Program (POCP), for prevention and control of oral mucositis (OM) during radiotherapy (RT) associated or not with chemotherapy protocol.

STUDY DESIGN/MATERIALS AND METHODS

In this randomized double-blinded clinical trial, 48 patients were randomly assigned to two groups: PBMT (n = 25) and Control (n = 23). In the PBMT group, patients were submitted to PBMT associated with the POCP. In the Control group, patients were submitted only to the POCP. Saliva samples were collected in the 1st (baseline), 7th, 14th, 21st, and 30th sessions of RT, and the levels of interleukin-6 (IL-6), IL-8, IL-10, IL-12p70, IL-1β, and tumoral necrosis factor-α (TNF-α) were measured using the cytometric bead array. Nitrite levels were measured by colorimetric method. OM was assessed using the World Health Organization and the National Cancer Institute scales.

RESULTS

Patients in the PBMT group presented less severe OM. PBMT tended to stabilize nitrite concentration levels during the RT regimen. The IL-1β concentration was associated with higher OM scores. PBMT promoted an increase in IL-12p70, TNF-α, and IL-10 concentration.

CONCLUSION

PBMT was effective in the prevention and control of severe OM, and its mechanism of action may be related to a better balance of inflammatory response that may favor injury control. Lasers Surg. Med. © 2020 Wiley Periodicals LLC.

Nutritional problems and their non-pharmacological treatment in adults undergoing haematopoietic stem cell transplantation-A systematic review

Objective

This systematic review aimed to identify the most relevant problems related to malnutrition in adult patients undergoing haematopoietic stem cell transplantation (HSCT) and to identify non‐pharmacological interventions to treat these problems.

Methods

A systematic search for each research question was performed in MEDLINE, CINAHL, Embase, the Cochrane Library, Google Scholar and reference lists in the period 2009–2019.

Results

Six and nine studies were included respectively. Quantitative pooling of data was not possible due to the heterogeneity of the studies. Oral mucositis (OM), nausea/vomiting, diarrhoea and dysgeusia were the most frequently reported nutritional problems. Cryotherapy and laser therapy seem to be effective in the prevention and treatment of OM. Recommendations for or against the use of mouth rinses and light therapy in the treatment of OM cannot be made, as too few studies have been conducted in this area. The evidence for non‐pharmacological treatment options in the case of nausea/vomiting and diarrhoea is rather limited. No study was identified with regard to treatment of dysgeusia.

Conclusion

Nutrition in HSCT patients has not yet been studied to a satisfactory extent. There is an urgent need for high‐quality studies to be conducted in this area to optimise the care of patients undergoing haematopoietic stem cell transplantation.

Radiation-Induced Oral Mucositis in Head and Neck Cancer Patients. Five Years Literature Review

Backround: Radiation-induced oral mucositis consists of a series of relatively frequent side effects after head and neck cancer radiotherapy and has an adverse impact on both regular treatment process and the quality of life of patients.

OBJECTIVE

The purpose of the present review is to optimize the current management of radiation-induced oral mucositis in head and neck cancer patients.

METHODS

PubMed database research was performed on articles published since 2015 that demonstrated efficacy in the management of radiation-induced oral mucositis in head and neck cancer patients. The study selection included observational, prospective, comparative, randomized, double- blind, placebo-controlled or uncontrolled, and retrospective studies, as well as systematic reviews and metanalyses.

RESULTS

From the 931 citations obtained from the search, only 94 articles met the inclusion criteria, including mucosal protectants, anti-inflammatory agents, growth factors, and various miscellaneous and natural agents. Several methods, including both pharmacological and natural agents, have been proposed for the management of oral mucositis. In addition to the already known interventions with strong evidence, according to the Multinational Association of Supportive Care in Cancer and he International Society of Oral Oncology guidelines, further agents have been used. However, a great number of them lack clear evidence, which surely requires the design of more controlled clinical trials for a better assessment of the ideal methods.

CONCLUSION

The management of oral mucositis constitutes an active area of research. In light of these results, it is aimed to illustrate those treatment strategies that are most effective regarding the treatment approach of oral mucositis.

