Sexual and reproductive health integration into pre-travel consultations: a scoping review

BACKGROUND

Casual sex during travel is a major preventable factor in the global transmission of sexually transmissible infections (STI). Pre-travel consults present an excellent opportunity for practitioners to educate travellers about sexual and reproductive health (SRH) and safety. The scoping review aims to explore and understand the extent to which SRH is included in pre-travel consultations.

METHODS

PubMed, Embase, CINAHL, Scopus, Medline and Web of Science were systematically searched for primary research articles exploring whether health care practitioners (HCP) included SRH in pre-travel consultations. Extracted findings were synthesised and presented in narrative form.

RESULTS

Findings across 13 articles suggest HCP infrequently broached SRH in pre-travel consultations with HCP discomfort, and lack of time and resources presented as key barriers. Urban practice settings, HCP experience, training in travel medicine, and traveller characteristics such as sexual orientation were positively correlated with discussions about SRH. SRH advice reported was general in nature, primarily focusing on safer sex, condoms, or unspecified STI advice. Risk assessments based solely on age or stereotypes around sexual preferences led to key aspects of SRH care being missed for some (e.g. SRH was less likely to be discussed with older travellers).

CONCLUSIONS

HCPs frequently miss opportunities to integrate SRH into pre-travel consultations. Strategies to promote HCP confidence and awareness present a promising means to boost the frequency and quality of SRH advice disseminated. Integrating culturally safe and responsive SRH history-taking and advice into pre-travel consultations may contribute to global reductions in STI transmission and promote traveller SRH well-being.

The provision of sexual and reproductive health information and services to travellers: an exploratory survey of Australian travel medicine clinicians

BACKGROUND

International travel can increase the risk of exposure to infectious diseases including sexually transmissible infections (STI). Pre-travel medical consultation provides an opportunity for travel-related health risk assessments and advice. This study explored how travel medicine clinicians integrate sexual and reproductive health (SRH) services into clinical practice.

METHODS

A convenience sample of travel medicine clinicians completed a cross-sectional survey online or via hard-copy disseminated at an annual national Australian travel medicine conference.

RESULTS

Of the 67 respondents, most (n , 51; 76.1%) had a postgraduate qualification relevant to travel medicine and 55.2% (n , 37) had worked in travel medicine for over 10years. Only 22.4% (n , 15) reported conducting a SRH history/STI risk assessment for all travel patients. STI testing pre-departure was conducted on patient request (48, 71.6%), if symptomatic (32, 47.8%) or based on risk history (28, 41.8%). SRH information pre-departure was most frequently provided if prompted by patient questions (n , 42; 62.7%), or based on the patient's history (n , 37; 55.2%). Over half the sample (n , 40; 59.7%) expressed interest in further training in SRH.

CONCLUSION

Providing and engaging with additional training may assist travel medicine clinicians to take a more proactive approach to SRH consultations and STI testing. Additional research is needed to explore models of care that will allow comprehensive SRH and STI services to be integrated into standard pre- and post-travel care.

Real-world application of tumor mutational burden-high (TMB-high) and microsatellite instability (MSI) confirms their utility as immunotherapy biomarkers

Introduction

Microsatellite instability (MSI) testing and tumor mutational burden (TMB) are genomic biomarkers used to identify patients who are likely to benefit from immune checkpoint inhibitors. Pembrolizumab was recently approved by the Food and Drug Administration for use in TMB-high (TMB-H) tumors, regardless of histology, based on KEYNOTE-158. The primary objective of this retrospective study was real-world applicability and use of immunotherapy in TMB/MSI-high patients to lend credence to and refine this biomarker.

Methods

Charts of patients with advanced solid tumors who had MSI/TMB status determined by next generation sequencing (NGS) (FoundationOne CDx) were reviewed. Demographics, diagnosis, treatment history, and overall response rate (ORR) were abstracted. Progression-free survival (PFS) was determined from Kaplan–Meier curves. PFS1 (chemotherapy PFS) and PFS2 (immunotherapy PFS) were determined for patients who received immunotherapy after progressing on chemotherapy. The median PFS2/PFS1 ratio was recorded.

