Risk of progression of cervical intraepithelial neoplasia grade 2 in human papillomavirus-vaccinated and unvaccinated women: a population-based cohort study

BACKGROUND

Many countries have implemented active surveillance (ie, leaving the lesion untreated) as an option among younger women with cervical intraepithelial neoplasia grade 2 because regression rates are high and excisional treatment increases the risk for preterm birth in subsequent pregnancies. However, early identification of women at increased risk for progression to cervical intraepithelial neoplasia grade 3 or worse is important to ensure timely treatment. Because women who have received a human papillomavirus vaccine have a lower risk for cervical cancer, they may have a lower risk for progression of untreated cervical intraepithelial neoplasia grade 2 to cervical intraepithelial neoplasia grade 3 or worse.

OBJECTIVE

This study aimed to investigate if women who received a human papillomavirus vaccine and who are undergoing active surveillance for cervical intraepithelial neoplasia grade 2 are less likely to progress to cervical intraepithelial neoplasia grade 3 or worse when compared with women who did not receive the vaccine.

STUDY DESIGN

We conducted a population-based cohort study in Denmark using data from national health registers. We identified all women aged 18 to 40 years who were undergoing active surveillance for cervical intraepithelial neoplasia grade 2 from January 1, 2007, to December 31, 2020. Women with a previous record of cervical intraepithelial neoplasia grade 2 or worse, hysterectomy, or a loop electrosurgical excision procedure were excluded. Exposure was defined as having received ≥1 dose of a human papillomavirus vaccine at least 1 year before the cervical intraepithelial neoplasia grade 2 diagnosis. We used cumulative incidence functions to estimate the risk for progression to cervical intraepithelial neoplasia grade 3 or worse within 28 months using hysterectomy, emigration, and death as competing events. We used modified Poisson regression to calculate crude and adjusted relative risks of progression during the 28-month surveillance period. Results were stratified by age at vaccination and adjusted for index cytology, disposable income, and educational level.

RESULTS

The study population consisted of 7904 women of whom 3867 (48.9%) were vaccinated at least 1 year before a diagnosis of cervical intraepithelial neoplasia grade 2. At the time of cervical intraepithelial neoplasia grade 2 diagnosis, women who were vaccinated were younger (median age, 25 years; interquartile range, 23-27 years) than those who were not (median age, 29 years; interquartile range, 25-33 years). The 28-month cumulative risk for cervical intraepithelial neoplasia grade 3 or worse was significantly lower among women who were vaccinated before the age of 15 years (22.9%; 95% confidence interval, 19.8-26.1) and between the ages of 15 and 20 years (31.5%; 95% confidence interval, 28.8-34.3) when compared with women who were not vaccinated (37.6%; 95% confidence interval, 36.1-39.1). Thus, when compared with women who were not vaccinated, those who were vaccinated before the age of 15 years had a 35% lower risk for progression to cervical intraepithelial neoplasia grade 3 or worse (adjusted relative risk, 0.65; 95% confidence interval, 0.57-0.75), whereas women who were vaccinated between the ages of 15 and 20 years had a 14% lower risk (adjusted relative risk, 0.86; 95% confidence interval, 0.79-0.95). For women who were vaccinated after the age of 20 years, the risk was comparable with that among women who were not vaccinated (adjusted relative risk, 1.02; 95% confidence interval, 0.96-1.09).

CONCLUSION

Women who were vaccinated and who were undergoing active surveillance for cervical intraepithelial neoplasia grade 2 had a lower risk for progression to cervical intraepithelial neoplasia grade 3 or worse during 28 months of follow-up when compared with women who were not vaccinated but only if the vaccine was administered by the age of 20 years. These findings may suggest that the human papillomavirus vaccination status can be used for risk stratification in clinical management of cervical intraepithelial neoplasia grade 2.

Anxiety and depression among women with newly diagnosed vulvar cancer - A nationwide longitudinal study

INTRODUCTION

Our objective was to investigate the trajectories of anxiety, depression, emotional and social functioning in women with newly diagnosed vulvar cancer from the time of diagnosis to 12 months after treatment. A further aim was to identify risk factors for high levels of anxiety.

MATERIAL AND METHODS

PROVE (PROspective Vulvar Cancer Evaluation) is a nationwide longitudinal cohort study investigating quality of life in women with newly diagnosed vulvar cancer by the following validated patient-reported outcome measures at diagnosis, and 3 and 12 months after treatment: The Hospital Anxiety and Depression Scale, the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30, and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Vulvar module VU34. Mean scores, changes over time and associations were analyzed by generalized estimated equations and log-linear regression models, adjusted for possible confounders.

RESULTS

Between 2019 and 2021, 105 (69%) women completed the questionnaires at all three time points. At diagnosis, 42% of the women reported elevated anxiety levels, decreasing significantly to 30% during the first 12 months. Insomnia, persisting vulvar symptoms and high information needs were significantly associated with a high level of anxiety (relative risk [RR] 2.1, 95% CI 1.2-3.7 for insomnia; RR 2.8, 95% CI 1.7-4.6 for vulvar symptoms, RR 2.7, 95% CI 1.5-4.9 for information needs). We found a trend towards a higher level of anxiety in younger women (<65 years: RR 1.5, 95% CI 1.0-2.5). Participants reported a low and stable prevalence of depression (14%) and high social functioning throughout the study period.

CONCLUSIONS

Women with newly diagnosed vulvar cancer report a high level of anxiety at diagnosis. Despite a significant improvement, anxiety remains widely prevalent during the first year of follow-up. Targeting insomnia, vulvar symptoms and unmet needs may decrease anxiety during surveillance.

Cancer worry is associated with increased use of supportive health care-results from the multinational InCHARGE study

PURPOSE

To assess use of health care following a diagnosis of endometrial, cervical, and ovarian cancer in the Netherlands, Norway, and Denmark. Furthermore, to analyze the association between cancer worry and use of supportive care.

METHODS

An international multicenter cross-sectional questionnaire study was undertaken among female cancer survivors with endometrial, cervical, or ovarian cancer 1-7 years post diagnosis. We investigated different aspects of cancer survivorship and follow-up care. Health care use included information on the use of supportive health care, general practitioner (GP), and follow-up visits to the department of gynecology. Cancer worry was assessed with the Impact of Cancer (IoCv2) questionnaire.

RESULTS

A total of 1433 women completed the questionnaire. Health care use decreased from time of diagnosis and was higher among cervical and ovarian cancer survivors than endometrial cancer survivors. Twenty-five percent of the women with ovarian cancer reported severe cancer worry, in contrast to 10 and 15% of women diagnosed with endometrial and cervical cancer, respectively. Women with severe worry had significantly higher use of supportive care activities. In a multivariable regression analysis, cancer worry remained a significant correlate for use of supportive health care services irrespective of disease severity or prognosis. The strongest association was found for use of a psychologist (OR 2.1 [1.71-2.58]).

CONCLUSION

Cancer worry is associated with increased use of supportive care.

IMPLICATIONS FOR CANCER SURVIVORS

Targeted, timely, and accessible psychological support aimed at severe cancer worry may improve survivorship care and ensure optimal referral of patients in need of additional care.

A federated approach to identify women with early-stage cervical cancer at low risk of lymph node metastases

OBJECTIVE

Lymph node metastases (pN+) in presumed early-stage cervical cancer negatively impact prognosis. Using federated learning, we aimed to develop a tool to identify a group of women at low risk of pN+, to guide the shared decision-making process concerning the extent of lymph node dissection.