Oral mucositis among Chinese cancer patients receiving chemotherapy: Effects and management strategies

Oral mucositis is a painful and distressing complication of chemotherapy-induced toxicity in cancer patients that can develop early during the treatment regimen. Previous studies have demonstrated that both oxidative stress and inflammation play a role in the development of the ulceration that is a characteristic of oral mucositis. To date, a few studies have investigated the effect of this complication on the well-being of patients, demonstrating its negative impact on patients' functional ability and quality of life. This effect may entail chemotherapeutic drug dose reduction among patients, in turn reducing their cancer survival rates. Therefore, interventions to address the detrimental effects of oral mucositis on the well-being of cancer patients are required. This review provides an overview of the studies that have examined the negative effects of oral mucositis on Chinese cancer patients undergoing chemotherapy, as well as the interventions shown to be effective in treating this complication, with a focus on interventions utilizing traditional Chinese medicine. Overall, both traditional Chinese medicine-based interventions and interventions involving patient education about effective oral care led by trained nurses were found to be useful in reducing the incidence and severity of oral mucositis among Chinese patients undergoing chemotherapy. Future oral mucositis management plans aiming at effective oral care among cancer patients undergoing chemotherapy should incorporate these types of interventions as integral components to enhance the well-being of these patients.

Photobiomodulation Therapy in Oral Mucositis and Potentially Malignant Oral Lesions: A Therapy Towards the Future

Photobiomodulation therapy (PBMT) is an effective treatment modality, which has the significant advantage of enhancing a patient’s quality of life (QoL) by minimising the side effects of oral cancer treatments, as well as assisting in the management of potentially cancerous lesions. It is important to note that the major evidence-based documentation neither considers, nor tackles, the issues related to the impact of PBMT on tumour progression and on the downregulation of cellular proliferation improvement, by identifying the dose- and time-dependency. Moreover, little is known about the risk of this therapy and its safety when it is applied to the tumour, or the impact on the factor of QoL. The review aimed to address the benefits and limitations of PBMT in premalignant oral lesions, as well as the conflicting evidence concerning the relationship between tumour cell proliferation and the applied dose of photonic energy (fluence) in treating oral mucositis induced by head and neck cancer (H&N) treatments. The objective was to appraise the current concept of PBMT safety in the long-term, along with its latent impact on tumour reaction. This review highlighted the gap in the literature and broaden the knowledge of the current clinical evidence-based practice, and effectiveness, of PBMT in H&N oncology patients. As a result, the authors concluded that PBMT is a promising treatment modality. However, due to the heterogeneity of our data, it needs to undergo further testing in well-designed, long-term and randomised controlled trial studies, to evaluate it with diligent and impartial outcomes, and ensure laser irradiation’s safety at the tumour site.

Radiotherapy-induced oral morbidities in head and neck cancer patients

The cumulative effect of radiation and the extent of related morbidities on oral tissues are enormous and increase over time. The numerous radiation-related side effects have a strong, negative influence on the oral functions and are responsible for a drastic reduction in the oral-health-related quality of life of the cancer survivors. In a significant deviation to the earlier approach of advising extraction of all remaining teeth before RT, the concept of preserving a maximum number of teeth in a state of health and for better oral functions postcancer cure has been globally accepted and is adhered to. The effects of radiation and their impact on the general well-being of the patients underscore the relevance of understanding the sequelae of radiation therapy on healthy oral tissues, preexisting oral diseases and their progression, impact on oral treatment needs, limitations in performing the indicated treatment, and shortcoming in treatment outcomes. It is vital for the professionals involved in head and neck cancer care to follow a well-devised referral system for oral care before and after RT and educate patients for a life-long follow-up.

Flow Cytometry Characterization of Pluripotent Transmembrane Glycoproteins on Resident Cervix Uteri Cells in Patients Screened for Cervical Cancer

The aim of this study was to characterize both by flow cytometry analysis and immunohistochemistry cervix uteri cells of nulliparous women screened for cervical intraepithelial neoplasia (CIN) in comparison to a group without CIN by using mesenchymal stem cell-like and hematopoietic lineage markers. A significant expression for CD29, CD38, HLA-I, and HLA-II was correlated positively to the CIN degree and it was more relevant in patients positive for human papilloma virus (HPV). Thus, identification and detailed characterization of pluripotent resident in uteri cells could be a promising therapeutic target.

