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Baird P, Drinkwater K, Forrest J, Stewart AJ. The Royal College of Radiologists National Vulvar Cancer Audit. Clin Oncol (R Coll Radiol) 2024; 36:e224-e234. [PMID: 38658266 DOI: 10.1016/j.clon.2024.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 03/14/2024] [Accepted: 03/26/2024] [Indexed: 04/26/2024]
Abstract
AIMS This audit examined UK vulvar cancer practice from March 2018 to January 2019 and compared it to standards from national and international recommendations. Follow-up data collection in 2020 examined patient outcomes and toxicity. MATERIALS AND METHODS Audit standards were based on Royal College of Radiologists (RCR) guidance and published literature. A web-based questionnaire was sent to the audit leads at all cancer centres in the UK. Prospective data collection included patient demographics, tumour characteristics, radiotherapy indications, dosimetry, timelines, and follow-up data. The audit targets were 95% compliance with the RCR dose/fractionation schemes in definitive and adjuvant patients, 40% use of intensity modulated radiotherapy (IMRT), 100% of radical patients treated as category 1, and 95% use of gap compensation for category 1 patients. RESULTS 34/54 UK radiotherapy centres (63%) completed data entry for 152 patients. 23 out of 34 (68%) centres submitted follow-up data for 94 patients. One indicator exceeded the audit target: 98% of radical patients received IMRT. The indicators of RCR dose/fractionation compliance for adjuvant/definitive radiotherapy were achieved by 80%/43% for the primary, 80%/86% for elective lymph nodes, and 21%/21% for pathological lymph nodes. The use of concomitant chemotherapy with radical radiotherapy in suitable patients was achieved by 71%. Other indicators demonstrated that 78% were treated as category 1 and 27% used gap compensation. Acute toxicity was mostly related to skin, gastrointestinal, and genitourinary sites. Grade 3 and Grade 4 toxicities were seen at acceptable rates within the radical and adjuvant groups. Late toxicity was mostly grade 0. CONCLUSION This audit provides a comprehensive picture of UK practice. IMRT is widely used in the UK, and treatment-related toxicity is moderate. The dose fractionation was very heterogeneous. The designation of vulvar cancer as category 1 was not regularly followed for radical/adjuvant patients, and there was minimal gap compensation during treatment.
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Affiliation(s)
- P Baird
- Belfast Health and Social Care Trust, Belfast, UK
| | | | - J Forrest
- Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - A J Stewart
- St Luke's Cancer Centre, Royal Surrey County Hospital, Guildford, UK; University of Surrey, Guildford, UK.
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Mousavi S, Ghasemi H, Najafi M, Yekta Z, Nejadghaderi S. Incidence Trends of Vulvar Cancer in the United States: A 20-Year Population-Based Study. Cancer Rep (Hoboken) 2024; 7:e2120. [PMID: 39031816 PMCID: PMC11190582 DOI: 10.1002/cnr2.2120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 05/02/2024] [Accepted: 05/21/2024] [Indexed: 07/22/2024] Open
Abstract
BACKGROUND Despite being uncommon, vulvar cancer is a serious health concern with a 5-year relative survival rate of 71%. AIMS The objective was to investigate the incidence rates of this disease across different racial, ethnic, and histological subgroups in the United States, as well as the effects of the COVID-19 pandemic on this cancer. METHODS We used the Surveillance, Epidemiology, and End Results (SEER) 22 database. The International Classification of Diseases for Oncology Version 3 topologic code C51 was assigned for vulvar cancer. Average annual percent change (AAPC) and the pairwise comparison with the parallelism and coincidence were reported. Counts and age-adjusted incidence rates per 100 000 individuals with their corresponding 95% confidence intervals (CIs) were reported. RESULTS The age-adjusted incidence rate of vulvar cancer was 2.40 (95% CI, 2.38-2.43) over the period 2000-2019, with an AAPC of 0.80 (95% CI, 0.63-0.99). By race/ethnicity, only non-Hispanic Whites had an increasing trend over 2000-2019 (AAPC: 1.30; 95% CI, 1.07-1.54). The highest age-adjusted incidence rate of vulvar cancer in the United States was for squamous cell carcinoma (SCC). There was a significant decrease in the age-standardized incidence rate of vulvar cancer in all races/ethnicities in all age groups (AAPC: -10.15; 95% CI, -15.35 to -4.94) over 2019-2020. Also, the incidence rates and incident numbers of vulvar cancer increased with aging and peaked at the 85+ age group. CONCLUSION There was an increase in the incidence rate of vulvar cancer in all races, with a significantly increased trend in non-Hispanic White women from 2000 to 2019. SCC displayed the highest incidence rate among vulvar cancer histological types. It is recommended to conduct further research to identify the relevant risk factors of vulvar cancer in the United States.
