Community Screening for High-Risk Human Papilloma Virus Infection using Self-Sampling and 'Point-Of-Care' Test

OBJECTIVE

HR-HPV types 16 and 18 are responsible for pre-invasive and invasive lesions of the cervix, accounting for 70-80% of the total subtypes. The aim of this study was to investigate the prevalence of high-risk HPV subtypes 16 and 18 in self-collected vaginal samples using real-time micro-PCR and to study the acceptability of self-sampling.

METHODS

Eligible women (30-65 years) were screened from a semi-urban area of Uttarakhand (India) using self-sampling. High-risk HPV genotypes (16/31 and 18/45) were tested using real-time micro-PCR technique with results available in one hour. The positive results were validated by standard RT-PCR for high-risk HPV 16, 18, separately and for 12 other high-risk genotypes, combined. Ease of the procedure, level of comfort, and recommendation to other women were studied and the acceptability of self-sampling was analyzed using the Likert scale.

RESULT

Of 975 eligible women screened, 45 participants tested positive for HR-HPV (16/31,18/45) using real-time micro-PCR with a prevalence of 4.6%. Positive samples were further tested through routine RT-PCR and 60% were found to be HR-HPV 16 and 18 positive. For self-sampling, 96.72% (n=943) participants were 'very satisfied' and 94.15% (n=918) found self-sampling to be 'very comfortable' and 88.51% (n=863) stated that they will strongly recommend this test to other eligible women in the community.

CONCLUSION

We conclude that HR-HPV testing with limited genotyping showed a prevalence of 4.6%, 60% of these were HPV 16/18 positive. Point of care testing was feasible in the community and self-sampling was acceptable.

Cervical Cancer Screening Coverage at Tertiary Care Institutes Across India

OBJECTIVES

The 70% screening coverage target proposed in the global cervical cancer elimination strategy is not achieved even at tertiary centres in India. A situational analysis was done to assess the currently existing facilities and barriers in tertiary care institutes.

METHODS

This cross sectional multicentric study was conducted from August to September 2021 in six tertiary care institutes across India. Women aged 30-49 years attending outpatient services (OPD) were invited for cervical screening. Women and health care professionals (HCPs) were administered structured questionnaires to assess knowledge, attitude and practices regarding cervical cancer screening services.

RESULTS

Out of 6709 eligible women who attended OPD, 1666 (24.8%; range:19-57%) received screening. Availability of screening kits was limited to 10-25 Pap/HPV tests per day. Visual inspection with acetic acid (VIA) and HPV testing were offered only at certain centres. Colposcopy and treatment facilities were optimal at all centres. Knowledge, attitude and practices were analysed for 1800 women: 45.7% had heard of cervical cancer, 78.0% did not know that it is preventable, 75.8% never heard about screening. Common symptoms correctly identified included postmenopausal bleeding (4.8%), postcoital bleeding (5.7%), intermenstrual bleeding (5.8%) and vaginal discharge (12.4%). Risk factors were identified by minority: poor menstrual hygiene (6.6%), oral contraceptive pill use (6.4%), multiparity (4.4%), and HPV infection (3.0%). Out of 21, mean total knowledge score (MTKS) was 2.07± 2.67. Out of 317 HCPs, 96.5% knew that cervical cancer is caused by HPV infection, is preceded by premalignant stage, and that it is preventable by screening and treatment (80.1%). Knowledge about screening modalities was present in 87.4% for cytology, 75.1% for VIA, 68.8% for HPV test. MTKS of HCPs was 20.88±6.61 out of 32.

CONCLUSION

Even at tertiary centres, limited availability of HPV tests, reluctance to implement VIA and lack of awareness among women remain the major barriers.

A novel technique of vagino-hysteroscopy using alginate gel interface: A proof of concept study

OBJECTIVE

To compare the feasibility of vagino-hysteroscopy using alginate gel Interface (VAGI) with conventional vaginoscopic hysteroscopy (CVH).

METHODS

Thirty women undergoing diagnostic vagino-hysteroscopy were randomly allocated into Group I (VAGI): Alginate occluder was used at introitus to facilitate hydrodistension during hysteroscopy; or Group II: Underwent no-touch hysteroscopy. Primary outcome was feasibility, defined as successful visualization of uterine cavity. Secondary outcomes included operative time, hydrostatic pressures for optimum visualization, pain experienced by patient on visual analog scale, maneuverability and surgeon satisfaction. Data analysis was performed using χ² and Fisher exact tests for qualitative variables and Student t test for quantitative variables.