Herb medicine for relieving radiation induced oral mucositis: A systematic review and meta-analysis protocol

BACKGROUND

Oral mucositis (OM) is a common and unavoidable side effect in patients suffering from head and neck cancer who are undergoing radiotherapy. It is characterized by unbearable pain, as well as eating and speech disorders. This has serious negative effects on the patients' quality of life and can even reduce radiotherapy tolerance, ultimately resulting in a poor prognosis. At present, many prevention and treatment methods are still in the experimental stage, and the efficacies are controversial.

METHODS

Four English databases: Medline via pubmed, EMBASE, the Cochrane Library, Web of Science and another 4 Chinese databases: China National Knowledge Infrastructure (CNKI), China Science and Technology Journal database (VIP), Wanfang Database and CBM, will be searched from inception to August 2019. All randomized controlled trials in Chinese and English language will be included. Literature selection, data extraction and quality assessment will be completed by 2 independent authors. The primary outcomes will include the incidence of OM (1-4 grade) and the pain degree. The onset time of OM, the improvement rate for quality of life, and any adverse effects will be evaluated as the secondary outcomes. The data will be synthesized by Review Manager and Stata software.

RESULTS

This study provides a high-quality synthesis from existing evidence for Chinese herbal medicine in radiotherapy induced OM treatment, according to the criteria: incidence of OM, onset time of OM, status changes in quality of life and adverse events.

CONCLUSION

This study will provide evidence to help determine whether Chinese herbal medicine is effective and safe for use in the prevention and/or treatment of radiotherapy induced OM.

ETHICS AND DISSEMINATION

No additional formal ethical recognition or informed consent is required since no primary data collection is involved. The study result will be published in peer-reviewed journals or at related conferences.PROSPERO registration number: PROSPERO CRD42019141900.

Urethral Prolapse: A Case Series and Literature Review

Introduction and Hypothesis

Urethral mucosal prolapse is most frequently seen in children and postmenopausal women, and extremely rare in young adult patients. In this context, we aim to describe our experience with this condition and compare our findings with the literature.

Methods

We reviewed the medical records of our outpatient micturition disorders clinic (between August 2014 and April 2017) for patients with a diagnosis of urethral mucosal prolapse, seeking to evaluate their demographic characteristics, presenting complaints, treatment, and outcomes.

Results

We found 12 cases of urethral mucosal prolapse, including a mother and daughter and a reproductive-aged patient. Presenting symptoms included bleeding, urinary retention, partially thrombosed mucosa, and pain. Misdiagnosis was common and caused treatment delay, even in some very symptomatic patients.

Conclusion

Urethral mucosal prolapse is a readily diagnosed condition and often associated with complications in our series. Proper diagnosis is key to successful, timely treatment. Descriptive studies such as this are important to raise awareness of this diagnosis and improve patient care.

REVASCULARIZAÇÃO MIOCÁRDICA: REFERÊNCIA E CONTRARREFERÊNCIA DO PACIENTE EM UMA INSTITUIÇÃO HOSPITALAR

RESUMO Objetivo: compreender o processo de referência e contrarreferência vivenciado pelo paciente com coronariopatia submetido à cirurgia de revascularização do miocárdio. Métodos: pesquisa qualitativa, ancorada na Teoria Fundamentada nos Dados. O cenário da pesquisa foi uma instituição hospitalar pública, referência em atendimento cardiovascular no Estado de Santa Catarina (Brasil). A coleta de dados ocorreu entre março de 2013 a junho de 2014, por meio de entrevista semiestruturada envolvendo 21 participantes, distribuídos em três grupos amostrais (pacientes, profissionais de saúde e profissionais gestores). Resultados: o processo de referência e contrarreferência aponta o fenômeno “Emergindo a alta complexidade como referência para a pessoa submetida à revascularização miocárdica diante da fragilidade da Atenção Primária à Saúde no acompanhamento e articulação com os demais níveis de atenção no Sistema Único de Saúde”, sustentado por cinco categorias. Conclusão: para que a referência aconteça há necessidade de consolidar o vínculo do paciente com coronariopatia com a atenção primária à saúde, uma vez que este encontra dificuldades no acompanhamento da sua condição na rede pública. Na contrarreferência evidenciou-se a desarticulação entre os serviços de atenção à saúde, a qual afeta o cuidado à pessoa submetida à revascularização miocárdica na manutenção da sua qualidade de vida.

