Trends in the Use of Hypofractionation in Treatment of Breast Cancer in Botswana

PURPOSE/OBJECTIVE(S)

Clinical trials have shown that moderate hypofractionation (HF) is clinically effective as adjuvant treatment to breast conserving surgery or following mastectomy with advanced disease. ASTRO issued updated guidelines in 2018, expanding the population eligible to receive HF to all patients, regardless of age and tumor stage. Use of HF can promote efficient resource utilization for over-burdened health care systems; however, global adoption of HF has been previously only reported via ESTRO survey of individual physicians. These data note that HF following lumpectomy is 40% in Africa vs. >90% in North America, with limited data on the uptake of HF within individual African countries. In this study, we characterize temporal trends and clinical, socio-demographic factors associated with the use of HF in breast cancer in Botswana.

MATERIALS/METHODS

We retrospectively analyzed a cohort of breast cancer patients receiving curative intent radiation between 2015 and 2022 at the only radiation clinic in Botswana. We compared patients' characteristics between those who received HF vs. standard fractionation (SF) and report chi-square statistics when appropriate. We fit a multilevel mixed-effects logistic regression model with a random intercept for district while adjusting for fixed effects such as HIV infection status, laterality, hormone receptor status, and marital status.

RESULTS

A total of 234 patients were prescribed curative intent radiation between 2015 and 2022 in Gaborone, Botswana. Median age at diagnosis was 51 years old, and the majority of patients presented with stage III disease (61.9%, 109/234). 26.9% of this population were women living with HIV (WLWH), and 71% lived >100km from the hospital. HF was utilized overall in 59.4% (139/234) of patients. Most common fractionation patterns included: 4005cGy/15fx and 4267cG/16fx. One patient received ultra-HF (2600cGy/5fx). In unadjusted chi-square analysis, a higher proportion of HF was seen in right vs left-sided breast cancer (65.8% vs. 50.9%, p = 0.02), increasing year of diagnosis from 2015 - 2022 (p<0.001), and among patients >/ = 40 years of age vs. those <40 years of age (62.8% vs 42.1%, p = 0.017). Temporal trends show a significant increase in the utilization of HF starting from 23.8% (5/21) in 2015, to 61.5% (32/52) in 2018, and finally 100% (11/11) of cases in 2022. Our regression analysis shows that there is no statistically significant between-district variance or patient-level factors that associate with the uptake of HF. The overall utilization rate for HF between 2015-2022 was 59.4% (95% CI: 53.0%-65.5%).

CONCLUSION

Based on recent survey results the uptake of HF among African countries is lower than that of North America. To our knowledge, this is the first quantitative analysis of the utilization of HF over 5 years in an African country. Further analysis on factors related to physician prescription of hypofractionation is warranted, including influence of breast laterality, age, and primary surgery type.

Distance Traveled by Patients Globally to Access Radiotherapy: A Systematic Review

PURPOSE/OBJECTIVE(S)

This systematic review aims to investigate the global travel patterns of patients seeking radiotherapy and examines the distance traveled by patients and its impact on secondary outcomes such as travel time and survival. The findings of this review will provide crucial information on barriers to accessing radiotherapy and inform the development of patient-centered care strategies aimed at improving access to this important form of treatment.

MATERIALS/METHODS

A comprehensive search of four databases was conducted from June to August 2022. Studies were included if they were observational, retrospective, or randomized/non-randomized, published between June 2000 and June 2022, and reported the distance traveled globally for the treatment of malignant or benign disease. Studies were excluded if they did not report travel distance or were not written in English.

RESULTS

A total of 176 studies were included. Most of the studies (69.9%) were conducted in North America, with the majority (68.7%) in the United States. The treatment modalities varied with external beam radiation therapy being the most common (17.0%). The most common disease site was breast (26.7%). Of the included studies, 49 reported the mean distance traveled for radiation therapy. The shortest mean distance was reported in the United States at 4.83 miles, while the longest was reported in Iran at 276.5 miles. It was observed that patients living in countries outside the United States traveled greater distances for radiation therapy than those living within the U.S. Additional factors such as urban vs. rural residence and treatment modality were also found to impact the distance traveled for radiation therapy. Our results indicate a wide range of travel times, with approximately half of the studies reporting values greater than 1 hour, which was the case for 100% of the studies on low-income populations (n = 4). Out of 176 studies, only 15% discussed patient survival and reported conflicting results between travel distance and survival rates, regardless of treatment, disease site, or country of origin.

CONCLUSION

This systematic review is the most comprehensive to date on the global travel patterns of patients seeking radiotherapy. Results show that travel distances varied, but overall, patients in the U.S. traveled shorter distances for radiation therapy than those living outside the country. Treatment center location, patient residence, and treatment modality impacted patient travel distance, but the patterns were inconsistent. These findings emphasize the importance of considering the distance traveled as a barrier to receiving radiotherapy and highlight the need for strategies to improve patient access and prioritize patient-centered care.

SCCAg as a Biomarker of Advanced Stage and OS in Limited Resource Setting for Cervical Cancer

PURPOSE/OBJECTIVE(S)

Elevated serum squamous cell antigen (SCCAg) has been previously correlated with poor survival, extensive tumor involvement, and recurrence for cervical cancer. Failure of serum SCCAg to normalize after treatment completion has also been studied as a poor prognostic indicator. This is the first study describing the association of SCCAg with stage and outcomes in patients diagnosed with cervical cancer in Botswana, in a population with a majority of women who are living with HIV (WLWH).

MATERIALS/METHODS

Patients with histologically confirmed cervical cancer were enrolled in a prospective observational study between August 2016 and April 2020 in Botswana. Among all patients undergoing definitive chemoradiation, serum SCCAg was determined at pre-treatment baseline, end of treatment (EOT), and 3-month follow-up (normal reference range 0.3 -1.9 ng/ml). Normalization of SCCAg was defined as return to the reference range after treatment (SCCAg response), and was measured first at EOT; if EOT values were not available, 3-month values were utilized. Patients were staged according to FIGO 2009 criteria, early stage was defined as Stage I-II; while advanced stage was defined as Stage III-IV. Median follow-up was 44 months. A significant cut-off point for baseline and SCCAg response correlated with overall survival (OS) was calculated utilizing a log-rank test RESULTS: Among 234 patients who were diagnosed with histologically confirmed cervical cancer, 73.5% were WLWH (mean CD4 count 466 cells/mL). 92.9% of all cancers were squamous cell carcinoma. 68.8% of patients had elevated SCCAg at time of diagnosis. There was no significant difference in mean baseline SCCAg between WLWH (13.3 ng/mL) and women living without HIV (9.07 ng/mL), p = 0.1052. There was a significant difference seen in mean SCCAg between early (7.9 ng/mL ± SD 13.4) and advanced (18.9 ng/mL, ± SD 29.8) stage disease at diagnosis, p < 0.0001. Baseline SCCAg > 7.9 ng/mL was found to be associated with worse OS (p < 0.001). 5-year OS was significantly different among patients with SCCAg response < = 2.8 (5-year OS 66.2%), vs. SCCAg >2.8 ng/mL (5-year OS 42.4%). There was no significant difference in average SCCAg values between EOT (p = 0.68) and 3-month follow-up (p = 0.24). There was no difference in the proportion of patients who experienced normalized SCCAg by HIV status (p = 0.67).

CONCLUSION

There was no significant difference in SCCAg among WLWH and women living without HIV. Among patients with elevated SCCAg above normal at baseline, SCCAg was associated with early vs. advanced stage disease. Additionally, there was a significant difference seen in overall survival by two measurement points: baseline SCCAg >7.9 ng/mL and response SCCAg >2.8 ng/mL. SCCAg may be utilized as a biomarker in low-resource settings to refine prognosis. Further studies will be needed to determine utility and validation in predicting recurrence risk and/or lymph node metastases.

