Human Papilloma Virus Typing as a Triage Tool for Women with Postcoital Bleeding: A Retrospective Cohort Study

Objective: To investigate the performance of human papilloma virus (HPV) typing as a triage tool in the management of patients with postcoital bleeding (PCB). Methods: All patients referred for colposcopy at a cervical pathology clinic of a nationwide health insurance organization, due to PCB and had a preceding high-risk HPV (hrHPV) test between 2018 and 2020, were retrospectively located. Demographic and pathologic data were collected from electronic medical files. Sensitivity, specificity, and negative and positive predictive value of hrHPV test according to final pathology were calculated. Results: Three hundred ninety patients referred for colposcopy due to PCB with a preceding hrHPV test were located. HrHPV-positive patients were significantly younger (33.7 ± 10 vs. 37.2 ± 9, p < 0.006) with a higher proportion of nulliparous, nonmarried, and smokers compared with hrHPV-negative patients (75% vs. 47%, p < 0.001; 75.4% vs. 45.1%, p < 0.001; and 24.6% vs. 12.8%, p < 0.028, respectively). No case of high-grade cervical intraepithelial neoplasia (CIN2/3) was identified among hrHPV-negative patients. The sensitivity and NPV of the hrHPV test for high-grade cervical lesions were both 100%, decreasing to 36% and 95%, respectively, for any cervical dysplasia (CIN1/CIN2/CIN3). Adding cytology to HPV typing had a negligible effect on test performance. At univariate analysis, age, HPV vaccine status, nulliparity, and positive HPV typing were independently associated with cervical dysplasia. At multivariate analysis, only positive HPV typing remained significantly associated with cervical dysplasia (hazard ratio 2.75, confidence interval 1.1-6.5, p = 0.023). Conclusion: A negative HPV test even in the presence of PCB may rule out cervical dysplasia with extremely high accuracy and may save unnecessary colposcopies.

The Association Between Depression and Invasive and In-situ Cervical Tumors: A Large Population Based Cohort Study

BACKGROUND

Depression has been shown to be associated with cervical tumors (CTs), an association mostly demonstrated in studies in which temporality could not have been ascertained.

OBJECTIVES

To study the association between depression and CTs and the influence of co-morbidities of this association in a large cohort study.

METHODS

A retrospective computer-based cohort study was conducted. The cohort included 357,450 female members of Maccabi Healthcare Services. The cohort was classified as depressed or non-depressed using the International Classification of Diseases 9/10 codes. For each subgroup, demographic characteristics, behavioral characteristics, co-morbidities, and CTs diagnosis were obtained. The burden of co-morbidities was defined as the sum of major co-morbidities. We used zero-inflated negative binomial regression analysis due to over-dispersion to estimate the relative risk (RR) for CTs with 95% confidence interval (95%CI).

RESULTS

Depression was diagnosed in 15,789 women. Among this group, CTs were diagnosed in 1585 (10.0%). Among the 341,661 non-depressed, CTs were diagnosed in 4185 (1.2%). After adjustment to age and socioeconomic status, the association between depression and CTs was RR=9.2 (95%CI 8.7-9.9, P-value < 0.0001). The association between depression and CTs increased as the burden of clinical conditions increased (P-value < 0.0001).

CONCLUSIONS

Women with depression are at a higher risk for CTs, especially among those who have several co-morbidities. Tighter gynecology surveillance is crucial among these women.

High-risk HPV testing vs liquid-based cytology for cervical cancer screening among 25- to 30-year-old women: A historical cohort study

INTRODUCTION

High-risk human papilloma virus (hrHPV) DNA testing is more sensitive than cytology screening, achieving greater protection against cervical cancer. Controversy exists regarding the preferred screening method for women 25-30 years of age. At this age, infection with HPV is common and usually transient. Consequently, hrHPV screening in this age group is fraught with high false-positive screening results, leading to more colposcopies and unnecessary treatments with the potential for harm. In the present study, we aimed to compare the results of two screening methods in relation to high-grade cervical intraepithelial lesion detection rate in the young age group of 25-30 years.

MATERIAL AND METHODS

Retrospective information on cervical cytology, hrHPV testing, colposcopy referrals and histologic results, from one screening round, were retrieved from the Maccabi HealthCare Health Maintenance Organization centralized database during the study period from March 1, 2017 to April 1, 2019 for 25- to 30-year-old women. Screening with hrHPV testing for types 16, 18 and 12 other hrHPV types was compared with the conventional PAP liquid-based cytology (LBC) test. Odds ratio (OR) of detection with 95% confidence interval (CI) was calculated for cervical intraepithelial neoplasia (CIN) grade 3 or higher (CIN 3+).

RESULTS

During the study period, 42 244 women 25-30 years old underwent cervical cancer screening; of them, 20 997 were screened with LBC between March 1, 2017 and March 1, 2018 and compared with 21 247 who were screened with hrHPV between April 1, 2018 and April 1, 2019. Testing for hrHPV resulted in a higher colposcopy referral rate compared with primary LBC screening: 9.8% vs 7.8%, respectively; (OR 1.28; 95% CI 1.2-1.37; p < 0.001). Screening with hrHPV led to significantly higher detection of CIN 3+ lesions (OR 1.4; 95% CI 1.2-1.6; p < 0.001) compared with LBC. HPV infections with non-16/18 hrHPV (other hrHPV) were the most prevalent (84.8%).