METHODS

Women with cervical cancer between 2005 and 2020 were identified retrospectively from population-based registries: the Danish Gynaecological Cancer Database, Swedish Quality Registry for Gynaecologic Cancer and Netherlands Cancer Registry. Inclusion criteria were: squamous cell carcinoma, adenocarcinoma or adenosquamous carcinoma; The International Federation of Gynecology and Obstetrics 2009 IA2, IB1 and IIA1; treatment with radical hysterectomy and pelvic lymph node assessment. We applied privacy-preserving federated logistic regression to identify risk factors of pN+. Significant factors were used to stratify the risk of pN+.

RESULTS

We included 3606 women (pN+ 11%). The most important risk factors of pN+ were lymphovascular space invasion (LVSI) (odds ratio [OR] 5.16, 95% confidence interval [CI], 4.59-5.79), tumour size 21-40 mm (OR 2.14, 95% CI, 1.89-2.43) and depth of invasion>10 mm (OR 1.81, 95% CI, 1.59-2.08). A group of 1469 women (41%)-with tumours without LVSI, tumour size ≤20 mm, and depth of invasion ≤10 mm-had a very low risk of pN+ (2.4%, 95% CI, 1.7-3.3%).

CONCLUSION

Early-stage cervical cancer without LVSI, a tumour size ≤20 mm and depth of invasion ≤10 mm, confers a low risk of pN+. Based on an international privacy-preserving analysis, we developed a useful tool to guide the shared decision-making process regarding lymph node dissection.

Radiotherapy Versus Inguinofemoral Lymphadenectomy as Treatment for Vulvar Cancer Patients With Micrometastases in the Sentinel Node: Results of GROINSS-V II

PURPOSE

The Groningen International Study on Sentinel nodes in Vulvar cancer (GROINSS-V)-II investigated whether inguinofemoral radiotherapy is a safe alternative to inguinofemoral lymphadenectomy (IFL) in vulvar cancer patients with a metastatic sentinel node (SN).

METHODS

GROINSS-V-II was a prospective multicenter phase-II single-arm treatment trial, including patients with early-stage vulvar cancer (diameter < 4 cm) without signs of lymph node involvement at imaging, who had primary surgical treatment (local excision with SN biopsy). Where the SN was involved (metastasis of any size), inguinofemoral radiotherapy was given (50 Gy). The primary end point was isolated groin recurrence rate at 24 months. Stopping rules were defined for the occurrence of groin recurrences.

RESULTS

From December 2005 until October 2016, 1,535 eligible patients were registered. The SN showed metastasis in 322 (21.0%) patients. In June 2010, with 91 SN-positive patients included, the stopping rule was activated because the isolated groin recurrence rate in this group went above our predefined threshold. Among 10 patients with an isolated groin recurrence, nine had SN metastases > 2 mm and/or extracapsular spread. The protocol was amended so that those with SN macrometastases (> 2 mm) underwent standard of care (IFL), whereas patients with SN micrometastases (≤ 2 mm) continued to receive inguinofemoral radiotherapy. Among 160 patients with SN micrometastases, 126 received inguinofemoral radiotherapy, with an ipsilateral isolated groin recurrence rate at 2 years of 1.6%. Among 162 patients with SN macrometastases, the isolated groin recurrence rate at 2 years was 22% in those who underwent radiotherapy, and 6.9% in those who underwent IFL (P = .011). Treatment-related morbidity after radiotherapy was less frequent compared with IFL.

CONCLUSION

Inguinofemoral radiotherapy is a safe alternative for IFL in patients with SN micrometastases, with minimal morbidity. For patients with SN macrometastasis, radiotherapy with a total dose of 50 Gy resulted in more isolated groin recurrences compared with IFL.

Lichen Sclerosis is Associated With a High Rate of Local Failure After Radio(chemo)therapy for Vulvar Cancer

AIMS

Radio(chemo)therapy plays an important role in the treatment of vulvar cancer, either as postoperative treatment or as definitive treatment in patients who present with inoperable disease. Only limited data are available regarding outcome after modern state of the art radio(chemo)therapy and more information regarding prognostic factors are warranted. The aim of this study was to evaluate disease outcomes after radio(chemo)therapy in patients with vulvar cancer with special emphasis on the impact of lichen sclerosis on local control.

MATERIALS AND METHODS

All consecutive patients (n = 109) from the western half of Denmark who were treated with definitive (n = 52) or postoperative (n = 57) radio(chemo)therapy between January 2013 and January 2020 were included. Local control, cause-specific survival and overall survival, as well as morbidity, were analysed using Kaplan-Meier statistics. Prognostic factors for local control were analysed in univariate and multivariate analysis.

RESULTS

At a median follow-up of 35 (4-95) months, 46 (42.0%) patients were diagnosed with recurrence. Eighty per cent of the recurrences were located to the vulva region, leading to a 5-year local control of 58.9% (confidence interval 47.9-69.9). Cause-specific survival was 62.9% (confidence interval 53.1-72.7), whereas overall survival was 58.0% (confidence interval 47.6-68.5). Grade 3-4 morbidity was diagnosed in 10 (9%) patients. Lichen sclerosis (hazard ratio 3.89; confidence interval 1.93-7.79) was an independent risk factors for local recurrence. Patients without lichen sclerosis had a 5-year local control rate of 83.6% (confidence interval 67.2-99.0) and 62.6% (confidence interval 43.2-82.0) after postoperative and definitive radio(chemo)therapy, respectively. In patients with lichen sclerosis, the local control rate was 44.0% (confidence interval 19.3-69.0) and 17.6% (confidence interval 0-30.0) after postoperative and definitive radio(chemo)therapy, respectively.

CONCLUSION

Radio(chemo)therapy plays an important role in the treatment of vulvar cancer. However, despite dose escalation, a substantial proportion of patients experienced local relapse. Pre-existing lichen sclerosis seems to have a significant impact on the risk of recurrence. This should influence surveillance programmes for these patients.

Post robotic investment: Cost consequences and impact on length of stay for obese women with endometrial cancer

INTRODUCTION

The aim of the study was to investigate whether robotic-assisted surgery is associated with lower incremental resource use among obese patients relative to non-obese patients after a Danish nationwide adoption of robotic-assisted surgery in women with early-stage endometrial cancer. This is a population-based cohort study based on registers and clinical data.

MATERIAL AND METHODS

All women who underwent surgery (robotic, laparoscopic and laparotomy) from 2008 to 2015 were included and divided according to body mass index (<30 and ≥30). Robotic-assisted surgery was gradually introduced in Denmark (2008-2013). We compared resource use post-surgery in obese vs non-obese women who underwent surgery before and after a nationwide adoption of robotic-assisted surgery. The key exposure variable was exposure to robotic-assisted surgery. Clinical and sociodemographic data were linked with national register data to determine costs and bed days 12 months before and after surgery applying difference-in-difference analyses.

RESULTS

In total, 3934 women were included. The adoption of robotic-assisted surgery did not demonstrate statistically significant implications for total costs among obese women (€3,417; 95% confidence interval [CI] -€854 to €7,688, p = 0.117). Further, for obese women, a statistically significant reduction in bed days related to the index hospitalization was demonstrated (-1.9 bed days; 95% CI -3.6 to -0.2, p = 0.025). However, for non-obese women, the adoption of robotic-assisted surgery was associated with statistically significant total costs increments of €9,333 (95% CI €3,729-€1,4936, p = 0.001) and no reduction in bed days related to the index hospitalization was observed (+0.9 bed days; 95% CI -0.6 to 2.3, p = 0.242).

CONCLUSIONS

The national investment in robotic-assisted surgery for endometrial cancer seems to have more modest cost implications post-surgery for obese women. This may be partly driven by a significant reduction in bed days related to the index hospitalization among obese women, as well as reductions in subsequent hospitalizations.

Psychometric validation of the European Organisation for Research and Treatment of Cancer-Quality of Life Questionnaire Sexual Health (EORTC QLQ-SH22)

BACKGROUND

The European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Group developed a questionnaire to assess sexual health in patients with cancer and cancer survivors. This study evaluates the psychometric properties of the questionnaire.