In situ expressions of protein 16 (p16CDKN2A) and transforming growth factor beta-1 in patients with cervical intraepithelial neoplasia and cervical cancer

OBJECTIVES

Protein 16 (p16^CDKN2A) and transforming growth factor-beta 1 (TGF- β1) are important tumor suppressor molecules. The aim of this study was to evaluate the frequency and simultaneous expression of p16^CDKN2A and TGF- β1 in cervical intraepithelial neoplasia (CIN) and cervical cancer and their relationship whit the neoplasia progression.

STUDY DESIGN

To evaluate the expressions of p16^CDKN2A and TGF- β1 an immunohistochemical study of both proteins in 75 cervical tissues (24 CIN I, 17 CIN II, 15 CIN III and 19 squamous cell cancer) was performed.

RESULTS

Increased expression of epithelial and stromal p16^CDKN2A in all grades of CIN and cancer was observed. Healthy controls were negative. The frequency of p16^CDKN2A expression in the patients was as follow: 75% in CIN I and 100% in CIN II, CIN III and cancer. TGF- β1 expression was found increased in all patients with CIN I and CIN II and decreased in CIN III and cancer; 60% of patients with CIN III and 16% with cancer showed reactivity for TGF- β1. High intensity of p16^CDKN2A reactivity and low intensity of TGF- β1 reactivity were observed.

CONCLUSIONS

The linear frequency of p16^CDKN2A expression accompanied by decreased frequency of TGF- β1 in CIN III and cancer could be involved in the neoplasia progression.

The Value of a Novel Panel of Cervical Cancer Biomarkers for Triage of HPV Positive Patients and for Detecting Disease Progression

In the era of primary vaccination against HPV and at the beginning of the low prevalence of cervical lesions, introduction of screening methods that can distinguish between low- and high-grade lesions is necessary in order to maintain the positive predictive value of screening. This case-control study included 562 women who attended cervical screening or were referred for colposcopy and 140 disease free controls, confirmed by histology and/or cytology. The cases were stratified by age. Using routine exfoliated liquid based cytological samples RT-PCR measurements of biomarker genes, high-risk HPV testing and liquid based cytology were performed and used to evaluate different testing protocols including sets of genes/tests with different test cut-offs for the diagnostic panels. Three new panels of cellular biomarkers for improved triage of hrHPV positive women (diagnostic panel) and for prognostic assessment of CIN lesions were proposed. The diagnostic panel (PIK3AP1, TP63 and DSG3) has the potential to distinguish cytologically normal hrHPV+ women from hrHPV+ women with CIN2+. The prognostic gene panels (KRT78, MUC5AC, BPIFB1 and CXCL13, TP63, DSG3) have the ability to differentiate hrHPV+ CIN1 and carcinoma cases. The diagnostic triage panel showed good likelihood ratios for all age groups. The panel showed age-unrelated performance and even better diagnostic value under age 30, a unique feature among the established cervical triage tests. The prognostic gene-panels demonstrated good discriminatory power and oncogenic, anti-oncogenic grouping of genes. The study highlights the potential for the gene expression panels to be used for diagnostic triage and lesion prognostics in cervical cancer screening.

A Case of Strangulated Urethral Prolapse in a Premenopausal Adult Female

Urethral prolapse in a premenopausal adult female is exceedingly rare. This paper describes a case of strangulated urethral prolapse presenting as a urethral mass in an unusual demographic and reviews the literature on etiology and management. Only a few cases have occurred in women of reproductive age. The etiology is likely multifactorial. Treatment with surgical excision provides good results in the majority of cases.

Multivariate analysis of risk factors for the persistence of high-grade squamous intraepithelial lesions following loop electrosurgical excision procedure

OBJECTIVE

To evaluate risk factors related to the persistence of high-grade squamous intraepithelial lesions (HSILs) following loop electrosurgical excision procedure (LEEP).