Results

MSI-high or TMB-H [≥20 mutations per megabase (mut/MB)] was detected in 157 adults with a total of 27 distinct tumor histologies. Median turnaround time for NGS was 73 days. ORR for most recent chemotherapy was 34.4%. ORR for immunotherapy was 55.9%. Median PFS for patients who received chemotherapy versus immunotherapy was 6.75 months (95% confidence interval, 3.9-10.9 months) and 24.2 months (95% confidence interval, 9.6 months to not reached), respectively (P = 0.042). Median PFS2/PFS1 ratio was 4.7 in favor of immunotherapy.

Conclusion

This real-world study reinforces the use of TMB as a predictive biomarker. Barriers exist to the timely implementation of NGS-based biomarkers and more data are needed to raise awareness about the clinical utility of TMB. Clinicians should consider treating TMB-H patients with immunotherapy regardless of their histology.

•

This retrospective study examined the real-world use of immune checkpoint inhibitors (ICIs) in TMB/MSI-high patients with a diverse set of cancer types.

•

TMB is an emerging tumor-agnostic biomarker for response to treatment with ICIs that may expand personalized cancer care.

•

ICIs remain underutilized as a first-line therapy for TMB/MSI-H patients without specific histologic approval for ICIs.

•

The PFS2 to PFS1 ratio was 4.7, favoring immunotherapy over chemotherapy even as a second-line therapy.

•

Our study reinforces the real-world evidence that TMB is a valid surrogate marker for MSI and can predict response to ICIs.

Faculty Respond to COVID-19: Reflections-on-Action in Field Education

The field placement process has become increasingly challenging for schools of social work, particularly for large graduate programs situated in urban centers with competing schools. The unprecedented circumstances created by the COVID-19 public health crisis further strained the placement process, revealing a delicate balance of interdependent systems that schools must address when confronted with an unforeseen disruption of field education. This paper reflectively examines the steps taken by the field faculty and department of one large school of social work to address the impact of the pandemic on field education and its placement process. Utilizing crisis and shared trauma perspectives, the field disruptions, continuity of learning, contingency plans, and the attendant anxiety caused by COVID-19 are discussed, as are the lessons learned. Though COVID-19 has significantly altered the placement process, this reflective frame allows faculty to take the lessons emerging from the crisis and use them to improve services and learning opportunities for students in the future.

O-008 Improving outcomes in women with Mullerian anomalies

Mullerian Anomalies are present in approximately 5% to 7% of the general population and the incidence is a little more in infertile and recurrent miscarriage women. Most of the recent studies have reported that the obstetric outcome is compromised in this group with greater risk of infertility, recurrent pregnancy loss, intrauterine growth retardation, preterm birth and many other obstetric complications, which may be individually related to the different types of Mullerian Anomalies. In this presentation, We are going to discuss on how the outcomes are different in the various Mullerian Anomalies depending upon the degree of the defects related to different complications with more profound defects. We will also discuss on how to optimize the pregnancy outcomes with various interventions and what the literature review supports.

Trial registration number

Study funding

Funding source

P–771 I hear, I forget. I see and I remember. I do and I understand. An Insight into the need for training for add on techniques

Study question

Do embryologists need additional training or certifications before using add on techniques in the lab ?

Summary answer

Out of 173 respondents majority feel add on techniques require training and/or certifications, the mode of training varies for different add ons.

What is known already

Cochrane reviews have suggested that minimal evidence exists for the use of add on treatments in ART, the data on the prevalence of add ons in IVF is unclear but the presence of technologies in ART laboratories world over suggests a increasing trend of adoption of unproven techniques. No data exists suggesting the role of embryologists in performing the Add on techniques and how their training or lack of, can impact patient safety. The most common method of training comes from the manufacturers and there is a lack of structured trainings for add on treatments worldover.

Study design, size, duration

An internet based survey was designed keeping in mind commonly available laboratory add ons. It comprised of 9 sections and a total of 18 multiple choice questions. Answer choices ranged from a simple yes or no to more complex choices suggesting the type of training and the potential benefits of training.