METHODS

The 22-item EORTC sexual health questionnaire (EORTC QLQ-SH22) was administered with the EORTC QLQ-C30 to 444 patients with cancer. The hypothesised scale structure, reliability and validity were evaluated through standardised psychometric procedures.

RESULTS

The cross-cultural field study showed that the majority of patients (94.7%) were able to complete the QLQ-SH22 in less than 20 min; 89% of the study participants did not need any help to fill in the questionnaire. Multi-item multi-trait scaling analysis confirmed the hypothesised scale structure with two multi-item scales (sexual satisfaction, sexual pain) and 11 single items (including five conditional items and four gender-specific items). The internal consistency yielded acceptable Cronbach's alpha coefficients (.90 for the sexual satisfaction scale, .80 for the sexual pain scale). The test-retest correlations (Pearson's r) ranged from .70 to .93 except for the scale communication with professionals (.67) and male body image (.69). The QLQ-SH22 discriminates well between subgroups of patients differing in terms of their performance and treatment status.

CONCLUSION

The study supports the reliability, the content and construct validity of the QLQ-SH22. The newly developed questionnaire is clinically applicable to assess sexual health of patients with cancer at different treatment stages and during survivorship for clinical trials and for clinical practice.

Identification of endometrial cancer recurrence - a validated algorithm based on nationwide Danish registries

INTRODUCTION

Recurrence of endometrial cancer is not routinely registered in the Danish national health registers. The aim of this study was to develop and validate a register-based algorithm to identify women diagnosed with endometrial cancer recurrence in Denmark to facilitate register-based research in this field.

MATERIAL AND METHODS

We conducted a cohort study based on data from Danish health registers. The algorithm was designed to identify women with recurrence and estimate the accompanying diagnosis date, which was based on information from the Danish National Patient Registry and the Danish National Pathology Registry. Indicators of recurrence were pathology registrations and procedure or diagnosis codes suggesting recurrence and related treatment. The gold standard for endometrial cancer recurrence originated from a Danish nationwide study of 2612 women diagnosed with endometrial cancer, FIGO stage I-II during 2005-2009. Recurrence was suspected in 308 women based on pathology reports, and recurrence suspicion was confirmed or rejected in the 308 women based on reviews of the medical records. The algorithm was validated by comparing the recurrence status identified by the algorithm and the recurrence status in the gold standard.

RESULTS

After relevant exclusions, the final study population consisted of 268 women, hereof 160 (60%) with recurrence according to the gold standard. The algorithm displayed a sensitivity of 91.3% (95% confidence interval (CI): 85.8-95.1), a specificity of 91.7% (95% CI: 84.8-96.1) and a positive predictive value of 94.2% (95% CI: 89.3-97.3). The algorithm estimated the recurrence date within 30 days of the gold standard in 86% and within 60 days of the gold standard in 94% of the identified patients.

DISCUSSION

The algorithm demonstrated good performance; it could be a valuable tool for future research in endometrial cancer recurrence and may facilitate studies with potential impact on clinical practice.

Satisfaction with care and adherence to treatment when using patient reported outcomes to individualize follow-up care for women with early breast cancer - a pilot randomized controlled trial

Background: The population of breast cancer survivors is increasing as a positive consequence of early detection and enhanced treatment. The disease and treatment associated side-effects or late-effects often impact on quality of life and daily life functions during survivorship. This calls for optimization of follow-up care. We aimed to evaluate the patients' satisfaction with the care provided, when using electronic patient reported outcomes (ePROs) to individualize follow-up care in women with early breast cancer receiving adjuvant endocrine therapy.Material and methods: Postmenopausal women treated for hormone receptor positive early breast cancer were included in a pilot randomized controlled trial and randomized to receive standard follow-up care with prescheduled consultations every six months or individualized follow-up care with the active use of ePROs to screen for the need of consultations. ePROs were distributed every third month over a two-year period. Primary outcomes were satisfaction with the assigned follow-up care and unmet needs. Secondary outcomes were use of consultations, adherence to treatment and quality of life.Results: Of the 207 consecutive patients who were potentially eligible for the study, 134 women were enrolled (65%). In total 64 women in standard care and 60 women in individualized care were analyzed. No statistically significant differences were reported in relation to satisfaction, unmet needs, adherence to treatment or quality of life. Women in standard care attended twice as many consultations during the two year follow-up period as women in individualized care; 4.3 (95% CI 3.9-4.7) versus 2.1 (95% CI: 1.6-2.6), p < .001.Conclusion: A significant reduction in consultations was observed for the group attending individualized care without compromising the patients' satisfaction, quality of life or adherence to treatment. For the majority of postmenopausal women treated for early breast cancer, implementation of ePROs to individualize follow-up care was feasible.

Surgeons' posture and muscle strain during laparoscopic and robotic surgery

Background

It is assumed that conventional laparoscopy (LAP) and robotic-assisted laparoscopic surgery (RALS) differ in terms of the surgeon's comfort. This study compared muscle workload, work posture and perceived physical exertion of surgeons performing LAP or RALS.

Methods

Colorectal surgeons with experience in advanced LAP and RALS performed one of each operation. Bipolar surface electromyography (EMG) recordings were made from forearm, shoulder and neck muscles, and expressed relative to EMG maximum (%EMGmax). The static, median and peak levels of muscle activity were calculated, and an exposure variation analysis undertaken. Postural observations were carried out every 10 min, and ratings of perceived physical exertion before and after surgery were recorded.

Results

The study included 13 surgeons. Surgeons performing LAP showed higher static, median, and peak forearm muscle activity than those undertaking RALS. Muscle activity at peak level was higher during RALS than LAP. Exposure variation analysis demonstrated long-lasting periods of low-level intensity muscle activity in the shoulders for LAP, in the forearms for RALS, and in the neck for both procedures. Postural observations revealed a greater need for a change in work posture when performing LAP compared with RALS. Perceived physical exertion was no different between the surgical modalities.

Conclusion

Minimally invasive surgery requires long-term static muscle activity with a high physical workload for surgeons. RALS is less demanding on posture.

Clinical impact of pre-treatment FDG-PET/CT staging of primary ovarian, fallopian tube, and peritoneal cancers in women

INTRODUCTION

To assess the clinical impact of preoperative fludeoxyglucose (FDG) with positron emission tomography (PET) and computed tomography (CT) in women with ovarian, fallopian tube, or peritoneal cancer with focus on consequences of added findings (AFs).

MATERIAL AND METHODS

FDG-PET/CT was implemented as a standard imaging modality for women with newly diagnosed ovarian, fallopian tube, or peritoneal cancer at our institution in 2008. After full implementation, all preoperative scans were reviewed and AFs were evaluated from January 2011 to December 2012. Decisions regarding further examination made at the first multidisciplinary team conference were recorded. Subsequent procedures were tracked via medical records, and the impact of AFs on additional examinations, delay, and change in treatment plans was evaluated.

RESULTS

Forty-four (21.1%) of 209 women presented with AFs. Further examination was performed in 35/44 (79.5%). Malignancy was identified in 15/35 (42.9%), revealing metastases from ovarian, fallopian tube, or peritoneal cancer in 11, a synchronous primary cancer in 3, and recurrence of a previous cancer in 1 woman. The ovarian, fallopian tube, or peritoneal cancer metastases were localized in the lungs, uterus, colon, vagina, and breasts. The remaining 20 AFs revealed 2 benign lesions and 1 pre-malignant lesion, whereas no abnormality was found in 17. Further examination of AFs resulted in a significant time delay until treatment start of median 4 days (range 1-83 days, P < 0.004).

CONCLUSIONS

Further examinations of AFs by FDG-PET/CT delayed time to start of treatment by median 4 days in women with newly diagnosed ovarian, fallopian tube, or peritoneal cancer in a contemporary institution with fast-track access to additional diagnostics. The clinical implications of this must be balanced against the gain of detecting unrecognized malignancy in 15 of 209 women (7.2%).