CONCLUSIONS

In women 25-30 years old, primary hrHPV screening was associated with a higher detection rate of CIN 3+ compared with cytology screening and should be considered for primary screening in this age group.

[RISK MANAGEMENT IN COMMUNITY GYNECOLOGY: "CLAIM MANAGEMENT VERSUS RISK MANAGEMENT"]

The goal of the study is to analyze the gynecological system in Maccabi HMO in the aspect of risk management and to define points for improving patient safety and minimalization of the risk of lawsuits. Maccabi's risk management system aims to improve the safety of treatment, which is based on independent gynecologists in private clinics (662 doctors), 20 women's health centers and 4 emergency centers in gynecology which provide solutions to urgent cases beyond working hours in community medicine. The service provides an answer to about 870,000 women with about 940,000 annual visits. Characteristics of events in gynecology at Maccabi: events related to pregnancy - 41%, to gynecologist 40%, laboratory 11% and doctor-patient interaction: 8% Event distribution by claim or claim potential: pregnancy 70%, gynecology 30%; in cases of pregnancy - 60% of claims are related to malformations. In the field of obstetrics: in 74% of cases there was a risk factor that could be detected during pregnancy. In pregnancy-related claims reveal that in most cases there are missing or structural defects or a genetic defect that was not diagnosed; in most cases of not finding a structural defect (64%) there was a maternal factor or other suspicious factor during pregnancy follow-up, that would contribute to an early diagnosis. In most cases of non-detection of a genetic defect (92%), some suspicious factor (maternal, familial or findings during pregnancy) could have been defined, which might have contributed to the diagnosis. In gynecological events occurring: about 17% were connected to PAP smears and 13% to intrauterine devices. There is a need for an organizational culture that will encourage reporting: direct reporting to the risk management department, reporting to field risk management referrals and reporting by entities not directly involved.

HPV Screening Test for the Detection of Precancerous Cervical Lesions and Cervical Cancer in Israeli Women

OBJECTIVES

This work is aimed to summarize the first year of the high-risk human papillomavirus (hrHPV) screening test and compare it to the cytology screening test, regarding positivity rates and premalignant lesions diagnosed in the Israeli population. A specific consideration is for the age group 25-30 that is not considered mandatory for the HPV primary screening testing.

METHODS

A retrospective study was performed in women who were screened for prevention of cervical cancer in Maccabi HealthCare HMO from March 2017 to March 2019. Screening methods included hrHPV typing for types 16, 18, and the other 12 hrHPV types and the PAP LBC test.

RESULTS

A total of 115,807 cervical samples were tested for HPV presence and 91% (105,225) were found negative for hrHPV. The other 9% (10,582) were positive for one or more of the 14 hrHPV types tested, and 37% (3,916) of them showed abnormal PAP LBC results. In the age group of 25-30, 3,104 (17.5%) women were found positive for hr-HPV (825 had hrHPV types 16 and/or 18), of which 42% (1,293) of them showed abnormal PAP LBC results. During the hrHPV versus PAP LBC screening era, 258 more women were diagnosed with precancerous cervical lesions (CIN2/3), 70% increased detection versus cytology screening.

CONCLUSIONS

The hrHPV screening test is currently the best method for the detection of precancerous cervical lesions and cervical cancer, and it is better started at age 25.

The impact of a Facebook campaign among mothers on HPV vaccine uptake among their daughters: A randomized field study

OBJECTIVE

The popularity of social networks provide an incredible opportunity to enhance the impact of preventive medicine programs. We aimed to assess whether a targeted Facebook campaign among mothers may increase the uptake of human Papilloma virus (HPV) immunization among their 8th-grade daughters.

METHODS

This field study was conducted among the members of a state-mandated health organization in Israel. Included were all 21,592 members who were mothers to 14 year-old daughters in the 2018-19 school-year. A total of 17,271 (80%) were randomly allocated to the campaign arm and the rest (n=4,321) were selected as a reference group. The Facebook ads addressed issues and concerns regarding HPV-related diseases and HPV vaccine. Main outcome measures were Facebook metrics on exposure to campaign and HPV immunization among eighth grade daughters of the study participants.

RESULTS

Between 8/2018-10/2018, Facebook ads were shown 1.8-million times (a reach of 88%). The uptake of HPV vaccine among daughters of women allocated to the campaign arm (55.3%) was similar (p = 0.749) to 55.0% in the control group. The only significant differences between study groups were observed when stratifying by SES level. In the lowest SES quartile, Facebook campaign significantly (p = .02) reduced vaccine uptake (35% vs. 39.0%), with a relative risk of 0.90 (95%CI: 0.82-0.98), while in the second SES quartile, Facebook campaign increased vaccine uptake from 52.6% to 55.8%, with a RR of 1.06 (95%CI,1.00-1.12). Among mothers in higher SES levels, daughters of exposed and unexposed mothers had similar immunization rates.

CONCLUSIONS

Facebook campaign may increase the uptake of HPV vaccine among daughters to mothers of medium-to-low SES level, but it may reduce vaccination among lower SES groups.