RESULTS

VAGI was significantly better than CVH (80% vs. 33.3%; relative risk 8, P = 0.025). With VAGI, optimum visualization was achieved at significantly lower pressures at all levels (vagina, P = 0.034; cervix, P = 0.01; uterus, P < 0.001), in less time (P = 0.007), and using less irrigation fluid (P < 0.001). Surgeon satisfaction was significantly higher for VAGI (P = 0.009). Subgroup analysis showed higher likelihood of success of VAGI in women who were premenopausal (P = 0.015), younger than 45 years (P = 0.024), and had a history of vaginal birth (P = 0.03).

CONCLUSIONS

VAGI is quicker to perform and provides optimum visualization at much lower pressures than CVH. Use of alginate is patient friendly and yields higher surgeon satisfaction rate.

Growing teratoma syndrome: a surgical conundrum

Growing teratoma syndrome (GTS) is a tumour growth, which contains mature teratomatous elements during or after chemotherapy for malignant germ cell tumours. Surgery is the only potential treatment option for GTS because these growing teratomas are resistant to chemotherapy and radiation therapy. Extensive surgeries may be needed in GTS with multivisceral resections to achieve no residual disease status. This report presents a case of GTS treated with multiple surgical resections in a woman with malignant immature teratoma ovary in her early thirties; she is disease free after 1 year of treatment.

PAX1 Methylation Status in Cervical Scrapes as Novel Diagnostic Biomarker in CIN 2/3 and Invasive Squamous Cell Carcinoma

Objectives

DNA methylation of paired box-1 (PAX-1) gene has been shown to be a potential biomarker for the detection of high-grade cervical intra-epithelial neoplasia (CIN) and invasive cervical cancer. The objective of this pilot study was to quantify and compare methylation percentage of PAX1 gene in benign cervical lesion, pre-invasive and invasive cervical cancer.

Methods

A total of 200 screen positive women (VIA, VILI and Pap test) underwent colposcopy. Cervical scrapes taken were taken and stored for DNA analysis and PAX 1 methylation status. Women with Swede score of 5 or more (n = 98) were biopsied. Cervical scrapes and biopsy were taken from women with obvious cervical growth (n = 14), without prior colposcopy. Sixty women were recruited to the study and allocated into three groups on the basis of histopathology, i.e., benign cervix (Group 1; n = 20), CIN 2/3 (Group 2; n = 20) and invasive cervical carcinoma (Group; n = 20). PAX 1 methylation percentage was calculated from the DNA extracted from the cervical scrapes of the women recruited.

Results

The mean PAX1 methylation percentage in benign lesions, CIN 2/3 and invasive cancer was 9.58% (SD ± 2.37%), 18.21% (SD ± 2.67%) and 24.34% (SD ± 4.09%), respectively, with p-value of < 0.001.

Conclusions

PAX 1 gene methylation has a promising role in identifying high-grade lesions and invasive cancer.

Bleomycin-Induced Flagellate Dermatitis: Revisited

Flagellate dermatitis caused by bleomycin is a rare side effect with a distinctive pattern of whip-like, linear streaks. The clinical presentation has become uncommon nowadays as bleomycin use in conventional chemotherapy regimens has decreased. We present a case of a 30-year-old female diagnosed with ovarian germ cell tumour, managed with bleomycin, etoposide, and cisplatin (BEP) and later developed a widespread rash indicative of classic flagellate dermatitis. This brief report emphasizes the significance of detection and management of this transient dermatological complication in patients receiving bleomycin.

Extrauterine Adenomyosis Coexistent with Mature Cystic Teratoma: An Extremely Rare Entity

Extrauterine adenomyosis is a rare entity. We present a case of a 32-year-old female who presented with this rare entity as a large abdominal mass and was a diagnostic and pathological dilemma.