Surgeons' muscle load during robotic-assisted laparoscopy performed with a regular office chair and the preferred of two ergonomic chairs: A pilot study

Surgeons work in awkward work postures and have high precision demands - well-known risk factors for musculoskeletal pain. Robotic-assisted laparoscopy is expected to be less demanding compared to conventional laparoscopy; however, studies indicate that robotic-assisted laparoscopy is also associated with poor ergonomics and musculoskeletal pain. The ergonomic condition in the robotic console is partially dependent upon the chair provided, which often is a regular office chair. Our study quantified and compared the muscular load during robotic-assisted laparoscopy using one of two custom built ergonomic chairs and a regular office chair. The results demonstrated no differences that could be considered clinically relevant. Overall, the study showed high levels of static and mean muscular activity, increased perceived physical exertion from pre-to-post surgery, and moderate to high risk for musculoskeletal injuries measured by the Rapid Upper Limb Assessment worksheet. Authors advocate for further investigation in surgeons' ergonomics and physical work demands in robotic surgery.

Long term resource consequences of a nationwide introduction of robotic surgery for women with early stage endometrial cancer

OBJECTIVE

The majority of cost-studies related to robotic surgery has a short follow-up and primarily report the costs from the index surgery. The aim of this study was to evaluate the long-term resource consequences of introducing robotic surgery for early stage endometrial cancer in Denmark.

METHODS

The study included all women with early stage endometrial cancer who underwent robotic, laparoscopic and open access surgery from January 2008 to June 2015. Data was linked from national databases to determine resource consumption and costs from hospital treatments, outpatient contacts, primary health care sector visits, labor market affiliation and prescription of medication. Each patient was observed in a period of 12 months before- and after surgery. The key exposure variable was women who were exposed to robotic surgery compared to those who were not.

RESULTS

A total of 4133 women underwent surgery for early stage endometrial cancer. The study found additional costs of $7309 (95% confidence interval [CI] 2100-11,620, P = 0.001) per patient in the group exposed to robotic surgery including long-term costs post-surgery compared to the non-exposed group (non-robotic group). When controlling for time trends, the introduction of robotic surgery did not reduce the number of bed days (mean diff -0.42, 95% CI -3.03-2.19, P = 0.752).

CONCLUSIONS

The introduction of robotic surgery for early stage endometrial cancer did not generate any long-term cost savings. The additional costs of robotic surgery were primarily driven by the index surgery. Any reduction in bed days could be explained by time trends.

How Do We Follow Up Patients With Endometrial Cancer?

PURPOSE OF REVIEW

In this review, we present the existing evidence regarding follow-up care after endometrial cancer, including content of follow-up and type of provider. We furthermore discuss the future perspectives for follow-up care and research in the field.

RECENT FINDINGS

Recently published randomized controlled trials show that nurse-led telephone follow-up and patient-initiated follow-up are feasible alternatives to routine hospital-based follow-up. No randomized or prospective study has evaluated the effect of routine follow-up on survival. Hence, current knowledge is derived from retrospective studies with the inherent risk of bias. The most important method for recurrence detection is a review of symptoms. There is no evidence to support a survival benefit from the use of routine physical examinations, additional tests, or imaging. One in three of the women attending hospital-based follow-up experience unmet needs, and alternative models for follow-up focused on survivorship care and empowerment should be tested.

A systematic review about costing methodology in robotic surgery: evidence for low quality in most of the studies

OBJECTIVES

The main objective of this review was to evaluate the methodological design in studies reporting resource use and costs related to robotic surgery in gynecology.

METHODS

Systematic searches were performed in the databases PubMed, Embase, Scopus, and The Centre for Reviews and Dissemination database for relevant studies before May 2016. The quality of the methodological design was assessed with items regarding methodology from the Consolidated Health Economic Evaluation Reporting Standards (CHEERS). The systematic review was reported according to the PRISMA guidelines.

RESULTS

Thirty-two relevant studies were included. None of the reviewed studied fully complied with the CHEERS methodological checklist. Background and objectives, Target population and subgroups and Setting and location were covered in sufficient details in all studies whereas the Study perspective, Justification of the time horizon, Discount rate, and Estimating resources and costs were covered in less than 50%. Most of the studies (29/32) used the health care sector perspective whereas the societal perspective was applied in three studies. The time horizon was stated in 18/32 of the studies.

CONCLUSIONS

The methodological quality of studies evaluating costs of robotic surgery was low. The longest follow-up was 4 months and in general, the use of detailed cost data were lacking in most of the investigations. Key determinants, such as purchasing, maintenance costs of the robotic platform, and the use of surgical equipment, were rarely reported. If health care cost analyses lack transparency regarding cost drivers included it may not provide a true foundation for decision-making.

Patient-initiated follow up affects fear of recurrence and healthcare use: a randomised trial in early-stage endometrial cancer

OBJECTIVE

To test the hypothesis that patient-initiated follow up reduces the fear of cancer recurrence (FCR) and healthcare use when compared with traditional hospital-based follow up.

DESIGN

Pragmatic, multicentre randomised trial.

SETTING

Four Danish departments of gynaecology between May 2013 and May 2016.

POPULATION

One hundred and fifty-six women diagnosed with International Federation of Gynecology and Obstetrics (FIGO) stage I low-intermediate risk endometrial carcinoma.

METHODS

Women allocated to the control group attended hospital-based follow up consisting of regular outpatient visits for 3 years after primary treatment. Women in the intervention group were instructed in patient-initiated follow up, which included careful instruction in alarm symptoms and options for self-referral rather than a schedule of examinations.

MAIN OUTCOME MEASURES

The primary end point was FCR as measured by the Fear of Cancer Recurrence Inventory (FCRI) after 10 months of follow up. Secondary end points included cancer-related use of primary and secondary health care during the first 10 months after treatment.

RESULTS

In the primary analysis, FCR decreased significantly more in the control group from baseline to 10 months of follow up (difference -5.9, 95% CI -10.9 to -0.9). The majority of this improvement happened after only 3 months of follow up. Women receiving the intervention had fewer examinations at the department compared with the control group (0 versus 2 median visits, P < 0.01) and 58% of these examinations were scheduled because of vaginal bleeding.

CONCLUSIONS

Hospital-based follow up alleviates FCR significantly more than patient-initiated follow up, though the estimated difference was small. Patient-initiated follow up is a feasible, potentially cost-reducing follow-up approach in a population of endometrial cancer survivors with low risk of recurrence. The decision to use patient-initiated follow up should balance these benefits and harms.

TWEETABLE ABSTRACT

Patient-initiated follow up reduces healthcare use but maintains fear of recurrence in endometrial cancer.

PLAIN LANGUAGE SUMMARY

Why and how was the study carried out? Follow up of women with endometrial cancer is resource consuming and previous research suggests that it is not effective. Even though the women benefit from reassurance at follow up, routine examinations may also remind the women of the disease and induce fear of cancer recurrence. Furthermore, routine follow up may delay recurrence diagnosis, because the women do not report their symptoms until the next scheduled visit. In the research explained in this article, patient-initiated follow up was evaluated as an alternative to traditional follow up. The women were randomly assigned to one of two follow-up programmes: regular gynaecological examinations at the department of gynaecology or self-referral with careful instruction in alarm symptoms, that is, patient-initiated follow up. The level of fear of cancer recurrence in the two groups was obtained by questionnaires. Information on healthcare use was obtained by questionnaires and a chart review. What were the main findings? Regular examinations at the department of gynaecology reduced the fear of cancer recurrence significantly more than patient-initiated follow up, though the difference was small. Women who were instructed in alarm symptoms, under self-referral, were able to monitor their symptoms, and this approach significantly reduced the number of examinations at the department of gynaecology. What are the limitations of the work? Participants in the self-referral group knew that they were examined less than other women, and this may have induced fear of cancer recurrence. Similarly, the regular completion of questionnaires regarding fear of cancer recurrence may have reminded the women of the disease and diminished the difference between the two groups. What are the implications for patients Patient-initiated follow up reduced healthcare use but maintained fear of cancer recurrence in women who had survived early-stage endometrial cancer. Future analyses on quality of life and cost-effectiveness are needed to balance the benefits and harms of patient-initiated follow up.