Impact of quadrivalent human papillomavirus vaccine on genital warts in an opportunistic vaccination structure

OBJECTIVE

Genital warts are the most common sexually transmitted disease and have a detrimental impact on quality of life. Genital warts could be prevented by prophylactic HPV vaccination. The objective was to study real-life benefit of opportunistic HPV vaccination on age and gender specific incidence of genital warts.

METHODS

We performed a register-based population cohort study from publicly funded health-care provider in Israel. The incidence of genital warts was assessed during three time frame intervals: 2006-2008 (pre-vaccination effect period) 2009-2012 (early post-vaccination effect period) and 2013-2015 (late post-vaccination effect period), with an average annual number of members of 1,765,481, 1,906,774 and 2,042,678 in the years 2006-2008, 2009-2012 and 2013-2015, respectively.

RESULTS

Among females, annual incidence of genital warts per 100,000 women decreased from 210.43 to 161.71 (OR 0.76, 95%CI 0.71-0.82, p<0.001) and to 146.8 (OR 0.69, 95%CI 0.66-0.72, p<0.001) between pre-vaccination period and early and late post-vaccination periods, respectively. Among males, annual incidence of genital warts per 100,000 men decreased from 262.85 to 232.40 (OR 0.88, 95%CI 0.83-0.93, p<0.001) and to 234.01 (OR 0.88, 95%CI 0.86-0.91, p<0.001) between pre-vaccination period and early and late post-vaccination periods, respectively.

CONCLUSIONS

There is a potential benefit in reducing incidence of genital warts even in opportunistic HPV vaccination structure. This information may be relevant for health-care providers in countries where national immunization programs do not include HPV vaccines.

Risk Factors for Cervical Cancer and CIN3 in Jewish Women in Israel - Two Case Control Studies

PURPOSE

The aim of the study was to identify risk and protective factors/markers for cervical cancer and cervical intraepithelial neoplasia 3 (CIN3) in Israeli Jewish women in order to settle the discrepancy of low incidence rate of cervical cancer and relatively high incidence rate of CIN3.

MATERIALS AND METHODS

We conducted two case control studies, which examined the association between potential risk and protective factors/markers for cervical cancer or CIN3 using self administered detailed questionnaires.

RESULTS

For studying cervical cancer, 40 cases and 40 matched controls were interviewed. In the univariable and multivariable analyses older age, depression or anxiety and ever smoking seemed to act as independent risk factors/markers, while older age at first intercourse was protective. For studying CIN3, 99 cases and 79 controls were interviewed. Multivariable analysis has demonstrated that being born in Israel, depression or anxiety and ever smoking were independent risk factors/markers for CIN3.

CONCLUSIONS

The risk factors/markers studied, that were associated with cervical cancer or CIN3 among Jewish women in Israel, are similar to those reported in other parts of the world, and do not explain the observed discrepancy of high in-situ cervical cancer rates and low invasive cervical cancer incidence in Israel.

[IMPLEMENTATION OF A NATIONAL SCREENING PROGRAM FOR DETECTION OF MALIGNANT AND PRE-MALIGNANT CERVICAL MORBIDITY IN ISRAEL]

The natural development of cervical cancer, which takes many years, is mostly initiated by infection with human papillomavirus (HPV) and is characterized by the development of precancerous lesions, cervical intraepithelial neoplasia 3 (CIN3), which are defined as abnormal changes in epithelial cells that cover the cervix surface. Since the pre-cancerous process is microscopic and asymptomatic, early detection is based on cytological screening, the Pap test. In Israel, Pap tests are performed based on selfreferral for testing and not within the framework of a national screening program because of the low incidence rate of cervical cancer in Israel. The current program is characterized by low coverage rates, redundancy checks conducted on a small and selective group of women and therefore, lower efficacy in comparison to an organized, national program. In recent decades, the incidence rates of pre-malignant and malignant cervical morbidity showed increasing trends in Israel, an increase which can be stopped. Launching a national, organized program for the early detection of cervical cancer using Pap test and raising the awareness of women and physicians in Israel regarding the importance of this test, will increase the test uptake and decrease its current selectiveness. Furthermore, this will, in the short run, improve serious cervical morbidity, and in the long run, also reduce the incidence of precancerous and cancerous cervical lesions, as has been described in many countries in the world.

[CERVICAL CANCER IN ISRAEL 2016: FACTS, INSIGHTS AND THOUGHTS FOR THE FUTURE]

The natural history of precancerous lesions and cervical cancer in Israeli women differs from that reported in the world. In 2011, 244 women were diagnosed in Israel with invasive cervical cancer, with the mortality of 79 women. The incidence of cervical cancer in Israel is about 5 new cases per year per 100,000 women (5.4 Jewish, 3.2 Arab). This figure is very low compared with statistics presented in other countries and has not changed over the last decades. The vast majority of Israeli women were diagnosed due to symptoms and not following Pap smear screening. The mortality rate in Israel is similar to that of other OECD countries. In Israel, 71% of patients survive five years or more, the rate is not significantly different from the percentage of survival of other OECD countries. Over half of the Israeli patients are diagnosed in the late stage disease. This delay in cervical cancer diagnosis is probably due to the lack of a national screening program. We recommend more efficient routing of national expenditure for cervical cancer screening and prevention in Israel, scanning asymptomatic women and targeting disadvantaged populations. By applying the proposed screening strategy, redirection of resources will reduce cervical cancer morbidity and mortality, and will increase the percentage of women from low socioeconomic populations tested in Israel.