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Affiliation(s)
- Seyed Ehsan Mousavi
- Neurosciences Research Center, Aging Research InstituteTabriz University of Medical SciencesTabrizIran
- Department of Community Medicine, Faculty of Medicine, Social Determinants of Health Research CenterTabriz University of Medical SciencesTabrizIran
| | - Hoomaan Ghasemi
- Center for Orthopedic Trans‐Disciplinary Applied ResearchTehran University of Medical SciencesTehranIran
| | - Morvarid Najafi
- Center for Orthopedic Trans‐Disciplinary Applied ResearchTehran University of Medical SciencesTehranIran
| | - Zahra Yekta
- Calaveras County Department of HealthCalaveras CountyCaliforniaUSA
| | - Seyed Aria Nejadghaderi
- HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in HealthKerman University of Medical SciencesKermanIran
- Systematic Review and Meta‐analysis Expert Group (SRMEG)Universal Scientific Education and Research Network (USERN)TehranIran
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Gazzetta S, Valent F, Sala A, Driul L, Brunelli L. Sexually transmitted infections and the HPV-related burden: evolution of Italian epidemiology and policy. Front Public Health 2024; 12:1336250. [PMID: 38560434 PMCID: PMC10978588 DOI: 10.3389/fpubh.2024.1336250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 02/26/2024] [Indexed: 04/04/2024] Open
Abstract
Sexually transmitted infections (STIs) are a major public health problem worldwide, with a high prevalence between the ages of 15 and 25 in most Western countries. High notification rates of chlamydia, gonorrhea, and syphilis are reported in the WHO European Region, with differences between countries. In Italy, the total number of STIs alerts increased by 18% from 2020 to 2021. HPV is the most common sexually transmitted infection; globally one in seven women is infected by this virus, and certain sexual behaviors are important risk factors for HPV-related cancers, particularly cervical cancer (CC), anogenital cancers and cancers of the head and neck. The burden of CC is relevant worldwide, in particular in Europe CC is the third leading cause of cancer-related deaths in women aged 15-44. This HPV-related tumor is preventable through a combined strategy of vaccination and screening for precursor lesions. In Italy, the coverage of organized screening varies from region to region and the average HPV vaccination rate is still far from the expected optimal threshold of 95% at the age of 12. To address the challenges of health promotion and HPV prevention, priority actions are needed such as: promoting education and information at every level, from schools to healthcare professionals. In Italy, education of adolescents on sexual and reproductive health, still remains critical, regionally inhomogeneous and much lower than in other European countries. Equitable measures need to be taken, and schools are an important place for health promotion activities.
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Affiliation(s)
| | - Francesca Valent
- Institute of Hygiene and Clinical Epidemiology, Friuli Centrale University Healthcare Trust, Udine, Italy
| | - Alessia Sala
- Departement of Medicine, University of Udine, Udine, Italy
| | - Lorenza Driul
- Departement of Medicine, University of Udine, Udine, Italy
- Department of Obstetrics and Gynaecology, ASUFC, Ospedale Santa Maria Della Misericordia, Udine, Italy
| | - Laura Brunelli
- Departement of Medicine, University of Udine, Udine, Italy
- Accreditation, Quality and Clinical Risk Unit, Friuli Centrale University Healthcare Trust, Udine, Italy
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Morrison J, Baldwin P, Hanna L, Andreou A, Buckley L, Durrant L, Edey K, Faruqi A, Fotopoulou C, Ganesan R, Hillaby K, Taylor A. British Gynaecological Cancer Society (BGCS) vulval cancer guidelines: An update on recommendations for practice 2023. Eur J Obstet Gynecol Reprod Biol 2024; 292:210-238. [PMID: 38043220 DOI: 10.1016/j.ejogrb.2023.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 11/10/2023] [Indexed: 12/05/2023]
Affiliation(s)
- Jo Morrison
- Department of Gynaecological Oncology, GRACE Centre, Musgrove Park Hospital, Somerset NHS Foundation Trust, Taunton TA1 5DA, UK.