Goal setting in cancer rehabilitation and relation to quality of life among women with gynaecological cancer

BACKGROUND

Rehabilitation should be integrated in the routine cancer care of women treated for gynaecological cancers. Goal setting is expected to facilitate the process through patient involvement and motivation. Our knowledge about goal setting in cancer rehabilitation is, however, sparse.

OBJECTIVES

This study aimed to: 1) analyse rehabilitation goals defined during hospital-based rehabilitation in patients with gynaecological cancer, with regard to number, category, changes over time, and differences between cancer diagnosis, and 2) analyse the association between health-related quality of life and goals defined for rehabilitation.

MATERIAL AND METHODS

Consecutively, all patients treated surgically for endometrial, ovarian, and cervical cancer were invited for hospital-based rehabilitation at Odense University Hospital, Denmark, including two sessions at the hospital one and three months following surgery and two phone calls for follow-up. Questionnaires from the EORTC were used to prepare patients and facilitate individual goal setting with definitions of up to three goals. All goals were grouped into six categories.

RESULTS

A total of 151 (63%) patients accepted the invitation including 50 endometrial, 65 ovarian, and 36 cervical cancers patients. All patients defined goals at the first session, 76.4% defined three goals, 21.9% two, and 1.6% had one goal. Physical goals decreased over time but were the most frequent at both sessions (98% and 89%). At both sessions, the social and emotional categories were the second and third most frequent among patients with endometrial and ovarian cancer. Sexual issues were dominant among the cervical cancer patients. Regression analysis showed significant association between quality of life scores and goal setting within the social and emotional domains.

CONCLUSION

Goal setting seemed feasible in all problem areas. The EORTC questionnaires were helpful during the process although expectations of the sub-scores being predictive of which areas to address were not convincing.

Rehabilitation of women with gynaecological cancer: the association between adult attachment, post-traumatic stress disorder and depression

OBJECTIVE

We hypothesised that being diagnosed with gynaecological cancer influences adult attachment and occurrence of depression and post-traumatic stress disorder (PTSD). The main aim of the study was to assess changes in the attachment dimensions, PTSD and depression from baseline to 5-month post-treatment. Further, we evaluated the association between attachment avoidance/anxiety dimensions and PTSD/depression among women newly diagnosed with ovarian, endometrial, or cervical cancer.

METHODS

Consecutive Danish-speaking women aged 20 to 75 years and treated surgically for primary gynaecological cancer were eligible. All patients were offered a rehabilitation programme consisting of two face-to-face sessions and two phone calls carried out by a nurse. Patients were asked to complete the Revised Adult Attachment Scale, the Harvard Trauma Questionnaire and the Major Depression Inventory at baseline and at 5-month follow-up. In all, 151 women consent to participate in the sessions where 51 fulfilled Revised Adult Attachment Scale questionnaire and contribute with socio-demographic data.

RESULTS

We found significant positive changes within the attachment anxiety dimension among women with ovarian cancer, a significant reduction of PTSD among endometrial cancer patients and insignificant changes in depression among all cancer types. The attachment anxiety dimension significantly increased the odds for PTSD and depression.

CONCLUSIONS

Depression and PTSD were prevalent among ovarian and cervical cancer patients. The adjustment of rehabilitation according to patients' attachment anxiety dimension contains possibilities for indirect impact on PTSD and depression symptoms. Copyright © 2015 John Wiley & Sons, Ltd.

Quality of life characteristics inpatients with cervical cancer

AIM

Annually about 500,000 women worldwide are diagnosed with cervical cancer. For many patients, young age at the time of diagnosis and a good prognosis regarding the disease imply a long life with the side-effects and sequels of various treatment options. The present study investigated the extent to which different quality of life (QoL) domains in patients during and after treatment for cervical cancer are affected according to menopausal status, treatment status and treatment modality.

METHODS

QoL data from 346 cervical cancer patients from 14 countries who were included in a cervical cancer module validation study of the European Organisation for Research and Treatment of Cancer (EORTC) Quality of life Group were analysed according to menopausal status, treatment status and treatment modality. QOL was assessed using the EORTC Quality of life Questionnaire (QLQ)-C30 and the QLQ-CX24 module. Statistical analyses were performed using descriptive statistics and analysis of covariance.

RESULTS

Active treatment had the strongest negative impact on 13 different QoL domains: physical, role, emotional, cognitive, social functioning, global health/QoL, fatigue, nausea and emesis, pain, appetite loss, constipation, symptom experience and sexual enjoyment. Irradiation alone ± other therapy was associated with most symptoms of diarrhoea. Age had the most negative impact on sexual activity and the strongest positive effect on sexual worry.

CONCLUSION

Our results revealed that patients with cervical carcinoma had different side-effects with different impacts on QOL depending on the menopausal status and therapy modalities. Patients should be informed about the possibility that therapy may have a negative impact on QoL.

The European Organization for Research and Treatment of Cancer (EORTC) Quality-of-Life questionnaire cervical cancer module: EORTC QLQ-CX24

BACKGROUND

The authors report on the development and validation of a cervical cancer module for the European Organization for Research and Treatment of Cancer (EORTC) Quality-of-Life (QoL) questionnaire (QLQ), which was designed to assess disease-specific and treatment-specific aspects of QoL in patients with cervical cancer.

METHODS

The cervical cancer module (EORTC QLQ-CX24) was developed in a multicultural, multidisciplinary setting to supplement the EORTC QLQ-C30 core questionnaire. The QLQ-C30 and the cervical cancer module were administered to 346 patients with cervical cancer who underwent radical hysterectomy and received radiotherapy and chemotherapy. Psychometric analyses were performed by using data from 2 independent samples.

RESULTS

The QLQ-CX24 consists of 3 multiitem scales and 5 single-item scales. Multitrait scaling analyses revealed high internal consistencies for the subscales with Cronbach alpha coefficients ranging from .72 to .87 (Symptom Experience, .72; Body Image, .86; Sexual/Vaginal Functioning, .87). Convergent and discriminant validity were fulfilled with scaling errors below 3%. The QLQ-CX24 was capable of discriminating between clinical subgroups. All items exhibited good compliance with <3% missing values. Most patients completed the EORTC QLQ-C30 and the QLQ-CX24 in <15 minutes (86%), and many did not require any assistance to complete the questionnaires (65%).

CONCLUSIONS

The current psychometric analyses supported the content and construct validity and the reliability of the EORTC QLQ-CX24 module. This newly developed module is a useful instrument for assessing the QoL of patients who are treated for cervical cancer both in clinical trials and in clinical practice.

