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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

CTRI/2021/09/036130.

Analysis of patients with endometrial carcinoma using the ProMise classifier: a pilot study from India

BACKGROUND

Molecular subtyping of endometrial carcinomas (EC) has been shown to classify tumors into prognostically relevant groups. Characterizing EC with a limited number of markers viz., POLE mutations, p53 mutations, and MMR status, can provide valuable information.

DESIGN

Paraffin sections of a cohort of 48 EC from a tertiary care center were characterized for the above-mentioned molecular markers and analyzed in the context of survival.

METHODS

Formalin fixed paraffin embedded tissues from 48 EC were characterized for POLE mutations by Sanger sequencing (exons 9-14), for MMR (MLH1, MH2, MSH6) using immunohistochemistry (IHC) and copy number (high/low) using p53 IHC. Mutational status was integrated along with the clinicopathological details and survival analysis performed.

RESULTS

Eleven (22.9%) patients were MMR deficient, 3 (6.3%) had POLE mutation, while 2 (4.1%) had both POLE and P53 mutations (regarded as multiple classifiers). Twelve (25%) patients were found to have P53 mutations, while the remaining 20 (41.7%) had no specific molecular profile (NSMP). Median follow-up duration was 43.5 (2-62) months with 8 recurrences and 9 deaths. Tumors with POLE mutation had the most favorable prognosis followed by the NSMP and the MMR mutated group while the P53 and multiple classifier groups had the worst prognosis in terms of OS (Log-rank p: 0.006) and PFS (Log-rank p: 0.001).

CONCLUSION

The integration of molecular-clinicopathologic data for endometrial cancer classification, through cost-effective, clinically applicable assays appears to be a highly objective tool that can be adopted even in resource-limited settings. It has the potential to cause a shift in the paradigm of EC pathology and management practice.

Survival outcomes of epithelial ovarian cancer treated at a tertiary-level hospital in India

BACKGROUND

One needs to choose wisely between primary neoadjuvant chemotherapy and primary cytoreductive surgery in ovarian cancer. The aim was to determine the recurrence free survival and overall survival after surgery for epithelial ovarian cancer and also the risk factors for recurrence and death.

METHODS

Electronic medical records of 322 women operated for ovarian, fallopian or primary peritoneal cancer between 2011 and 2015table were reviewed. Descriptive statistics were used to describe patients and their clinical outcomes. Cox proportional hazard models were used for risk factor analysis. Adjusted hazard ratios were obtained for recurrence and death, adjusted for stage, primary treatment modality, residual disease and histology. Kaplan-Meier curves were drawn for probability of recurrence-free survival and overall survival. The log rank test was used to compare survival probabilities.

RESULTS

The majority were stage III or stage IV (78%), serous histology (71%) and high grade (64%). Primary cytoreduction was done in 48% and interval cytoreduction in 52%. The median duration of follow up (survival) was 77 months (95% CI 72-82). There were 179 known recurrences (55.6 %). The estimated median time to recurrence was 22 (95% CI 14.5- 29.5) months. The independent risk factors for recurrence were neoadjuvant chemotherapy [HR 2.14, 95% CI 1.48-3.09], stage III/IV [HR 2.75; 95% CI 1.40-5.41], high grade serous histology [HR 1.69; 95% CI 1.12-2.54] and sub-optimal debulking [HR 3.15, 95% CI 2.19-4.55]. There were 78 known deaths (24.2 %) with a mean time to death of 24.3 (SD 16.1) months. The independent risk factors for death were sub-optimal debulking [HR 3.07; 95% CI 1.78-5.29] and stages III and IV cancer [HR 3.07; 95% CI 1.14-8.27].

CONCLUSIONS

Most ovarian cancers recur within 2 years. Risk factors for mortality are advanced stage and sub-optimal debulking. Maximal efforts at down staging and surgical resection will increase survival.

Fat mass: a novel digital biomarker for remote monitoring that may indicate risk for malnutrition and new complications in decompensated cirrhosis

BACKGROUND

Cirrhosis is associated with sarcopaenia and fat wasting, which drive decompensation and mortality. Currently, nutritional status, through body composition assessment, is not routinely monitored in outpatients. Given the deleterious outcomes associated with poor nutrition in decompensated cirrhosis, there is a need for remotely monitoring this to optimise community care.

METHODS

A retrospective analysis was conducted on patients monitored remotely with digital sensors post hospital discharge, to assess outcomes and indicators of new cirrhosis complications. 15 patients had daily fat mass measurements as part of monitoring over a median 10 weeks, using a Withing's bioimpedance scale. The Clinical Frailty Score (CFS) was used to assess frailty and several liver disease severity scores were assessed.

RESULTS

73.3% (11/15) patients were male with a median age of 63 (52-68). There was a trend towards more severe liver disease based on CLIF-Consortium Acute Decompensation (CLIF-C AD) scores in frail patients vs. those not frail (53 vs 46, p = 0.072). When the cohort was split into patients who gained fat mass over 8 weeks vs. those that lost fat mass, the baseline CLIF-C AD scores and WBC were significantly higher in those that lost fat (58 vs 48, p = 0.048 and 11.2 × 109 vs 4.7 × 109, p = 0.031).

CONCLUSIONS

This proof-of-principle study shows feasibility for remote monitoring of fat mass and nutritional reserve in decompensated cirrhosis. Our results suggest fat mass is associated with greater severity of acute decompensation and may serve as an indicator of systemic inflammatory response. Further prospective studies are required to validate this digital biomarker.

The clinico pathological features and survival in serous endometrial cancers

Background & Introduction

Serous cancers are a biologically aggressive variety of endometrial cancer (EC) with a high rate of recurrence and mortality among all the subtypes. Herein we describe our experience with serous endometrial cancer.