Screening for Cervical Cancer Among Low-Risk Populations: Orthodox Jewish Women as a Model

OBJECTIVE

To explore the prevalence of abnormal Papanicolaou (PAP) smears among asymptomatic Orthodox Jewish women, characterized by conservative sexual habits, in comparison to secular Jewish women.

METHODS

A retrospective analytical cohort study of 600 consecutive PAP smears, performed as a screening test on asymptomatic Orthodox Jewish women (mean age 43.4 ± 12.6 years), compared to 600 consecutive smears performed on secular Jewish women (mean age 38.2 ± 11.5 years). Primary outcome measures comprised incidence and clinical significance of abnormal cytological findings among the two subgroups. Secondary outcome measures included possible risk factors for abnormal cytological findings within the study population.

RESULTS

In the Orthodox group, only seven (1.2%) PAP smears were interpreted as abnormal, compared with 33 (5.5%) abnormal smears among the secular group (p < 0.001). All seven abnormal PAP smears from the Orthodox Jewish group were classified as atypical squamous cells of undetermined significance (ASCUS), compared with 16 ASCUS smears and 17 low-grade squamous intraepithelial lesion smears in the secular group (2.67% and 2.83% of the secular women, respectively). The vast majority of ASCUS cases in the Orthodox Jewish group were followed up with repeated normal PAP smears.

CONCLUSIONS

The incidence rate of abnormal PAP smears taken as a routine screening test among Orthodox Jewish women is very low (1.2%). Furthermore, the vast majority of abnormal smears in these women were later found to be false positive, with no clinical significance. These findings raise doubt as to the need for systematic screening and/or comprehensive vaccination against the papilloma virus among low-risk populations.

Can we predict the need for pharmacological treatment according to demographic and clinical characteristics in gestational diabetes?

OBJECTIVE

To determine the ability to predict the need for pharmacological treatment in gestational diabetes mellitus (GDM).

METHOD

A retrospective cohort study. Data were collected from medical records of 1324 GDM patients including demographic data, family history of diabetes, obstetrical history, laboratory results, treatment modality and level of glycemic control. Patients who were identified as pre-gestational diabetes were excluded.

RESULTS

Overall, 143 (10.8%) GDM patients required pharmacological therapy. Of women who had GDM in their previous pregnancy; only 11.65% achieved desired glycemic control solely by diet treatment. Moreover, 62.5% of patients requiring pharmacological therapy in their previous pregnancy achieved desired level of glycemic control only by diet. Of patients who achieved desired level of glycemic control on diet until the second antenatal visit, 95% continued to maintain desired level glycemic control throughout pregnancy. Pre-pregnancy BMI >30, fasting plasma glucose >95 mg/dL and maternal age above 30 were associated with increase need for pharmacological treatment. One abnormal value in the OGTT and GCT result >2 mg/dL did not predict the need for pharmacological therapy. Primigravida and family history of GDM were not found to be predictors for treatment modality.

CONCLUSION

Using clinical and demographical data can predict the need for pharmacological treatment for GDM.

Recent trends of cervical cancer and Cervical Intraepithelial Neoplasia 3 (CIN3) in Israel

PURPOSE

This study describes time trends of cervical cancer and Cervical Intraepithelial Neoplasia 3 (CIN3) in Israel in the years 1986-2010 and characterizes these patients by demographics.

METHODS

A retrospective survey based on cervical cancer and CIN3 data documented in the computerized system of the second largest Health Maintenance Organizations (HMO) in Israel, "Maccabi Healthcare Services" (MHS) between 1986 and 2010.

RESULTS

737 cervical cancer patients and 3,459 patients of CIN3 were reported between 1986 and 2010. The mean age of women with cervical cancer was significantly higher (mean 49.1 years) than that of CIN3 patients (mean 36.3 years) (p-value < 0.0001). The annual age-adjusted incidence rate of cervical cancer increased significantly from 1.6 per 100,000 in 1986 to 3.7 per 100,000 in 2010 (p for trend = 0.0001) and for CIN3, from 3.9 per 100,000 in 1986 to 40.4 per 100,000 in 2010 (p for trend = 0.0001). For cervical cancer, using the Joinpoint software we demonstrated an increase in the age-adjusted incidence rate between 1986 and 2003 and since then, a decrease was observed. Cervical cancer and CIN3 were mostly common in the Tel Aviv District.

CONCLUSIONS

Although quite low to begin with, the incidence rates of cervical cancer and CIN3 in Israel may be further lowered by implementing an organized screening program and introduction of the HPV vaccine into the national immunization program.