Validation of a questionnaire for self-assessment of sexual function and vaginal changes after gynaecological cancer

The Sexual function-Vaginal changes Questionnaire (SVQ), was developed to investigate sexual and vaginal problems in gynaecological cancer patients. The instrument consists of 20 core items, measuring sexual interest, lubrication, orgasm, dyspareunia, vaginal dimensions, intimacy, sexual problems of partner, sexual activity, sexual satisfaction, and body image. Seven additional items assessing current levels of sexual and vaginal problems compared to pre-diagnosis are intended to be used only once in longitudinal studies. The SVQ was validated in two ways: first, the comprehensibility of each item was investigated through combined quantitative and qualitative assessment of patient-observer agreement in 75 gynaecological cancer patients, second, multitrait analyses and principal component analyses were applied to responses from 257 patients with cervical cancer to investigate the scale properties. The level of agreement between the patients' and the observer's ratings was high (median overall agreement 0.84, range 0.46-1.00; median kappa: 0.80, range 0.52-1.00). From the 10 items applicable to all patients, three scales were hypothesized: intimacy, sexual interest and global sexual satisfaction. For sexually active respondents an additional two scales were hypothesized: vaginal changes and sexual functioning. The psychometric analyses confirmed these scales. The internal consistency of the scales ranged 0.76-0.83 (Cronbach's alpha). The study supports the validity and reliability of the SVQ.

Longitudinal study of sexual function and vaginal changes after radiotherapy for cervical cancer

PURPOSE

To investigate the longitudinal course of self-reported sexual function and vaginal changes in patients disease free after radiotherapy (RT) for locally advanced, recurrent, or persistent cervical cancer.

MATERIALS AND METHODS

A total of 118 patients referred for RT were included. The patients were assessed, using a validated self-assessment questionnaire, at the termination of RT and 1, 3, 6, 12, 18, and 24 months later. The results were compared with an age-matched control group from the general population.

RESULTS

Persistent sexual dysfunction and adverse vaginal changes were reported throughout the 2 years after RT, with small changes over time: approximately 85% had low or no sexual interest, 35% had moderate to severe lack of lubrication, 55% had mild to severe dyspareunia, and 30% were dissatisfied with their sexual life. A reduced vaginal dimension was reported by 50% of the patients, and 45% were never, or only occasionally, able to complete sexual intercourse. Despite sexual dysfunction and vaginal adverse effects, 63% of those sexually active before having cancer remained sexually active after treatment, although with a considerably decreased frequency.

CONCLUSIONS

Patients who are disease free after RT for locally advanced, recurrent, or persistent cervical cancer are at high risk of experiencing persistent sexual and vaginal problems compromising their sexual activity and satisfaction.

Early-stage cervical carcinoma, radical hysterectomy, and sexual function

BACKGROUND

Limited knowledge exists concerning the impact of radical hysterectomy (RH) alone on the sexual function of patients with early-stage cervical carcinoma. The authors investigated the longitudinal course of self-reported sexual function after RH.

METHODS

The current study was comprised of 173 patients with lymph node-negative, early-stage cervical carcinoma who had undergone RH and pelvic lymphadenectomy. They were assessed prospectively using a validated self-assessment questionnaire 5 weeks and 3 months, 6 months, 12 months, 18 months, and 24 months after RH. Results were compared with an age-matched control group from the general population.

RESULTS

Compared with control women, patients experienced severe orgasmic problems and uncomfortable sexual intercourse due to a reduced vaginal size during the first 6 months after RH, severe dyspareunia during the first 3 months, and sexual dissatisfaction during the 5 weeks after RH. A persistent lack of sexual interest and lubrication were reported throughout the first 2 years after RH. Long-term lack of sexual interest and insufficient vaginal lubrication were confirmed by the patient's self-reported changes 12 months after RH compared with before the cancer diagnosis and by a pre-post comparison within patients. However, most of the patients who were sexually active before their cancer diagnosis were sexually active again 12 months after surgery (91%), although with a decrease in sexual frequency reported.

CONCLUSIONS

RH had a persistent and negative impact on patients' sexual interest and vaginal lubrication whereas the majority of other sexual and vaginal problems disappeared over time. Sexual and vaginal problems in the short-term and long-term after RH should be discussed with the patient before and after surgery.

Self-assessment in cancer patients referred to palliative care: a study of feasibility and symptom epidemiology

BACKGROUND

Research in palliative care is considered difficult due to the poor health of patients. However, patient-provided data are essential for a thorough description of patient symptomatology and for the evaluation of care.

METHODS

The authors examined the feasibility of a questionnaire-based study using the European Organization for Research and Treatment of Cancer quality-of-life instrument EORTC QLQ-C30, the Edmonton Symptom Assessment System (ESAS), and the Hospital Anxiety and Depression Scale (HADS) in cancer patients who were receiving palliative care. This report describes the symptomatology of participating patients and examines differences in symptomatology between patients in three palliative care functions: inpatient, outpatient, and palliative home care.

RESULTS

Of 267 eligible patients who were referred to a department of palliative medicine, initial self-assessment questionnaires were obtained from 176 patients (65.9%). The 91 nonparticipants were older and had lower Karnofsky Performance status (KPS) values than the participants. Almost all participating patients suffered from impaired role function and physical function and had high levels of pain, fatigue, and other symptoms. According to the HADS, 47% of patients suffered from depression. Outpatients had better scores than inpatients and patients in palliative home care for physical function, role function, cognitive function, depression, and inactivity.

CONCLUSIONS

It is possible to carry out a questionnaire-based study of symptomatology in consecutive cancer patients in palliative care, achieving rather complete data from the participants. The symptomatology in these patients was very pronounced. The questionnaires were able to detect clinically important differences between places of service.

Pulsed dose rate (PDR) brachytherapy as salvage treatment of locally advanced or recurrent gynecologic cancer

PURPOSE

Pulsed dose rate (PDR) brachytherapy is a new treatment option permitting dose distribution optimization in interstitial implants. It possesses the advantage of equipment simplification and radiation protection to the staff, compared to the manually afterloading technique. This study presents the first clinical results from The Finsen Center with PDR-brachytherapy in patients with locally advanced or recurrent gynecologic cancer.

METHODS AND MATERIALS

Between June 1993 and August 1996, 34 patients with gynecologic malignancies (22 pelvic recurrences, 12 primary locally advanced) have been treated with external irradiation, four-field box technique, to 46 Gy/23 fractions, 5 F/week and 192Ir-interstitial PDR-brachytherapy in pulses of 0.6 Gy, one pulse per hour to a total of 30 Gy. The Martinez Universal Perineal Interstitial Template applicator was used for all implantations.

RESULTS

The overall complete response rate was 74%. At median 14 months follow-up (range 3-40) 15 patients were alive with no evidence of disease. Seven of 14 patients with a second recurrence or progressive disease were still alive. The overall 1- and 2-year survival was 71% and 63%, respectively. There was no difference in survival probability when stratifying the patients by primary diagnosis (recurrent vs. primary advanced), relapse locations (central vs. central + pelvic wall mass) or treatment volume. Seventeen chronic grade III complications were observed in 10 patients. Large treatment volumes significantly correlated to severe gastrointestinal complications. Fifteen of 17 chronic grade III complications were observed in patients treated for recurrent disease.

CONCLUSION

PDR-brachytherapy in combination with external irradiation is an effective treatment option for patients with locally advanced or recurrent gynecologic cancer, although substantial toxicity is observed in patients with large treatment volumes and recurrent disease.