Objective

This study was conducted to identify the clinicopathological characteristics, treatment modalities and survival outcomes in women diagnosed with serous endometrial malignancies.

Methods

This was a retrospective descriptive analysis of data on patients diagnosed with serous endometrial tumours between January 2010 to September 2019 in our institute collected from electronic medical records. Descriptive statistics such as proportions, means and standard deviations and Cox regression hazards model on risk factors were performed. Survival was plotted by Kaplan-Meier curves.

Results

During the study period, 32 (5.7%) patients out of 564 diagnosed cases of endometrial cancer had serous histology. The mean age at diagnosis was 62.5 years (SD 7.6) while mean BMI was 26.4 kg/m² (SD 4.6). Staging laparotomy was done in 27(84%) of the patients. Advanced stages (III and IV) were detected in 16 patients (50%) at primary surgery.Adjuvant chemo therapy and radiation was received by 21(65.6%) patients therapy. Out of 32 patients, 13 (40%) developed recurrence while another 13 expired. Stage at diagnosis and type of adjuvant therapy were important factors in determining the outcome. Median recurrence free and overall survival was 22(95% CI 1.4-42) and 36 months (95% CI 10.1-61.8) respectively.

Conclusion

Serous endometrial cancers are an intrusive subtype of EC. Comprehensive surgical staging with optimal cytoreduction should be aimed at. Adequate upfront molecular categorization of these tumors is mandated. Adjuvant therapy with chemotherapy and radiation is given in postoperative setting. Targeted therapies and immunotherapy could be considered in recurrences.

Malignant Metastatic Steroid Cell Tumor NOS: A rare presentation of a subtype of sex cord stromal tumor

Steroid cell tumors - not otherwise specified (NOS) - are rare sex cord stromal tumors that lack characteristic histology, are benign, and usually present with androgenic manifestations. Metastatic malignant steroid cell tumors pose treatment challenges due to their chemoresistance nature. This is a case report of a metastatic steroid cell tumor - NOS with extensive peritoneal disease.

HPV and molecular mimicry in systemic lupus erythematosus and an impact of compiling B-cell epitopes and MHC-class II binding profiles with in silico evidence

Epidemiological link between HPV and SLE is evolving. The possibility of HPV infection-induced molecular mimicry and systemic lupus erythematosus (SLE) was elucidated through detailed in silico analyses. Conserved regions in the structural protein sequences of high-risk HPV types were inferred, and sequence homologies between viral and human peptides were identified to delineate proteins implicated in SLE. B-cell epitopes and MHC-class II binding were compiled using Immune Epitope Database and ProPred II analysis tool. Molecular modeling and molecular dynamics/simulation (MDS) were performed using AutoDock Vina and GROMACS, respectively. Sequence alignment revealed 32 conserved regions, and 27/32 viral peptides showed varying similarities to human peptides, rich in B-cell epitopes with superior accessibility, high hydrophilicity, antigenicity and disposition to bind many class-II HLA alleles. Molecular docking of 13 viral peptides homologous (100%) to human peptides implicated in SLE showed that VIR-PEP1 (QLFNKPYWL) and VIR-PEP2 (DTYRFVTS) exhibited higher binding affinities than corresponding human peptides to SLE predisposing HLA-DRB1 allele. MDS of these peptides showed that the viral peptides had superior folding, compactness, and a higher number of hydrogen bonds than human peptides throughout the simulation period. SASA analysis revealed that the VIR-PEP1&2 fluctuated less frequently than corresponding human peptides. MM-PBSA revealed that the VIR-PEP2 complex exhibited higher binding energy than the human peptide complex. This suggests that highly conserved structural peptides of high-risk HPV types homologous to human peptides could compete and bind avidly to the HLA allele associated with SLE and predispose HPV-infected individuals to SLE through molecular mimicry.Communicated by Ramaswamy H. Sarma.

A longitudinal study of sexual health and quality of life in endometrial carcinoma survivors

OBJECTIVES

This study aimed to assess sexual health and quality of life (QoL) in endometrial cancer survivors and the factors influencing these variables.

METHODS

A mixed method design comprising quantitative (cohort design) and qualitative (face-to-face interviews) aspects was chosen. A total of 132 patients who underwent surgery alone, surgery followed by adjuvant vaginal brachytherapy, or surgery followed by chemotherapy and radiation were included. Female Sexual Function Index (FSFI) and Functional Assessment of Cancer Therapy General (FACT-G) questionnaires were used to assess the participants' sexual health and QoL at 6 months and 1 year post-treatment. Multivariate logistic regression models were used to analyze the factors associated with general and sexual well-being.

RESULTS

At 1 year, 89% of the participants still had low sexual function scores. Survivors over 50 years (OR 284.7, 95% CI 13 to 364, p<0.001) and educated below graduate level (OR 26.8, 95% CI 2 to 370, p=0.014) had low sexual function scores. Patients who had surgery alone had better QoL than those who received adjuvant radiation. Women who had surgery, chemotherapy, and radiation had the lowest QoL scores (OR 6.4, 95% CI 2.1 to 19.5, p=0.001). All scores improved with time.

CONCLUSIONS

This study demonstrated the high prevalence of low sexual function and poor QoL in endometrial cancer survivors. There was a communication gap between the women and their partners as well as their healthcare providers. This study highlights the need for discussion about the survivors' sexual well-being and QoL.

[Evaluation of rule out strategy for patients with non-ST-elevation acute coronary syndrome with single measurement of high-sensitivity cardiac troponin I from one sample tested beetween 3 and 6 hours after chest pain onset]

BACKGROUND

Guidelines recommend to consider excluding non-ST-segment elevation myocardial infarction (NSTEMI) when high-sensitivity cardiac troponin is below the limit of quantification and a single blood sample is taken > 6 h after the onset of chest pain. The aim of our study was to assess such exclusion when a single blood sample was taken 3-6 h after the onset of permanent chest pain.