Assessment of safety culture in the fireworks industry

Workers in the fireworks industry are affected mentally because of hazards that occurred in and around the working environment which caused injuries/fire accidents due to carelessness of workers and poor maintenance of rules and regulations by management. Primary data were collected from 451 workers in 25 fireworks industries randomly. A structured questionnaire is developed to measure safety culture in the fireworks industry in terms of dimensions like work environment, worker awareness, process, governance and safety satisfaction. This instrument is tested for purification of items in terms of stability by various statistical tests like reliability and validity in statistical software like SPSS and AMOS. This field-based study examines safety culture among workers in the fireworks industry to find the real scenario in the workplace and give recommendations for management to control accidents and fire or explosions to save the lives of workers.

Screening for cervical cancer: Choices & dilemmas

Cervical cancer is the fourth most common cancer in women in the world. To eliminate cervical cancer by 2030, the World Health Organization has given the target of 70 per cent coverage of twice lifetime screening. A multitude of screening methods are available, including cytology, human papillomavirus (HPV) DNA testing and visual inspection tests. Precision tests, including molecular and protein biomarkers such as DNA methylation, p16 immunostaining, and HPV mRNA testing help to enhance specificity of the screening. Worldwide HPV DNA testing with or without cytology is used as a screening method of choice, while in resource-poor settings, visual inspection tests are recommended. The major hurdle is a uniform and systematic implementation with a recall method in the population. Besides, controversies still exist regarding strategies to manage HPV-positive women and developing guidelines to screen the vaccinated population.

Literature Review on History and Pharmacotherapy of Parkinson`s Disease

Introduction: Parkinson’s disease (PD) is a slowly progressive neurodegenerative disease characterized by: Pill rolling tremors, Akathisia (inability to sit still), Rigidity, Kinesis (akinesia, dyskinesia), Instable (stooped) posture, no arm swinging in rhythm with legs, Sialorrhea Oculogyric crisiseyes are held fixed for a variable length of time), Nervous depression, Involuntary tremors, Seborrhoea and Masked facial expression. Parkinson’s disease is a chronic, progressive, neurodegenerative disorder with an estimated prevalence of 31 to 328 per 100,000 people worldwide. It is estimated that more than 1 percent of the population over age 65 are afflicted with Parkinson’s disease; incidence and prevalence increase with age. There are numerous unanswered questions regarding the diagnosis and management of Parkinson’s disease. Surgical treatment for Parkinson’s disease is generally considered for patients who respond to medications but have intolerable side effects. Surgical options include ablative procedures, deep brain stimulation, and tissue transplantation. This review focused on History and management of Parkinson’s disease. The purpose of this literature review is to gain an understanding of the existing research relevant to history and pharmacotherapy of Parkinson’s disease. Conclusion: Pharmacological treatment of PD should be tailored to the individual patient. Drug therapy is not obligatory in early PD; many patients can be managed for a time with exercise and lifestyle interventions. For patients with mild symptoms, MAO-B inhibitors, amantadine, or (in younger patients) anticholinergics are reasonable choices.

Human telomerase RNA component (hTERC) gene expression and chromosome 7 ploidy correlate positively with histological grade of cervical intraepithelial neoplasia

OBJECTIVE

Cervical cancer screening by primary human papilloma virus detection and cytology is fraught with low specificity and variable sensitivity, respectively. Cytology-histology correlation remains modest. Biomarkers associated with early genetic events in cervical squamous carcinogenesis and detectable in cytology material are likely to be relevant. Human telomerase RNA component (hTERC) gene overexpression and aneuploidy are promising candidates in view of their reported early and consistent association with cervical squamous oncogenesis.

METHODS

We analysed hTERC gene expression and chromosome 7 ploidy by fluorescent in-situ hybridisation (FISH) in 50 women with cytological precursor squamous intraepithelial lesions and available histology outcomes. Results were expressed as percentages of cells showing ≥3 signals, mean signals/nucleus, and maximum amplitude across various cytology and histology categories. Proportions of positive cases were calculated from threshold values derived from 6 controls. Distribution of above indices with respect to ≥cervical intraepithelial neoplasia 2 (CIN2) was explored.

RESULTS

For both genetic aberrations, there was significant positive correlation (for all indices) between the proportion of positive cases and worsening cytological and histological outcomes (P < .05), with significant intergroup differences (P < .05). High-grade lesions (≥CIN2) had significantly higher results compared to <CIN2 lesions (P ≤ .001). In five discordant cases with ≥CIN2 under- or overdiagnosed on cytology, FISH supported the histological diagnosis.