Association of Bacterial Composition and Diversity in the Cervical Tumor Microbiome with HPV Genotype in a Large, International Patient Cohort

PURPOSE/OBJECTIVE(S)

Tumor bacterial composition is strongly associated with response to cancer therapy, and is impacted by environment, including geography. Human papillomavirus (HPV) genotypic diversity composition and load are dynamic during pelvic radiation (RT) and correlate with differential responses to RT in cervical cancer patients. In this multi-institutional, collaborative study, we aimed to explore associations between bacterial composition, HPV serotypes, and geographical distribution in an international patient population.

MATERIALS/METHODS

Cervical swabs were collected from 287 patients diagnosed with cervical cancer/ dysplasia in four locations: Houston, USA (TX; N = 94), Ethiopia (ETH; N = 85), Puerto Rico (PR; N = 71), and Botswana (BOT; N = 37). Swabs were collected prior to treatment and were subjected to 16S V4 rRNA gene sequencing and HPV genotyping. We compared HPV types and geography via Chi-squared test. We analyzed bacterial composition, alpha diversity (ANOVA), and beta diversity (principal coordinates analysis [PCoA] with PERMANOVA) for HPV type and geography. We used Linear Discriminant Effect Size (LEfSe) analysis to distinguish taxa associated with HPV types.

RESULTS

Overall, the global bacterial composition for patients with cancer or dysplasia did not significantly vary by location. However, the proportion of patients with each HPV type varied by location (p<0.01); HPV16 was most frequent in TX (54%), BOT (70%) and ETH (61%), while HPV18 was most frequent in PR (62%). The proportion of patients with HPV low-risk/negative tumors was highest in ETH (25%) compared to other sites (2% - 14%). Patients with HPV 16 had significantly higher bacterial alpha diversity across locations (all p<0.01). The bacterial composition also differed by HPV type across locations (p = 0.01). On LEfSe, bacterial genera enriched in HPV 16 samples were Bacteroides, Clostridium, and Prevotella. Non-HPV16 tumors were enriched in species of Lactobacillus and Gardnerella and HPV 18 and high-risk type tumors were enriched in Escherichia.

CONCLUSION

In thislarge, international cohort of cervical cancer and dysplasia patients, bacterial composition was more closely associated with cervical HPV genotype than with geography. This finding has implications for the development of biomarkers and interventions aimed at improving chemotherapy and radiation response through manipulation of the microbiome.

Host-microbe interaction and pathogen exclusion mediated by an aggregation-prone surface layer protein of Lactobacillus helveticus

Probiotic surface layer proteins (Slps) have multiple functions and bacterial adhesion to host cells is one of them. The precise role of Slps in cellular adhesion is not well understood due to its low native protein yield and self-aggregative nature. Here, we report the recombinant expression and purification of biologically active Slp of Lactobacillus helveticus NCDC 288 (SlpH) in high yield. SlpH is a highly basic protein (pI = 9.4), having a molecular weight of 45 kDa. Circular Dichroism showed a prevalence of beta-strands in SlpH structure and resistance to low pH. SlpH showed binding to human intestinal tissue, enteric Caco-2 cell line, and porcine gastric mucin, but not with fibronectin, collagen type IV and laminin. SlpH inhibited the binding of the enterotoxigenic E. coli by 70 % and 76 % and that of Salmonella Typhimurium SL1344 by 71 % and 75 % to enteric Caco-2 cell line in the exclusion and competition assays, respectively. The pathogen exclusion and competition activity and tolerance to harsh gastrointestinal conditions show the potential for developing SlpH as a prophylactic or therapeutic agent against enteric pathogens.

Postbiotic Lipoteichoic acid of probiotic Lactobacillus origin ameliorates inflammation in HT-29 cells and colitis mice

Lipoteichoic acid (LTA) is a key surface component of probiotic lactobacilli that is involved in important cellular functions including cross talk with the host immune cells. In this study, the anti-inflammatory and ameliorative properties of LTA from probiotic lactobacilli strains were assessed in in vitro HT-29 cells and in vivo colitis mice. The LTA was extracted with n-butanol and its safety was confirmed based on its endotoxin content and cytotoxicity in HT-29 cells. In the Lipopolysaccharide stimulated HT-29 cells, the LTA from the test probiotics evoked a visible but non-significant increase in IL-10 and decrease in TNF-α levels. During the colitis mice study, probiotic LTA treated mice showed substantial improvement in external colitis symptoms, disease activity score and weight gain. The treated mice also showed improvements in key inflammatory markers such as the gut permeability, myeloperoxidase activity and histopathological damages in colon, although non-significant improvements were recorded for the inflammatory cytokines. Furthermore, structural studies by NMR and FTIR revealed increased level of D-alanine substitution in the LTA of LGG strain over MTCC5690. The present study demonstrates the ameliorative effect of LTA as a postbiotic component from probiotics which can be helpful in building effective strategies for combating gut inflammatory disorders.

A114 UNIFIED MAGNIFYING ENDOSCOPIC CLASSIFICATION (UMEC) FOR GASTROINTESTINAL LESIONS: A NORTH AMERICAN EDUCATION STUDY

Background

Magnification endoscopy and magnification narrow-band imaging are image enhanced endoscopy technologies that may allow for the diagnosis of advanced neoplasia in the GI tract on the basis of imaging characteristics. Recently, the Unified Magnifying Endoscopic Classification (UMEC) has been developed, which unified the criteria for the esophagus, stomach, and colon. UMEC divides optical diagnosis into one of the three categories: non-neoplastic, intramucosal neoplasia, and deep submucosal invasive cancer.

Purpose

The objective of this study is to educate North American endoscopists on the use of the UMEC schema, and to ascertain performance of the UMEC framework among North American endoscopists.

Method

Using UMEC, five North American endoscopists (&gt;1000 procedures) without prior training in magnifying endoscopy independently diagnosed previously collected endoscopic image set of the esophagus, stomach, and colon. The endoscopists were trained on the use of UMEC via an eleven-minute training video with exemplars of each element of UMEC from esophagus, stomach, and colon. All endoscopists were blinded to white-light and non-magnifying NBI findings as well as histopathological diagnosis. The diagnostic performance of UMEC was assessed while using the gold standard histopathology as a reference.

Result(s)

A total of 299 gastrointestinal lesions (77 esophagus, 92 stomach, and 130 colon) were assessed using UMEC. For esophageal squamous cell carcinoma, the sensitivity, specificity, and accuracy for all 5 endoscopists ranged from 65.2% (95% CI: 50.9–77.9) to 87.0% (95% CI: 75.3–94.6), 77.4% (95% CI: 60.9–89.6) to 96.8% (95% CI: 86.8–99.8), and 75.3% to 87.0%, respectively. For gastric adenocarcinoma, the sensitivity, specificity, and accuracy for all 5 endoscopists ranged from 94.9% (95% CI: 85.0–99.1) to 100%, 52.9% (95% CI: 39.4–66.2) to 92.2% (95% CI: 82.7–97.5), and 73.3% to 93.3%, respectively. For colorectal adenocarcinoma, the sensitivity, specificity, and accuracy for all 5 endoscopists ranged from 76.2% (95% CI: 62.0–87.3) to 83.3% (95% CI: 70.3–92.5), 89.7% (95% CI: 82.1–94.9) to 97.7% (95% CI: 93.1–99.6), and 86.8% to 90.7%, respectively.

Image

Conclusion(s)

UMEC is a simple and practical classification that can be used to introduce and educate endoscopists to magnification narrow-band imaging and optical diagnosis.

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CAG

Disclosure of Interest

M. R. A. Fujiyoshi Grant / Research support from: 2022 CAG/AbbVie Education Research Grant, Y. Fujiyoshi: None Declared, N. Gimpaya: None Declared, R. Bechara: None Declared, T. Jeyalingam: None Declared, N. Calo: None Declared, N. Forbes: None Declared, R. Khan: None Declared, M. Atalla: None Declared, A. Toshimori: None Declared, Y. Shimamura: None Declared, M. Tanabe: None Declared, J. Mosko: None Declared, H. Inoue: None Declared, S. Grover: None Declared

A128 GLOBAL TRENDS IN TRAINING AND CREDENTIALING GUIDELINES FOR GASTROINTESTINAL (GI) ENDOSCOPY: A SYSTEMATIC REVIEW

Background

Credentialing in GI endoscopy is not a universally standardized process. National guidelines may provide a framework for local training, however in certain settings, training committees set minimal competency requirements that must be met before a clinician can be accredited to practice independently. There is a paucity of literature assessing the inter-societal and geographic variability in guidelines and training requirements in endoscopy.