METHODS

This observational study included consecutive patients admitted into the emergency room of our hospital with chest pain and suspected NSTEMI, with non-contributive electrocardiograms and a single high-sensitivity cardiac troponin I (hs-cTnI) blood sample taken 3-6 h after the onset of chest pain and hs-cTnI < 4 ng/l (Abbott Diagnostic). Clinical follow-up was undertaken 1 month after admission.

RESULTS

The mean age of the 432 patients was 48.5 ± 5.6 years and 51% were male. Based on a clinical algorithm, the pre-test probability of NSTEMI was low in 70%, and intermediate in 21% of patients. Among 419 patients with available 1-month follow-up data, there were no myocardial infarctions or deaths. Thirty-eight patients (9%) were admitted into hospital but none for cardiac reasons.

CONCLUSIONS

Our results suggest that exclusion of NSTEMI in patients with a non-contributive electrocardiogram and a single "negative" troponin test in a blood sample taken 3-6 h after the onset of symptoms is valid.

Platinum-Pemetrexed Chemotherapy for Recurrent Ovarian Cancer (ROC): A Single Center Experience

In this retrospective analysis of 36 patients with recurrent ovarian cancer (ROC) treated with platinum pemetrexed doublet ± bevacizumab, the median age was 54.5 years (47-60) and 33 (91.7%) had serous histology. The overall response rate [ORR = complete (CR)+partial (PR) response] was 83.3%. At a median follow-up of 16 months, the median PFS was 13.8 months (95% CI: 10.849-20.580) and median OS 30.6 months, (95% CI: 21.46 months-NR). The incidence of Grade 3/4 anemia, thrombocytopenia, neutropenia and non-hematological toxicity was 19.4%, 3.9%, 16.6%, and 8.3%. Platinum pemetrexed chemotherapy in ROC is safe and effective treatment option.

Training for next-generation gynaecologic surgical & radiation oncologists - opportunities & challenges

The global increase in cancer burden is a challenge for countries with scarce resources. Amongst all the malignancies, gynaecological cancer still continues to have a high incidence and prevalence leading to significant morbidity and mortality. While a multipronged strategy of decreasing the gynaecological cancer burden is a global priority, one of the key strategies to decrease the morbidity and mortality is to train gynaecological oncology specialists. Most of the developed nations have an established gynaecologic oncology training programme in the form of a well-designed curriculum and skill training. However, in developing countries where the actual disease burden of these cancers is highest, such focused training programmes have only started emerging and evolving over the past two decades. While it is a positive step to initiate such training programmes in a country like India, there are still gaps in the uniformity of curriculum and training. Also, exposure to modern practices in gynaecologic oncology surgery, chemotherapy and technology in radiation oncology, especially brachytherapy, is still insufficient in many centres. This review discusses some of the challenges and opportunities in the still evolving programmes for training gynaecologic oncologists in India.

Role of Hysterectomy in Gestational Trophoblastic Neoplasia

Hysterectomy has a limited role in the management of gestational trophoblastic neoplasia because of the high effectiveness of chemotherapy and the young age of patients. In selected patients, it is believed to help in reducing the number of chemotherapy cycles, overcoming chemo-resistance, and treating acute haemorrhagic events. The present study aimed to evaluate the indications and outcomes of hysterectomy in patients with GTN at a tertiary care centre in India. Between 2012 and 2019, we identified all patients with GTN from the hospital database. Demographic, clinical, and follow-up details of patients who underwent hysterectomy were obtained from the electronic medical records. During the study period, 98 cases of GTN were treated at our centre of which 54% were low-risk and 46% were high-risk cases. Twenty-six patients (26%) underwent hysterectomy as part of their management for GTN. The patients belonging to the high-risk group had more hysterectomies (65%) with an odds ratio of 2.96. The common pathological diagnosis was choriocarcinoma in 44% and an invasive mole in 30% of patients. Bleeding, either intraperitoneal or vaginal, was the most common indication for hysterectomy (48%). The median number of chemotherapy cycles received was 5 in patients who had primary hysterectomy and 6 in patients who did not have hysterectomy. The majority of patients received EMACO (57.7%) chemotherapy. The mean duration of follow-up was 18 months (range 1-67). After treatment, complete remission was achieved in 94 out of 98 (95.9%) and also in all patients (100%) who had undergone hysterectomy as adjuvant procedure. Three patients died during treatment (3.06%), all belonging to the high-risk group, and one patient had a recurrence (0.01%). In selected cases of GTN, hysterectomy may be an effective means to reduce or eliminate tumour bulk, to overcome chemoresistance and manage acute bleeding events.

Treatment Outcomes of Early Carcinoma Cervix Before and After Sub-specialization

This study aimed to compare the treatment outcomes in carcinoma cervix before and after gynecologic oncology sub-specialization at a tertiary care hospital, in India. This was a retrospective cohort study comparing women with operable cervical cancer who underwent radical hysterectomy before and after gynecologic oncology sub-specialization. Electronic medical records of women operated for early carcinoma cervix between 2001 and 2010 and 2011-2015 were reviewed and compared for treatment and oncological outcomes. Seventy-four patients were operated over 5 years after sub-specialization as against 59 over 10 years before sub-specialization, with similar clinical characteristics. After surgical-pathological examination, both cohorts were comparable with regard to mean tumor size, lymph nodes retrieved, deep stromal invasion, and involvement of lymph nodes, parametrium, and vaginal margins. After sub-specialization, the rate of intraoperative (3% versus 14%, p = 0.018) and postoperative complications (15% versus 46%, p < 0.001) was lower. Adjuvant radiation was used more after sub-specialization (50% versus 24%, p < 0.001). The follow-up rates were similar in both groups with comparable 5-year recurrence-free survival and overall survival rates. The hazard ratio for death after sub-specialization was 0.39 (95% CI 0.12 to 1.22) after adjusting for histology, stage, grade, and presence of intermediate or high risk factors. Gynecological oncologic sub-specialization decreased intraoperative and postoperative complications, improved pathological reporting, and enabled appropriate tailoring of adjuvant therapy.