CONCLUSIONS

HTERC gene amplification and chromosome 7 ploidy showed positive association with cervical squamous carcinogenesis and could be relevant in settings of discrepant cytology-histology correlation.

Evaluating Progestogens for Preventing Preterm birth International Collaborative (EPPPIC): meta-analysis of individual participant data from randomised controlled trials

BACKGROUND

Preterm birth is a global health priority. Using a progestogen during high-risk pregnancy could reduce preterm birth and adverse neonatal outcomes.

METHODS

We did a systematic review of randomised trials comparing vaginal progesterone, intramuscular 17-hydroxyprogesterone caproate (17-OHPC), or oral progesterone with control, or with each other, in asymptomatic women at risk of preterm birth. We identified published and unpublished trials that completed primary data collection before July 30, 2016, (12 months before data collection began), by searching MEDLINE, Embase, CINAHL, the Maternity and Infant Care Database, and relevant trial registers between inception and July 30, 2019. Trials of progestogen to prevent early miscarriage or immediately-threatened preterm birth were excluded. Individual participant data were requested from investigators of eligible trials. Outcomes included preterm birth, early preterm birth, and mid-trimester birth. Adverse neonatal sequelae associated with early births were assessed using a composite of serious neonatal complications, and individually. Adverse maternal outcomes were investigated as a composite and individually. Individual participant data were checked and risk of bias assessed independently by two researchers. Primary meta-analyses used one-stage generalised linear mixed models that incorporated random effects to allow for heterogeneity across trials. This meta-analysis is registered with PROSPERO, CRD42017068299.

FINDINGS

Initial searches identified 47 eligible trials. Individual participant data were available for 30 of these trials. An additional trial was later included in a targeted update. Data were therefore available from a total of 31 trials (11 644 women and 16185 offspring). Trials in singleton pregnancies included mostly women with previous spontaneous preterm birth or short cervix. Preterm birth before 34 weeks was reduced in such women who received vaginal progesterone (nine trials, 3769 women; relative risk [RR] 0·78, 95% CI 0·68-0·90), 17-OHPC (five trials, 3053 women; 0·83, 0·68-1·01), and oral progesterone (two trials, 181 women; 0·60, 0·40-0·90). Results for other birth and neonatal outcomes were consistently favourable, but less certain. A possible increase in maternal complications was suggested, but this was uncertain. We identified no consistent evidence of treatment interaction with any participant characteristics examined, although analyses within subpopulations questioned efficacy in women who did not have a short cervix. Trials in multifetal pregnancies mostly included women without additional risk factors. For twins, vaginal progesterone did not reduce preterm birth before 34 weeks (eight trials, 2046 women: RR 1·01, 95% CI 0·84-1·20) nor did 17-OHPC for twins or triplets (eight trials, 2253 women: 1·04, 0·92-1·18). Preterm premature rupture of membranes was increased with 17-OHPC exposure in multifetal gestations (rupture <34 weeks RR 1·59, 95% CI 1·15-2·22), but we found no consistent evidence of benefit or harm for other outcomes with either vaginal progesterone or 17-OHPC.

INTERPRETATION

Vaginal progesterone and 17-OHPC both reduced birth before 34 weeks' gestation in high-risk singleton pregnancies. Given increased underlying risk, absolute risk reduction is greater for women with a short cervix, hence treatment might be most useful for these women. Evidence for oral progesterone is insufficient to support its use. Shared decision making with woman with high-risk singleton pregnancies should discuss an individual's risk, potential benefits, harms and practicalities of intervention. Treatment of unselected multifetal pregnancies with a progestogen is not supported by the evidence.

FUNDING

Patient-Centered Outcomes Research Institute.