METHODS

The present prospective, observational study evaluated a convenience sample of participants with HSILs who were treated using LEEP between January 7, 2003 and December 30, 2011. Participants were evaluated 6months and 1year after treatment. Potential risk factors included in multivariate analyses were HIV co-infection, involved margins, multicentric lesions, smoking, and use of hormonal contraception.

RESULTS

The present study enrolled 307 participants. At 1year, 250 (81.4%) participants were free from lesions, 30 (9.8%) had low-grade squamous intraepithelial lesions, 26 (8.5%) had persistent HSILs, and 1 (0.3%) had developed invasive carcinoma. The risk of lesions persisting at 1year after LEEP was increased by HIV infection (P=0.003), involved margins (P=0.05), and smoking (P=0.02). The presence of multicentric lesions (P=0.73) and the use of hormonal contraception (P=0.99) did not increase the risk of lesion persistence. The risk of HSIL persistence was increased by the presence of involved margins (relative risk 3.25; 95% confidence interval 1.55-6.80; P=0.001).

CONCLUSIONS

The presence of involved margins was the only variable that increased the risk of HSIL persistence after LEEP, increasing the risk of patients requiring further treatment.

p16 staining has limited value in predicting the outcome of histological low-grade squamous intraepithelial lesions of the cervix

In order to evaluate the usefulness of p16 staining in predicting the outcome of histological low-grade squamous intraepithelial lesion/cervical intraepithelial neoplasia grade 1 (LSIL/CIN1) we prospectively recruited all the patients referred to colposcopy from 2003 to 2011 due to abnormal screening test results and diagnosed with LSIL/CIN1 at biopsy (n=507). All biopsies were stained for p16 and re-evaluated after three years by the same gynecological pathologist using the LAST criteria. Follow-up was conducted every 6 months and included a Pap test (liquid-based cytology), high-risk human papillomavirus testing (Hybrid Capture 2 test), and colposcopy. The mean follow-up was 28 months. An outcome diagnosis of HSIL was defined as a histological diagnosis of high-grade SIL/CIN (HSIL/CIN2-3). The diagnosis of LSIL/CIN1 was confirmed in 416 out of 507 biopsies (82%), whereas 58 (11%) were reclassified as negative and 33 (6%) as HSIL/CIN2-3. During follow-up, 86/507 women initially diagnosed with LSIL/CIN1 (17%) showed an outcome diagnosis of HSIL/CIN2-3, with the rate of HSIL final diagnosis of 3% (2/58) in the women with biopsies reclassified as negative, 17% (70/416) in the group with confirmed LSIL and 42% (14/33) in the women with biopsies reclassified as HSIL (P<0.001). p16 was positive in 245/507 patients (48%) and in 210/416 patients (50%) with confirmed LSIL/CIN1 at re-evaluation. Although positive p16 immunostaining was associated with risk of HSIL/CIN2-3 outcome in the multivariate analysis (Hazard ratio (HR) 1.9; 95% confidence interval (CI): 1.2-3.1; P=0.009) in the overall group of patients with LSIL/CIN1, this association was not verified in the subset of patients with confirmed LSIL/CIN1 after re-evaluation (HR: 1.6; 95% CI: 0.9-2.6; P=0.095). In conclusion, in LSIL/CIN1 lesions p16 should be limited to equivocal cases in which HSIL/CIN2 is included in the differential diagnosis since it has low value in clinical practice as a marker of progression of LSIL/CIN1.

p16INK4A expression in squamous cell carcinomas of the vagina and the vulva in Tunisian women

BACKGROUND

The role of p16INK4A expression in uterine cervix cancer is well established. In the remaining female lower genital tract cancers, the importance of p16INK4A up-regulation is less clear. In our study, we analyzed the role of p16INK4A expression and HPV infection in carcinomas of the vulva and the vagina in Tunisian women.

MATERIALS AND METHODS

We conducted a retrospective study of 30 carcinomas including 15 vulvar squamous cell carcinomas (SCCs) and 15 vaginal SCCs. Immunohistochemistry was used to determine p16INK4A expression. HPV detection and typing was by in situ hybridization.