Purpose

To systematically review the available credentialing guidelines proposed by different GI endoscopy societies and affiliated training committees internationally.

Method

We conducted a systematic review according to the PRISMA guidelines. A comprehensive literature search was performed for credentialing guidelines for GI endoscopy from inception until January 2022. Two reviewers screened and one reviewer abstracted data using a pre-defined data collection form.

Result(s)

From the 653 records obtained from our search, 20 credentialing guidelines from 12 different GI societies were ultimately included in the review. These guidelines encompassed the following procedures and outlined the following key-performance indicators; a) Colonoscopy: the recommended minimum number of procedures performed ranged from 150-275 with a minimum cecal intubation and adenoma detection rate of 85-90% and 20-30% respectively; b) EGD: the minimum number of procedures prior to credentialing ranged from 130-1000, the minimum duodenal intubation rate ranged from 95-100%, and the range for minimum number of upper GI bleeds managed was 20-45 (in addition to other procedural KPIs); c) ERCP: the recommended minimum number of procedures prior to credentialing ranged from 100-300 cases with a minimum selective duct cannulation rate of 80-90%. Guidelines for flexible sigmoidoscopy, EUS and capsule endoscopy were also obtained.

Image

Conclusion(s)

There is a general concordance amongst the various international GI societies with regards to minimum procedural volume and performance in key procedural tasks prior to credentialing, however the use of validated education assessment tools was lacking in the majority of guidelines. Additional KPI’s need to be explored for less routinely performed procedures such as EUS and capsule endoscopy.

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None

Disclosure of Interest

None Declared

A115 THE PERFORMANCE OF NATURAL LANGUAGE PROCESSING IN INTERPRETING COLONOSCOPY REPORTS: A SYSTEMATIC REVIEW AND META-ANALYSIS

Background

Screening colonoscopy is integral in the effort to identify and remove potentially cancerous lesions. Important quality indicators include the adenoma detection rate and more recently, the sessile/serrated adenoma detection rate. Natural language processing (NLP) is a computer-based linguistic technique that leverages artificial intelligence to abstract meaningful information from text. This tool carries the potential to automate the task of analyzing large volumes of colonoscopy and pathology reports to generate data on key performance metrics.

Purpose

The aim of this study is to systematically review the available literature on the performance of NLP in identifying the presence of an adenoma or a sessile/serrated adenoma in colonoscopy reports.

Method

We performed a systematic review and meta-analysis according to PRISMA recommendations. A comprehensive literature query was conducted on MEDLINE, EMBASE, CINAHL, and CDSR, through July 2022. Studies were included if they evaluated the performance of NLP in extracting data from colonoscopy reports. Our primary outcome was the performance of NLP models in correctly identifying an adenoma reported in a colonoscopy report. Two authors independently screened studies and abstracted data using an a priori designed data collection form. We pooled the sensitivity and specificity of our primary outcome using a univariate analysis first, followed by a bivariate analysis. Using the open-source package ‘mada’ which is written in R, we generated a summary estimate and a summary receiver operating characteristic curve.

Result(s)

From the 1030 unique studies obtained from our literature search, 13 studies met the inclusion criteria. Eligible studies were used for our meta-analysis. In the univariate analysis, the pooled sensitivity and specificity for detecting an adenoma by the NLP systems was 0.978 (95% CI 0.938-0.992) and 0.997 (95% CI 0.984-0.999), respectively. Similarly, in univariate analysis, the pooled sensitivity and specificity for detecting a sessile/serrated adenoma by the NLP systems was 0.984 (95% CI 0.929-0.996) and 1.0 (95% CI 0.998-1.000), respectively. In the bivariate analysis, the summary estimates for the sensitivity and specificity of the NLP system in detecting an adenoma were 0.973 (95% CI 0.929-0.990) and 0.992 (95%CI 0.978-0.997) respectively. For detecting a sessile/serrated adenoma, the summary estimates for sensitivity and specificity were 0.964 (95% CI 0.895-0.988) and 0.998 (95% CI 0.995-0.999) respectively.

Conclusion(s)

NLP models have excellent performance in extracting quality metric data from colonoscopy reports. Based on the available literature, we suggest integration of NLP in quality improvement efforts in colonoscopy.

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None

Disclosure of Interest

None Declared

A117 VALIDITY EVIDENCE FOR ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY COMPETENCY ASSESSMENT TOOLS: A SYSTEMATIC REVIEW

Background

Assessment of competence in endoscopic retrograde cholangiopancreatography (ERCP) is essential to ensure trainees possess the skills needed for independent practice. Traditionally, ERCP training has used the apprenticeship model, whereby novices learn skills under the supervision of an expert. A growing focus on procedural quality, however, has supported the implementation of competency-based medical education models which require documentation of a trainee’s competence for independent practice. Observational assessment tools with strong evidence of validity are critical to this process. Validity evidence supporting ERCP observational assessment tools has not been systematically evaluated.

Purpose

To conduct a systematic review of ERCP assessment tools and identify tools with strong evidence of validity using a unified validity evidence framework

Method

We conducted a systematic search using electronic databases and hand-searching from inception until August 2021 for studies evaluating observational assessment tools of ERCP performance. We used a unified validity framework to characterize validity evidence from five sources: content, response process, internal structure, relations to other variables, and consequences. Each domain was assigned a score of 0-3 (maximum score 15). We assessed educational utility and methodological quality using the Accreditation Council for Graduate Medical Education framework and the Medical Education Research Quality Instrument, respectively.

Result(s)

From 2769 records, we included 17 studies evaluating 7 assessment tools. Five tools were studied for clinical ERCP, one on simulated ERCP, and one on simulated and clinical ERCP. Validity evidence scores ranged from 2-12. The Bethesda ERCP Skills Assessment Tool (BESAT), ERCP Direct Observation of Procedural Skills Tool (ERCP DOPS), and The Endoscopic Ultrasound (EUS) and ERCP Skills Assessment Tool (TEESAT) had the strongest validity evidence with scores of 10, 12, and 11, respectively. Regarding educational utility, most tools were easy to use and interpret, and required minimal additional resources. Overall methodological quality was strong, with scores ranging from 10-12.5 (maximum 13.5).

Conclusion(s)

The BESAT, ERCP DOPS, and TEESAT have strong validity evidence compared to other assessments. Integrating tools into training may help drive learners’ development and support competency decision-making.

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CAG

Disclosure of Interest

None Declared

Prognostic impact of tumour budding in squamous cell carcinoma of the lung: a systematic review and meta-analysis

Tumour budding is an established prognostic factor in various solid tumours, including colorectal cancers and oral squamous cell carcinomas. However, its role is unclear and needs to be defined for squamous cell carcinoma of the lung (LSCC). Hence, we conducted a systematic review and meta-analysis investigating the prognostic role of tumour budding in LSCC. PubMed, Embase and Scopus were searched for peer-reviewed literature investigating the association between tumour budding and survival outcomes or clinicopathological variables in LSCC. The primary outcomes were pooled estimates for overall and recurrence-free survival with hazard ratio (HR) as the effect measure. The association between tumour budding and clinicopathological parameters was also investigated. Of 243 studies, nine were included, comprising 2546 patients. An increased risk of death [HR = 1.76, 95% confidence interval (CI) = 1.50-2.05, P < 0.00001] and recurrence (HR = 1.37, 95% CI = 1.12-1.68, P = 0.003) was evident in patients with high-grade tumour budding. Sensitivity and subgroup analyses revealed consistent results. Pathological stage II, lymph node metastasis, lymphovascular and pleural invasion were associated with high-grade tumour budding. Tumour budding is a new and promising prognostic factor in patients with LSCC. However, pervasive heterogeneity and publication bias reduces the credibility of these findings and the applicability of tumour budding in clinical practice. Future studies are required to standardise reporting on tumour budding in LSCC.

