Rate of Involved Endocervical Margins According to High-Risk Human Papillomavirus Subtype and Transformation Zone Type in Specimens with Cone Length ≤ 10 mm versus > 10 mm-A Retrospective Analysis

The aim of this study was to evaluate the endocervical margin status according to transformation zone (TZ) and high-risk HPV (hr-HPV) subtype in specimens with cone length ≤ 10 mm versus > 10 mm to provide data for informed decision making and patients counseling especially for women wishing to conceive. In this retrospective cohort study, 854 patients who underwent large loop excision of the transformation zone during a nine-year period (2013-2021) for cervical disease were analyzed. The main outcome parameters were excision length, histological result, TZ type, HPV subtype and endocervical margin status. A subgroup analysis was performed according to excision length, with a cut-off value of 10 mm. A two-step surgical procedure was performed in case of an excision length of > 10 mm. The overall rate of positive endocervical margins irrespective of excision length was 17.2%, with 19.3% in specimens with ≤ 10 mm and 15.0% with > 10 mm excision length. Overall, 41.2% of women with a visible TZ and HPV 16/hr infection and 27.0% of women with HPV 18 received an excisional treatment of > 10 mm length without further oncological benefit, respectively. In contrast, assuming that only an excision of ≤ 10 mm length had been performed in women with visible TZ, the rate of clear endocervical margins would have been 63.7% for HPV 16/hr infections and 49.3% for HPV 18 infections. In conclusion, the decision about excision length should be discussed with the patient in terms of oncological safety and the risk of adverse pregnancy events. An excision length > 10 mm increases the number of cases with cervical tissue removed without further oncological benefit, which needs to be taken into account in order to provide an individual therapeutic approach. Furthermore, HPV 18 positivity is related to a higher rate of positive endocervical margins irrespective of TZ.

HPV screening in the urine of transpeople - A prevalence study

BACKGROUND

There is limited data on human papillomaviruses (HPV) prevalence in transpeople due to low acceptance rate of screening methods. HPV tests from self-collected urine are gender-neutral, have a high acceptance, and have a comparable accuracy in females to clinician-collected samples. The aim of this study was to evaluate both the HPV prevalence in the urine in a large cohort of 200 transpeople with common risk profiles and the acceptability of such screening method.

METHODS

The study was conducted at the outpatient clinic for transpeople at the Department of Obstetrics and Gynaecology, Medical University of Vienna, Austria. 200 transpeople have been enrolled between May and October 2021. Inclusion criteria were gender identity dysphoria, age over 18 years, and adequate language skills.Subjects were asked to answer a survey concerning gender identity, established risk factors for HPV infections as well as their preference regarding urine or provider-collected cytology-/HPV-based screening, and to provide a urine sample. Five patients not able to provide urine were excluded. HPV genotyping was performed using a validated multiplex real-time PCR assay, which simultaneously detects 28 HPV genotypes. This trial is registered at ClinicalTrials.gov, NCT04864951.

FINDINGS

Overall HPV positivity was 19·0% (37/195), 24·2% in female to male, 11·8% in male to female, 26·3% in genderqueer/non binary/other subjects, 27·9% in subjects currently having a cervix, and 26·0% in subjects born with cervix. Independent of gender reassignment surgery, being born with a cervix was associated with a higher risk of HPV infections (p = 0·008), yet 42·3% (44/104) have never attended cervical cancer screening. Overall, 79·0% (154/195) of transpeople would prefer urine HPV tests to provider-collected HPV screening.

INTERPRETATION

HPV testing in self-collected urine samples provides a unique opportunity for screening of this hard-to-reach population and should be evaluated in further studies.

FUNDING

None.

Prevalence of Gestational Diabetes in Triplet Pregnancies: A Retrospective Cohort Study and Meta-Analysis

Background: Over the last decades, there has been a substantial increase in the incidence of higher-order multiple gestations. Twin pregnancies are associated with an increased risk of gestational diabetes mellitus (GDM). The literature on GDM rates in triplet pregnancies is scarce. Methods: A retrospective cohort study was performed to assess the prevalence of GDM in women with a triplet pregnancy. GDM was defined through an abnormal oral glucose tolerance test (OGTT). A meta-analysis of GDM prevalence was also carried out. Results: A cohort of 60 women was included in the analysis. Of these, 19 (31.7%) were diagnosed with GDM. There were no differences in pregnancy outcomes between women with and without GDM. In the meta-analysis of 12 studies, which used a sound GDM definition, an estimated pooled prevalence of 12.4% (95% confidence interval: 6.9–19.1%) was found. In a leave-one-out sensitivity analysis, the estimated GDM prevalence ranged from 10.7% to 14.1%. Conclusion: The rate of GDM seems increased in women with triplets compared to singleton pregnancies. However, GDM did not impact short-term pregnancy outcomes.

Effect of Viewing Disney Movies During Chemotherapy on Self-Reported Quality of Life Among Patients With Gynecologic Cancer: A Randomized Clinical Trial

IMPORTANCE

In addition to treatment efficacy, evaluation of adverse effects and quality of life assessments have become increasingly relevant in oncology.

OBJECTIVE

To evaluate the association of watching Disney movies during chemotherapy with emotional and social functioning and fatigue status.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial was performed from December 2017 to December 2018 at a cancer referral center in Vienna, Austria. A consecutive sample of women with gynecologic cancers was recruited through July 2018. Inclusion criteria included age older than 18 years, written informed consent, and planned 6 cycles of chemotherapy with either carboplatin and paclitaxel or carboplatin and pegylated liposomal doxorubicin. Exclusion criteria were inadequate knowledge of the German language or receipt of other chemotherapy regimens. Data analysis was performed from February 2019 to April 2019.

INTERVENTION

Participants were either shown Disney movies or not during 6 cycles of chemotherapy. Before and after every cycle, they completed standardized questionnaires from the European Organisation for Research and Treatment of Cancer (EORTC).

MAIN OUTCOMES AND MEASURES

Primary outcomes were change of quality of life, as defined by the EORTC Core-30 (version 3) questionnaire, and fatigue, as defined by the EORTC Quality of Life Questionnaire Fatigue, during 6 cycles of chemotherapy.