Effect of Diluted Vasopressin vs Saline on Intraoperative Blood Loss during Vaginal Hysterectomy- A Randomised Controlled Trial

Introduction: Vasopressin has been used to control blood loss in gynaecological surgeries such as in myomectomy, abdominal hysterectomy etc. Only few studies have demonstrated its efficacy in Vaginal Hysterectomy (VH) in reducing intraoperative blood loss. VH is frequently performed gynaecological surgery in safe lower dose of vasopressin. There is no consensus on dose of infiltration. Aim: To compare submucosal vasopressin vs saline infiltration during VH and assess surgical parameters i.e., intraoperative blood loss, postinfiltration vitals, ease of dissection, use of electrocautery, need of blood transfusion and complications. Materials and Methods: This randomised controlled trial was done in department of Obstetrics and Gynaecology in collaboration with Department of Anaesthesia from November 2017 to April 2019. Low risk women aged <65 years with Pelvic Organ Prolapse Quantification-Stage (POP-Q stage) III/IV prolapse were recruited from Outpatient Department (OPD). They were randomised into two groups. Group I (n=35) patients received submucosal infiltration with diluted vasopressin (40mL vasopressin of 0.1U/mL, total 4U), prior to the incision. Group II (n=35) patients received 40cc of normal saline. Vitals were checked at one and five minutes postinfiltration. All the qualitative parameters were compared between the two groups by chi-square test and quantitative parameters by unpaired t-test. Inter and intragroup comparison was done by Repetitive Measure ANOVA followed by Tukey’s test. For the parameters, which did not follow the Gaussian distribution, were compared by non-parametric Mann-Whitney test between the two groups. A p-value <0.05 was considered as significant. All the data analysis was carried out in Statistical Package for the Social Sciences (SPSS) version 20.0. Results: The mean estimated blood loss from incision till creation of flaps was half in vasopressin group as compared to saline group (21.33 mL vs 49.67 mL, p-value=0.001). Vasopressin group had less use of electrocautery, whereas ease of dissection was more in saline group. There was no significant difference in duration of surgery till flap creation and need of blood transfusion. There was fall in pulse rate and Blood Pressure (BP) in both groups which did not require medical intervention and was likely due to neuraxial anaesthesia. Conclusion: Vasopressin appears to be safe and effective in VH at infiltration dose of four units in dilution. However further studies on larger sample size are recommended to gather more evidence in this regard.

Minimally invasive management of pyoperitoneum in a COVID-19 patient: A therapeutic dilemma

A case report of successful minimally invasive management of puerperal sepsis with pyoperitoneum and acute peritonitis in a COVID‐19‐positive patient.

Clinicopathological correlation of serum vascular endothelial growth factor and tissue carbonic anhydrase factor IX in stage IA to IIA carcinoma cervix

e18012

Background: VEGF initiates endothelial cell proliferation and angiogenesis in tumour cells while CA IX has an important role in pH regulation and elimination of hypoxia generated acid load during glycolysis.The present study was designed to identify these biomarkers and their correlation with tissue spread and behavior and eventually could lead to development of novel target therapies. The objective of this study was to correlate serum VEGF levels and tissue CA IX expression with clinicopathological features of carcinoma cervix stage IA to IIA. Methods: This exploratory case-control study included 19 cases with carcinoma cervix FIGO 2009 stage IA to IIA and 19 age matched controls. Out of the 19 cases, 12 underwent surgery and 7 received chemoradiation. Pre-therapy blood samples were collected for serum VEGF estimation from both cases and controls. For CA IX expression estimation, cervical tissue was taken for analysis. For cases, post-operative / post chemoradiation blood samples were taken for VEGF level estimation after 6 weeks. Results: The difference in mean serum VEGF levels between cases 1235.84 pg/ml (SD± 433.67) and controls 153.74 pg/ml (SD± 108.11) was statistically significant (p = 0.001). Mean serum VEGF level between pre and post-operative cases was 1108 pg/ml (SD± 407.62) and 391.42 pg/ml (SD± 270.71) while in pre and post chemoradiation cases it was 1455 pg/ml (SD± 413.38) and 623 pg/ml (SD± 238.41). This decrease was statistically significant (p = 0.00 & p = 0.018). VEGF positively correlated with histopathologic type (p = 0.016), grade (p = 0.012), and lymphovascular space invasion (p = 0.042).CA IX expression was seen in all cases while in controls no expression was seen. CA IX expression had a positive association with lymphnode metastasis (p = 0.041). Conclusions: Elevated pre-therapeutic serum VEGF suggests spread of tumor and can be used as a prognostic marker for cancer cervix. CA IX immunostaining in cervical biopsy samples can be used as a surrogate marker for tumor aggressiveness and distant spread.