Human papillomavirus prevalence among unvaccinated young female college students in Botswana: A cross-sectional study

BACKGROUND

Human papillomavirus (HPV) is a sexually transmitted infection and a causative agent of cervical cancer. It is common in adolescent girls and young women, and the majority of infections are transient and asymptomatic. In Botswana, there are currently no data on the HPV prevalence against which the impact of prophylactic HPV vaccines can be measured.

OBJECTIVES

To establish a baseline HPV prevalence in an unvaccinated cohort of young women.

METHODS

Women aged ≥18 years were recruited from the University of Botswana between September 2016 and May 2020. Demographic and behavioural characteristics of participants were collected. Subsequently, cervicovaginal swabs were obtained and tested for HPV using polymerase chain reaction-restriction fragment length polymorphism. We determined the prevalent HPV types, and evaluated the risk factors associated with HPV positivity.

RESULTS

A total of 978 young women were recruited. Overall, there were 589 (60.2%) participants with HPV infection and 12 (1.2%) with HIV. The median (interquartile range) age of the study participants was 19 (18 - 20) years. Multivariate logistic regression analysis showed that significant factors associated with HPV positivity were sexual activity (adjusted odds ratio (aOR) 2.06; 95% confidence interval (CI) 1.49 - 2.63; p&lt;0.001), number of sex partners ≥3 (aOR 2.10; 95% CI 1.39 - 3.18; p&lt;0.001), and smoking (aOR 2.00; 95% CI 1.26 - 3.20; p=0.004).

CONCLUSION

Our results demonstrate for the first time the prevalence of HPV in unvaccinated young women in Botswana. We found a high prevalence of HPV infection, with statistical differences with different risk factors. This finding supports the need for HPV vaccination strategies for females prior to sexual debut to reduce the future burden of cervical cancer in Botswana.

Chronic hypertension, perinatal mortality and the impact of preterm delivery: a population-based study

OBJECTIVES

To estimate the association between chronic hypertension and perinatal mortality and to evaluate the extent to which risks are impacted by preterm delivery.

DESIGN

Cross-sectional analysis.

SETTING

United States, 2015-18.

POPULATION

Singleton births (20-44 weeks of gestation).

EXPOSURE

Chronic hypertension, defined as elevated blood pressure diagnosed before pregnancy or recognised before 20 weeks of gestation.

MAIN OUTCOMES AND MEASURES

We derived the risk of perinatal mortality in relation to chronic hypertension from Poisson models, adjusted for confounders. The impacts of misclassification and unmeasured confounding were assessed. Causal mediation analysis was performed to quantify the impact of preterm delivery on the association.

RESULTS

Of the 15 090 678 singleton births, perinatal mortality rates were 22.5 and 8.2 per 1000 births in chronic hypertensive and normotensive pregnancies, respectively (adjusted risk ratio 2.05, 95% CI 2.00-2.10). Corrections for exposure misclassification and unmeasured confounding biases substantially increased the risk estimate. Although causal mediation analysis revealed that most of the association of chronic hypertension on perinatal mortality was mediated through preterm delivery, the perinatal mortality rates were highest at early term, term and late term gestations, suggesting that a planned early term delivery at 37-38^6/7  weeks may optimally balance risk in these pregnancies. Additionally, 87% (95% CI 84-90%) of perinatal deaths could be eliminated if preterm deliveries, as a result of chronic hypertension, were preventable.

CONCLUSIONS

Chronic hypertension is associated with increased risk for perinatal mortality. Planned early term delivery and targeting modifiable risk factors for chronic hypertension may reduce perinatal mortality rates.

TWEETABLE ABSTRACT

Maternal chronic hypertension is associated with increased risk for perinatal mortality, largely driven by preterm birth.

A104 PATIENT AND PUBLIC INVOLVEMENT (PPIN) IN IBD RESEARCH - A SCOPING REVIEW

Background

Over the past 10 years, interest in patient and public involvement (PPIn) in research has grown. Several arguments support the engagement of patients as partners in the research process. Patients with lived experience of a condition can offer their knowledge to study design as experience-based experts, helping researchers incorporate patient-pertinent outcomes. PPIn has also been shown to boost patient enrolment and retention in clinical trials. Benefits, challenges, and best practices of PPIn have been examined in other fields. However, to date, no study has examined PPIn in inflammatory bowel disease (IBD) research. Many factors amenable to research involvement may impact IBD patients’ quality of life, including disease morbidity, complications, and efficacy/side effects of therapy.

Aims

This review aims to characterize methods of PPIn in IBD research and highlight themes relating to best practices, benefits, and challenges.

Methods

We ran a systematic search on MEDLINE, EMBASE, and Cochrane for all IBD research studies in which IBD patients were involved in the research process. PPIn included but was not limited to patient input in one of the following 3 stages: Study Design (prioritization of research topics, outcome selection, study tool development), Study Execution (recruitment, data collection & analysis), and Dissemination of Research. After abstract and full-text screening, 14 studies were selected.

Results

Patients were recruited for PPIn through IBD and patient organizations (7/14), outpatient clinics (4/14), tertiary care sites (2/14), and pre-existing patient advisory groups (1/14). The majority of studies (11/14) engaged patients in the development of study materials, which included a physical activity intervention for stoma patients, an IBD pregnancy decision aid, and a quality of life questionnaire. Two studies interviewed patients to determine comprehensibility of survey items and guide revisions. One study involved patients in data analysis and manuscript development. Most consultations were open-ended, including focus groups (8/14) and semi-structured interviews (3/14). According to study authors, PPIn helps guide IBD research priorities by focusing on patient-relevant issues. Authors also cited the role of PPIn in designing patient-friendly study tools. One challenge reported by 2 studies was that PPIn requires patients to have access to high-quality information and requires a significant time commitment, which may contribute to demographic biases.

Conclusions

The majority of IBD studies engaged patients in an open-ended format and were engaged in study design, particularly in developing study materials. Authors recommend continuous involvement of patients throughout the research process to address their research priorities.

Funding Agencies

None

A140 INTEROBSERVER RELIABILITY OF THE PARIS CLASSIFICATION FOR SUPERFICIAL GASTROINTESTINAL TRACT NEOPLASMS: A SYSTEMATIC REVIEW AND META-ANALYSIS

Background

The Paris classification is an international classification system that characterizes the morphology of superficial gastrointestinal tract neoplasms. Given its ability to predict the risk of submucosal invasion, this tool plays an important role in the preliminary endoscopic assessment of early gastrointestinal neoplastic lesions. Despite its international prevalence, there are no pooled reliability analyses to assess agreement amongst endoscopists using this classification system.

Aims

To systematically review and meta-analyze the interobserver reliability (IOR) of the Paris classification system.

Methods

We conducted a systematic review and meta-analysis according to the PRISMA recommendations. A comprehensive literature query was conducted on biomedical databases through December 2020. Studies were included if they quantitively evaluated the IOR of the Paris classification with at least 5 endoscopists participating in the study cohort. Two authors independently screened studies and abstracted data using an a priori designed data collection form. We pooled the results of studies which provided IOR with kappa statistics and confidence intervals using DerSimonian and Laird random effects models. Risk of bias was independently assessed by two study authors using the Guidelines for Reporting Reliability and Agreement Studies (GRRAS) tool.

Results

From an initial 1541 studies, 5 were included in the qualitative review and 3 reported data that allowed for a quantitative analysis of the primary outcome, representing a total of 28 endoscopists. All three of these studies were high quality. The IOR for the Paris classification amongst all endoscopists was 0.541 (95% CI, 0.466–0.617). There was no significant improvement (p=0.551) in the IOR of the Paris classification system following an educational training intervention (pre-education pooled kappa, 0.498; 95% CI, 0.429–0.567 compared to post-education pooled kappa, 0.530; 95% CI, 0.451–0.608).