RESULTS

Fifty-six women entered the study, and 50 completed it, including 25 women in the Disney group (mean [SD] age, 59 [12] years) and 25 women in the control group (mean [SD] age, 62 [8] years). In the course of 6 cycles of chemotherapy, patients in the Disney group felt less tense and worried less than patients in the control group according to their responses to the questions about emotional functioning (mean [SD] score, 86.9 [14.3] vs 66.3 [27.2]; maximum test P = .02). Furthermore, watching Disney movies was associated with less encroachment on patients' family life and social activities, as evaluated by the social functioning questions (mean [SD] score, 86.1 [23.0] vs 63.6 [33.6]; maximum test P = .01). Moreover, this intervention led to fewer fatigue symptoms (mean [SD] score, 85.5 [13.6] vs 66.4 [22.5]; maximum test P = .01). Perceived global health status was not associated with watching Disney movies (mean [SD] score, 75.9 [17.6] vs 61.0 [25.1]; maximum test P = .16).

CONCLUSIONS AND RELEVANCE

These findings suggest that watching Disney movies during chemotherapy may be associated with improvements in emotional functioning, social functioning, and fatigue status in patients with gynecologic cancers.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03863912.

The impact of p16ink4a positivity in invasive vulvar cancer on disease-free and disease-specific survival, a retrospective study

Purpose

To evaluate HPV and p16^ink4a status as prognostic factors in patients with invasive vulvar cancer.

Methods

Retrospective analysis of disease-free (DFS) and disease-specific survival (DSS) of patients with invasive vulvar cancer at a single tertiary care center. Histology, HPV and p16^ink4a status were evaluated in the context of a global multicenter trial. Logistic regression models were performed to identify the impact of p16^ink4a positivity.

Results

135 patients were included in the analysis. 32 (23.7%) showed a p16^ink4a expression of over 25%. Disease-free and disease-specific survival was longer in p16^ink4a positive patients (23 vs. 10 months, p = 0.004, respectively, 29 vs. 21 months, p = 0.016). In multivariate analysis, p16^ink4a positivity was an independent parameter for DFS (p = 0.025, HR: 2.120 (1.100–4.085)), but not for DSS (p = 0.926, HR: 1.029 (0.558–1.901), in contrast to age and tumor stage.

Conclusions

Age and tumor stage negatively affect survival. However, disease-free survival is significantly longer in patients with p16^ink4a positive invasive vulvar cancer.

Heavy black tea consumption and elevated CA 19-9 and CA 125 levels. A case report on a patient with ovarian endometriotic cysts

In this case report, we present a case of false positive CA 19-9 and CA 125 levels in a patient with suspected endometriotic cysts. The patient is a 34-year-old nulliparous woman with heavy black tea consumption and elevated CA 19-9 and CA 125 levels. After discontinuation of black tea intake and careful exploration of other possible factors, CA 19-9 and CA 125 levels dropped markedly. As a conclusion, heavy black tea consumption can lead to false positive results of elevated CA 19-9 and CA 125 levels.

Prognostic Laboratory Parameters in Placental Abruption: A Retrospective Case-Control Study

To evaluate routine laboratory parameters in women with and without placental abruption (PA) and in controls, 417 women were included in this retrospective cohort study in a tertiary-care center. 118 women with PA (Group A: 54 without vaginal bleeding and Group B: 64 with bleeding), 130 women without either PA or vaginal bleeding throughout their pregnancy (Group C), 123 women with vaginal bleeding but without PA (Group D), and 46 healthy pregnant women who had undergone a control laboratory evaluation in the second/third trimester for history of previous cytomegalovirus (additional control group) were included. Hemoglobin, leukocytes, thrombocytes, C-reactive protein (CRP), and fibrinogen were obtained within 48 hours before C-section and/or at the time of bleeding onset. Cases (Groups A and B) revealed higher CRP levels than controls (Groups C and D) after multivariate analysis in the sub-analyses of bleeding (0.56 mg/dL, interquartile range (IQR) 0.28–1.24 vs. 0.51 mg/dL, IQR 0.28–0.84; odds ratio (OR) 1.108, p = 0.006) and non-bleeding women (0.64 mg/dL, IQR 0.48–1.08 vs. 0.32 mg/dL, IQR 0.18–0.61; OR 7.454, p < 0.001). The non-bleeding cases (Group A) revealed significantly higher leukocyte (12.01 g/L, IQR 9.41–14.10 vs. 9.21 g/L, IQR 7.95–10.49; OR 1.378, 95% confidence interval (CI): 1.095⁻1.735; p = 0.006) and CRP levels (0.64 mg/dL, IQR 0.48–1.08 vs. 0.33 mg/dL, IQR 0.20–0.50; OR 7.942, 95% CI: 1.435–43.958; p = 0.018) than the additional control group. In cases, none of the laboratory parameters differed between women with and without bleeding. The significantly increased CRP levels found for women with PA and the lack of a difference in CRP between bleeding and non-bleeding cases point toward a chronic process underlying placental abruption. However, this laboratory parameter does not seem clinically relevant for distinguishing between women with and without placental abruption at this point in time.

Risk-adapted management for vasa praevia: a retrospective study about individualized timing of caesarean section

Purpose

Vasa praevia is a rare condition with high foetal mortality if not detected prenatally. There is limited evidence available to determine the ideal timing of delivery and management recommendations. The aim of this study was to critically review our experience with vasa praevia, with a focus on diagnosis and management.

Methods

In a retrospective analysis, all cases of vasa praevia identified in our department from January 2003 to December 2017 were included. All cases were diagnosed antenatally during sonographic inspection of the placenta, and individualized management for each patient was performed based on individual risk factors. 19 cases of vasa praevia were identified (15 singletons, four twins). 13 patients (79%) presented placental anomalies. In patients at high risk for preterm birth, caesarean delivery was performed between 34–35 weeks after early hospitalization and administration of corticosteroids, whereas in patients at low risk for preterm birth, caesarean section could be delayed to 35–37 weeks of gestation. Administration of corticosteroids was not obligatory in the latter cases.

Results

There were two acute caesarean sections, due to premature abruption of the placenta and vaginal bleeding. There was no maternal or foetal/neonatal death. None of the neonates required blood transfusion. There is limited evidence available with which to determine the ideal timing of delivery.

Conclusion

However, our individualized, risk-adapted management, which attempts to delay the timing of caesarean section up to two weeks beyond the standard recommendation, seems feasible, with just two emergency caesarean sections and no case of foetal or maternal death.