| | - Peter Baldwin
- Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Louise Hanna
- Department of Oncology, Velindre Cancer Centre, Whitchurch, Cardiff CF14 2TL, UK
| | - Adrian Andreou
- Department of Radiology, Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Bath BA1 3NG, UK
| | - Lynn Buckley
- Department of Gynae-Oncology, Castle Hill Hospital, Hull University Teaching Hospitals NHS Trust, East Yorkshire HU16 5JQ, UK; Perci Health Ltd, 1 Vincent Square, London SW1P 2PN, UK. https://www.percihealth.com/
| | - Lisa Durrant
- Radiotherapy Department, Beacon Centre, Musgrove Park Hospital, Somerset NHS Foundation Trust, Taunton TA1 5DA, UK
| | - Katharine Edey
- Centre for Women's Health Royal Devon and Exeter NHS Foundation Trust, Barrack Road, Exeter EX2 5DW, UK
| | - Asma Faruqi
- Department of Cellular Pathology, The Royal London Hospital, Barts Health NHS Trust, London E1 2ES, UK
| | - Christina Fotopoulou
- Department of Cellular Pathology, The Royal London Hospital, Barts Health NHS Trust, London E1 2ES, UK; Gynaecologic Oncology, Imperial College London Faculty of Medicine, London SW7 2DD, UK
| | - Raji Ganesan
- Department of Cellular Pathology, Birmingham Women's Hospital, Birmingham B15 2TG, UK
| | - Kathryn Hillaby
- Department Gynaecological Oncology, Cheltenham General Hospital, Gloucestershire, Hospitals NHS Foundation Trust, GL53 7AN, UK
| | - Alexandra Taylor
- The Royal Marsden NHS Foundation Trust, Fulham Road, London SW3 6JJ, UK
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Huang J, Chan SC, Fung YC, Pang WS, Mak FY, Lok V, Zhang L, Lin X, Lucero-Prisno DE, Xu W, Zheng ZJ, Elcarte E, Withers M, Wong MCS. Global incidence, risk factors and trends of vulvar cancer: A country-based analysis of cancer registries. Int J Cancer 2023; 153:1734-1745. [PMID: 37531169 DOI: 10.1002/ijc.34655] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 06/21/2023] [Accepted: 06/23/2023] [Indexed: 08/03/2023]
Abstract
Vulvar cancer is an uncommon malignancy. Vulvar cancer alarmed the public health problem in terms of the cost of diagnostic and medical treatments and psychical health of females. Our study aims to provide a thorough analysis of the global disease burden, related risk factors and temporal incidence trends of vulvar cancer in population subgroups. Data from Global Cancer Observatory and the Cancer Incidence in Five Continents Plus were used for the vulvar cancer incidence. Age-standardized rates (ASR) were used to depict the incidence of vulvar cancer. The 10-year trend of incidence was assessed using joinpoint regression with average annual percentage change and 95% confidence intervals in various age groups, while its correlations with risk factors were investigated using linear regression. Higher ASR were found in Western Europe (2.4), Northern America (1.9), Northern Europe (1.9), Australia and New Zealand (1.8) and Eastern Africa (1.4). The associated risk factors of higher vulvar cancer incidence were gross domestic product per capita, Human Development Index, higher prevalence of smoking, alcohol drinking, unsafe sex and human immunodeficiency virus infection. The overall trend of vulvar cancer incidence was increasing. An increasing trend was found in older females while a mixed trend was observed in younger females. The disease burden of vulvar cancer follows a bimodal pattern according to its two histologic pathways, affecting women in both developed and developing regions. Smoking cessation, sex education and human papillomavirus vaccination programs should be promoted among the general population. Subsequent studies can be done to explore the reasons behind the increasing trend of vulvar cancer.