Conclusions

Interobserver reliability of the Paris classification is moderate with no significant improvement following educational intervention.

Funding Agencies

None

A120 AUTOMATED BOWEL PREPARATION DETECTION WITH DEEP. CONVOLUTIONAL NEURAL NETWORKS

Background

Introduction: Bowel preparation inadequacy has been shown to increase post-colonoscopy colorectal cancer. As such, the USMSTF recommends repeating colonoscopy within 1 year if bowel preparation is inadequate. However, bowel preparation documentation is variable in clinical practice, and physician recommendations adherent to USMTF guidelines are inconsistent.

Aims

Aims: We present an automated computer assisted method using deep convolutional neural networks to detect bowel preparation and adequacy of bowel preparation with the Boston Bowel Preparation Scale (BBPS).

Methods

Methods: We extracted 38523 images of colonic lumen between 2015 and 2017 from screening colonoscopies. Bowel preparation scores were assessed with BBPS. Adequate bowel preparation was defined as BBPS ≥2, and inadequate bowel preparation was defined as BBPS <2. The dataset was split into 26966 images for training, 7704 for validation, and 3853 for testing. Training data was sampled with replacement from a multinomial distribution to balance subclass distributions in each batch. We developed 2 convoluted neural networks (CNN) using PyTorch with a Densenet-169 backbone pre-trained on ImageNet and fine-tuned on our data for classifying adequacy of bowel preparation (binary) and for subclassification of BBPS (multi-class). We used Adam optimiser with an initial learning rate of 3x10^-4 and a scheduler to decay the learning rate of each parameter group by 0.1 every 7 epochs along with focal loss as our criterion for both classifiers.

Results

Results: The overall accuracy on the test data set for BBPS subclassification was 0.91. The sensitivity for BBPS 0, 1, 2 and 3 were 0.84, 0.91, 0.86, and 0.96, respectively. The specificity for BBPS 0, 1, 2, and 3 were 1.00, 0.98, 0.95, and 0.93, respectively. The overall accuracy of the test data set for adequacy of bowel preparation was 0.97. The sensitivity for adequacy of bowel preparation for BBPS <2 and BBPS ≥2 was 0.92 and 0.99, respectively. The specificity for adequacy of bowel preparation for BBPS <2 and BBPS ≥2 was 0.99 and 0.92, respectively.

Conclusions

Conclusion: We present an automated computer-assisted detection method of bowel preparation with deep convolutional neural networks. The algorithm is capable of accurate classification of adequacy of bowel preparation (97%) and subclassification of bowel preparation (91%) with high sensitivity and specificity. This algorithm can be applied to automate documentation of bowel preparation and adequacy of bowel preparation. Additional studies will need to be conducted to demonstrate its applicability in real-time colonoscopy.

Funding Agencies

None

A32 DEVELOPMENT AND VALIDATION OF THE TORONTO UPPER GASTROINTESTINAL CLEANING SCORE

Background

High quality esophagogastroduodenoscopy (EGD) depends on the ability to appropriately visualize upper gastrointestinal (GI) mucosa pathology. Evaluation can be limited by the presence of mucus, foam, bubbles and solid materials. Currently, there is no standardized method to assess mucosal visualization for use in clinical or research settings.

Aims

To develop and establish the content validity of the Toronto Upper Gastrointestinal Cleaning Score (TUGCS) and evaluate its interrater reliability.

Methods

An international panel of endoscopy experts rated potential items and their associated anchors for importance as indicators of adequacy of mucosal visualization during EGD. The survey utilized a Likert scale (1 (strongly disagree) to 5 (strongly agree)). The Delphi process was repeated until consensus was reached. Consensus was defined priori as ≥80% of experts in a given round scoring ≥4 on all survey items. To assess content validity, 48 EGD procedures were evaluated in real-time by two endoscopist reviewers using the TUGCS at a single institution. The interrater agreement between assessments was calculated for TUGCS total scores using intraclass correlation coefficient, one-way random effects model (ICC 1,1).

Results

Fourteen experts agreed to be part of the Delphi panel. An anatomical framework representing the upper GI mucosa and anchors for each mucosal portion representing various levels of visibility was generated through systematic review. Three survey rounds, with response rates of 100%, 100% and 71% respectively, achieved consensus. The final TUGCS includes four anatomical areas (fundus, body, antrum, duodenum) and mucosal visualization anchors ranging from 0 to 3 (Figure 1). TUGCS was used to assess foregut cleaning in 48 procedures (Table 1). The mean TUGCS for staff and trainee were 8.1 (±2.4) and 8.1 (±2.6), respectively. The ICC was 0.78 (95% confidence interval 0.62–0.88) indicating good reliability.

Conclusions

We developed and generated content validity evidence for the TUGCS through rigorous Delphi methodology, reflective of practice across different centres. Planned as future research is a video survey distributed to endoscopists internationally to further validate the TUGCS to create a tool that may be used to judge mucosal visualization for EGD in research and clinical settings.

Funding Agencies

None

A89 PERCEPTIONS OF NON-TECHNICAL SKILLS IN GASTROINTESTINAL ENDOSCOPY: A THEMATIC ANALYSIS OF FOUR FOCUS GROUPS

Background

Nontechnical skills (NTS), which involve an individual’s cognitive, attitudinal, and social skills that supplement task expertise, are an essential component in the practice of gastrointestinal endoscopy. There is a growing body of literature that highlights the association between these skills and patient outcomes. To date, however, these skills have not been adequately defined within the context of gastrointestinal endoscopy.

Aims

To define the domain and corresponding characteristics of NTS in GI endoscopy.

Methods

We conducted a qualitative study at a tertiary-care academic center in Toronto, Ontario. Specifically, we held four focus groups with physician endoscopists, nurses who work in an endoscopy unit, and patients who have had previous endoscopies, in order to ascertain their input on the role of NTS in gastrointestinal endoscopy. The three groups were interviewed independently and there was one focus group of both physicians and nurses that was used for validation of our initial thematic framework. Data from the focus groups was collected using a combination of field notes and discussion transcriptions. Three authors independently generated codes from these data. Using these codes, a thematic network analysis was used to identify emerging themes. The primary outcome of this study was the development of a cohesive thematic network of NTS in endoscopy, including their characteristics and examples.

Results

The four focus groups included a total of 34 participants, including 15 physician endoscopists, 15 nurses, and 4 patients. Using thematic network analysis, we identified six dimensions of NTS using the first three focus groups: communication; professionalism; teamwork; leadership; decision-making; and situational awareness. Additional topics related to the practice and evaluation of NTS were identified. In particular, there is a degree of subjectivity in the appraisal of NTS due to the nuances among individual practice, aside from egregious errors of NTS (e.g. unprofessional behaviours). The use of video recordings was suggested as a way to capture signs of good NTS, such as appropriate levels of calmness during procedures and attention to patient comfort. Finally, patient involvement can be useful for evaluating communication and professionalism based on patient comprehension and the nature of the therapeutic relationship.

Conclusions

Our findings provide the first cohesive framework of NTS in gastrointestinal endoscopy that is anchored in real world experiences with relevant stakeholders – physicians, nurses, and patients. Future research should consolidate these findings into an assessment tool for NTS in order to evaluate and provide feedback to endoscopists who are both in training and in practice.

Funding Agencies

CAG

A25 CRITICAL APPRAISAL OF GI ENDOSCOPY CLINICAL PRACTICE GUIDELINES DURING THE COVID-19 PANDEMIC

Background

Clinical Practice Guidelines (CPGs) are integral during a pandemic, offering guidance to clinicians through uncertainty. Existing literature has established that the need for rapid publication of CPGs during previous infectious disease outbreaks resulted in less rigorous guidelines. CPGs were rapidly developed since the onset of the pandemic in December 2019, providing guidance in gastrointestinal (GI) endoscopy, an area where COVID-19 may pose risk of transmission.