Cervical cancer screening, human papillomavirus vaccination practices and current infrastructure in Israel

The incidence rates for premalignant lesions in Jewish women in Israel are similar to those observed in Western countries, but the incidence of cervical cancer in Israel is low; this discrepancy is not yet clearly understood. Because of the low incidence of cervical cancer in Israel, it was decided to base cervical cancer prevention on opportunistic screening: every woman from the ages of 35-54 years can have a Pap test smear free of charge every 3 years. Over the last decade 12.2% of the women population had an annual Pap test. From 36 to 50% of women who attended the Clalit Health Maintenance Organization (HMO) and the Maccabi HMO, the two largest HMOs in Israel, did so. There were also discrepancies between women of different socio-economic status (SES): <10% in the lowest SES level were screened compared to almost 55% in the higher level. HPV vaccination was opportunistic but it will be introduced to the school-based vaccine program at age of 13 years old as of September 2013. The Israel Society of Obstetrics and Gynecology recommends continuing cytologic screening in vaccinated women as recommended for the general population. This article forms part of a regional report entitled "Comprehensive Control of HPV Infections and Related Diseases in Israel" Vaccine Volume 31, Supplement 8, 2013. Updates of the progress in the field are presented in a separate monograph entitled "Comprehensive Control of HPV Infections and Related Diseases" Vaccine Volume 30, Supplement 5, 2012.

Cervical Pap screening among Israeli women, 2005-2010

PURPOSE

This study describes the distribution and the trends of cervical abnormalities in Israel, based on Pap smear results.

METHODS

A retrospective analysis of cervical smears received by the Central Pathology Laboratory of Maccabi Healthcare Services between January 2005 and December 2010.

RESULTS

In total, 711,541 Pap smears were screened in the study period. Cytological abnormalities were observed in 4.78% of the total smears screened. An increase was observed in the rate of positive results from 2.63% in 2005 to 6.78% in 2010 (p = 0.0026). The cervical abnormalities in the study period distributed as follows: atypical squamous cell (ASC)-2.72%, low-grade squamous intraepithelial lesion (LSIL)-1.54%, high-grade squamous intraepithelial lesion (HSIL)-0.34%, squamous cell carcinoma-0.01%, atypical glandular cells (AGC)-0.10%, adenocarcinoma in situ (AIS)-0.06% and invasive adenocarcinoma-0.01%. The increase was statistically significant for ASC (p = 0.0028), LSIL (p = 0.0069) and for HSIL (p = 0.0260). The mean ages at diagnosis of women with ASCUS, LSIL, HSIL, squamous cell carcinoma, AGC, AIS and adenocarcinoma were 37.8, 33.2, 38.6, 55.4, 41.1, 49.9 and 57.1 years, respectively.

CONCLUSIONS

The increase in the rate of squamous cell abnormalities demonstrated in this study emphasizes the need of implementing an education and a screening program among Israeli women. HPV vaccine, sexual behavior, cytology performance and HPV test are primary and secondary prevention tools which may reduce morbidity and mortality in the future. In addition, based on the age at diagnosis of the different pathologies, the age group in which Pap test is performed in Israel should be expanded from 35-54 to 25-65 years.

Uptake of Pap smears among women in a large Israeli HMO between 2006 and 2008

OBJECTIVES

The Papanicolaou (Pap) smear test is used in many countries as a screening procedure for cervical cancer and precancerous lesions. The actual uptake of this screening test among women at risk for cervical cancer is unknown. The aim of this study was to estimate the percentage of women who are screened by Pap smears from the relevant population at risk, and to detect factors that are independently associated with uptake of cervical screening.

STUDY DESIGN

Retrospective database study.

METHODS

This study was undertaken at Maccabi Healthcare Services (MHS), the second largest publicly funded health maintenance organization in Israel. The study population consisted of Israeli women aged 21-59 years who were insured by MHS between 2006 and 2008. Logistic regression analyses were used to determine the independent relationships between immigration and socio-economic status and cervical screening.

RESULTS

The study population included 489,663 women who had a total of 313,602 Pap smears between 2006 and 2008. Fifty-four percent of the women did not have a Pap smear during the study period, 32% had at least one smear, and 14% had at least two smears. Living in a low socio-economic neighbourhood and recent immigration were independently and negatively associated with screening uptake.

CONCLUSION

Despite the clinical guidelines and the low costs, many Israeli women who are at risk for cervical cancer are not screened.

Evaluating the epidemiology and morbidity burden associated with human papillomavirus in Israel: accounting for CIN1 and genital warts in addition to CIN2/3 and cervical cancer

BACKGROUND

Human papillomavirus (HPV) infection is mostly associated with cervical cancer (CC). However, it can cause other illnesses as well, all of which impact on people's wellbeing and consume healthcare resources. Measures for prevention or early detection of these conditions differ in their effectiveness and cost. An informative evaluation of the projected benefit of these measures depends on understanding the current unmet need, not only limited to CC.

OBJECTIVE

To evaluate the burden of HPV-related conditions in Israel, including CC, cervical precancerous lesions and genital warts.

METHODS

A retrospective database analysis was conducted for the second largest health management organization (HMO) in Israel, covering approximately 1.8 million people. Records were drawn following a search for key words indicative of related diagnoses, lab results, medications, or procedures for the time period of 2006-2008. Prevalence, incidence and resource utilization were analysed. Findings were extrapolated to the whole Israeli population using age and gender incidence rates.

RESULTS

Incidence of CC was found to be 5 per 100,000 females. Incidences of cervical intraepithelial neoplasia (CIN) grades 1, 2 and 3 were 74, 27 and 36 per 100,000 females, respectively. Incidence of genital warts was 239 and 185 per 100,000 for men and women, respectively. The overall annual economic burden was calculated to be $US48,838,058 (year 2010 values).