Participants/materials, setting, methods

The Survey includes results from 173 embryologists from india with varying degree of experience. Add ons included in the survey were Sperm DNA Fragmentation test, IMSI, PICSI, Microfluidics, MACS, Advanced culture media, Oocyte vitrification, Assisted hatching, Time Lapse imaging, spindle view and Electronic Witnessing. The most common practice suggestions were tabulated and identified.

Main results and the role of chance

The survey reports huge need for training for different add on treatments (SDF –91.4%, IMSI - 81.2%, PICSI- 66.5%, Microfluidics- 55.9%, MACS –55.3%, MicroTese- 86.9%, using advanced culture medias{Calcium ionophore- 73.4%, Hyaluronan rich media- 52.1%, growth cytokine rich media–48.5%, Theophylline for sperm motility–50.9%},oocyte Vitrification 85.5%, Assisted Hatching 75.4%, Time-lapse and Electronic witnessing 77.3%, Polarised microscopy for spindle assessment 73.5%). The Most preferred mode of training for more invasive procedures was Hands on training, followed by On the job training and validation followed by workshops(SDF- 62.6%, IMSI- 61%,PICSI–56.1%, MACS and Microfluidics 38.8%,microTese- 50.6%,Oocyte freezing 85.5%, assisted hatching 67.8%,Time-lapse and electronic witnessing 77.3%, Spindle view 73.5% ). The most preferred mode of training for non invasive procedures was Workshops and Observerships, followed by CME’s, followed by product Leaflets(44.4%,42.1%,13.5% respectively). The most common answer for the disadvantages of not being trained was unable to use the technology to its fullest potential(88.5%), whereas the most common answer for the benefit of being trained was better outcomes with said technologies(76.6%).

Limitations, reasons for caution

This study includes responses from embryologists who have varied levels of experience, while the need for training can be established based on these results, a junior level embryologist might answer the survey differently as compared to a senior or a lab director.

Wider implications of the findings: This is a first of its kind large survey, suggesting the need for training and validation from the perspective of the embryologist. This data can be used in formulating guidelines for future trainings and can help regulators in deciding on the most preferred mode of training.

Trial registration number

-

British and Canadian views on the ethics of paediatric clinical trials

BACKGROUND

Ethical problems are quoted as a reason not to perform clinical trials in children. Little is known about the views of researchers regarding ethics.

OBJECTIVES

A pilot study was conducted to assess the applicability of a questionnaire design containing trial scenarios to examine views regarding the use of children in drug trials and to elicit possible international differences.

SETTING

Paediatricians and researchers in the United Kingdom and Canada.

METHODS

Responders were presented with a questionnaire containing direct questions and six trial scenarios, each containing an ethical dilemma. Responders were asked regarding their own approval and their perceived opinion of whether an ethical review board (ERB) would approve.

RESULTS

One hundred questionnaires (50 each country) were received. Few responders had research ethics training (14% United Kingdom and 8% Canada). Most (80 and 88%) felt children could be harmed by participation in trials and half (47 and 59%) felt children should only participate if they receive direct benefit. Many (58 and 61%) disagreed with payments beyond travel expenses. In the trial scenarios, 34% of responders were willing to enter healthy children in a pharmacokinetics study of an antibiotic for cystic fibrosis and 22% considered their ERBs would approve. Only a third (33%) would enter children in an analgesia trial that was placebo-controlled.

CONCLUSION

Using healthy children and placebos in trials caused concern. Similar views were found between the two countries. The majority had no training in research ethics. The study highlights the usefulness of a questionnaire with clinical trial scenarios to try to elicit views on the ethics of conducting research in children.

Antiepileptic drug therapy in the twenty first century

In the last 25 years, particularly the last decade, there have been many advances relating to all aspects of epilepsy i.e. pathophysiology, diagnosis, pharmacotherapy and surgical interventions. Noteworthy has been the progress in terms of understanding of the established antiepileptic drugs (AEDs) and introduction of several newer agents developed rationally, on the basis of now available information on the biochemical changes in the epileptic brain. Data is accumulating regarding the use of newer agents but they still need to stand the test of time. Many of the newer AEDs may offer a better tolerability because of favorable pharmacokinetic characteristics and minimal drug interactions. However, serious adverse events have been associated with felbamate and lamotrigine already and for other newer agents reliable and accurate data needs to be generated.