Aims

To evaluate the quality of GI endoscopy guidelines developed during the COVID-19 pandemic and to compare these with (a) endoscopy CPGs developed prior to the pandemic; (b) CPGs for other endoscopic topics unrelated to COVID-19; and, (c) non-endoscopic CPGs published during the pandemic.

Methods

We systematically searched Medline, Embase and Scopus for CPGs published by GI societies from January 1, 2018 to December 31, 2020. A grey literature search was conducted. Two authors screened full-texts. In this interim analysis, CPGs were grouped based on publication year: before 2020, or 2020. Endoscopy CPGs published in 2020 were categorized as COVID or non-COVID related. Two authors independently assessed the CPGs using the AGREE II tool, consisting of six domains for evaluating guidelines. A domain score of 60 was set as a threshold to indicate good quality.

Results

There were 70 endoscopy guidelines and 27 CPGs focused on other GI topics. The mean overall scores were 69% (±12%) for endoscopy CPGs published before 2020 (n=28), and 51% (±23%) for CPGs published in 2020 (n=42). For individual AGREE II domains, mean scores for pre-2020 CPGs ranged from 33.11 (±17.39) in Applicability to 81.55 (±10.37) in Clarity of Presentation. For CPGs published during COVID-19, mean domain scores ranged from 34.18 (±10.52) in Applicability to 75.26 (±13.85) in Clarity of Presentation. 21 of 42 CPGs published in 2020 were related to COVID. Mean overall scores were 35% (±20%) for COVID-related CPGs and 67% (±13%) for non-COVID-19 CPGs. For COVID-19 CPGs, scores ranged from 27.88 (±20.31) in Rigour of Development to 69.58 (±10.81) in Scope and Purpose. For non-COVID CPGs, the scores ranged from 37.30 (±8.93) in Applicability to 84.52 (±5.93) in Clarity of Presentation.

Conclusions

The difference in overall scores between COVID-19 endoscopy CPGs and non-COVID endoscopy CPGs may suggest that the urgency to disseminate COVID-19 information decreased CPG quality or completeness of reporting. This interim analysis is limited by the lack of distinction between peer-reviewed CPGs and non-peer reviewed recommendations. Given the importance of CPGs in clinical decision making, it is important to ensure that the rapid development of guidelines does not compromise quality and rigour.

Funding Agencies

None

A99 PHARMACEUTICAL INDUSTRY FUNDING TO GASTROINTESTINAL PATIENT ADVOCACY ORGANIZATIONS

Background

Patient advocacy organizations (PAOs) are not-for-profit organizations that aim to support families and individuals afflicted by illnesses. PAOs play a significant role in guiding health policy, providing education to patients, lobbying, and supporting research. Previous studies have demonstrated that PAOs may receive financial payments from pharmaceutical and medical device manufacturers. This may create a risk of conflict of interest.

Aims

To assess the prevalence and transparency of financial donations from industry to gastrointestinal patient advocacy groups based in the United States (US).

Methods

We conducted a cross-sectional study to determine the prevalence of industry donations to PAOs. Data was extracted from the Kaiser Health News (KHN) Database, a database that tracked payments from pharmaceutical companies to PAOs in 2015. After an initial list of 1215 PAOs was obtained from the database, authors extracted the annual revenues, websites and mission statements for each PAO. Authors individually screened each organization’s mission statement and website to determine whether their primary scope of focus included gastroenterology. A final list of 11 PAOs with annual revenues surpassing $500,000 USD was included for descriptive analysis. From this list, the annual reports and websites of each group were reviewed to determine the extent of transparency of PAOs disclosing financial relationships with industry sponsors. The primary outcome of our study was the total amount of funding that each PAO received from pharmaceutical companies. The secondary outcome was the self-reported amount of funding stated on each PAO’s website and annual report.

Results

From our analysis of 11 PAOs, 9 (81%) organizations received payments from pharmaceutical companies. The median dollar value of donations received was $31,052 USD (IQR=$25 to $302,550). The total dollar value of donations received was $4,059,433 USD. Across the 9 PAOs that received donations, 5 (56%) organizations disclosed a financial relationship with a pharmaceutical company on their website and 2 (22%) disclosed the value of industry donations within a range. No group specified an exact amount of funding received.

Conclusions

Our results demonstrate that a majority of US based gastrointestinal PAOs receive funding from pharmaceutical companies. Furthermore, our results show that many PAOs that receive industry funding do not disclose this amount on their website or annual reports. Given their role in providing patient centered support, it is important for PAOs to disclose financial relationships with industry so as to not produce a conflict of interest.

Funding Agencies

None

728 A Systematic Review of The Efficacy and Safety of Outpatient Bladder Tumour Ablation

Introduction

The management of recurrent non-muscle-invasive bladder cancer (NMIBC) typically requires repeated transurethral resections under general anaesthesia. This is costly and results in poor health-related quality-of-life for patients. Outpatient-based laser ablation and diathermy to recurrent tumours could reduce morbidity and cost of managing NMIBC. This systematic review evaluates the safety and efficacy of outpatient-based diathermy or laser ablation for recurrent NMIBC.

Method

The EMBASE, MEDLINE and Cochrane Library were searched until June 2020. All studies evaluating the use of outpatient diathermy or laser ablation for NMIBC were included. The quality of evidence and risk of bias were assessed using the GRADE and ROBINS-I tools, respectively.

Results

From 1328 studies identified, 17 studies (1584 patients) were included. Overall, the majority of tumours (80%) were low-grade (G1 and G2). Laser ablation and diathermy resulted in a mean recurrence rate of 47% and 40% at 20-31 months follow-up, respectively, with a mean progression rate of 3-11%. Both procedures were well-tolerated with low pain scores (mean score of 1) and low periprocedural complication rates. However, the overall quality of evidence of low.

Conclusions

This review demonstrates that both procedures have good short-term efficacy in patients with low-grade NMIBC. The procedures are well-tolerated with low complication rates and importantly, reduce the need for intervention under general anaesthesia. These findings can aid patient counselling regarding less invasive treatment options, avoiding the morbidity of transurethral resection. Future randomised studies with standardised risk stratification and outcome measures are required to add to the quality of evidence.

733 Long-Term Outcomes of Outpatient Laser Ablation for Recurrent Non-Muscle Invasive Bladder Cancer: A Retrospective Cohort Study

Aim

Non-muscle-invasive bladder cancer (NMIBC) is the most prevalent form of bladder cancer, predominantly affecting the elderly population. The most common treatment for recurrent NMIBC is transurethral resection of the bladder tumour (TURBT), which carries a risk of perioperative morbidity and mortality in this often-co-morbid population. Outpatient laser ablation of low-grade NMIBC recurrences is a minimally invasive treatment option, but long-term efficacy is poorly reported.

Method

We retrospectively reviewed the case notes of all patients treated with Holmium:YAG laser ablation from 2008-2016. Data regarding patient demographics, original histology, dates of procedures, follow-up time, recurrence, progression, and complications were recorded.

Results

A total of 199 procedures were performed on 97 patients (mean age of 83.56), 73 (75.3%) of which originally had low-grade (G1 or G2) tumours. Overall, 55 (56.7%) patients developed tumour recurrence at long-term follow-up (mean 5.36 years), and only 9 (9.3%) patients had tumour progression to a higher stage or grade, but there was no progression to muscle-invasive disease. The median recurrence-free, progression-free and overall survival times were 1.69 years (95% CI 1.20-2.25), 5.70 years (95% CI 4.10-7.60) and 7.60 years (95% CI 4.90-8.70), respectively. No patients required emergency inpatient admission after laser ablation for any associated complications.

Conclusions

Office-based Holmium: YAG laser ablation is an oncologically-safe method of managing recurrent low-grade non-muscle-invasive bladder cancer in the long-term, with no patients progressing to muscle-invasive disease. Furthermore, the procedure is safe, and no significant complications were seen in this elderly and co-morbid population.