CONCLUSIONS

HPV poses a significant burden in terms of health (clinical and quality of life) and in monetary terms, even for conditions that are sometimes regarded as benign, such as CIN1 or genital warts. Current findings should be used for proper evaluation of measures to reduce HPV-related morbidity and mortality, such as regular screening and vaccination.

Treatment of high-grade squamous intraepithelial lesions: A “see and treat” versus a three-step approach

OBJECTIVE

The study's subject was to examine the correlation between histologic findings in patients with high-grade squamous intraepithelial lesion (HGSIL) who have undergone loop electrosurgical excisional procedure (LEEP) with and without prior colposcopically directed biopsy.

STUDY DESIGN

This retrospective study included 144 patients with cytologic HGSIL, of which 62 were treated by a three-step protocol, in which LEEP was performed only if the colposcopically directed cervical biopsies were positive (CIN II-III), and 82 women who were treated by "see and treat" protocol, in which LEEP was immediately performed if colposcopy was suggestive of CIN II or III lesions.

RESULTS

There were no differences in the final histological findings between the groups.

CONCLUSIONS

The colposcopically directed LEEP after a HGSIL on PAP-smear may reduce the time interval between diagnosis and treatment with a similar accuracy of diagnosis compared to the standard three-step protocol.

Membranal effects of phytoestrogens and carboxy derivatives of phytoestrogens on human vascular and bone cells: new insights based on studies with carboxy-biochanin A

Estradiol-17beta (E2) and some phytoestrogens induce a biphasic effect on DNA synthesis in cultured human vascular smooth muscle cells (VSMC), i.e., stimulation at low concentrations and inhibition at high concentrations. These compounds also increase the specific activity of creatine kinase (CK) as well as intracellular Ca2+ concentration in both VSMC and human female-derived cultured bone cells (OBs), and stimulate ERK1/2 phosphorylation in VSMC. At least some of these effects are exerted via membranal binding sites (mER), as would appear from observations that protein-bound, membrane impermeant estrogenic complexes can mimic the effect of E2 on DNA synthesis, intracellular Ca2+ concentration and MAPK, but not on CK activity. We now extend these studies by examining the effects of a novel carboxy-derivative of biochanin A, 6-carboxy-biochanin A (cBA) in VSMC and human osteoblasts in culture. cBA increased DNA synthesis in VSMC in a dose-dependent manner and was able to maintain this effect when linked to a cell membrane impermeable protein. In VSMC both cBA and estradiol, in their free or protein-bound forms induced a steep and immediate rise in intracellular calcium. Both the free and protein-bound conjugates of cBA and estradiol increased net MAPK-kinase activity. Neither the stimulatory effect of cBA nor the inhibitory effect of estradiol on DNA synthesis in VSMC could be shown in the presence of the MAPK-kinase inhibitor UO126. The presence of membrane binding sites for both estradiol and cBA was supported by direct visualization, using fluorescence labeling of their respective protein conjugates, E2-BSA and cBA-ovalbumin. Furthermore, these presumed membrane ER for estradiol and cBA were co-localized. In cultured human osteoblasts, cBA stimulated CK activity in a dose related fashion, which paralleled the increase in CK induced by estradiol per se, confirming the estrogenic properties of cBA in human bone cells. Both the free and protein-bound forms of cBA elicited immediate and substantial increments in intracellular Ca2+, similar to, but usually larger than the responses elicited by estradiol per se. cBA also increased ERalpha and suppressed ERbeta mRNA expression in human osteoblasts. Cultured human osteoblasts also harbor membrane binding sites for protein-bound form of cG, which are co-localized with the binding sites for protein-bound estradiol. The extent to which these properties of the novel synthetic phytoestrogen derivatives may be utilized to avert human vascular and/or bone disease requires further study.

Clinical evaluation of atypical glandular cells of undetermined significance upon cervical cytologic examination in Israeli Jewish women

The adjusted incidence of cervical carcinoma among Israeli Jewish women is ∼5 out of 100 000. This retrospective study sought to determine the clinical implications of finding atypical glandular cells of undetermined significance (AGUS) in cervical cytologic specimens in this population. Cervical cytologic examinations during January 2001–June 2003 diagnosed as AGUS were identified by a computerised database. Medical records were reviewed to determine the presence or absence of associated significant pathologic conditions of the cervix and identified 45 out of 11 800 patients (0.38%) with AGUS. AGUS was the only cytologic diagnosis in 14 patients, while 31 patients had both AGUS and an additional atypical squamous cell of undetermined significance (ASCUS). All subjects underwent colposcopy, endocervical curettage, and cervical biopsy. A clinically significant diagnosis (cervical intraepithelial neoplasia (CIN) II, CIN III, or carcinoma) was made in 24 patients (53.3%), including cancer in three (6.7%): one had microinvasive adenocarcinoma and two had microinvasive squamous cell carcinoma. Squamous carcinoma coexisting with a clinically significant lesion carried a risk of 61.3%, compared with a risk of 35.7% for AGUS alone (P=0.20). Detection of AGUS during cervical cytologic screening, especially with a coexisting ASCUS, indicates the existence of serious pathologic processes; management by cervical colposcopy, endocervical curettage, and cervical biopsy is recommended.