Endometriosis and malignancy: The intriguing relationship

OBJECTIVE

To determine the prevalence and study the association of ovarian, uterine, and breast cancers with endometriosis.

METHODS

A cross-sectional study of all women with a tissue-proven diagnosis of endometriosis postoperatively in a tertiary care hospital between January 1, 2010, and December 31, 2019, was conducted to determine the prevalence of coexistent malignancy. Patient details were obtained from electronic clinical records. Univariate analysis followed by multivariate analysis was done to find independent risk factors associated with malignancy.

RESULTS

Out of 800 patients, 104 (13.0%) were found to have coexistent malignancy: ovarian (50, 6.2%); endometrial (33, 4.1%); synchronous ovarian and endometrial (7, 0.9%); and breast (14, 1.8%). Increasing age (odds ratio [OR] 1.13; 95% confidence interval [CI] 1.09-1.16), higher levels of cancer antigen 125 (CA 125) (OR 1.002; 95% CI 1.001-1.005), postmenopausal status (OR 6.2; 95% CI 2.0-19.2), duration of endometriosis over 5 years (OR 4.7; 95% CI 2.5-9.0), and endometriomas larger than 8 cm (area under the curve 0.83) were predictive of coexistent malignancy.

CONCLUSION

Endometriosis is associated with an increased risk of ovarian, endometrial, and breast malignancy. Increasing age, postmenopausal status, higher levels of CA 125, larger endometrioma, and long-standing disease are predictive risk factors.

Metastatic Tumors to the Ovary-a Surgeon's Dilemma

The ovary is a common site of metastasis. Differential diagnosis of ovarian carcinomas, including secondary tumors, remains a challenging task. Clinical decision-making depends on an accurate diagnosis of the type of ovarian cancer. This study was done to evaluate the pattern of metastatic tumors to the ovary and clinical details and to analyze the survival outcomes over a period of 5 years. Patients who had metastatic tumors to the ovary are identified from the electronic database from 1 January 2015 to 30 September 2019. Clinical details are collected from the electronic charts. Survival data is collected over the phone. The total number of ovarian cancers treated during the time period was 720, of which primary high-grade mucinous tumors contributed 9 (1.2%), and metastatic tumors to ovary 70 (10%). The highest levels of CEA were seen in carcinoma rectum, colon, and cholangiocarcinoma. CA 19-9 was very high in carcinoma gall bladder, pancreas, and cholangiocarcinoma. Common primaries were stomach (23%), gall bladder (13%), and colon (13%). Adenocarcinoma with signet ring cells was found in 29% of the patients. The median follow-up was 7 months (range 1 to 40 months). The median overall survival was 10 months after diagnosis (95% CI,7.9-12.0). There was no statistically significant difference in survival between patients who had peritoneal carcinomatosis with enlarged ovaries and those who had metastasis confined to ovaries (p value 0.360). A diagnosis of metastatic tumors to the ovary is associated with a very poor prognosis and the focus of treatment should be to improve the quality of life.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13193-020-01267-4.

HuBiogel incorporated fibro-porous hybrid nanomatrix graft for vascular tissue interfaces

Native extracellular matrix (ECM) possesses the biochemical cues to promote cell survival. However, decellularized, the ECM loses its cell supporting mechanical integrity. We report, here, a novel biohybrid vascular graft of polycaprolactone (PCL), poliglecaprone (PGC) incorporated with human biomatrix as functional materials for vascular tissue interfacing by electrospinning, thus harnessing the biochemical cues from the ECM and the mechanical integrity of the polymer blends. The fabricated fibro-porous tubular small diameter graft (i.d. = 4 mm) from polymer blend was coated with a cocktail of collagenous matrix derived from human placenta called HuBiogel™. The compositional, morphological, and mechanical properties of graft were measured and compared with a non-coated tubular PCL/PGC graft using Fourier Transform infrared spectroscopy (FTIR), x-ray photoelectron spectroscopy (XPS), and scanning electron microscopy (SEM). BCA assay was used to calculate the protein content and coating-uniformity throughout the hybrid graft. Mechanical properties such as tensile strength (1.6 MPa), Young's modulus (2.4 MPa), burst pressure (>1900 mmHg), and suture retention strength (2.3 N) of hybrid graft were found to be comparable to native blood vessels. Protein coating has improved the hydrophilicity and the biocompatibility (cell viability and cell-attachment) enhanced with human umbilical vein endothelial cells (HUVECs) seeded in vitro onto the lumen layer of the graft over two weeks. The overall results promise this new biohybrid graft to be a potential candidate for vascular tissue interface and regeneration.

Evaluating the PGMY-centre hospitalier universitaire vaudois assay as a cost-effective tool for human papillomavirus genotyping in HIV-infected women

Aims

Cervical cancer is one of the leading causes of cancer among women, worldwide. HIV-positive women tend to have persistent infection and infection with multiple human papillomavirus (HPV) types. There is a need for affordable HPV DNA tests as viable alternatives to the existing costly commercial assays. The aim of the study was to establish PGMY-CHUV reverse hybridization assay as a cost-effective tool for HPV genotyping.

Study Design

This was a prospective study conducted in a tertiary care centre from March 2011 to July 2012.