RESULTS

p16INK4A expression was detected in 86.7% of vaginal SCCs with a strong and diffuse immunostaining in 60% of cases, and also in 73.3% of vulvar SCCs with focal immunoreactivity in 53.3% The association between p16INK4A expression and HPV infection was significant in vaginal SCCs (p=0.001) but not vulvar SCCs (p>0.05).

CONCLUSIONS

p16INK4A expression could be used as a useful marker for HPV positivity in vaginal SCCs similar to that described in uterine cervix cancers. However, our data support the presence of 2 different mechanisms for p16INK4A expression in HPV-related and HPV-unrelated vulvar carcinomas.

Clinical Role of the Detection of Human Telomerase RNA Component Gene Amplification by Fluorescence in situ Hybridization on Liquid-Based Cervical Samples: Comparison with Human Papillomavirus-DNA Testing and Histopathology

OBJECTIVE

This study was designed to evaluate whether the adjunct of human telomerase RNA component (hTERC) fluorescence in situ hybridization (FISH) analysis to cytological diagnosis and human papillomavirus (HPV)-DNA testing may serve as a predictive marker for distinguishing cervical lesions destined to regress from those at high risk of progression towards invasive cancer.

STUDY DESIGN

hTERC FISH analysis was performed on 54 residual liquid-based cytology specimens obtained from women referred to colposcopy for the detection of atypical squamous cells of undetermined significance or worse (ASCUS+) lesions. Histological diagnosis was considered the gold standard and cervical intraepithelial neoplasia of grade 2 or worse (CIN2+) as the worst outcome.

RESULTS

Oncogenic HPV-DNA was found in 96.3% of the specimens. Among these, 38.5% revealed a CIN2+ diagnosis. hTERC gene amplification was detected in 37% of the cases; among these, 70% showed up as CIN2+. hTERC FISH analysis significantly improves the specificity and positive predictive value of HPV-DNA testing, thus differentiating patients with a CIN2+ diagnosis from those with a CIN2- diagnosis.

CONCLUSIONS

Despite the limitation of a small study sample, our findings provide promising data, indicating the possible role of hTERC analysis in the assessment of the risk of developing cervical cancer. This approach would implement the specificity of DNA testing, avoiding overtreatment at the same time. Prospective follow-up studies are needed with the aim of introducing hTERC FISH into decision-making algorithms.

Antitumour potential of BPT: a dual inhibitor of cdk4 and tubulin polymerization

The marine natural product fascaplysin (1) is a potent Cdk4 (cyclin-dependent kinase 4)-specific inhibitor, but is toxic to all cell types possibly because of its DNA-intercalating properties. Through the design and synthesis of numerous fascaplysin analogues, we intended to identify inhibitors of cancer cell growth with good therapeutic window with respect to normal cells. Among various non-planar tryptoline analogues prepared, N-(biphenyl-2-yl) tryptoline (BPT, 6) was identified as a potent inhibitor of cancer cell growth and free from DNA-binding properties owing to its non-planar structure. This compound was tested in over 60 protein kinase assays. It displayed inhibition of Cdk4-cyclin D1 enzyme in vitro far more potently than many other kinases including Cdk family members. Although it blocks growth of cancer cells deficient in the mitotic-spindle checkpoint at the G0/G1 phase of the cell cycle, the block occurs primarily at the G2/M phase. BPT inhibits tubulin polymerization in vitro and acts as an enhancer of tubulin depolymerization of paclitaxel-stabilized tubulin in live cells. Western blot analyses indicated that, in p53-positive cells, BPT upregulates the expression of p53, p21 and p27 proteins, whereas it downregulates the expression of cyclin B1 and Cdk1. BPT selectively kills SV40-transformed mouse embryonic hepatic cells and human fibroblasts rather than untransformed cells. BPT inhibited the growth of several human cancer cells with an IC50<1 μM. The pharmacokinetic study in BALB/c mice indicated good plasma exposure after intravenous administration. It was found to be efficacious at 1/10th the maximum-tolerated dose (1000 mg/kg) against human tumours derived from HCT-116 (colon) and NCI-H460 (lung) cells in SCID (severe-combined immunodeficient) mice models. BPT is a relatively better anticancer agent than fascaplysin with an unusual ability to block two overlapping yet crucial phases of the cell cycle, mitosis and G0/G1. Its ability to effectively halt tumour growth in human tumour-bearing mice would suggest that BPT has the potential to be a candidate for further clinical development.