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Affiliation(s)
- Junjie Huang
- The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong SAR, China
- Centre for Health Education and Health Promotion, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Sze Chai Chan
- The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong SAR, China
| | - Yat Ching Fung
- The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong SAR, China
| | - Wing Sze Pang
- The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong SAR, China
| | - Fung Yu Mak
- The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong SAR, China
| | - Veeleah Lok
- Department of Global Public Health, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - Lin Zhang
- Suzhou Industrial Park Monash Research Institute of Science and Technology, China
- The School of Public Health and Preventive Medicine, Monash University, Victoria, Australia
| | - Xu Lin
- Department of Thoracic Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Don Eliseo Lucero-Prisno
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Wanghong Xu
- School of Public Health, Fudan University, Shanghai, China
| | - Zhi-Jie Zheng
- Department of Global Health, School of Public Health, Peking University, Beijing, China
| | - Edmar Elcarte
- College of Nursing, University of the Philippines, Manila, Philippines
| | - Mellissa Withers
- Department of Population and Health Sciences, Institute for Global Health, University of Southern California, Los Angeles, California, USA
| | - Martin C S Wong
- The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong SAR, China
- Centre for Health Education and Health Promotion, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
- Department of Global Health, School of Public Health, Peking University, Beijing, China
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Chelmow D, Cejtin H, Conageski C, Farid H, Gecsi K, Kesterson J, Khan MJ, Long M, O'Hara JS, Burke W. Executive Summary of the Lower Anogenital Tract Cancer Evidence Review Conference. Obstet Gynecol 2023; 142:708-724. [PMID: 37543740 PMCID: PMC10424818 DOI: 10.1097/aog.0000000000005283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 05/16/2023] [Accepted: 05/25/2023] [Indexed: 08/07/2023]
Abstract
The Centers for Disease Control and Prevention sponsored a project conducted by the American College of Obstetricians and Gynecologists to develop educational materials for clinicians on the prevention and early diagnosis of gynecologic cancers. For this final module, focusing on the cancers of the lower anogenital tract (vulva, vagina, and anus), a panel of experts in evidence assessment from the Society for Academic Specialists in General Obstetrics and Gynecology, ASCCP, and the Society of Gynecologic Oncology reviewed relevant literature and current guidelines. Panel members conducted structured literature reviews, which were then reviewed by other panel members. Representatives from stakeholder professional and patient advocacy organizations met virtually in September 2022 to review and provide comment. This article is the executive summary of the review. It covers prevention, early diagnosis, and special considerations of lower anogenital tract cancer. Knowledge gaps are summarized to provide guidance for future research.
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Affiliation(s)
- David Chelmow
- Departments of Obstetrics and Gynecology, Virginia Commonwealth University School of Medicine, Richmond, Virginia, Feinberg School of Medicine Northwestern University, Stroger Hospital, Chicago, Illinois, University of Colorado School of Medicine, Aurora, Colorado, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, Medical College of Wisconsin, Milwaukee, Wisconsin, Stanford University School of Medicine, Palo Alto, California, Mayo Clinic Alix School of Medicine, Rochester, Minnesota, and Stony Brook University Hospital, Stony Brook, New York; the Division of Gynecologic Oncology, UPMC-Central PA, Mechanicsburg, Pennsylvania; and the American College of Obstetricians and Gynecologists, Washington, DC
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Taran FA, Pasternak J, Staebler A, Rohner A, Neis F, Engler T, Oberlechner E, Schönfisch B, Juhasz-Böss I, Hartkopf AD, Brucker S, Walter CB. Tumor-Free Resection Margin Distance in the Surgical Treatment of Node-Negative Squamous Cell Cancer of the Vulva Has No Impact on Survival: Analysis of a Large Patient Cohort in a Tertiary Care Center. Cancers (Basel) 2023; 15:4110. [PMID: 37627138 PMCID: PMC10452494 DOI: 10.3390/cancers15164110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 08/11/2023] [Accepted: 08/14/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND The aim of this study was to evaluate the impact of pathological tumor-free margin distance on survival in SCC patients treated with surgery alone. METHODS This retrospective study included 128 patients with node-negative disease that received no adjuvant treatment. Disease-free and overall survival were analyzed according to pathological tumor-free margin distance. RESULTS The patients were subclassified into three resection margin category groups: "1 to 3 mm" (n = 42), ">3 to 8 mm" (n = 47) or ">8 mm" (n = 39). Thirty-nine of the 128 patients (30.5%) developed recurrent disease. Median follow-up for disease-free survival (DFS) was 6.49 years (95% CI 5.16 years; 7.62 years), and median follow-up for overall survival (OS) was 6.29 years (95% CI 5.45 years; 7.33 years). The 5-year DFS rate was 0.70 (95% CI: 0.62-0.79), and the 5-year OS rate was 0.79 (95% CI: 0.71-0.87). Regarding the survival outcome, there were no independent significant differences in either disease-free survival (DFS) (p = 0.300) or overall survival (p = 1.000) among patients within the three tumor-free resection margin categories. Multivariate analyses did not show any statistically significant association between tumor-free resection margin distance and recurrent disease or death, either when analyzed as a categorical variable or when analyzed as a continuous variable. CONCLUSION The present study did not show a significant impact of pathological tumor-free resection margin distance following surgery in patients with node-negative SCC of the vulva (that did not receive adjuvant treatment) on disease-free and overall survival.