Nation-wide Salmonella enterica surveillance and control in Danish slaughter swine herds

A nation-wide Salmonella enterica surveillance and control programme was initiated in Danish finishing herds over the first quarter of 1995. In Denmark, all swine for slaughter are identifiable by a unique herd code. For each herd code, and depending on the herd's annual kill, random samples ranging from four to more than 60 swine are obtained quarterly at the abattoir. A meat sample from each pig is frozen, and meat juice (harvested after thawing) is examined for specific antibodies against S. enterica using an indirect enzyme-linked immunosorbent assay (ELISA). The ELISA combines several S. enterica O-antigens, and allows detection of antibody response after a variety of different S. enterica serovar infections. Results are transferred to a central database, which each month (based on meat-juice tests obtained in the previous 13 weeks) assigns all herds into three S. enterica infection levels: Level 1, in which the S. enterica prevalence is deemed low and acceptable; Level 2, where there is a moderate prevalence of S. enterica seroreactors (from > 50% in the smallest to > 10% in the largest herds); Level 3, in which S. enterica seroreactor prevalence is clearly unsatisfactory (> 50% for most herd sizes). Irrespective of Salmonella level, all herds receive a monthly update on the current results of the S. enterica test results. If a herd is categorized in Level 2 or 3, it must receive an advisory visit by a practising veterinarian and a local swine extension specialist, and certain management hygiene precautions must be taken. If a herd is categorized in Level 3, the finishers from the herd must additionally be slaughtered under special hygiene precautions. This is supervised by the veterinary authorities. During 1995, 604000 samples were tested for S. enterica, corresponding to 3.0% of the total kill. In December 1995, 15522 herds (representing > 90% of the national production) were categorized into one of the three levels: 14551 herds (93.7%) in Level 1; 610 herds (3.9%) in Level 2; 361 herds (2.3%) in Level 3. The proportion of serologically positive meat-juice samples collected during 1995 ranged from a mean of 2.9% in smaller herds (101-200 swine slaughtered per year) to 6.1% in relatively large herds (more than 5000 swine slaughtered per year).

Mulberry heart disease in young pigs without vitamin E and selenium deficiency

Mulberry heart disease persists among young pigs in Denmark although abundant supplies of selenium and vitamin E are added to feedstuffs for sows and pigs. The concentrations of selenium and vitamin E in the liver and heart tissues of young pigs which had died suddenly, and had the characteristic lesions of mulberry heart disease post mortem, were not significantly different from the concentrations found in pigs of the same age which had died suddenly for other reasons. The concentrations of selenium and vitamin E in the livers (0.3 mg/kg and 4 mg/kg, respectively) appeared to be satisfactory in all the pigs examined.

Studies on boar semen. III. Sperm concentration and seminal plasma total solids followed in Danish AI boars through a 10-year-period

Semen samples from 1531 young boars eligible for AI service were examined for normality. Sperm concentration (s.c.) was determined by the hemocytometer technique in 1348 of the samples. Seminal plasma total solids (t.s.) were determined on all samples in order to control whether the semen samples originated from complete ejaculates.

The hemocytometer counts showed an arithmetic mean of 370 × 10⁶/ml with a standard deviation of 188×10⁶/ml. No correlation was found either between s.c. and age or between s.c. and season of the year.

The seminal plasma t.s. showed an arithmetic mean of 4.6% with a standard deviation of 1.35%. No correlation was found between t.s. and s.c. or between t.s. and the age of the boars. Neither was there any association between t.s. and the season of the year.

Values of t.s. below 1.6% combined with aspermia were regarded as the result of incomplete ejaculations and the following retest from such cases gave ejaculates showing normal values concerning s.c. and t.s. A drop in t.s. combined with an admixture of pathological cells to the ejaculate may indicate an inflammatory condition in the vesicular glands.

Serological comparison of type strains of porcine, bovine, and ovine mycoplasmas with atypical colony morphology

The type strains of Mycoplasma hyopneumoniae, M. flocculare, M. dispar, and M. ovipneumoniae, all characterized by nipple-less colonies on solid media, were compared serologically. By indirect hemagglutination and by complement fixation tests they were found to constitute a related group. By crossed immunoelectrophoresis a sharing of common antigens was demonstrated, whereas no cross reactivity was noted by the metabolism inhibition test.

The type strains of Mycoplasma hyorhinis and Mycoplasma bovirhinis were included in the study for comparison. Although some cross reaction was noted, they appeared just moderately related to the nipple-less group as well as to each other.

Hereditary dwarfism in pigs

In a swine production herd dwarfs with extremely short limbs were observed in 3 litters sired by the same boar. Clinical, radiographical, and pathologic-anatomical examinations, showed the affected individuals to be chondrodysplastic dwarfs. Such dwarfism has not been reported previously in pigs. An inbreeding experiment conducted with a dwarf gilt and related boars indicated that the dwarfism was hereditary with a simple autosomal recessive inheritance.

Congenital ascorbic acid deficiency in pigs

In a swine production herd, spontaneous scurvy was observed among piglets 2–3 weeks after weaning. All affected pigs had the same boar as both maternal and paternal grandfather. The affected pigs had only traces of ascorbic acid in blood and tissues as compared to litter mates and other normal pigs. The ratio between the total numbers of normal and affected pigs in the 4 litters concerned was in agreement with a 3:1 segregation, which is characteristic of simple autosomal recessive inheritance in matings between non-affected carriers.

Two affected pigs were restored to normal when given ascorbic acid in the diet. Without vitamin C supplement affected pigs died or had to be euthanized.

Liver microsomes from an affected pig were unable to synthesize ascorbic acid in vitro with 1-gulonolactone as a substrate, unlike microsomes from normal control pigs.

Effect of dietary and injectable vitamin E on the antioxidant status of pigs

An experiment concerning 6 different vitamin E treatments was conducted with 30 young pigs. From 4 to 15 weeks of age the pigs were kept in individual pens and fed a selenium supplemented basal diet consisting mostly of propionic acid treated barley and soybean meal, and containing 4.4 mg vitamin E per kg. The treatments were periods with or without vitamin E supplement (20 mg/kg) or a vitamin E injection (200 mg). Blood samples collected during the period of investigation were examined for vitamin E and for resistance against erythrocyte lipid peroxidation (ELP) in order to evaluate the antioxidant status.

Analysis of variance showed a litter effect on ELP values at all the weekly investigations and a treatment effect from two weeks after the experiment had started. Also the blood vitamin E level was litter dependent and influenced by treatment. Paired comparisons by Student’s t-test showed a delay of 1 to 2 weeks in the effect on ELP of a dietary vitamin E supplement. In contrast, both ELP and vitamin E changed very rapidly (hours) after vitamin E injections.

Independently of the vitamin E treatments there was a rise in ELP within the first 2 or 3 weeks after weaning; this was taken as an index of a reduced antioxidant status during that period.

Procedure for blood glutathione peroxidase determination in cattle and swine

An improved testing system has been developed for direct measurement of glutathione peroxidase activity in heparinized whole blood at 37°C. Without loss in net yield the consumption of reagents has been found to be considerably lower with the new technique than with previously described techniques. Within the range 0–700 mKat/1 the GSH-Px activity in red cells may be measured with a high degree of accuracy and reproducibility without preceding separation and washing. The stability of the enzyme in bovine and porcine whole blood at 22°C, 4°C, and —20°C was determined.

Clinico-pathologic findings in young pigs fed different levels of selenium, vitamin E and antioxidant

A randomized, blocked 2³ factorial experiment was conducted with 48 young pigs. The treatment factors were: 2 levels of selenium (55 and 115 µg/kg), 2 levels of vitamin E (3 and 53 mg/kg) and 2 levels of the antioxidant feed additive Ethoxyquin (0 and 150 mg/kg). All pigs were kept in single pens and fed ad libitum throughout the experimental period of 9 weeks, i.e. from 3 to 12 weeks of age.

Plasma, heart, liver and muscle Se levels as well as whole blood glutathione peroxidase activity (EC 1.11.1.9 GSH-Px) were significantly higher in pigs given a dietary supplement of Se than in pigs given no supplement of Se (P ≤ 0.001). The Se-supplemented pigs showed a tendency to lower mean serum transaminase activity (ASAT and ALAT) than unsupplemented pigs, but the influence was significant (P ≤ 0.05) only for the ALAT activity.

Blood vit. E levels were higher for pigs receiving a supplement of vit. E than for unsupplemented pigs (P ≤ 0.001), and so was the resistance of red blood cells against lipid peroxidation (ELP), as expressed by lower ELP values.

There were no effects of Ethoxyquin supplementation on the biochemical variables included in the study.