p16INK4a immunohistochemical and histopathologic study of Pap test cases interpreted as HSIL without CIN2-3 identification in subsequent cervical specimens

Tissue biopsy following a pap test diagnosis of high grade squamous intraepithelial lesion (HSIL) sometimes fails to confirm the presence of a corresponding high grade cervical intraepithelial lesion (CIN 2-3), leading to confusion as to how best to manage the patient. It has been shown that these patients are still at higher risk for future detection of CIN 2-3 even if the initial biopsy fails to detect it. It has also been shown that immunohistochemical staining for p16INK4a can be reliably used as a surrogate marker for infection with high risk human papillomavirus in cervical samples, and that it can be used to enhance detection of CIN2-3 in cases where suspicion is high. To evaluate the use of p16INK4a staining in cases of HSIL which were not confirmed on initial biopsy, two pathologists rereviewed Pap and hematoxylin and eosin preparations from all such cases seen within the preceding 3 years. Immunohistochemical study for p16INK4a was performed and graded on representative sections. The results were tabulated and analyzed. Of the identified 596 HSIL Pap cases, 82% had HSIL on initial cervical specimens. Table 1 shows the 56 cases included in the study with graded and stratified p16INK4a results. On review of the p16INK4a slides, only 2 cases could be upgraded to HSIL/CIN2-3 from the original diagnosis. p16INK4a 2-3+ was expressed more frequently in cases initially interpreted on Pap as low-grade cervical lesion as compared with benign (24 of 35 cases). In the younger than 24-yr-old group p16 2-3+ reactivity was more frequent in benign and low-grade cervical lesion/CIN1 groups (benign: 3 of 5 cases, and CIN1: 6 of 8), and p16 negative reactivity was not seen. p16INK4a was graded 0-1+ more frequently in specimens interpreted as benign in the older than 25 yr olds (10 of 16 cases). The study suggests some diagnostic benefit from the use of p16INK4a immunohistochemical study on cervical specimens from women with a HSIL Pap test without HSIL/CIN2-3 on original hematoxylin and eosin review.

Internal quality control for cervical cytopathology: comparison of potential false-negatives detected at rapid prescreening and at 100% rapid review

OBJECTIVE

To evaluate the performance of rapid prescreening (RPS) and 100% rapid review (RR-100%) as internal quality control (IQC) methods assessed by outcome at colposcopy, histopathology and repeat cytopathology for cases with false-negative results on cervical cytopathology at routine screening (RS).

STUDY DESIGN

Out of 12,208 cytology smears analyzed, 900 were abnormal. Of these, 656 were identified at RS, and 244 were false-negative, with 90.2% identified at RPS and 57.4% at RR-100%. Of the 900 abnormal cases, 436 were submitted for additional testing.

RESULTS

Of the 244 women with cytopathological abnormalities identified only by the IQC methods, 114 had supplementary examinations: 35 were submitted for colposcopy, 22 for biopsy and 99 for repeat cytopathology. The sensitivity of RPS for the detection of abnormalities identified on colposcopy, histopathology and repeat cytopathology was 87.5% (95% CI 67.6-97.3), 82.4% (95% CI 56.6-96.2) and 95.7% (95% CI 85.2-99.5), respectively. The sensitivity of RR-100% was 54.2% (95% CI 32.8-74.4), 52.9% (95% CI 27.8-77.0) and 47.8% (95% CI 32.9-63.1), respectively. RPS was more sensitive than RR-100% when compared to the findings on colposcopy (p = 0.011) and repeat cytopathology (p = 0.000). When compared to colposcopy, histopathology and repeat cytopathology, the sensitivity of RS was 83.2% (95% CI 76.1-88.9), 85.7% (95% CI 78.1-91.5) and 73.3% (95% CI 66.0-79.7), respectively.

CONCLUSION

RPS performed better than RR-100% when compared to the results of colposcopy and repeat cytopathology.