Ameliorative Effect of Surface Proteins of Probiotic Lactobacilli in Colitis Mouse Models

The increase in concern from viable cells of probiotics specifically in acute inflammatory conditions has led to the emergence of the concept of postbiotics as a safer alternative therapy in the field of health and wellness. The aim of the present study was to evaluate the efficacy of surface proteins from three probiotic strains in dextran sodium sulfate and trinitrobenzenesulphonic acid = induced colitis mouse models. The molecular weight of total surface proteins extracted from the three probiotic strains ranged from ∼25 to ∼250 kDa with the presence of negligible levels of endotoxins. Surface layer proteins (SLPs) (∼45 kDa) were found to be present only in the Lactobacillus acidophilus NCFM strain. In the in vivo study, significant differences were not observed in the weight loss and general appetite, however, the decrease in colon length was apparent in TNBS colitis control mice. Further, the administration of these surface proteins significantly reversed the histopathological damages induced by the colitogens and improved the overall histological score. The oral ingestion of these surface proteins also led to a decrease in myeloperoxidase activity and TNF-α expression while the IL-10 levels significantly increased for the strain NCFM followed by MTCC 5690 and MTCC 5689. Overall, the present study signifies the ameliorative role of probiotic surface proteins in colitis mice, thereby, offering a potential and safer alternative for the management of inflammatory bowel disorders.

Eliminating Cervical Cancer: Progress and Challenges for High-income Countries

In 2020, the World Health Organization launched a major initiative to eliminate cervical cancer globally. The initiative is built around the three key pillars of human papillomavirus (HPV) vaccination, cervical screening and treatment, with associated intervention targets for the year 2030. The '90-70-90' targets specify that 90% of adolescent girls receive prophylactic HPV vaccination, 70% of adult women receive a minimum twice-in-a-lifetime cervical HPV test and 90% receive appropriate treatment for preinvasive or invasive disease. Modelling has shown that if these targets are met, the elimination of cervical cancer, defined as fewer than four cases per 100 000 women per annum, will be achieved within a century. Many high-income countries are well positioned to eliminate cervical cancer within the coming decades, but few have achieved '90-70-90' and many challenges must still be addressed to deliver these critical interventions effectively. This review considers the current status of cervical cancer control in relation to each of the three elimination pillars in high-income countries and discusses some of the developments that will assist countries in reaching these ambitious targets by 2030.

Incidence, Treatment and Outcomes of Cervical Cancer in Low- and Middle-income Countries

Cervical cancer is one of the most common cancers in developing nations. It has had a tremendous impact on the lifetime of millions of women over the last century and continues to do so. In this collaborative clinicians' review, we highlight the incidence, treatment and clinical outcomes of cervical cancer in low-income (LICs) and low- and middle-income countries (LMICs) across Asia, South America, South Africa and Eastern Europe. With the cervical cancer burden and locally advanced cancers being high, the majority of LICs/LMICs have been striving to adhere to optimal evaluation and treatment guidelines. However, the huge gap in resource availability, rural versus urban disparity and access to resources have led to poor compliance to evaluation, treatment and post-treatment rehabilitation. To mitigate the overwhelming numbers, various treatment strategies like neoadjuvant chemotherapy, hypofractionation radiation schedules (both external and brachytherapy) have been attempted with no major success. Also, the compliance to concurrent chemoradiation in various regions is a major challenge. With the burden of advanced cancers, the lack of palliative care services and their integration in cancer care is still a reality.

The Missing Uterus, the Missed Diagnosis, and the Missing Care. Mayer-Rokitansky-Küster-Hauser Syndrome in the Lives of Women in Malaysia

STUDY OBJECTIVE

To explore the effect of the diagnosis of Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome on affected Malaysian women.

DESIGN

Qualitative study with a quantitative component.

SETTING

Pediatric and adolescent gynecology unit at Universiti Kebangsaan Malaysia Medical Centre, Malaysia.

PARTICIPANTS

Twelve women with MRKH.

INTERVENTIONS

Face-to-face interview and short questionnaire.

MAIN OUTCOME MEASURES

Thematic analysis was used to understand participants' experiences.

RESULTS

There were 7 themes identified: (1) delayed diagnoses; (2) doctors' roles and attitudes; (3) gender identity; (4) family and society's response; (5) reaction toward infertility; (6) managing sexual intimacy; and (7) coping mechanisms. Several participants consulted their physicians regarding their primary amenorrhea at an opportunistic setting. When they were referred to the gynecologists, they were dismayed at the lack of information given. The term, "MRKH" plays an important role to ease information-seeking. Participants felt that the doctors were insensitive toward them. Mental illness is a significant complication of MRKH. All participants acknowledged that infertility was the hardest part of the condition. The importance of blood lineage affects their outlook on childbearing options. Some were afraid of sexual intimacy and worried that they would not be able to satisfy their partners. Participants gained support and bonded with their counterparts in the MRKH support group.

CONCLUSION

A multidisciplinary approach including medical, psychological, and social support is essential for the management of MRKH. Adequate information and sexual education plays the utmost importance in preventing social-related complications of MRKH.

Introduction of case-based learning aided by WhatsApp messenger in pathology teaching for medical students

Aims:

The present study was carried out for comparative evaluation of case-based learning (CBL) aided with WhatsApp and didactic lectures (DL) while teaching a pathology topic to second-year medical students. In addition, the acceptability of WhatsApp as an aid to CBL was assessed.

Material and Methods:

After obtaining informed consent, 70 second-year Bachelor of Medicine and Bachelor of Surgery (MBBS) students were exposed to six sessions of CBL aided by case scenarios for one set of topics of anemia posted on WhatsApp groups. This was followed by six sessions of DL for separate set of topics in anemia. The multiple-choice questions (MCQ) test scores obtained pre and postintervention, of CBL and DL sessions, were compared to paired t-test (within the groups) and Student's t-test (between the groups). Categorical data were analyzed using Chi-square (χ²) test. Student's self-administered questionnaires and focus group discussions (FGDs) were used to collect student perceptions and analyzed quantitatively, as well as qualitatively.

Results:

The mean MCQ scores obtained postintervention in CBL topics were significantly higher compared to DL (22.78 ± 2.99 vs 17.78 ± 3.35; P < 0.001). Students perceived that CBL enhanced their curiosity; hence, the acquired knowledge through various resources was retained better. It enhanced their analytical skills and interest in learning pathology. In FGDs, the students appreciated the use of WhatsApp as an aid to CBL for its ease of sharing scenario-related additional information and prior discussions among themselves in chat groups at their convenience.

Conclusion:

CBL aided by WhatsApp helped students acquire knowledge, discuss and learn actively, score more, and retain better than DL. Using WhatsApp as a platform helped them to interact at their ease and seek guidance from their mentors without resistance and hesitation.

Long-term clinical outcomes of troponin-positive chest pain and unobstructed coronary arteries assessed by cardiovascular magnetic resonance imaging

Background and introduction

Troponin-positive chest pain with unobstructed coronary arteries is a distinct entity with different pathophysiological causes. We have previously reported on the incremental diagnostic capability of cardiovascular magnetic resonance (CMR) in this cohort. However, there is paucity of literature on the long-term clinical outcomes of these patients assessed with CMR.

Objectives

Using the unique cohort of patients previously studied, we sought to assess the long-term clinical outcomes in patients with troponin-positive chest pain and unobstructed coronary arteries, as graded by their acute CMR presentation.

Methods

A total of 122 consecutive patients with troponin-positive chest pain and unobstructed coronary arteries undergoing CMR assessment during the acute admission (2010–2014) were studied. The primary endpoint was major adverse cardiac event (MACE), defined as a composite of all-cause mortality and cardiovascular readmissions (heart failure, acute myocardial infarction [AMI], atrial or ventricular arrhythmia and stroke). Patients were grouped into 4 categories based on their initial CMR findings: AMI, acute myocarditis, Takotsubo cardiomyopathy and normal CMR.