The histological examination of heart muscle showed that the score for changes was negatively influenced by both Se and vit. E supplement (P ≤ 0.001) and to some extent also by Ethoxyquin supplement (P ≤ 0.05). The histological picture of m. long dorsi was influenced only by the vit. E supplement (P ≤ 0.01). No histological changes were found in the liver in this study. There were inverse relationships between whole blood GSH-Px defluorescence time and blood Se, and between ELP and whole blood vit. E (P ≤ 0.001).

The influence of sow colostrum trypsin inhibitor on the immunoglobulin absorption in newborn piglets

The influence of sow colostrum trypsin inhibitor (SCTI) on the immunoglobulin absorption from the gut of 16 newborn colostrum-deprived piglets was investigated in a paired feeding experiment.

Three times at 1 h intervals the piglets were fed an experimental diet consisting of sow milk, purified swine serum immunoglobulins containing agglutinins against Bordetella bronchiseptica, and purified SGTI (diet I) or saline (diet II). The serum concentrations of IgG, IgM, IgA, and antibodies for B. bronchiseptica were measured by single radial immunodiffusion and by a tube agglutination procedure and used to evaluate the immunoglobulin absorption. Four and 6 h after the first experimental meal, blood samples from the piglets given SGTI in their diet had a generally higher level of IgG, IgA and aggutinins against B. bronchiseptica than blood samples from the piglets d no SGTI. No real differences were found in the IgM levels. Although the piglets fed no SGTI all showed a considerable immunoglobulin absorption, the SCTI was found to have a statistically significant positive influence on the IgG and IgA absorption.

In vitro evaluation of porcine lymphocyte response to phytohaemagglutinin using a modified "whole blood" technique

The purpose of these investigations was to develop a modified whole blood technique for measuring quantitatively the responsiveness of pig peripheral blood lymphocytes to phytohemagglutinin (PHA) in vitro. Washed blood cells from a fixed volume of blood were suspended in culture medium supplemented with foetal calf serum and stimulated with a pure mitogenic PHA preparation. The stimulation was measured by the incorporation of 3H-thymidine. Data are presented to show the effect of different variables on the culture system. The transformation response was measured at different levels of PHA and the reproducibility of the different responses from repeated investigations was used to evaluate the usefulness of the test. The best reproducibilities of the stimulation response were found at the high PHA concentrations. Also the calculated PHA concentration giving maximum stimulation response had a relatively high reproducibility and indicates that this value is a convenient and reliable alternative measure of the functional capacity of the lymphocytes.

Genetic studies on the in vitro PHA-transformation of porcine blood lymphocytes

The response of pig peripheral blood lymphocytes to phytohaemagglutinin (PHA) was studied by a whole blood technique. The material for study comprised 441 offspring from one generation of a randomly mated Danish Landrace pig herd. The pigs were blood-sampled at a weight of 90 kg. After correlation for influence from other blood cells and for seasonal variation, the heritability of the PHA stimulation responses at different PHA concentrations were estimated. The heritability estimates ranged from 0.15 to 0.53. Also the PHA concentration giving maximum stimulation response, as calculated by a dose response function, was found to vary depending on genetic variation among the pigs with an estimated heritability of 0.38.

Studies on immunoglobulins and trypsin inhibitor in colostrum and milk from sows and in serum of their piglets

The concentrations of IgG, IgM, IgA and the specific sow colostrum trypsin inhibitor (SCTI) were measured by radial immunodiffusion in colostrum and milk samples from sows and in serum samples from their offspring during the suckling period. A clear time dependence was found for all the measured variates in both whey and serum. Statistically significant positive correlations were found between, on the one hand, concentrations of IgG and IgA, but not IgM, in sera from 39 suckling piglets 1 and 3 days old, and, on the other hand, concentrations of the same immunoglobulins and of the trypsin inhibitor in maternal colostrum (n = 7). Multiple regression analyses showed that at day 1 and day 3 the levels of both IgG and IgA in serum samples from the suckling piglets were positively influenced by both the SCTI and the IgG or IgA contents in maternal colostrum.

Glutathione peroxidase activity and erythrocyte lipid peroxidation as indices of selenium and vitamin E status in young pigs

A randomized, blocked 2³ factorial experiment was conducted with 48 pigs from sows fed a diet low in selenium and vitamin E. From 3 to 12 weeks of age the piglets were kept in single pens and fed a basic diet consisting mostly of barley, dried skim milk, soybean meal and dried yeast, and containing 55 µg selenium and 3 mg vitamin E per kg. The treatment factors — i.e. feed supplements — were 2 levels of Se (nil, 60 µg/kg), 2 levels of vitamin E (nil, 50 mg/kg), and 2 levels of the feed antioxidant ethoxyquin (nil, 150 mg/kg). Blood samples, collected at termination of the experiment, were examined for glutathione peroxidase activity (GSH-Px) and resistance against erythrocyte lipid peroxidation (ELP) to evaluate Se and vitamin E status, respectively. Analysis of variance showed the GSH-Px activity to be litter-dependent (P < 0.001) and influenced by selenium supplementation (P < 0.001) but not by the other supplements or by interactions between supplements. Resistance against ELP was influenced only by vitamin E supplementation (P < 0.001). GSH-Px and ELP thus seem to be valuable and simple methods for evaluating, respectively, Se status and vitamin E status in growing pigs.

Immunoglobulins in bovine ostertagiasis

Lowered albumin levels with normal or slightly elevated γ-globulin levels are well known features of various gastro-intestinal disorders in cattle. Thus, this picture is a prominent finding in clinical ostertagiasis, where hypercatabolism of both albumin (Nielsen 1966) and IgG (Nansen 1970) has been demonstrated. The hypercatabolism is explained by gastric loss, and evidence suggests that this takes place as a non-selective loss of protein through the hyperplastic abomasal wall (Murray 1969). The albumin hypercatabolism is not compensated for by an increased synthesis, and thus leads to hypoalbuminaemia also during part of the non-diarrhoeal phase. The IgG hypercatabolism, on the other hand, is compensated for by increased synthesis, which may lead to elevated serum IgG levels, especially in phases without diarrhoea. There seems to be no comparative data available for IgG-1, IgG-2, IgM, and Ig A levels in ostertagiasis. The purpose of the present study was to analyse the influence of ostertagiasis on the serum levels of immunoglobulins, albumin and total protein in young cattle. The study comprised two groups of randomly selected Red Danish calves, approx. % year old. Half the calves (Group A) grazed the same paddock from May to late September and were exposed to heavy infection from August onwards as evidenced by high herbage larval counts, high faecal egg counts, and elevated serum pepsinogen levels (see Table 1). Most of the calves were clinically affected, and in the last part of August and September some had profuse diarrhoea. The other calves (Group B) were moved in mid July to a paddock not grazed earlier that season. Accordingly, these calves were exposed to only a relatively low pasture infection in the second half of the grazing season. None of them showed clinical signs, and pepsinogen levels were only slightly elevated (Table 1).

Utilisation of glucose by Mycoplasma suipneumoniae and Mycoplasma flocculare

The utilisation of glucose by Mycoplasma suipneumoniae and Mycoplasma flocculare was examined by chemical determination of glucose disappearance during growth, and by examination for hexokinase activity in cell preparations. Both species degraded glucose during growth and possessed hexokinase activity as evidence of the presence of a glycolytic pathway. The glucose utilisation capacity was found to be greater for M. flocculare than for M. suipneumoniae.

Enzyme-linked immunosorbent assay (ELISA) for detection of antibodies to Mycobacterium paratuberculosis in cattle

Paratuberculosis may be diagnosed by clinical, bacteriological and immunological methods, but so far only the demonstration of M. paratuberculosis is considered a definite proof of the infection. World-wide use is being made of the complement fixation (CF) test as a valuable immunological test for diagnosis of clinical cases, but its low specificity and sensitivity makes its value problematic in non-clinical cases.