Premalignant lesions of the uterine cervix in a large cohort of Israeli Jewish women

Israeli Jewish women are at low risk for cancer of the uterine cervix. In view of absent screening programs in Israel, there are only scarce data available with regard to results of PAP smears. The aim of this study was to assess the incidence of premalignant cervical lesions in the largest sample of PAP smears reported so far from Israel. We retrospectively analyzed the results of 297,849 PAP smears, which had been examined in a single laboratory, during 9 years (1991-1999). The incidence of low- and high-grade squamous intraepithelial was 0.69% and 0.29%, respectively. Our data indicate similar incidence rates for premalignant lesions in Jewish Israeli women as observed in Western countries, but no increase during the study period. In spite of relatively high incidence rates for premalignant lesions of the uterine cervix, the incidence rate for invasive cervical cancer remains conspicuously low. For unknown reason the conversion rate from premalignant cervical lesions to invasive cancer is lower in Israeli Jewish women than in European and North American women. We discuss possible reasons for this phenomenon and suggest that at this time mass screening for cervical cancer in Israel may probably not be justified.

arrow encodes an LDL-receptor-related protein essential for Wingless signalling

The Wnt family of secreted molecules functions in cell-fate determination and morphogenesis during development in both vertebrates and invertebrates (reviewed in ref. 1). Drosophila Wingless is a founding member of this family, and many components of its signal transduction cascade have been identified, including the Frizzled class of receptor. But the mechanism by which the Wingless signal is received and transduced across the membrane is not completely understood. Here we describe a gene that is necessary for all Wingless signalling events in Drosophila. We show that arrow gene function is essential in cells receiving Wingless input and that it acts upstream of Dishevelled. arrow encodes a single-pass transmembrane protein, indicating that it may be part of a receptor complex with Frizzled class proteins. Arrow is a low-density lipoprotein (LDL)-receptor-related protein (LRP), strikingly homologous to murine and human LRP5 and LRP6. Thus, our data suggests a new and conserved function for this LRP subfamily in Wingless/Wnt signal reception.

Ovarian carcinoma associated thrombocytosis. Correlation with prognostic factors and with survival

OBJECTIVE

To assess the prevalence of thrombocytosis (platelets > or = 400,000 microliters) in ovarian cancer of epithelial origin as compared to benign controls consisting of benign ovarian cysts of epithelial origin and to correlate it with prognostic factors of ovarian cancer and survival.

METHOD

Hospital records of 82 consecutive patients with ovarian carcinoma, 12 with low malignant potential tumors and 70 with invasive carcinoma, and of 32 patients with benign cysts of epithelial origin were reviewed. The clinical data and preoperative platelet counts were recorded.

RESULTS

The prevalence of thrombocytosis in invasive ovarian carcinoma of epithelial origin was significantly higher than in benign controls (24.3% vs 2.9%; p = 0.006). No statistically significant correlation was found between thrombocytosis with age, grade and residual disease. A statistically non-significant excess of thrombocytosis was found among patients with advanced disease, but the survival of patients with thrombocytosis was significantly less favorable (p = 0.04).

CONCLUSIONS

Thrombocytosis is significantly more prevalent in ovarian cancer patients than in benign controls and has a statistically significant correlation with poorer survival. The prevalence of thrombocytosis in ovarian carcinoma and its significance in various studies is inconsistent and should be elucidated in large prospective studies.

Tissue-specific processing and polarized compartmentalization of clone-produced cholinesterase in microinjected Xenopus oocytes

1. To approach the involvement of tissue-specific elements in the compartmentalization of ubiquitous polymorphic proteins, immunohistochemical methods were used to analyze the localization of butyrylcholinesterase (BuChE) in Xenopus oocytes microinjected with synthetic BuChEmRNA alone and in combination with tissue-extracted mRNAs. 2. When injected alone BuChEmRNA efficiently directed the synthesis of small membrane-associated accumulations localized principally on the external surface of the oocyte's animal pole. Tunicamycin blocked the appearance of such accumulations, suggesting that glycosylation is involved in the transport of nascent BuChE molecules to the oocyte's surface. Coinjection with brain or muscle mRNA, but not liver mRNA, facilitated the formation of pronounced, tissue-characteristic BuChE aggregates. 3. These findings implicate tissue-specific mRNAs in the assembly of the clone-produced protein and in its nonuniform distribution in the oocyte membrane or extracellular material.

Observations on the ultrasound diagnosis of ovarian neoplasms

In order to determine whether sonography could differentiate between benign and malignant ovarian neoplasms a retrospective analysis of preoperative ultrasound examination was made. The ultrasound images were evaluated for internal consistency, presence of septae, presence of solid nodules, papillary projections and tumor borders. Evidence of ascites and omental involvement were also assessed. Our study showed that benign ovarian serous tumors had a similar appearance to low grade malignant serous tumors, and were undistinguishable from the borderline serous carcinoma. The poorly differentiated serous adenocarcinoma was characterized by the presence of thick papillary projections rather than echogenicity. However, benign or malignant mucinous tumors gave the same pattern. Loss of tumor wall definition, ascites and omental involvement may signal malignancy. The dermoid tumor had a characteristic sonographic appearance.