Subjects and Methods

Fifty cervical brush samples from HIV-infected women and 43 WHO reference samples were tested by both the CHUV assay and linear array (LA).

Results

The CHUV assay in comparison to the LA showed a sensitivity of 91%, specificity of 52% and a moderate agreement for all samples that were compared. However, most high-risk HPV types were identified amongst the clinical samples, and the entire range of genotypes in the WHO reference panel was detected.

Statistical Analysis

The accuracy indices such as sensitivity, specificity, positive predictive value and negative predictive value were calculated. The level of agreement (kappa value) between the two assays was also calculated.

Conclusion

The CHUV assay had an acceptable sensitivity, but it lacked specificity for HPV detection. Despite the lower rates of detection of multiple infections from clinical samples, better results were obtained with the WHO reference samples and the ability of the assay to identify the entire range of genotypes suggests that it can be an efficient tool for genotyping.

A benchmark for Monte Carlo simulation in gamma-ray spectrometry

Monte Carlo (MC) simulation is widely used in gamma-ray spectrometry, however, its implementation is not always easy and can provide erroneous results. The present action provides a benchmark for several MC software for selected cases. The examples are based on simple geometries, two types of germanium detectors and four kinds of sources, to mimic eight typical measurement conditions. The action outputs (input files and efficiency calculation results, including practical recommendations for new users) are made available on a dedicated webpage.

The Mobile Analyzer of Radioactive Gases OuTflows (MARGOT): A promising environmental xenon radionuclides detection system

An ultra-compact and unshielded spectrometer for analysis of atmospheric xenon radionuclides has been developed: the MARGOT system. This system works at ambient temperature and high pressure, and has a 54.3 cm³ inner active volume. Atmospheric xenon radionuclide activities are determined with the electron-photon coincidence technique using both NaI(Tl) detectors and large pixellized Si-PIN detectors. The MARGOT system integrates an enhanced version of the PIPSBox™, Geant4 simulation and first calibration results are discussed.

Effect of cylinder power and axis changes on vision in astigmatic participants

PURPOSE

To ascertain the impact of altering cylinder (cyl) power and axis on vision in astigmatism.

METHODS

In a prospective, randomized, participant-masked, crossover clinical trial, 28 astigmatic participants were tested for the following conditions on different days: full sphero-cyl correction and undercorrection by 0.25, 0.50, and 0.75 DC while maintaining spherical equivalence. Axis was also misaligned between -30° and +30°, in 10° steps. For each configuration, monocular high- and low-contrast visual acuities (HCVA, LCVA) were measured at 6 m, and participants rated vision clarity (1-10), vision satisfaction (1-10), and vision acceptability (yes/no). Linear mixed models were used to compare visual performance in the overall group and in low, medium, and high cyl subgroups.

RESULTS

Undercorrecting cyl power affected all groups equally (P≥0.073). Undercorrection by 0.75 DC was significantly different to full cyl power for all variables (P≤0.007), while 0.25 DC undercorrection did not cause any significant decreases (P>0.05). Undercorrection by 0.50 DC was significantly different to full cyl power for HCVA (P=0.006, however not clinically significant) and vision acceptability (P=0.034). Axis misalignment affected the cyl groups differently (P<0.001), with the greatest impact in the high cyl group, followed by the medium then the low-cyl group. Misalignment by ±30° caused significant decreases in almost all cases (P≤0.003), while misalignments by ±10° or ±20° caused significant decreases for some cyl groups and test variables.

CONCLUSION

Undercorrection of cyl by ≤0.50 DC while maintaining spherical equivalence has no significant effect on HCVA, LCVA, vision clarity, and vision satisfaction, while the amount of axis misalignment that can be tolerated is dependent on the cyl power. These results may have practical ophthalmic applications, such as reducing the total number of stock keeping units of toric contact lenses.

Inadequately Staged Endometrial Cancer: a Clinical Dilemma

Incidental diagnosis of carcinoma endometrium following hysterectomy requires clinical expertise from a gynecologic oncologist, with regard to subsequent management. We report our experience with completion staging in endometrial cancer, to determine the benefits and risks of completion staging in women with posthysterectomy diagnosis of endometrial cancer.

DESIGN

A retrospective case series of 20 women with postoperative diagnosis of endometrial cancer, who had undergone completion staging.

SETTING

A gynaecologic oncology unit in a tertiary level hospital in Tamil Nadu, India.

PATIENTS

Electronic medical records of patients who underwent completion staging between January 2011 and December 2014 for endometrial cancer were reviewed. Two hundred and sixty four women with endometrial cancer were evaluated during this period. Twenty women with carcinoma endometrium, with a mean age of 53 (range 31-67) who were previously inadequately staged, were found to be at risk of extrauterine disease, following histopathological review, consented to undergo completion staging over an average of 57 days (range 30-91) following the initial surgery. Forty-five percent (9/20) had a BMI of more than 30, and 40% (8/20) had metabolic syndrome. The most common indications for the initial surgery were perimenopausal abnormal uterine bleeding and postmenopausal bleeding. Only eight patients had a pre-hysterectomy endometrial sampling/biopsy (40%) of whom, one had a pre-operative diagnosis of carcinoma endometrium. Sixteen (80%) had pathological risk factors for lymph nodal involvement and in the others, besides histological grading, surgicopathological details for risk assessment were unavailable. Adnexae were retained in 11, and uterus was bisected/cored during surgery in three women. Following completion staging, 5/20 (25%) patients were upstaged, 9 (45%) required no adjuvant treatment, 5 required vaginal brachytherapy therapy alone and 5 were advised chemotherapy and radiation. Two patients during the study period of 48 months had disease recurrence, and two women died of disease progression. Complications of surgery included the following: iliac vein injury (1) and bladder injury (1). Patients with incidental diagnosis of endometrial cancer following hysterectomy after clinical and radiological assessment and histopathological review, should be offered completion staging, if at risk for extrauterine disease. Completion staging permits appropriate prognostication of disease and thereby allows tailoring of adjuvant treatment, avoiding risks of overtreatment and undertreatment.