Dopaminergic involvement in adenosine A1 receptor-mediated antinociception in the tail flick latency model in mice

The interaction between the adenosinergic and dopaminergic systems in nociception was assessed in the tail flick latency (TFL) test in mice. Adenosine exhibited qualitatively different responses depending on the dose: Adenosine 10 and 100 mg/kg i.p. caused antinociception as evidenced by an increase in TFL while the middle dose of 30 mg/kg decreased TFL. On the other hand, the specific adenosine A1 receptor agonist N6-cyclopentyladenosine (CPA) at doses of 0.05, 0.1, 0.25 and 0.5 mg/kg (i.p.) resulted in dose-dependent antinociception. The antinociceptive effect of CPA was reversed by classical albeit nonspecific adenosine receptor antagonist theophylline (5 mg/kg) at a dose which had no effect on TFL per se. A low dose (1 mg/kg i.p.) of the dopaminergic agonist apomorphine caused an early mild hyperalgesic response while the high dose (10 mg/kg i.p.) had no significant effect on TFL. The antinociceptive effect of CPA was attenuated by pretreatment with low dose apomorphine while pretreatment with the high dose caused mild but insignificant potentiation. Theophylline, when administered prior to apomorphine failed to modify the nociceptive response. The results suggest that an interaction between adenosine and dopamine may be involved in nociception.

Effect of adenosinergic modulation on the anticonvulsant effect of phenobarbitone and carbamazepine

Adenosine has been demonstrated to have an anticonvulsant action which is mediated predominantly by the adenosine A1 receptor subtype. The present study was conducted to determine if the adenosinergic system and adenosine A1 receptors are involved in the anticonvulsant action of the antiepileptic drugs phenobarbitone and carbamazepine, in pentylenetetrazole (PTZ)-induced seizures in rats. The specific adenosine A1 receptor antagonist, DPCPX (1 mg/kg i.p.), had no effect on the anticonvulsant action of the two antiepileptic drugs. However, the nonspecific adenosine receptor antagonist, theophylline (50 and 100 mg/kg i.p.), reversed the anticonvulsant action of carbamazepine completely and that of phenobarbitone partially. This suggests that adenosine A1 receptors do not mediate the anticonvulsant effects of these agents. When phenobarbitone/carbamazepine were coadministered with adenosine/N6-cyclopentyladenosine (CPA), a specific adenosine A1 receptor agonist, an enhancement in protection against PTZ-induced seizures was observed. The diversity of anticonvulsant mechanism of carbamazepine/phenobarbitone and that of adenosinergic agents could be responsible for this effect.

Effect of different lithium priming schedule on pilocarpine-induced status epilepticus in rats

The conventional method of inducing status epilepticus by injecting pilocarpine 24 h after lithium chloride (LiCl) administration lacks kinetic correlate. Therefore, the present study was conducted to see the effect of altering the time schedule of lithium administration (from 2 to 72 h) on the convulsive behavior in response to pilocarpine challenge in rats. It was observed that reducing the pretreatment time of lithium from 24 to 2 h produced convulsions in 100% of the rats. However, incidence of convulsions decreased when lithium pretreatment time was increased to 48 h and no convulsions were recorded with 72-h lithium time schedule. The neuronal damage assessed histologically and the effectiveness of diazepam was similar irrespective of time schedule. This study provides evidence that LiCl pretreatment schedule can be adopted at any time between 2 to 24 h to suit the convenience and objectives of the experiment.

METHODS AND CONSIDERATIONS FOR EXPERIMENTAL EVALUATION OF ANTIEPILEPTIC DRUGS

Research into epilepsy and development of antiepileptic drugs relies heavily on studies in experimental animals. Though the conventional pentylenetetrazole-induced seizures and electroshock-induced seizures remain the mainstay of any antiepileptic drug screening protocol, considering the diversity of seizure types and underlying pathologies encountered in epilectics, numerous other seizure models have been developed. Some of these experimental models of seizures and considerations governing their selection are reviewed.