Divergent regulation of muscarinic binding sites and acetylcholinesterase in discrete regions of the developing human fetal brain

The expression of muscarinic acetylcholine binding sites and of cholinesterases was studied in extracts prepared from discrete regions of the human fetal brain, between the gestational ages of 14 and 24 weeks. The specific binding of [3H]N-methyl-4-piperidyl benzilate [( 4H]-4NMPB) to muscarinic binding sites ranged between 0.05 and 1.30 pmol/mg protein in the different brain regions, with Kd values of 1.2 +/- 0.2 nM. Binding of the cholinergic agonist oxotremorine fitted, in most of the brain regions examined, with a two-site model for the muscarinic binding sites. The density of muscarinic binding sites increased with development in most regions, with different rates and onset times. It was higher by about sixfold in some areas destined to become cholinergic, such as the cortex and midbrain, than in noncholinergic areas such as the cerebellum. In other areas destined to become cholinergic, such as the hippocampus and the caudate putamen, the receptor density remained low. Average density values increased from 0.1 +/- 0.1 at 14 weeks up to 0.7 +/- 0.4 pmol/mg protein at 24 weeks. The variability in the specific activities of cholinesterase was relatively low, and extracts from different brain regions hydrolyzed from 5 to 30 nmol of [3H]acetylcholine/min/mg protein. These were mostly "true" acetylcholinesterase (EC 3.1.1.7) activities, inhibited by 10(-5) M BW284C51, with minor pseudocholinesterase (EC 3.1.1.8) activities, inhibited by 10(-5) M iso-OMPA. The enzyme from different brain regions and developmental stages displayed similar Km values toward [3H]acetylcholine (ca. 4 X 10(-4) M-1). The ontogenetic changes in cholinesterase specific activities had no unifying pattern and/or relationship to the cholinergic nature of the various brain areas. In most of the brain regions, the arbitrary ratio between the specific activity of cholinesterase and the density of muscarinic binding sites decreased with development, with average values and variability ranges of 83 +/- 50 and 19 +/- 19 at 14 and 24 weeks, respectively. Our findings suggest divergent regulation for cholinergic binding sites and cholinesterase in the fetal human brain and imply that the expression of muscarinic receptors is related to the development of cholinergic transmission, while acetylcholinesterase is also involved in other functions in the fetal human brain.

Polymorphism of acetylcholinesterase in discrete regions of the developing human fetal brain

The molecular forms and membrane association of acetylcholinesterase (acetylcholine hydrolase, EC 3.1.1.7) and pseudocholinesterase (acylcholine acylhydrolase, EC 3.1.1.8) were determined in the presence of protease inhibitors in dissected regions of developing human fetal brain, as compared with parallel areas from mature brain. All areas contained substantial cholinesterase activities, of which acetylcholinesterase accounted for almost all the activity. Two major forms of acetylcholinesterase activity, sedimenting at 10-11S and 4-5S, respectively, were detected on sucrose gradients and possessed similar catalytic properties, as judged by their individual Km values toward [3H]acetylcholine (ca. 4 X 10(-4) M). The ratio between these forms varied by up to four- to fivefold, both between different areas and within particular areas at various developmental stages, but reached similar values (about 5:2) in all areas of mature brain. Acetylcholinesterase activity was ca. 35-50% low-salt-soluble and 45-65% detergent-soluble in various developmental stages and brain areas, with an increase during development of the detergent-soluble fraction of the light form. In contrast, pseudocholinesterase activity was mostly low-salt-soluble and sedimented as one component of 10-11S in all areas and developmental stages. Our findings suggest noncoordinate regulation of brain acetylcholinesterase and pseudocholinesterase, and indicate that the expression of acetylcholinesterase forms within embryonic brain areas depends both on cell type composition and on development.

The Drosophila ras oncogenes: structure and nucleotide sequence

Three Drosophila genes homologous to the Ha-ras probe were isolated and mapped to positions 85D, 64B, and 62B on chromosome 3. Two of these genes (termed Dras 1 and Dras 2) were sequenced. In the case of Dras 1, which contains multiple introns, a cDNA clone was isolated and sequenced. In the case of Dras2, the nucleotide sequence fo the genomic clone was determined. Each gene codes for a protein with a predicted molecular weight of 21.6 kd. Alignment of the amino acid sequence of Dras 1 with the vertebrate Ha-ras protein shows that at the amino terminus and central portion (residues 1-121 and 137-164) the two proteins are remarkably similar, and have an overall homology of 75%. The Dras 2 gene lacks significant homology to the vertebrate counterpart at the extreme amino terminus and is homologous only between positions 28-120 and 139-161 (overall homology of 50%). This result suggests that the N terminus of p21 forms a distinct regulatory or functional domain. At the carboxy terminus, the major region of variability among the vertebrate ras proteins, the two Drosophila sequences also display considerable variability. However, both appear to be more similar to exon 4B of the Ki-ras gene.

Nuclear Overhauser effect study of yeast tRNAVal 1: evidence for uridine-pseudouridine base pairing

The proton NMR spectrum of yeast tRNAVal 1 has been studied using nuclear Overhauser effect (NOE), including comparison of NOE patterns between purine C8 deuterated and nondeuterated samples. Studies of the downfield region enable us to reliably assign many resonances in the acceptor and D stems. Prominent among these reliable assignments is that of the unusual base pair U psi, which is made here for the first time. Other identifications include GU2, U8-A14, the three AU base pairs of the acceptor stem, and N1 and N3 protons of psi 55.