Assessment of a Combination of Clinical Maneuvers in Evaluation of Post-Laparoscopic Pain: A Randomized Clinical Trial

Background

To assess the efficacy of the combined maneuvers in evaluation of post-laparoscopic pain.

Material and Methods

A randomized controlled study was conducted. Sixty-four women were included in the study and were randomly divided into two groups. Intervention group received combined maneuvers such as intraperitoneal normal saline infusion, pulmonary recruitment maneuver and local bupivacaine instillation at port sites after laparoscopic surgery. Control group received routine care.

Main Outcome Measures

Upper abdominal pain, shoulder pain and incision site pain were noted in both groups at 3, 6, 12, 24 and 48 h postoperatively.

Results

The median interquartile range (in centiles) of upper abdominal pain score 3, 6 and 12 h postoperatively in the intervention group was 1.0 (0.25-1.0), 1.0 (0.0-1.0) and 0.50 (0.0-1.0), and in the control group, the values were 2.0 (2.0-1.0), 2.0 (2.0-1.0) and 1.0 (0-1.0) at 3, 6 and 12 h, respectively (p < 0.000). The median interquartile range of shoulder pain score 3, 6 and 12 h postoperatively in the intervention group was 0.0 (0.0-1.0), 0.0 (0.0-0.75) and 0.0 (0.0-1.0), and in the control group, the values were 1.0 (0.0-2.0), 1.0 (0.0-1.75) and 1.0 (0-1.0) at 3, 6, and 12 h. The upper abdominal pain and shoulder pain relief was significantly more in the intervention group than in the control group in the first 12 h of surgery.

Conclusion

Combined maneuvers could significantly reduce post-laparoscopic upper abdominal and shoulder pain.Clinical Trial CTRI Registration Number-CTRI/2017/07/0089, web address of CTRI-http://ctri.nic.in.

Comparison of the AV Magnivisualizer device with colposcopy to detect cervical intraepithelial neoplasia using the Swede scoring system

OBJECTIVE

To compare the AV Magnivisualizer with colposcopy to detect cervical intraepithelial neoplasia (CIN) using the Swede scoring system.

METHODS

Cross-sectional study conducted in a tertiary care hospital from May 2017 to March 2018. One hundred women with positive results at visual inspection with acetic acid underwent cervical inspection using the Magnivisualizer followed by a colposcope. Biopsies were taken if the Swede score was greater than 4. Pregnant women, women with an obvious cervical growth, acute cervicitis, or prior cervical surgery were excluded. Diagnostic accuracy of the Magnivisualizer and colposcope was calculated for high-grade lesions (CIN 2/CIN 2+) and agreement was compared between the two modalities.

RESULTS

The sensitivity, specificity, and positive and negative predictive values of the Magnivisualizer were 88.2%, 70.0%, 50.0%, and 94.6%, respectively, to detect high-grade lesions at a Swede score cutoff of 5 or more. The area under the curve for the Magnivisualizer was 0.80 (95% CI, 0.67-0.92), which was comparable with colposcopy (AUC 0.86; 95% CI, 0.76-0.96). There was very good agreement between the Magnivisualizer and colposcopy (κ=0.865, P<0.001) for high-grade lesions.

CONCLUSION

The Magnivisualizer had high diagnostic accuracy to detect high-grade CIN in screen-positive women, which was comparable with colposcopy.

Oral progesterone for the prevention of recurrent preterm birth: systematic review and metaanalysis

OBJECTIVE DATA

The purpose of this study was to perform a systematic review and metaanalysis of randomized controlled trials on oral progesterone compared with placebo or other interventions for preterm birth prevention in singleton pregnancies with previous spontaneous preterm birth. The primary outcome was preterm birth at <37 weeks gestation; the secondary outcomes included preterm birth rate at <34 weeks gestation, neonatal morbidity/death, and maternal side-effects.