Outcomes of carcinosarcoma in a tertiary care institution in India

Background:

Carcinosarcoma is a rare malignancy, and reports are often mixed along with other sarcomas. The literature on uterine carcinosarcoma per se is sparse.

Aims:

This study aims to evaluate the demography, survival, and optimal treatment strategy of uterine carcinosarcoma.

Settings and Design:

A tertiary care center in India. The study design was descriptive with survival analysis.

Materials and Methods:

The medical records of all 18 patients admitted with uterine carcinosarcoma between January 2011 and December 2015 were reviewed. Baseline characteristics and outcomes were studied. Survival analysis was done using the Kaplan–Meier method and compared between treatment groups using the Log-rank test.

Results:

The total number of uterine malignancies operated in our center over this time period was 311 of which 18 were carcinosarcomas (5.7%). Median age of presentation was 61 years (36–77 years). Most women (94%) were postmenopausal and 67% of them presented with postmenopausal bleeding. Over half of the patients (56%) presented late (Stage III or IV). Only 11 (61%) had adjuvant treatment and 7 patients had expired at the time of follow-up. The median survival was 284 days (95% confidence interval 107–461). Patients who received adjuvant therapy did better compared to those who did not (P = 0.036).

Conclusions:

Carcinosarcomas are aggressive tumors of postmenopausal women who present with bleeding or discharge per vaginum. In spite of adequate surgical staging followed by adjuvant therapy, survival remains poor. Improvements in early detection and optimal therapy need to be made.

Recommendations on diagnostic tools for Batrachochytrium salamandrivorans

Batrachochytrium salamandrivorans (Bsal) poses a major threat to amphibian, and more specifically caudata, diversity. Bsal is currently spreading through Europe, and mitigation measures aimed at stopping its spread and preventing its introduction into naïve environments are urgently needed. Screening for presence of Bsal and diagnosis of Bsal-induced disease in amphibians are essential core components of effective mitigation plans. Therefore, the aim of this study was to present an overview of all Bsal diagnostic tools together with their limitations and to suggest guidelines to allow uniform interpretation. Here, we investigate the use of different diagnostic tools in post-mortem detection of Bsal and whether competition between Bd and Bsal occurs in the species-specific Bd and Bsal duplex real-time PCR. We also investigate the diagnostic sensitivity, diagnostic specificity and reproducibility of the Bsal real-time PCR and show the use of immunohistochemistry in diagnosis of Bsal-induced chytridiomycosis in amphibian samples stored in formaldehyde. Additionally, we have drawn up guidelines for the use and interpretation of the different diagnostic tools for Bsal currently available, to facilitate standardization of execution and interpretation.

GRIPP2 reporting checklists: tools to improve reporting of patient and public involvement in research

BACKGROUND

While the patient and public involvement (PPI) evidence base has expanded over the past decade, the quality of reporting within papers is often inconsistent, limiting our understanding of how it works, in what context, for whom, and why.

OBJECTIVE

To develop international consensus on the key items to report to enhance the quality, transparency, and consistency of the PPI evidence base. To collaboratively involve patients as research partners at all stages in the development of GRIPP2.

METHODS

The EQUATOR method for developing reporting guidelines was used. The original GRIPP (Guidance for Reporting Involvement of Patients and the Public) checklist was revised, based on updated systematic review evidence. A three round Delphi survey was used to develop consensus on items to be included in the guideline. A subsequent face-to-face meeting produced agreement on items not reaching consensus during the Delphi process.

RESULTS

One hundred forty-three participants agreed to participate in round one, with an 86% (123/143) response for round two and a 78% (112/143) response for round three. The Delphi survey identified the need for long form (LF) and short form (SF) versions. GRIPP2-LF includes 34 items on aims, definitions, concepts and theory, methods, stages and nature of involvement, context, capture or measurement of impact, outcomes, economic assessment, and reflections and is suitable for studies where the main focus is PPI. GRIPP2-SF includes five items on aims, methods, results, outcomes, and critical perspective and is suitable for studies where PPI is a secondary focus.

CONCLUSIONS

GRIPP2-LF and GRIPP2-SF represent the first international evidence based, consensus informed guidance for reporting patient and public involvement in research. Both versions of GRIPP2 aim to improve the quality, transparency, and consistency of the international PPI evidence base, to ensure PPI practice is based on the best evidence. In order to encourage its wide dissemination this article is freely accessible on The BMJ and Research Involvement and Engagement journal websites.

GRIPP2 reporting checklists: tools to improve reporting of patient and public involvement in research

Background While the patient and public involvement (PPI) evidence base has expanded over the past decade, the quality of reporting within papers is often inconsistent, limiting our understanding of how it works, in what context, for whom, and why.Objective To develop international consensus on the key items to report to enhance the quality, transparency, and consistency of the PPI evidence base. To collaboratively involve patients as research partners at all stages in the development of GRIPP2.Methods The EQUATOR method for developing reporting guidelines was used. The original GRIPP (Guidance for Reporting Involvement of Patients and the Public) checklist was revised, based on updated systematic review evidence. A three round Delphi survey was used to develop consensus on items to be included in the guideline. A subsequent face-to-face meeting produced agreement on items not reaching consensus during the Delphi process.Results 143 participants agreed to participate in round one, with an 86% (123/143) response for round two and a 78% (112/143) response for round three. The Delphi survey identified the need for long form (LF) and short form (SF) versions. GRIPP2-LF includes 34 items on aims, definitions, concepts and theory, methods, stages and nature of involvement, context, capture or measurement of impact, outcomes, economic assessment, and reflections and is suitable for studies where the main focus is PPI. GRIPP2-SF includes five items on aims, methods, results, outcomes, and critical perspective and is suitable for studies where PPI is a secondary focus.Conclusions GRIPP2-LF and GRIPP2-SF represent the first international evidence based, consensus informed guidance for reporting patient and public involvement in research. Both versions of GRIPP2 aim to improve the quality, transparency, and consistency of the international PPI evidence base, to ensure PPI practice is based on the best evidence. In order to encourage its wide dissemination this article is freely accessible on The BMJ and Research Involvement and Engagement journal websites.