Does anti-Mullerian hormone predict the outcome of further pregnancies in idiopathic recurrent miscarriage? A retrospective cohort study

Purpose

To evaluate whether anti-Mullerian hormone, basal follicle-stimulating hormone, luteinizing hormone, estradiol, and female age would predict future outcomes in women with idiopathic recurrent miscarriage.

Methods

One hundred and sixteen women with idiopathic recurrent miscarriage were retrospectively included. Luteal support with or without a combined treatment regimen for idiopathic recurrent miscarriage was applied in a tertiary-care center in Vienna. Occurrence and outcome of further pregnancies were analyzed.

Results

Within a median follow-up duration of 42.3 months, 94 women (81.0%) achieved one or more pregnancies. Further miscarriages occurred in 47 patients in whom only a higher number of previous miscarriages was predictive (OR 3.568, 95% CI 1.457–8.738; p = 0.005). Fifty-seven women had a live birth > 23 + 0 gestational weeks. In a multivariate analysis, age (OR 0.920, 95% CI 0.859–0.986; p = 0.019) and the number of previous miscarriages (OR 0.403, 95% CI 0.193–0.841; p = 0.016), but not AMH (OR 1.191, 95% CI 0.972–1.461; p = 0.091) were significantly predictive.

Conclusion

AMH seems of either no or only minor relevance for the prediction of further miscarriages and live birth in women with idiopathic recurrent miscarriage.

Reliability of sonographic fetal weight estimation in triplet pregnancies: a retrospective cohort study

PURPOSE

To review our experience in ultrasound fetal weight estimation in our large population of triplet pregnancies.

METHODS

Ninety-seven triplet pregnancies were retrospectively included between January 2003 and January 2017. Sonographic fetal weight estimation using Hadlock's and Schild's formulas was compared to actual birth weight in a tertiary-care center in Vienna, Austria. Statistical analyses were performed using a stepwise linear regression model and crosstabs.

RESULTS

The median discrepancy between the sonographically estimated fetal weight by Hadlock's formula and the actual birth weight was 106 g (IQR 56-190). The percentage error and its standard deviation were - 2.5 ± 12.1%, and the median percentage error was - 3.6%. Concerning the use of Hadlock's formula, estimated fetal weight was the most important factor predictive of actual birth weight with an estimate of 0.920 (p < 0.001). Female neonates had been overestimated by a mean of 50.473 g per fetus. The sonographic prediction of small-for-gestational-age neonates was significantly reliable (p < 0.001), with positive and negative predictive values ranging from 81.3 to 100.0%. Similar results were obtained for Schild's formula.

CONCLUSION

Even if sonographically estimated fetal weight in triplet pregnancies has a high overall accuracy of fetal weight estimation, there are some limitations in prediction of intrauterine growth restrictions, especially in female fetuses.

Oligomannosidic glycans at Asn-110 are essential for secretion of human diamine oxidase

N-Glycosylation plays a fundamental role in many biological processes. Human diamine oxidase (hDAO), required for histamine catabolism, has multiple N-glycosylation sites, but their roles, for example in DAO secretion, are unclear. We recently reported that the N-glycosylation sites Asn-168, Asn-538, and Asn-745 in recombinant hDAO (rhDAO) carry complex-type glycans, whereas Asn-110 carries only mammalian-atypical oligomannosidic glycans. Here, we show that Asn-110 in native hDAO from amniotic fluid and Caco-2 cells, DAO from porcine kidneys, and rhDAO produced in two different HEK293 cell lines is also consistently occupied by oligomannosidic glycans. Glycans at Asn-168 were predominantly sialylated with bi- to tetra-antennary branches, and Asn-538 and Asn-745 had similar complex-type glycans with some tissue- and cell line-specific variations. The related copper-containing amine oxidase human vascular adhesion protein-1 also exclusively displayed high-mannose glycosylation at Asn-137. X-ray structures revealed that the residues adjacent to Asn-110 and Asn-137 form a highly conserved hydrophobic cleft interacting with the core trisaccharide. Asn-110 replacement with Gln completely abrogated rhDAO secretion and caused retention in the endoplasmic reticulum. Mutations of Asn-168, Asn-538, and Asn-745 reduced rhDAO secretion by 13, 71, and 32%, respectively. Asn-538/745 double and Asn-168/538/745 triple substitutions reduced rhDAO secretion by 85 and 94%. Because of their locations in the DAO structure, Asn-538 and Asn-745 glycosylations might be important for efficient DAO dimer formation. These functional results are reflected in the high evolutionary conservation of all four glycosylation sites. Human DAO is abundant only in the gastrointestinal tract, kidney, and placenta, and glycosylation seems essential for reaching high enzyme expression levels in these tissues.

Intra- versus retroplacental hematomas: a retrospective case-control study on pregnancy outcomes

Background

Intrauterine hematomas are a common pregnancy complication. The literature lacks studies about outcomes based on hematoma localization. Thus, we aimed to compare pregnancies complicated by an intraplacental hematoma to cases with a retroplacental hematoma and to a control group.

Methods

In a retrospective case-control study, 32 women with an intraplacental hematoma, 199 women with a retroplacental hematoma, and a control group consisting of 113 age-matched women with no signs of placental abnormalities were included. Main outcome measures were pregnancy complications.

Results

Second-trimester miscarriage was most common in the intraplacental hematoma group (9.4%), followed by women with a retroplacental hematoma (4.2%), and controls (0%; p = 0.007). The intraplacental hematoma group revealed the highest rates for placental insufficiency, intrauterine growth retardation, premature preterm rupture of membranes, preterm labor, preterm delivery <37 weeks, and early preterm delivery <34 weeks (p < 0.05), followed by the retroplacental hematoma group. When tested in multivariate models, intraplacental hematomas were independent predictors for placental insufficiency (ß = 4.19, p < 0.001) and intrauterine growth restriction (ß = 1.44, p = 0.035). Intrauterine fetal deaths occurred only in women with a retroplacental hematoma (p = 0.042).

Conclusions

Intra- and retroplacental hematomas have different risk profiles for the affected pregnancy and act as independent risk factors.

HPV prevalence in vulvar cancer in Austria

Background

Even if vulvar cancer is not common, over one hundred women are affected in Austria per year. There is strong evidence that basaloid and warty variants are associated with types of human papillomavirus (HPV).