Influence of adenosine agonists and antiepileptic drugs on theophylline-induced seizures in rats

Seizures is a major toxicity of theophylline. The mechanism of theophylline-induced seizures is not known, but antagonism at adenosine receptors may be a possibility. The effect of pretreatment with different doses of adenosine (100, 500 and 1000 mg/kg, i.p.), and the adenosine A1 receptor agonist N6-cyclopentyladenosine (CPA), 1, 5 and 10 mg/kg, i.p., was studied against seizures induced by theophylline in rats. Both these drugs, at all dose levels tested, failed to protect theophylline seizures. Thus adenosinergic system is unlikely to be involved in mediating the convulsant action of theophylline. On the other hand, the conventional antiepileptic drugs, i.e. diazepam (4 mg/kg), sodium valproate (300 mg/kg) and phenobarbitone (50 mg/kg), but not carbamazepine, afforded some protection. The modification of course of seizures, by the antiepileptic drugs suggests the involvement of some other alternate mechanism in theophylline-induced seizures.

Adenosinergic system as an endogenous anticonvulsant mechanism

The treatment of epilepsies remains far from adequate primarily due to inadequate understanding of the pathophysiology of seizures. The conventional approach for research into epilepsy has been study of factors responsible for initiation of seizures. However, now attention is being drawn to the spontaneous and abrupt arrest of seizures which suggests a distinct possibility of activation of an endogenous anticonvulsant mechanism(s), which may be targeted in future for controlling seizures. Of the various endogenous anticonvulsant mechanisms, the concept of an endogenous anticonvulsant substance has gained much experimental support and, many potential candidates have been postulated. Of these adenosinergic system appears to be the most promising. This review discusses the possible role of adenosinergic system in seizures, in relation to the available antiepileptic drugs and its therapeutic implications.

Effect of theophylline on diazepam and sodium valproate protection in pentylenetetrazole - kindled seizures in rats

Theophylline is well known for its convulsant and proconvulsant action. Some experimental studies also suggest that theophylline and other methylxanthines may impair the protection of antiepileptic drugs. The interaction of theophylline and the antiepileptic drugs diazepam and sodium valproate was studied in pentylenetetrazole (PTZ) - kindled seizures in rats. Pretreatment with both diazepam 4 mg/kg and sodium valproate 300 mg/kg, i.p., showed protection against PTZ kindled seizures. Theophylline, 50 mg/kg, i.p., when given before the antiepileptic drugs, failed to reverse their protection. Since theophylline has an adenosine receptor antagonist activity which may be responsible for its convulsant potential, the results indicate non-involvement of adenosinergic mechanisms in the mechanisms of actions of these antiepileptic drugs.

Effect of adenosine receptor modulation on pentylenetetrazole-induced seizures in rats

1. The effects of adenosine, the adenosine analogue, 2-chloroadenosine (2-CADO), the specific adenosine A1 receptor agonist, N6-cyclopentyladenosine (CPA) and A2 receptor agonist 5'-(N-cyclopropyl) carboxamidoadenosine (CPCA), were examined against seizures induced by acute administration of pentylenetetrazole (PTZ), 60 mg kg-1, and PTZ kindled seizures, in rats. 2. Adenosine 1000 mg kg-1, i.p., 5 min pretreatment and CPA 10 mg kg-1 i.p., 60 min pretreatment, showed significant protection against acute PTZ-induced seizures while, CPCA up to 10 mg kg-1 was ineffective. The adenosine analogue 2-CADO in a dose of 5 mg kg-1 was only partially protective and on increasing the dose to 10 mg kg-1, this protection was lost. 3. Theophylline, a non specific adenosine receptor antagonist at 50 mg kg-1 and the specific adenosine A1 receptor antagonist, 8-cyclopentyl-1,3-dipropylxanthine (DPCPX), at 1 mg kg-1, if administered before the maximally protective doses of adenosine and CPA, completely reversed the protection afforded by them against PTZ seizures. While, pretreatment with the adenosine A2 receptor antagonist, 3,7-dimethyl-1-propargylxanthine (DMPX), failed to reverse the protection. 4. Adenosine and the adenosine A1 receptor agonist in doses that protected against seizures after acute PTZ administration, offered only incomplete protection when tested against PTZ kindled seizures. 5. The effects of adenosine and adenosine receptor agonists on mean arterial pressure, heart rate and rectal temperature were studied, to rule out the possibility of their systemic effects mediating the protection of PTZ seizures. All these agents produced a fall in mean arterial pressure, heart rate and hypothermia in the doses exhibiting an anticonvulsant response. While the effect on blood pressure and heart rate was immediate i.e. seen within 5 min and, maintained throughout the observation period, the development of hypothermia lagged behind the onset of hypotension and bradycardia. However, there was no correlation between haemodynamic and hypothermic response and the anticonvulsant effect. 6. The results indicate that the adenosine mediated anticonvulsant effect is via stimulation of A1 receptors. Hypotension and hypothermia do not appear to contribute to the protection observed with adenosine and the adenosine A1 receptor agonists.