Inhibition by tadalafil of contractility of isolated nonpregnant human myometrium

Objective:

To investigate the inhibitory effect of tadalafil on the contractility of isolated nonpregnant human myometrium.

Materials and Methods:

The ability of tadalafil (25, 40, and 63 μM) to inhibit 55 mM KCl-induced contractility of isolated nonpregnant human myometrium was studied. The ability of the ATP-sensitive potassium channel blocker glibenclamide (10 μM) and the calcium-sensitive potassium channel (BKCa) blocker iberiotoxin (100 nM) to reverse the inhibitory effect of 40 μM tadalafil on 55 mM KCl-induced myometrial contractility was also studied.

Results:

Tadalafil produced a concentration-dependent inhibition of myometrial contractility that was statistically significant at 40 and 63 μM concentrations of tadalafil. The inhibition by tadalafil of myometrial contractility was statistically significantly reversed by the concurrent administration of glibenclamide and iberiotoxin.

Conclusions:

These results suggest that tadalafil inhibits human myometrial contractility by opening ATP-sensitive potassium channels and BKCa channels. The opening of these channels could have been due to the action of raised intracellular levels of cGMP due to inhibition of PDE-5 by tadalafil. The results suggest that tadalafil could be investigated for use in clinical conditions requiring relaxation of the myometrium.

Optical analysis of samarium doped sodium bismuth silicate glass

Samarium doped sodium bismuth silicate glass was synthesized using the melt quenching method. Detailed optical spectroscopic studies of the glassy material were carried out in the UV-Vis-NIR spectral range. Using the optical absorption spectra Judd-Ofelt (JO) parameters are derived. The calculated values of the JO parameters are utilized in evaluating the various radiative parameters such as electric dipole line strengths (S_ed), radiative transition probabilities (A_rad), radiative lifetimes (τ_rad), fluorescence branching ratios (β) and the integrated absorption cross- sections (σ_a) for stimulated emission from various excited states of Sm³⁺‡ ion. The principal fluorescence transitions are identified by recording the fluorescence spectrum. Our analysis revealed that the novel glassy system has the optimum values for the key parameters viz. spectroscopic quality factor, optical gain, stimulated emission cross section and quantum efficiency, which are required for a high performance optical amplifier. Calculated chromaticity co-ordinates (0.61, 0.38) also confirm its application potential in display devices.

Spectral and Lensing Characteristics of Gel-Derived Strontium Tartrate Single Crystals Using Dual-Beam Thermal Lens Technique

The Dual Beam mode-matched thermal lens spectrometry is a sensible technique for direct measurements of the thermal properties of tartrate crystalline materials. Here we report the measurement of thermal diffusivity of Strontium Tartrate single crystals incorporated with Rhodamine 6G using the thermal lens experiment. The respective crystals were prepared by solution-gel method at room temperature. The absorption characteristics of three different Strontium Tartrate crystals viz. pure, electric field applied and magnetic field applied were also carried out.

Abstract P2-09-06: Multi-gene panel testing for hereditary cancer risk

Background: Multi-gene panels are widely available for assessing hereditary cancer risk in high risk individuals. Due to the use of these panels, many genetic mutations other than BRCA 1 or 2 can be detected which can potentially affect management. This study presents the results of multi-gene panel testing performed at Beaumont Health System.

Methods:All patients who underwent multi-gene panel testing at Beaumont Health System between November 1, 2012 and January 15, 2015 were included in this study. This cohort consisted of patients who met criteria for genetic testing due to personal or family history. All patients received comprehensive pre and post-test genetic counseling. The panels ranged from 5 to 43 genes associated with risk for breast and other cancers.

Results: 653 multi-gene panel tests were performed. The majority of these consisted of either a 5 gene high risk breast panel (25%), an 18 gene moderate to high risk breast panel (21%), or a 9 gene high risk breast and gynecologic panel (17%). 184 variants of undetermined significance (VUS) were identified with a pooled VUS rate of 28%. Among the commonly used panels, there was a positive correlation between VUS rate and the number of genes included in the panel (r = 0.86, p = 0.01, Range 6% to 70%). A pathogenic mutation was identified in one or more genes in 65 (10%) panels for a total of 67 mutations. Of these, 17 mutations were in BRCA1 or BRCA2 gene. Fifty non-BRCA deleterious mutations were identified with the following frequencies: CHEK2(12), MUTYH(7 monoallelic, 1 biallelic), TP53(4), PTEN(4), ATM(4), MSH6(3), PALB2(3), MSH2(2), CDH1(2), APC(2), NF1(2), BARD1(2), MLH1(1) and PMS2(1). Of these non-BRCA mutations, 41(82%) had a significant impact on management.

Conclusions: Our study demonstrates that multi-gene panel testing identifies several genes that can impact management and would likely not have been discovered by pedigree analysis alone. However, this added detection is associated with a higher VUS rate, especially using larger panels. Further research is needed to better define the role of multi-gene panel testing in high risk patients, with a focus on choosing appropriate genes, understanding the magnitude of cancer risk and delineating impact on management.