Methods

The aim of this study is to analyze the types of HPV in vulvar cancer in Austria. This cross-sectional period-prevalence international collaborative study on archival specimens was performed in cooperation with the Institut Catalan di Oncologia in Barcelona, Spain. A total of 177 consecutive samples of Austrian women were analyzed to detect the presence of various HPV types using the SPF10 PCR/DEIA/LiPA25 system. Furthermore, the expression of the tumor suppressor protein p16^INK4a was analyzed by immunohistochemistry (CINtec histology kit, ROCHE). A tumor was considered HPV-driven if an overexpression of p16^INK4a was detected.

Results

In all, 41 cases of vulvar cancer tested positive for HPV DNA (23%) and 32 (18%) were p16 positive. Patients with warty and basaloid squamous cell cancer were significantly younger than those with keratinizing squamous cell cancer (63.3 years vs. 71.0 years, p = 0.021). In addition, 77.4% of all cases suffering from warty or basaloid squamous cell cancer tested positive for HPV, compared to 9.5% of the keratinizing squamous cell cancer cases (p < 0.001). The most commonly detected HPV strain was type 16, followed by 31 and 33.

Conclusion

Infection with HPV type 16 appears to be strongly correlated to the development of warty or basaloid squamous cell cancer. Vaccination against HPV can be expected to prevent this type of vulvar cancer.

Anti-Mullerian hormone is linked to the type of early pregnancy loss in idiopathic recurrent miscarriage: a retrospective cohort study

We correlated Anti-Mullerian hormone (AMH) levels and other parameters for ovarian reserve to the gestational age at the time of pregnancy loss in women with idiopathic recurrent miscarriage. In a retrospective study, 79 patients had suffered a total of 266 miscarriages. When comparing women with an "unembryonic" to those with an "embryonic" most recent miscarriage, there was no difference in median age (36.3 years, IQR 31.6-40.1 versus 34.2 years, IQR 29.9-38.0; p = 0.303) but in median AMH levels (0.7, IQR 0.2-18, versus median 1.8, IQR 1.3-3.3, respectively, p = 0.044) and in the rate of patients with an AMH ≤ 1 ng/mL (23/37, 62.2%, versus 8/42, 19%; p < 0.001). Thus, AMH might add to the diagnostic process in recurrent miscarriage in the future.

Impact of baseline covariates on the immunogenicity of the 9-valent HPV vaccine - A combined analysis of five phase III clinical trials

BACKGROUND

The immunogenicity profile of the 9-valent HPV (9vHPV) vaccine was evaluated across five phase III clinical studies conducted in girls and boys 9-15 years of age and young women 16-26 years of age. The effect of baseline characteristics of subjects on vaccine-induced HPV antibody responses was assessed.

METHODS

Immunogenicity data from 11,304 subjects who received ≥1 dose of 9vHPV vaccine in five Phase III studies were analyzed. Vaccine was administered as a 3-dose regimen. HPV antibody titers were assessed 1 month after dose 3 using a competitive Luminex immunoassay and summarized as geometric mean titers (GMTs). Covariates examined were age, gender, race, region of residence, and HPV serostatus and PCR status at day 1.

RESULTS

GMTs to all 9 vaccine HPV types decreased with age at vaccination initiation, and were otherwise generally similar among the demographic subgroups defined by gender, race and region of residence. For all subgroups defined by race or region of residence, GMTs were higher in girls and boys than in young women. Vaccination of subjects who were seropositive at day 1 to a vaccine HPV type resulted in higher GMTs to that type, compared with those in subjects who were seronegative for that type at day 1.

CONCLUSIONS

9vHPV vaccine immunogenicity was robust among subjects with differing baseline characteristics. It was generally comparable across subjects of different races and from different regions. Greater immunogenicity in girls and boys versus young women (the population used to establish 9vHPV vaccine efficacy in clinical studies) indicates that the anti-HPV responses generated by the vaccine in adolescents from all races or regions were sufficient to induce high-level protective efficacy. This immunogenicity profile supports a widespread 9vHPV vaccination program and early vaccination.

Cervical length dynamics in triplet pregnancies: a retrospective cohort study

Purpose

To review our experience with a screening program that included sequential cervical length measurements in our large population of triplet pregnancies.

Methods

Seventy-eight triplet pregnancies were retrospectively included. Cervical length measurements were performed by transvaginal ultrasound in 2-week intervals from week 16 + 0 onwards in a tertiary-care center in Vienna. The main outcome measurement was preterm delivery prior to 32 + 0 weeks of gestation. Statistical analyses were performed using paired and unpaired t tests and a stepwise linear regression model.

Results

There were 26 cases of preterm delivery (33.3%). Women with preterm delivery revealed significant cervical length shortening from week 22 + 0 (median 33 mm, interquartile range, IQR 17–39) to 24 + 0 (median 21 mm, IQR 7–30; p = 0.005). This was not observed in women without preterm delivery. From week 22 + 0 onwards, both groups showed further significant 2-week differences in cervical length (p < 0.05). Univariate analysis of cervical length in weeks 20 + 0, 22 + 0, and 24 + 0 as well as cervical length dynamics from 22 + 0 to 24 + 0 predicted preterm delivery.

Conclusions

In triplet pregnancies, a decrease in cervical length seems physiological from week 22 + 0 onwards. A sharp decrease in cervical length from the 22 + 0 to the 24 + 0 week as well as the smaller cervical length in weeks 20 + 0, 22 + 0, and 24 + 0 increase the risk of preterm delivery.

Vaccines against human papillomavirus infections: protection against cancer, genital warts or both?

Since 2006, three vaccines against infections and disease caused by human papillomavirus (HPV) became available in Europe-in 2006 a quadrivalent HPV 6/11/16/18 vaccine, in 2007 a bivalent HPV 16/18 vaccine and in 2015 a nonavalent HPV 6/11/16/18/31/33/45/52/58 vaccine. HPV 16 and 18 are the most oncogenic HPV strains, causing about 70% of cervical and other HPV-related cancers, HPV 6 and 11 cause 85% of all genital warts. The additional types of the polyvalent vaccine account for about 20% of invasive cervical cancer and >35% of pre-cancer. The potential differences between these vaccines caused some debate. All three vaccines give a robust and long-lasting protection against the strains in the various vaccines. The promise of cross-protection against other types (i.e. HPV 31/33/45) and hence a broader cancer protection was not fulfilled because these observations were confounded by the vaccine efficacy against the vaccine types. Furthermore, cross-protection was not consistent over various studies, not durable and not consistently seen in the real world experience. The protection against disease caused by oncogenic HPV strains was not compromised by the protection against low-risk types causing genital warts. The most effective cancer protection to date can be expected by the nonavalent vaccine, data indicate a 97% efficacy against cervical and vulvovaginal pre-cancer caused by these nine HPV types.