STUDY

Searches were performed in PubMed, Scopus, ClinicalTrials.gov, PROSPERO, EMBASE, and the Cochrane Register with the use of a combination of words related to "preterm birth," "preterm delivery," "progesterone," "progestogens," and "oral" from inception of each database to April 2018. Additionally, systematic reviews on progesterone for preterm birth prevention that were identified in our search were also reviewed for additional studies. We included all randomized trials of asymptomatic singleton gestations with previous spontaneous singleton preterm birth that had been randomized to prophylactic treatment with oral progesterone vs placebo, no treatment, or other preterm birth intervention. Exclusion criteria included quasirandomized trials, trials that involved women with preterm labor/membrane rupture at the time of randomization or multiple gestations.

STUDY APPRAISAL AND SYNTHESIS METHODS

The risk of bias and quality of evidence were assessed for each study. All analyses were done with an intention-to-treat approach. The primary outcome was incidence of preterm birth at <37 weeks gestation; the secondary outcomes included preterm birth at <34 and <28 weeks gestation, maternal adverse events, maternal serum progesterone level, and neonatal morbidity and death. Summary measures were reported as relative risk or mean difference. I² >30% was used to identify heterogeneity.

RESULTS

The search strategy identified 79 distinct studies. Three trials on oral progesterone vs placebo (involved 386 patients: 196 in oral progesterone and 190 in placebo) met the inclusion criteria; there were no studies on oral progesterone vs other intervention that met inclusion criteria. Metaanalysis demonstrated a significantly decreased risk of preterm birth at <37 weeks gestation (42% vs 63%; P=.0005; relative risk, 0.68; 95% confidence interval, 0.55-0.84), preterm birth at <34 weeks gestation (29% vs 53%; P<.00001; relative risk, 0.55; 95% confidence interval, 0.43-0.71), and increased gestational age of delivery (mean difference, 1.71 weeks; 95% confidence interval, 1.11-2.30) with oral progesterone compared with placebo. There was a significantly lower rate of perinatal death (5% vs 17%; P=.001; relative risk 0.32; 95% confidence interval, 0.16-0.63), neonatal intensive care admission (relative risk, 0.39; 95% confidence interval, 0.25-0.61), respiratory distress syndrome (relative risk, 0.21; 95% confidence interval, 0.05-0.93), and higher birthweight (mean difference, 435.06 g; 95% confidence interval, 324.59-545.52) with oral progesterone. There was a higher rate of maternal adverse effects with oral progesterone that included dizziness (relative risk, 2.95; 95% confidence interval, 1.47-5.90), somnolence (relative risk, 2.06; 95% confidence interval, 1.29-3.30), and vaginal dryness (relative risk, 2.37; 95% confidence interval, 1.10-5.11); no serious adverse effects were noted.

CONCLUSION

Oral progesterone appears to be effective for the prevention of recurrent preterm birth and a reduction in perinatal morbidity and mortality rates in asymptomatic singleton gestations with a history of previous spontaneous preterm birth compared with placebo. There were also increased adverse effects with oral progesterone therapy compared with placebo, although none were serious. Further randomized study on oral progesterone compared with other established therapies for the prevention of recurrent preterm birth are warranted.

Cancer in pregnancy

The incidence of cancer in pregnancy is increasing. The most frequent malignancies include breast and cervical cancers. Diagnosis may be complicated by late presentation. Imaging during pregnancy should consider risks to the fetus. Diagnostic work-up, including tumor markers, can be influenced by the physiology of pregnancy. Treatment of cancer can often be safely administered with good maternal and fetal outcomes. Chemotherapy, radiotherapy, and surgery must be adapted to the pregnancy state. Counselling and emotional support are an essential part of management.

2556. Retrospective Evaluation of Mismatch From Egg-Based Isolation of Influenza Strains Compared With Cell-Based Isolation and the Possible Implications for Vaccine Effectiveness

Background

Lower influenza vaccine effectiveness (VE) against circulating H3N2 strains compared with other influenza viruses is partly explained by antigenic mismatch between circulating strains and the vaccine strain (Belongia 2016). This mismatch has recently been linked to a new glycosylation site introduced in the egg-adaptation step (Zost 2017) and HA L194P substitution (Wu 2017) for H3N2. Vaccine manufactured using seed virus wholly grown in mammalian (e.g., Madin–Darby Canine Kidney—MDCK) cells, as with the NH17-18 version of Flucelvax®, avoids these mutations. Preliminary reports suggest that this cell-based vaccine showed greater VE than did similar egg-based vaccines [FDA Statement]. This study aimed to compile existing data on antigenic similarity to measure the degree of match with circulating wild-type isolates of egg- and MDCK-propagated versions of the vaccine H3N2 virus over multiple seasons.