Citation Format: Yadav S, Ladkany R, Fulbright J, Dreyfuss H, Reeves A, Campian S, Thomas V, Zakalik D. Multi-gene panel testing for hereditary cancer risk. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-09-06.

Epidemiological cut-off values for Flavobacterium psychrophilum MIC data generated by a standard test protocol

Epidemiological cut-off values were developed for application to antibiotic susceptibility data for Flavobacterium psychrophilum generated by standard CLSI test protocols. The MIC values for ten antibiotic agents against Flavobacterium psychrophilum were determined in two laboratories. For five antibiotics, the data sets were of sufficient quality and quantity to allow the setting of valid epidemiological cut-off values. For these agents, the cut-off values, calculated by the application of the statistically based normalized resistance interpretation method, were ≤16 mg L(-1) for erythromycin, ≤2 mg L(-1) for florfenicol, ≤0.025 mg L(-1) for oxolinic acid (OXO), ≤0.125 mg L(-1) for oxytetracycline and ≤20 (1/19) mg L(-1) for trimethoprim/sulphamethoxazole. For ampicillin and amoxicillin, the majority of putative wild-type observations were 'off scale', and therefore, statistically valid cut-off values could not be calculated. For ormetoprim/sulphadimethoxine, the data were excessively diverse and a valid cut-off could not be determined. For flumequine, the putative wild-type data were extremely skewed, and for enrofloxacin, there was inadequate separation in the MIC values for putative wild-type and non-wild-type strains. It is argued that the adoption of OXO as a class representative for the quinolone group would be a valid method of determining susceptibilities to these agents.

Improving medication adherence in rheumatoid arthritis (RA): a pilot study

The aim of this exploratory pilot study was to adapt a psychological intervention to improve adherence to medication for patients with rheumatoid arthritis (RA). The approach draws on cognitive behavioural therapy (CBT) techniques, including motivational interviewing . The current study aimed to (i) adapt the intervention for patients with RA, (ii) assess its effectiveness in improving adherence to medication and (iii) evaluate patients' experience of the intervention. Participants were randomly allocated to either the 'intervention group' (N  =  10), receiving up to six weekly sessions of 'Compliance Therapy', or to the 'wait-list control' group (N  =  8), who received standard care. Data was collected pre intervention (baseline), post intervention and at six weeks post intervention (follow-up). Eighteen female participants with a mean age of 48.78 years (SD 15.12) took part in the study. Comparisons across the two time points for each group found that only those in the 'intervention' group demonstrated significant improvement in mean scores on adherence measures. Between-group comparisons were not significant. The pilot study suggests that an intervention based on CBT may improve adherence in patients with RA, but further research is required.

Cleaning, disinfection and sterilization of surface prion contamination

BACKGROUND

Prion contamination is a risk during device reprocessing, being difficult to remove and inactivate. Little is known of the combined effects of cleaning, disinfection and sterilization during a typical reprocessing cycle in clinical practice.

AIM

To investigate the combination of cleaning, disinfection and/or sterilization on reducing the risk of surface prion contamination.

METHODS

In vivo test methods were used to study the impact of cleaning alone and cleaning combined with thermal disinfection and high- or low-temperature sterilization processes. A standardized test method, based on contamination of stainless steel wires with high titres of scrapie-infected brain homogenates, was used to determine infectivity reduction.

FINDINGS

Traditional chemical methods of surface decontamination against prions were confirmed to be effective, but extended steam sterilization was more variable. Steam sterilization alone reduced the risk of prion contamination under normal or extended exposure conditions, but did show significant variation. Thermal disinfection had no impact in these studies. Cleaning with certain defined formulations in combination with steam sterilization can be an effective prion decontamination process, in particular with alkaline formulations. Low-temperature, gaseous hydrogen peroxide sterilization was also confirmed to reduce infectivity in the presence and absence of cleaning.

CONCLUSION

Prion decontamination is affected by the full reprocessing cycle used on contaminated surfaces. The correct use of defined cleaning, disinfection and sterilization methods as tested in this report in the scrapie infectivity assay can provide a standard precaution against prion contamination.

Pan-European resistance monitoring programmes encompassing food-borne bacteria and target pathogens of food-producing and companion animals

Antimicrobial resistance is a concern both for animal and human health. Veterinary programmes monitoring resistance of animal and zoonotic pathogens are therefore essential. Various European countries have implemented national surveillance programmes, particularly for zoonotic and commensal bacteria, and the European Food Safety Authority (EFSA) is compiling the data. However, harmonisation is identified as a weakness and an essential need in order to compare data across countries. Comparisons of resistance monitoring data among national programmes are hampered by differences between programmes, such as sampling and testing methodology, and different epidemiological cut-off values or clinical breakpoints. Moreover, only very few valid data are available regarding target pathogens both of farm and companion animals. The European Animal Health Study Centre (CEESA) attempts to fill these gaps. The resistance monitoring programmes of CEESA have been a collaboration of veterinary pharmaceutical companies for over a decade and include two different projects: the European Antimicrobial Susceptibility Surveillance in Animals (EASSA) programme, which collects food-borne bacteria at slaughter from healthy animals, and the pathogen programmes that collect first-intention target pathogens from acutely diseased animals. The latter comprises three subprogrammes: VetPath; MycoPath; and ComPath. All CEESA projects include uniform sample collection and bacterial identification to species level in various European Union (EU) member states. A central laboratory conducts quantitative susceptibility testing to antimicrobial agents either important in human medicine or commonly used in veterinary medicine. This 'methodology harmonisation' allows easy comparisons among EU member states and makes the CEESA programmes invaluable to address food safety and antibiotic efficacy.