Strategies for primary HPV test-based cervical cancer screening programme in resource-limited settings in India: Results from a quasi-experimental pragmatic implementation trial

BACKGROUND

In order for low and middle income countries (LMIC) to transition to Human Papilloma Virus (HPV) test based cervical cancer screening, a greater understanding of how to implement these evidence based interventions (EBI) among vulnerable populations is needed. This paper documents outcomes of an implementation research on HPV screening among women from tribal, rural, urban slum settings in India.

METHODS

A mixed-method, pragmatic, quasi-experimental trial design was used. HPV screening on self-collected cervical samples was offered to women aged 30-60 years. Implementation strategies were 1) Assessment of contextual factors using both qualitative and quantitative methods like key informant interviews (KII), focus group discussions (FGDs), pre-post population sample surveys, capacity assessment of participating departments 2) enhancing provider capacity through training workshops, access to HPV testing facility, colposcopy, thermal ablation/cryotherapy at the primary health care centers 3) community engagement, counselling for self-sampling and triage process by frontline health care workers (HCWs). Outcomes were assessed using the RE-AIM (Reach, Effectiveness, adoption, implementation, maintenance) framework.

RESULTS

Screening rate in 8 months' of study was 31.0%, 26.7%, 32.9%, prevalence of oncogenic HPV was 12.1%, 3.1%, 5.5%, compliance to triage was 53.6%, 45.5%, 84.6% in tribal, urban slum, rural sites respectively. Pre-cancer among triage compliant HPV positive women was 13.6% in tribal, 4% in rural and 0% among urban slum women. Unique challenges faced in the tribal setting led to programme adaptations like increasing honoraria of community health workers for late-evening work and recalling HPV positive women for colposcopy by nurses, thermal ablation by gynaecologist at the outreach camp site.

CONCLUSIONS

Self-collection of samples combined with HCW led community engagement activities, flexible triage processes and strengthening of health system showed an acceptable screening rate and better compliance to triage, highlighting the importance of identifying the barriers and developing strategies suitable for the setting.

TRIAL REGISTRATION

CTRI/2021/09/036130.

ABSENCE OF SUPERFICIAL PALMAR ARCH WITH PERSISTENT MEDIAN ARTERY - A CASE REPORT

The anatomical variations in the arterial supply of the palm are frequently reported. One such variation reported during routine dissection for undergraduate medical students in our college is the absence of superficial palmar arch and presence of persistent median artery. The arterial supply to the palm is in the form of superficial and deep palmar arches. In the present case the median artery and ulnar artery supplies the palm without forming an arch on the left extremity. Awareness of variations in the vascular pattern of the palm is clinically important in case of angiographic procedures and surgical emergencies.

EVALUATION OF RADIO PROTECTIVE EFFECT OF AVERRHOA CARAMBOLA LEAVES EXTRACT IN WISTAR RATS

The present study was designed to investigate the radio protective efficacy of ethanolic extract of leaves of the Averrhoa carambola by studying the following parameters: radioprotective effect before and after radiation, estimating the Total Antioxidant Status, haematological parameters, assessing the histopathology of liver and kidney. Extract was given orally at a dose of 450 mg/kg, orally for 15 days prior to and 15 days after radiation (2 Gy). The rats were kept under observation for 15 days for any sign of radiation sickness, morbidity, behavioural toxicity, urination and defecation pattern or mortality, which showed no changes. The haematological parameters showed a significant decrease in the irradiated rat when compared with the control group. Antioxidant activity revealed from the data obtained in the present study showed that A.carambola leaves ethanolic extract possess good antioxidant activity. Histopathological changes in the irradiated liver and kidney sections showed improved cellular architecture when compared to the normal. The present study suggests that supplementation with Averrhoa carambola has potent antioxidant activity and act as probable radioprotector against gamma radiation induced oxidative damage.

UNILATERAL RECTUS STERNALIS MUSCLE: A CASE REPORT

The Rectus Sternalis muscle is a small supernumerary muscle occasionally present in the anterior thoracic wall. During routine dissection for undergraduate medical students we observed a unilateral left sided rectus sternalis present on the anterior thoracic wall.The knowledge about this variation is very useful for morphologists and anatomists. The presence of this muscle may be mistaken by surgeons, radiologists and physicians for tumor on mammogram or during mastectomy which may increase unnecessary burden on their patients.

COMMUNICATION BETWEEN THE MUSCULOCUTANEOUS AND MEDIAN NERVE: OCCURRENCE ON BOTH SIDES

Communications between musculocutaneous nerve and median nerve may be of considerable significance to neurologists and orthopaedicians when dealing with patients of nerve entrapment syndromes of the upper limb. Many authors have mentioned about an occurrence of such a variation previously, but the presence of a communication between the two nerves in both the arms has not been cited to the best of our knowledge. During routine dissection on a 72 year old male cadaver for the under graduate students in the Department of Anatomy at K.S. Hegde Medical Academy, we encountered an anomalous communication between musculocutaneous and median nerve in both the upper limbs. The communicating branch arose from the musculocutaneous nerve at a distance of 12.6 cm and 12.5 cm from the tip of coracoid process on right and left side and joined the median nerve 16.2 cm from the same bony point. Communications between nerves like this may explain abnormal debilities in certain cases of trauma of the upper arm. Lack of awareness of such variations with different patterns of communications between musculocutaneous and median nerve might complicate surgical repair of the nerves.