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Affiliation(s)
- Florin Andrei Taran
- Department of Obstetrics and Gynecology, Medical Center, University of Freiburg, 79106 Freiburg, Germany
| | - Jana Pasternak
- Department of Women’s Health, Tuebingen University Hospital, 72076 Tuebingen, Germany
| | - Annette Staebler
- Institute of Pathology and Neuropathology, Tuebingen University Hospital, 72076 Tuebingen, Germany
| | - Annika Rohner
- Department of Women’s Health, Tuebingen University Hospital, 72076 Tuebingen, Germany
| | - Felix Neis
- Department of Women’s Health, Tuebingen University Hospital, 72076 Tuebingen, Germany
| | - Tobias Engler
- Department of Women’s Health, Tuebingen University Hospital, 72076 Tuebingen, Germany
| | - Ernst Oberlechner
- Department of Women’s Health, Tuebingen University Hospital, 72076 Tuebingen, Germany
| | - Birgitt Schönfisch
- Department of Women’s Health, Tuebingen University Hospital, 72076 Tuebingen, Germany
| | - Ingolf Juhasz-Böss
- Department of Obstetrics and Gynecology, Medical Center, University of Freiburg, 79106 Freiburg, Germany
| | | | - Sara Brucker
- Department of Women’s Health, Tuebingen University Hospital, 72076 Tuebingen, Germany
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Iglesias P, Tendobi C, Carlos S, Lozano MD, Barquín D, Chiva L, Reina G. Characterization of Human Papillomavirus 16 from Kinshasa (Democratic Republic of the Congo)-Implications for Pathogenicity and Vaccine Effectiveness. Microorganisms 2022; 10:microorganisms10122492. [PMID: 36557745 PMCID: PMC9782055 DOI: 10.3390/microorganisms10122492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 11/24/2022] [Accepted: 12/06/2022] [Indexed: 12/23/2022] Open
Abstract
Human Papillomavirus (HPV) type 16 is the main etiological agent of cervical cancer worldwide. Mutations within the virus genome may lead to an increased risk of cancer development and decreased vaccine response, but there is a lack of information about strains circulating in Sub-Saharan Africa. Endocervical cytology samples were collected from 480 women attending a voluntary cervical cancer screening program at Monkole Hospital and four outpatient centers in Kinshasa, Democratic Republic of the Congo (DRC). The prevalence of HPV infection was 18.8% and the most prevalent high-risk types were HPV16 (12.2%) followed by HPV52 (8.8%) and HPV33/HPV35 (7.8% each). HPV16 strains were characterized: 57.1% were classified as C lineage; two samples (28.6%) as A1 and one sample belonged to B1 lineage. HPV33, HPV35, HPV16, and HPV58 were the most frequent types associated with low-grade intraepithelial lesion while high-grade squamous intraepithelial lesions were predominantly associated with HPV16. Several L1 mutations (T266A, S282P, T353P, and N181T) were common in Kinshasa, and their potential effect on vaccine-induced neutralization, especially the presence of S282P, should be further investigated. Long control region (LCR) variability was high with frequent mutations like G7193T, G7521A, and G145T that could promote malignancy of these HPV16 strains. This study provides a helpful basis for understanding HPV16 variants circulating in Kinshasa and the potential association between mutations of LCR region and malignancy and of L1 and vaccine activity.
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Affiliation(s)
- Paula Iglesias
- Microbiology Department, Clínica Universidad de Navarra, 31008 Pamplona, Spain
| | - Celine Tendobi
- Department of Obstetrics and Gynecology, Centre Hospitalier Mère-Enfant (CHME), Ngafani, Kinshasa 4484, Democratic Republic of the Congo
| | - Silvia Carlos
- Department of Preventive Medicine and Public Health, Universidad de Navarra, 31008 Pamplona, Spain
- IdiSNA, Navarra Institute for Health Research, 31008 Pamplona, Spain
- ISTUN, Institute of Tropical Health, Universidad de Navarra, 31008 Pamplona, Spain
- Correspondence: ; Tel.: +34-948425600 (ext. 826636)
| | - Maria D. Lozano
- IdiSNA, Navarra Institute for Health Research, 31008 Pamplona, Spain
- Department of Pathology, Clínica Universidad de Navarra, 31008 Pamplona, Spain
| | - David Barquín
- Microbiology Department, Clínica Universidad de Navarra, 31008 Pamplona, Spain
| | - Luis Chiva
- IdiSNA, Navarra Institute for Health Research, 31008 Pamplona, Spain
- Department of Obstetrics and Gynecology, Clínica Universidad de Navarra, 28027 Madrid, Spain
| | - Gabriel Reina
- Microbiology Department, Clínica Universidad de Navarra, 31008 Pamplona, Spain
- IdiSNA, Navarra Institute for Health Research, 31008 Pamplona, Spain
- ISTUN, Institute of Tropical Health, Universidad de Navarra, 31008 Pamplona, Spain
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