A Retrospective Study on the Association between Thyroid Autoantibodies with β2-glycoprotein and Cardiolipin Antibodies in Recurrent Miscarriage

Etiologic factors for recurrent miscarriage (RM) include autoimmune diseases, the most frequently antiphospholipid syndrome and thyroiditis. Some women who suffer from RM might also have an altered immune system. We aimed to evaluate possible associations between anti-thyroid and anti-phospholipid antibodies in women with RM. In a retrospective case series 1 on 156 women with RM, major outcome parameters were antibodies against cardiolipin, β2-glycoprotein I, thyreoperoxidase (TPO-Ab), and thyroglobulin (TG-Ab). Significant (p<0.05) positive correlations were found between TPO-Ab and TG-Ab (r=0.577), TPO-Ab and IgG anti-cardiolipin antibodies (r=0.284), TPO-Ab and IgG anti- β2-glycoprotein I antibodies (r=0.196), and TG-Ab and IgG anti-cardiolipin antibodies (r=0.193), as well as between all types of anti-phospholipid antibodies. Women with both increased TPO-Ab and TG-Ab levels revealed higher (p<0.001) IgG anti-cardiolipin and IgG anti-β2-glycoprotein I antibodies. Anti-thyroid antibodies were linked to anti-phospholipid antibodies and should be in the focus of future research on RM.

Altered glucose profiles and risk for hypoglycaemia during oral glucose tolerance testing in pregnancies after gastric bypass surgery

AIMS/HYPOTHESIS

A history of gastric bypass surgery can influence the results of the OGTT recommended during pregnancy. Therefore, we compared OGTT glucose kinetics and pregnancy outcome between pregnant gastric bypass patients and BMI-matched, lean and obese controls.

METHODS

Medical records were used to collect data on glucose measurements during the 2 h 75 g OGTT as well as on pregnancy and fetal outcome for 304 women (n = 76 per group, matched for age and date of delivery).

RESULTS

Women after bariatric surgery had lower fasting glucose levels compared with lean, obese and BMI-matched controls, and showed altered postprandial glucose kinetics, including a rise at 60 min followed by hypoglycaemia with serum glucose of <3.34 mmol/l (which occurred in 54.8%). Moreover, their risk of pre-eclampsia or gestational hypertension was reduced, with an increased risk of delivering small for gestational age infants.

CONCLUSIONS/INTERPRETATION

Alternative strategies to accurately define impaired glucose metabolism in pregnancies after bariatric surgery should be explored.

Quantification of human diamine oxidase

OBJECTIVES

Diamine oxidase (DAO) is essential for extracellular degradation of histamine. For decades activity assays with inherent limitations were used to quantify the relative amounts of DAO. No reference DAO standard is available. Absolute DAO amounts cannot be determined. Controversy exists, whether DAO is circulating or not in non-pregnant individuals. The role of DAO as biomarker in various diseases is ambiguous. It is not clear, whether precise quantification of human DAO antigen using commercially available enzyme-linked immunosorbent assays (ELISAs) is possible. The objective was to develop a precise and robust ELISA to quantify DAO in various biological fluids.

DESIGN AND METHODS

A research prototype ELISA was established using a mouse monoclonal antibody for capturing and a polyclonal rabbit serum IgG fraction for the detection of human DAO. The limit of blank (LoB), limit of detection (LoD) and estimated limit of quantification (eLoQ) and normal DAO concentrations in serum and plasma were determined.

RESULTS

The LoB, LoD and eLoQ derived from 42 standard curves are 0.27, 0.48 and 0.7ng/mL respectively. The detection range using the LoD as the lower and the highest DAO standard as the upper boundary is 0.5 to 450ng/mL. Serum and plasma mean/median concentrations are between 0.5 and 1.5ng/mL in healthy volunteers (n=58) and mastocytosis patients (n=19) and plateau at approximately 145ng/mL (n=16) during pregnancy. Accurate quantification was not influenced by heparin (DAO is a heparin-binding protein), lipaemic or hemolytic serum. The measured DAO antigen concentrations are in close agreement with published enzymatic activity data using radioactive putrescine as substrate.

CONCLUSIONS

This research prototype ELISA is able to reliably and accurately quantify human DAO in different biological fluids. The potential of DAO as biomarker in various diseases can be evaluated.

Decreased Ovarian Reserve Predicts Inexplicability of Recurrent Miscarriage? A Retrospective Analysis

Objective

To evaluate anti-Mullerian hormone, basal follicle stimulating hormone, luteinizing hormone, estradiol, and female age in women with recurrent miscarriage and to compare women with explained and idiopathic recurrent miscarriage.

Design

Retrospective cohort study.

Setting

University hospital, tertiary care center.

Patients

Women with recurrent miscarriage (78 explained, 66 idiopathic).

Intervention(s)

None.

Main Outcome Measures(s)

Anti-Mullerian hormone, basal follicle stimulating hormone, luteinizing hormone, estradiol, and age.

Results

Anti-Mullerian hormone and estradiol were significantly lower in women with idiopathic recurrent miscarriage (median 1.2 ng/ml, IQR 0.6–2.1, and median 36.5 pg/ml, IQR 25.8–47.3, respectively) than in women with explained recurrent miscarriage (median 2.0 ng/ml, IQR 1.1–2.7, and median 42.5 pg/ml, IQR 32.8–59.8, respectively; p<0.05). Optimized cut-off values for the prediction of idiopathic recurrent miscarriage were <39.5 pg/ml for estradiol (sensitivity: 63.3%, 95% CI: 50.9–75.1; specificity: 56.4%, 95% CI: 44.7–67.6) and <1.90 ng/ml for anti-Mullerian hormone (sensitivity: 72.7%, 95% CI: 60.4–83.0; specificity: 52.6%, 95% CI: 40.9–64.0).

Conclusion

Idiopathic recurrent miscarriage was associated with lower basal estradiol and anti-Mullerian hormone levels compared to explained recurrent miscarriage.