A simple device for recording seizure activity in rats

Experimental research on epilepsy and antiepileptic drugs in rodents utilizes different models (e.g., chemical, electrical or genetic) which have different end points for evaluating seizure activity. To overcome the possibility of observer bias and the limitation of nonavailability of a hard copy of seizure activity, a simple method is described. A horizontal perspex platform is mounted on four springs of suitable tension inside a perspex chamber. A force transducer is attached to the platform to record seizure activity on paper by a physiograph. Using this assembly, the incidence, latency and duration of different seizure components, i.e., myoclonic jerks and generalized clonic seizures, after pentyleneterrazole administration (60 mg/kg i.p.) in rats were recorded. The effects of pretreatment with anticonvulsant doses of diazepam (4 mg/kg i.p.) and sodium valproate (300 mg/kg i.p.) were studied. Chemical kindling was induced by repeated, alternate-day injections of a subconvulsant dose of pentylenetetrazole (30 mg/kg i.p.) for 10 weeks and seizure activity during different stages of development of kindling was recorded. The described method not only successfully records the different seizure components but also quantifies the latency and duration of seizure activity.

Adenosinergic mechanisms in anticonvulsant action of diazepam and sodium valproate

The effects of adenosine receptor agonists and antagonists were studied in pentylenetetrazole (PTZ)-induced seizures in rats. Animals were pretreated with the non-specific adenosine receptor antagonist, theophylline (50 and 100 mg/kg, i.p.), or the specific A(1) adenosine receptor antagonist, 8-cyclopentyl-1,3-dipropylxanthine (DPCPX), in a dose of 1 mg/kg, i.p., followed by 100% anticonvulsant doses of diazepam (4 mg/kg)/sodium valproate (300 mg/kg, i.p.). Subsequently, they were challenged with convulsant doses of PTZ i.e. 60 mg/kg, i.p. It was seen that while DPCPX could not reverse the protection of both the antiepileptic drugs, theophylline significantly reversed this protection, as assessed by percent incidence of seizures and change in latency parameters. In another set of experiments, the rats were pretreated with a combination of subanticonvulsant doses of adenosine (500 mg/kg) or specific adenosine A(1) receptor agonist, cyclopentyladenosine (CPA) and diazepam (0.5 and 1 mg/kg)/sodium valproate (150 mg/kg), prior to PTZ challenge. We observed a decrease in incidence and increase in latency of seizures following either combination. The protection observed was independent of the hypothermic and hypotensive effects of adenosine and CPA. These results indicate that though A(1) agonist enhances the protection of diazepam and sodium valproate, a direct involvement of adenosine A(1) receptor in anticonvulsant action of these drugs is doubtful.

Anaesthetic steroids--a review

Steroids produce anaesthesia besides producing the well known metabolic and hormonal effects. A number of anaesthetic steroids have been synthesized and tried clinically. Hydroxydione, althesin, minaxolone and pregnanolone are among those studied in detail. They act through GABAergic mechanism and are known to be advantageous over barbiturates.