Results

The mean age of the study cohort was 55.6±16.5 years and 56.5% were women. CMR (performed at a median of 6 days from presentation) provided a diagnosis in 87% of the patients (38% myocarditis, 28% Takotsubo cardiomyopathy and 21% AMI). Patients with a diagnosis of AMI were prescribed guideline recommended medical therapy. Over a median follow-up of 2524 days (6.9 years), 32 (26.2%) patients experienced a MACE. The all-cause mortality was 2.5%. The most common indication for cardiovascular readmissions in this cohort was heart failure (12.3%) and AMI (9%). In multivariate analysis, a CMR diagnosis of AMI (hazard ratio = 2.6; 95% confidence interval = 1.2, 5.7; p=0.019) and peak troponin (hazard ratio = 1.0003; 95% confidence interval = 1.00003, 1.0006; p=0.028) were significantly associated with MACE after adjusting for age and gender. In addition, CMR diagnosis of AMI was significantly associated with a lower event-free survival rate compared with a diagnosis of non-AMI (adjusted hazard ratio = 2.57, p=0.019) (Figure).

Conclusions

The long-term prognosis of patients with troponin-positive chest pain and unobstructed coronary arteries is not benign. CMR diagnosis of AMI is a significant predictor of MACE even in the absence of significant coronary artery obstruction and despite guideline recommended post AMI therapy.

Figure 1

Funding Acknowledgement

Type of funding source: None

Psychiatric morbidity among patients attending a rural non-communicable disease clinic

Background

The presence of psychiatric illness among patients with physical illnesses leads to poor treatment adherence, poor lifestyle, increased cost of treatment, poor quality of life, worsening of physical illness, work absenteeism, increased hospital visits, poor self-care and higher mortality. The study evaluated the prevalence of cognitive impairment and psychiatric morbidity in non-communicable disease patients. The study highlights that NCD patients should be provided information about the development of cognitive impairment in order to prevent it.

Methods

It was a cross-sectional study conducted among the patients attending the non-communicable disease clinic of a rural community health centre run in collaboration with the Postgraduate Institute Medical Education and Research (PGIMER), Chandigarh. We registered 124 patients after obtaining written informed consent. Instruments: Hindi Mental Status Examination (HMSE), Patient Health Questionnaire-9, Generalized anxiety disorder-7 (GAD-7) scale. Analysis of covariance was applied to see the relationship between the domain of the HMSE and NCDs.

Results

The mean age of the participants was 55.5 years (SD-11.9, Range-26-90). A little more than one third (N = 48, 38.7%) were diagnosed with hypertension only, one-sixth (N = 22; 17.7%) were diagnosed with diabetes mellitus only, and 54 (43.5%) patients were diagnosed with both hypertension and diabetes mellitus. A slightly more than one-third of the study participants were diagnosed with depressive disorder (N = 44, 35.5%), and 29% (N = 36) of the participants were diagnosed with an anxiety disorder. About one-fourth of patients with NCD have cognitive impairment and 39.51% have psychiatric morbidity.

Conclusions

The prevalence of cognitive impairment is higher among patients of NCD with psychiatric morbidity. Patients with NCDs should be routinely screened for cognitive functioning and provided information about the development of cognitive impairment.

Key messages

Because of high prevalence of cognitive impairment and psychiatric morbidity in NCD patients, patients should be provided information to prevent it. There is a need to screen NCD patients routinely for cognitive functioning, and provide them information to prevent cognitive impairment.

Human immunodeficiency virus infection amongst newly diagnosed tuberculosis patients and their clinico-radiological profile: A prospective study from Western India

Background

Since time immemorial tuberculosis (TB) has been and continues to be one of the most significant infections causing human disease. In tropical countries, TB remains a leading cause of death. Human immunodeficiency virus (HIV) epidemic continues to fuel this global TB epidemic. The rapid growth of the HIV epidemic in many countries has resulted in an equally dramatic rise in the estimated number of new TB cases, which present therefore the integration of HIV and TB testing at the primary level is need of the hour.

Methods

A prospective study was conducted on newly diagnosed, untreated TB patients aged 15-45 year and patients were screened for HIV infection. Clinico-radiological spectrum of TB among HIV seropositive and seronegative patients was evaluated.

Results

Out of a total of 307 patients screened, 17 (5.54%) were found to be HIV seropositive. Seroprevalence was found significantly (P < 0.01, χ² 9.301) more common in 26-35 year age group and higher in Extrapulmonary TB (EPTB) patients than that in pulmonary TB (PTB) patients (9.90% vs 3.4%). Fever was the most common presenting symptom for TB in HIV seropositive patients. On examination pallor (58.82% vs. 15.86%), oral ulcer (35.3% vs. 0.35%) was found more common and on chest X-ray mid-lower zone involvement and mediastinal lymphadenopathy were more common in HIV seropositive patients.

Conclusion

HIV seropositivity rates among newly diagnosed TB patients aged 15-45 year was 5.54 percent. The presentation of TB was more often atypical among these patients. Thus, an integrated model of TB and HIV at primary healthcare service delivery is an efficient use of resources that would address the two very important co-epidemics and thereby result in better management.

Assessing the Safety and Efficacy of Lactobacillus plantarum MTCC 5690 and Lactobacillus fermentum MTCC 5689 in Colitis Mouse Model

Probiotic lactobacilli have an unprecedented history of safe use, although some cases of infections have raised concerns about their safety, and hence, a rigorous screening of any new strain even of Lactobacillus is a must in order to study possible adverse interactions with the host, particularly under unhealthy conditions. The present study was, therefore, undertaken to investigate the safety as well as therapeutic efficacy of probiotic Lactobacillus plantarum MTCC 5690 and L. fermentum MTCC 5689 strains in dextran sodium sulfate (DSS)-induced colitis mouse model. Both MTCC 5690 and MTCC 5689 did not induce any detrimental effect on the colitic mice, as was reflected by normal colon and caecum length, blood biochemistry, hematology, and absence of inflammation. Although translocation of both the strains was observed in extraintestinal organs, probiotic-fed mice had significantly improved intestinal permeability and decreased myeloperoxidase (MPO) activity. Probiotic interventions also led to an improved health index and better growth of colitis mice compared to colitis animals with no probiotic intervention. These results point towards the safe use of L. plantarum MTCC 5690 and L. fermentum MTCC 5689 as biotherapeutics for amelioration of inflammatory conditions after establishing their efficacy in human clinical trials.

Comparative Analysis of Radiotherapy Linear Accelerator Downtime and Failure Modes in the UK, Nigeria and Botswana

The lack of radiotherapy linear accelerators (linacs) in low- and middle-income countries (LMICs) has been recognised as a major barrier to providing quality cancer care in these regions, together with a shortfall in the number of highly qualified personnel. It is expected that additional challenges will be faced in operating precise, high-technology radiotherapy equipment in these environments, and anecdotal evidence suggests that linacs have greater downtime and higher failure rates of components than their counterparts in high-income countries. To guide future developments, such as the design of a linac tailored for use in LMIC environments, it is important to take a data-driven approach to any re-engineering of the technology. However, no detailed statistical data on linac downtime and failure modes have been previously collected or presented in the literature. This work presents the first known comparative analysis of failure modes and downtime of current generation linacs in radiotherapy centres, with the aim of determining any correlations between linac environment and performance. Logbooks kept by radiotherapy personnel on the operation of their linac were obtained and analysed from centres in Oxford (UK), Abuja, Benin, Enugu, Lagos, Sokoto (Nigeria) and Gaborone (Botswana). By deconstructing the linac into 12 different subsystems, it was found that the vacuum subsystem only failed in the LMIC centres and the failure rate in an LMIC environment was more than twice as large in six of the 12 subsystems compared with the high-income country. Additionally, it was shown that despite accounting for only 3.4% of the total number of faults, linac faults that took more than 1 h to repair accounted for 74.6% of the total downtime. The results of this study inform future attempts to mitigate the problems affecting linacs in LMIC environments.