Safety Profile of the 9-Valent HPV Vaccine: A Combined Analysis of 7 Phase III Clinical Trials

OBJECTIVES

The overall safety profile of the 9-valent human papillomavirus (9vHPV) vaccine was evaluated across 7 Phase III studies, conducted in males and females (nonpregnant at entry), 9 to 26 years of age.

METHODS

Vaccination was administered as a 3-dose regimen at day 1, and months 2 and 6. More than 15 000 subjects received ≥1 dose of 9vHPV vaccine. In 2 of the studies, >7000 control subjects received ≥1 dose of quadrivalent HPV (qHPV) vaccine. Serious and nonserious adverse events (AEs) and new medical conditions were recorded throughout the study. Subjects testing positive for pregnancy at day 1 were not vaccinated; those who became pregnant after day 1 were discontinued from further vaccination until resolution of the pregnancy. Pregnancies detected after study start (n = 2950) were followed to outcome.

RESULTS

The most common AEs (≥5%) experienced by 9vHPV vaccine recipients were injection-site AEs (pain, swelling, erythema) and vaccine-related systemic AEs (headache, pyrexia). Injection-site AEs were more common in 9vHPV vaccine than qHPV vaccine recipients; most were mild-to-moderate in intensity. Discontinuations and vaccine-related serious AEs were rare (0.1% and <0.1%, respectively). Seven deaths were reported; none were considered vaccine related. The proportions of pregnancies with adverse outcome were within ranges reported in the general population.

CONCLUSIONS

The 9vHPV vaccine was generally well tolerated in subjects aged 9 to 26 years with an AE profile similar to that of the qHPV vaccine; injection-site AEs were more common with 9vHPV vaccine. Its additional coverage and safety profile support widespread 9vHPV vaccination.

Acetylic Salicylic Acid for the Treatment of Chronic Obstructive Pulmonary Disease: A Randomized, Double-Blind, Placebo-Controlled Trial

PURPOSE

Chronic obstructive pulmonary disease (COPD) is one of the leading causes of death in the world. Current treatment options provide relief from symptoms rather than stop disease progress. Results from various preclinical experiments suggest a causal benefit of acetylic salicylic acid (ASA) in the treatment of COPD. Hence, this study set out to examine the clinical benefit of ASA in the treatment of COPD. COPD patients (Global Initiative for Chronic Obstructive Lung Disease II-III) received either once daily 500 mg of ASA or a matching placebo for 12 weeks in addition to their preexisting medication. Clinical response in terms of pulmonary function testing, symptomatic response and adverse events were assessed. After 40 subjects were included, the study was stopped and an interim analysis was performed. The addition of ASA to the treatment of subjects with COPD had no effect on clinical features or spirometry (forced expiratory volume in 1 s: F = 0.49, d.f.1 = 1, d.f.2 = 74, p = 0.486) and non-pulmonary markers. COPD represents a complex of different diseases, although currently classified mainly by markers of lung function. If future trials test the effects of anti-inflammatory therapies, COPD subpopulations should be predefined based on inflammatory features.

The predictive value of sequential cervical length screening in singleton pregnancies after cerclage: a retrospective cohort study

Background

There are few valid predictors for preterm delivery after cerclage. Experience with a screening program that included four sequential cervical length measurements in singleton pregnancies after cerclage is reviewed.

Methods

In this retrospective cohort study, 88 singleton pregnancies after cerclage were included. Cervical length (CL) measurements were performed perioperatively and at weeks 16 + 0, 18 + 0, 20 + 0, and 22 + 0 by transvaginal ultrasound. Predictive factors for early preterm delivery included patient characteristics, obstetric history and CL measurements and were analyzed separately for women with ultrasound-indicated cerclage and those with history-indicated cerclage. Women with emergency cerclage were excluded.

Results

In women with delivery <35 weeks, CL declined from the 16 + 0 to the 22 + 0 weeks of gestation (p = 0.009). In univariate analysis, all CL measurements were predictive for delivery <35 weeks in women who underwent ultrasound-indicated cerclage and in women who received a history-indicated cerclage, whereas in multivariate analysis only CL three to six days after cerclage remained significant (odds ratio 0.85, 95 % CI 0.73–0.98). In women with ultrasound-indicated cerclage, optimized cut-off was ≤20 mm (specificity 83.8 %, sensitivity 84.2 %).

Conclusions

CL measured three to six days after cerclage placement provides the best information about the risk for delivery <35 weeks.

Velamentous cord insertion as a risk factor for obstetric outcome: a retrospective case-control study

PURPOSE

Velamentous umbilical cord insertion (VCI) is associated with adverse pregnancy outcomes. Literature lacks data on Doppler. We aimed to evaluate obstetric outcomes and results of uterine and umbilical artery Doppler flowmetry associated with VCI.

MATERIALS AND METHODS

In a retrospective case-control study, 108 singleton pregnancies with VCI were age- and body mass index-matched to 108 singleton pregnancies without VCI. The main outcome parameters were obstetric outcome, pregnancy-related complications, uterine artery flowmetry at the second-trimester screening, and umbilical artery flowmetry before delivery. Statistical analysis was accomplished using Pearson's Chi-square test or Fisher's exact test, and the Mann-Whitney U test, where appropriate.

RESULTS

Pregnancies with VCI revealed a significantly higher PI in the umbilical artery during the last measurement before delivery (1.00 ± 0.25 vs. 0.90 ± 0.10; p = 0.001). Gestational age at this measurement did not differ between the groups. Fetal malformations and intrauterine fetal death were more common in pregnancies with VCI (12.7 vs. 0 %; p < 0.001, and 6.5 vs. 0 %; p = 0.014, respectively). Patients with VCI delivered significantly earlier (36.2 ± 4.5 vs. 38.4 ± 2.6; p < 0.001).

CONCLUSION

Higher rates of (early) preterm delivery were found in pregnancies with VCI. Fetuses with VCI also suffered from malformations and IUFD more frequently. The last pulsatility index value in the umbilical artery, before delivery, was significantly higher in pregnancies with VCI, which is of uncertain clinical value.

A retrospective study on perineal lacerations in vaginal delivery and the individual performance of experienced mifwives

BACKGROUND

Medical staff's influence on patient outcomes has become a subject of interest. We evaluated experienced midwives and compared their performance concerning perineal lacerations (PL).

METHODS

In a retrospective cohort study, 1937 women with singleton pregnancies who had delivered spontaneously with a cephalic presentation by experienced midwives in the Medical University of Vienna from January 2009 to April 2014 were included. As predictive parameters, we included basic patient-, pregnancy- and delivery-related characteristics including the individual midwife who delivered the child. The incidence of PL was the main outcome measure.

RESULTS

Overall PL and severe PL were found in 508/1937 (26.2%) and 19/1937 women (1.0%), respectively. In a multivariate analysis for PL of any degree, maternal age (ß = 0.170 ± 0.080), gestational age at delivery (ß = 0.190 ± 0.320), and birth weight (ß = 0.002 ± 0.000) significantly increased the risk, whereas multiparity (ß = -0.379 ± 0.141) and mediolateral episiotomy (ß = -1.514 ± 0.284) decreased it (p < 0.05). In addition, the individual midwife who delivered the child was a significant influencing factor, with ß-values ranging from -0.028 to 0.899 compared to the reference midwife. For severe PL, the midwife was not of significant influence.

CONCLUSIONS

The individual midwife is an independent factor that influences the risk for overall PL, not for severe PL. Other risk factors include maternal age, gestational age at delivery, birth weight, parity and episiotomy.

Association of -463G/A MPO gene polymorphism and risk of cervical intraepithelial neoplasia

PURPOSE

The MPO system plays an important role in the control of infections and the deletion of malignant cells. Nevertheless, alternations in the MPO system can lead to DNA damage and carcinogenesis. Polymorphisms in the MPO Gene have been associated with an increased expression of MPO and a higher risk for development of cancer. This study evaluates the association between -463G/A MPO gene polymorphism and the risk for CIN.

METHODS

The MPO gene polymorphism (-463G/A) was investigated in 616 women with cervical intraepithelial neoplasia and in 206 healthy women. Association between MPO gene polymorphism and risk of cervical intraepithelial neoplasia were analyzed by univariate and multivariable models.

RESULTS

No significant difference in genotype distribution of the MPO gene polymorphism was observed in women with CIN and controls (p = 0.4; OR 1.2, 95 % CI 0.8-1.6). A subgroup analysis only including women with CIN did not show an association between -463G/A MPO gene polymorphism and risk for high-grade CIN (CIN 2/3) (p = 0.09; OR 1.5, 95 % CI 0.9-2.3).

CONCLUSIONS

The investigated MPO gene polymorphism is not associated with risk for the development of cervical intraepithelial neoplasia.

From the monovalent to the nine-valent HPV vaccine

An investigational monovalent human papillomavirus (HPV) 16 virus-like particle vaccine has been shown to prevent persistent infection and cervical disease related to HPV 16 and was proof of concept (2002). Designed to prevent the bulk of invasive cervical cancer, quadrivalent (HPV 6/11/16/18) and bivalent (HPV 16/18) vaccines have been available since 2006 and 2007, respectively. They are highly effective in preventing HPV 16/18-related cervical precancer; the quadrivalent version also prevents genital warts related to HPV 6/11. It has been shown that the precursors of vulvar, vaginal and anal cancer related to the vaccine types are effectively prevented. This led to a paradigm shift from a female-only cervical cancer vaccine to a vaccine for the prevention of HPV-related disease and cancer for both sexes. Vaccination before the start of sexual activity is most effective, and consequently most programs target 9- to 12-year-olds. Additionally, recent studies have proven the noninferior immunoresponse of a two-dose schedule in these age cohorts. Gender-neutral vaccination has become more common; it improves coverage and also provides protection to all males. Recently a nine-valent HPV vaccine (HPV 6/11/16/18/31/33/45/52/58) was licensed; it provides high and consistent protection against infections and diseases related to these types, with ∼90% of cervical and other HPV-related cancers and precancers potentially being avoided. Coverage is key. Efforts must be made to provide HPV vaccination in low-resource countries that lack screening programs. In countries with cervical cancer screening, HPV vaccination will greatly affect screening algorithms.

What do women with gynecologic cancer know about HPV and their individual disease? A pilot study

Background

The vaccinations against human papilloma virus (HPV) are highly effective in preventing persistent infection. The level of knowledge about HPV and the consequences of an infection with this virus are low in the general population and in patients who suffer from HPV-associated diseases. We aimed to compare the level of knowledge about HPV and about the women’s individual malignant disease between women with and without HPV-associated gynecologic cancer as well as the knowledge about individual malignant diseases.

Methods

In a pilot study, 51 women with HPV-related cancer (cervical cancer: n = 30; vulvar or vaginal cancer: n = 21) and 60 women with non-HPV associated gynecologic malignancies (ovarian cancer: n = 30; endometrial cancer, n = 30) were included. They answered a questionnaire including questions about personal medical history, risk factors for cancer development, and HPV.

Results

The general level of knowledge of the term “HPV” was low (29.7%, 33/111) and it was similar in patients with HPV-related and non-HPV-associated cancer (18/60, 30.0% vs. 15/51, 29.4%, respectively; p = 1.000). When asked about their disease, 80% (24/30) of women with ovarian cancer correctly named their diagnosis, followed by women with cervical cancer (73.3%, 22/30), endometrial cancer (70%, 21/30) and vaginal or vulvar cancer (42.9%, 9/21; p = 0.008).

Conclusion

The level of knowledge about HPV and the malignant diseases the patient suffered from was low. This applied even to patients with HPV associated malignancies.

Prenatal sonography can predict degree of placental invasion

OBJECTIVE

To evaluate whether the maximum degree of placental invasion (placenta accreta, increta or percreta) can be predicted with ultrasound imaging, using criteria developed in our department.

METHODS

This was a retrospective study of all 232 patients at risk for placental invasion who were part of a routine screening program for placental invasion from January 2001 to January 2011. The whole placenta was scanned in a systematic manner using both gray-scale ultrasound and color-flow mapping. Sonographic findings were compared with the clinical outcome during and after delivery and the histomorphological examination of the placenta.

RESULTS

Placental invasion was suspected by ultrasound in 40 (17.2%) patients and was clinically/histopathologically confirmed in a total of 35 (15.1%) patients. The sensitivity, specificity and positive and negative predictive values of ultrasound for placental invasion were 91.4% (95% CI, 77.6-97.0%), 95.9% (95% CI, 92.2-97.9%), 80.0% (95% CI, 65.2-89.5%) and 98.4% (95% CI, 95.5-99.5%), respectively. No case of placenta increta (n = 7) or percreta (n = 17) was diagnosed as showing normal placentation or placenta accreta on ultrasound, giving an overall accuracy for the differentiation between normal placentation/placenta accreta and placenta increta/percreta of 100%.

CONCLUSION

Our data suggest that prediction of the degree of placental invasion is possible using prenatal ultrasound, with high overall accuracy.

Sequential cervical length screening in pregnancies after loop excision of the transformation zone conisation: a retrospective analysis

OBJECTIVE

To review our experience with a screening programme that included four sequential cervical length (CL) measurements from 16 to 22( ) weeks of gestation.

DESIGN

Historical cohort study.

SETTING

Tertiary-care centre in a university hospital.

POPULATION

There were 312 singleton pregnancies in 321 women with a previous large loop excision of the transformation zone (LLETZ), and 62 pregnancies after a second-trimester miscarriage in a previous pregnancy.

METHODS

The CL measurements were performed by transvaginal ultrasound at 16, 18, 20, and 22 completed weeks of gestation.

MAIN OUTCOME MEASURES

Early preterm delivery before 34 completed weeks of gestation.

RESULTS

Early preterm delivery was found in 7.4%. The CL at 16 completed weeks of gestation was smaller in the LLETZ group (36 mm, interquartile range 30-40 mm) compared with the control group (38 mm, interquartile range 32-42 mm; P = 0.040). For the analysis of risk factors for early preterm delivery after LLETZ, only cases with a complete data set were included (n = 145). In a multivariate analysis, two parameters remained significantly predictive, with CL at 16 completed weeks of gestation being the most significant measure (P < 0.001, OR 0.90, 95% CI 0.83-0.98), followed by conception using IVF treatment (P = 0.031, OR 0.64, 95% CI 1.54-34.80).

CONCLUSIONS

Even as early as 16 weeks of gestation, women with early preterm delivery reveal a significantly lower CL than those without. Dynamics in the CL do not add to this information.

Impact of conization type on the resected cone volume: results of a retrospective multi-center study

PURPOSE

The extent of conization seems to influence the risk of preterm birth. The aim of this study was to compare the cone volume after surgical resection with large loop excision of the transformation zone (LLETZ) and cold knife conization (CKC).

METHODS

The present retrospective multi-center study comprises 804 consecutive women, who underwent LLETZ (n = 412) or CKC (n = 392) between 2004 and 2009. Univariate and multivariable analyses were performed to compare cone volumes removed by LLETZ and CKC and identify independent risk factors for large cone volume.

RESULTS

The median resected cone volume after LLETZ was significantly smaller [1.6 cm(3) (0.8-2.9)] than after CKC [2.1 cm(3) (1.4-3.5)] (<0.0001). Complete resection rates were comparable in both groups. Conization method, cone depth, and institution type were independent risk factors for removal of a large cone volume.

CONCLUSION

CKC removes larger cone volumes than LLETZ without the advantage of higher complete resection rates.

The prognostic value of estrogen receptor beta and proline-, glutamic acid- and leucine-rich protein 1 (PELP1) expression in ovarian cancer

Background

Proline-, glutamic acid-, and leucine-rich protein 1 (PELP1), a coregulator of the estrogen receptors (ERs) alpha and beta, is a potential proto-oncogene in hormone dependent gynecological malignancies. To better understand the role of PELP1 in epithelial ovarian cancer (EOC), the protein expression and prognostic significance of PELP1 was evaluated together with ERalpha and ERbeta in EOC tissues.

Methods

The expression of PELP1, ERalpha, and ERbeta was characterized in tumor tissues of 63 EOC patients. The prognostic value was calculated performing log-rank tests and multivariate Cox-Regression analysis. In a second step, validation analysis in an independent set of 86 serous EOC patients was performed.

Results

Nuclear PELP1 expression was present in 76.2% of the samples. Prevalence of PELP1 expression in mucinous tumors was significantly lower (37.5%) compared to serous (85.7%) and endometrioid tumors (86.7%). A significant association between PELP1 expression and nuclear ERbeta staining was found (p=0.01). Positive PELP1 expression was associated with better disease-free survival (DFS) (p=0.004) and overall survival (OS) (p=0.04). The combined expression of ERbeta+/PELP1+ revealed an independent association with better DFS (HR 0.3 [0.1-0.7], p=0.004) and OS (HR 0.3 [0.1-0.7], p=0.005). In the validation set, the combined expression of ERbeta+/PELP1+ was not associated with DFS (HR 0.7 [0.4-1.3], p=0.3) and OS (HR 0.7 [0.3-1.4], p=0.3).

Conclusion

Positive immunohistochemical staining for the ER coregulator PELP1, alone and in combination with ERbeta, might be of prognostic relevance in EOC.

Dexmedetomidine as an adjuvant to ropivacaine prolongs peripheral nerve block: a volunteer study

BACKGROUND

Dexmedetomidine is an α-2-receptor agonist which might be used as an additive to local anaesthetics for various regional anaesthetic techniques. We therefore designed this prospective, double-blinded, controlled volunteer study to investigate the effects of dexmedetomidine as an adjuvant to ropivacaine on peripheral nerve block.

METHODS

Ultrasound-guided ulnar nerve block (UNB) was performed in 36 volunteers with either 3 ml ropivacaine 0.75% (R), 3 ml ropivacaine 0.75% plus 20 µg dexmedetomidine (RpD), or 3 ml ropivacaine 0.75% plus systemic 20 µg dexmedetomidine (RsD). UNB-related sensory and motor scores were evaluated.

RESULTS

Sensory onset time of UNB was not different between the study groups, whereas motor onset time was significantly faster in Group RpD when compared with the other study groups [mean (sd)] [21 (15) vs 43 (25) min in Group RsD and 47 (36) min in Group R, P<0.05 Group RpD vs other groups]. The duration of sensory block was 350 (54) min in Group R, 555 (118) min in Group RpD, and 395 (40) min in Group RsD (P<0.01 Group RpD vs other groups, P<0.05 Group RsD vs Group R). Motor block duration was similar to the duration of sensory block.

CONCLUSIONS

A profound prolongation of UNB of ∼60% was detected with perineural dexmedetomidine when added to 0.75% ropivacaine. The systemic administration of 20 µg dexmedetomidine resulted in a prolongation of ∼10% during UNB with 0.75% ropivacaine. Eudra-CT No.: 2012-000030-19.