Methods

Using publicly available reports from the Worldwide Influenza Centre, London (Crick), we compiled data on antigenic similarity, defined as H3N2 circulating wild-type virus isolates showing no more than a 4-fold reduction in titer to antisera raised against wholly MDCK- or egg-propagated versions of the vaccine H3N2 viruses. Titers were compared using hemagglutination inhibition (HI) assays and/or plaque reduction neutralization assays (PRNA).

Results

Data from Northern Hemisphere influenza seasons of 2011–2012 to 2017–2018 show a substantially higher proportion of tested circulating influenza H3N2 viruses matched the MDCK-propagated reference viruses than did corresponding egg-propagated reference vaccine viruses (Figures 1 and 2). In half of the seasons evaluated, there was little to no antigenic similarity between circulating viruses and the egg-based vaccine viral seed.

Conclusion

These data suggest higher levels of mismatch have occurred consistently with egg-propagated H3N2 reference viruses compared with MDCK-propagated reference viruses when measured against circulating wild-type isolates and may further explain the potential for lower VE observed against H3N2 historically. Furthermore, these data point to the importance of continuing to utilize cell-derived seeds in creating seasonal influenza vaccines for this strain.

Disclosures

S. Rajaram, Seqirus: Employee, Salary. J. Van Boxmeer, Seqirus: Employee, Salary. B. Leav, Seqirus: Employee and Shareholder, Salary. P. Suphaphiphat, Seqirus: Employee, Salary. I. Iheanacho, Seqirus: Consultant, Research support. K. Kistler, Seqirus: Consultant, Research support.

Neutrophil-to-lymphocyte ratio and platelet indices in pre-eclampsia

OBJECTIVE

To compare the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and platelet indices between women with pre-eclampsia and normotensive pregnant women.

METHODS

A cross-sectional study conducted from January to July 2017 at a tertiary care hospital in Delhi, India. The study compared pregnant women aged 18-40 years with pre-eclampsia diagnosed at term with healthy pregnant women matched for gestational age. Venous blood samples were drawn and complete blood count was analyzed. The parameters recorded were hemoglobin, red cell distribution width (RDW), platelet count, mean platelet volume (MPV), plateletcrit, and platelet distribution width.

RESULTS

There were 67 women included in each group. NLR was higher in women with pre-eclampsia compared with the control group (6.8 ± 7.6 vs 3.0 ± 0.98; P=0.001). Both PLR (14.18 ± 14.4 vs 9.54 ± 3.6; P=0.012) and MPV (9.45 ± 1.19 vs 9.02 ± 1.1; P=0.029) were higher in the study group compared with the control group. Platelet count was lower in pre-eclamptic women compared with the control group (188 ± 89.7 vs 200.1 ± 62.36; P=0.014). RDW was also higher in the study group (P=0.025).

CONCLUSIONS

The present study found that the inflammatory markers NLR, PLR, RDW, and MPV were higher in women with pre-eclampsia. Measuring NLR and PLR may be useful in predicting pre-eclampsia among women at high risk during prenatal follow-up.

Tissue Culture Mediated Allelic Diversification and Genomic Enrichment of Wheat to Combat Production Constraints and Address Food Security

In view of the emerging population trends and that wheat crop is the major unequivocally recognized conduit towards addressing the food security challenges of 2050 this discourse embraces various research options that are viewed as possible solutions toward delivering those targets for providing nutritious food and meeting the aspirations that policy setters have debated on the subject for decades. The underlying strength for achieving these targets will require concerted efforts from plant researchers that are well integrated within effectively harnessing and utilizing prevalent genetic diversity of the wide array of alleles in a holistic pro‐active manner. We argue that the purists of basic and strategic research dimensions need to be thoughtfully defined, so that the vital target of delivering the “applied” gains are only realized from the outputs on farmer’s fields and measured by tons per hectare. In this quest, the pre‐breeding disciplines “classical mode” and its recently surfaced “modified sense” are pivotal, where within the former facet “tissue culture” (TC)/artificial culturing is embodied integrally. Taken for granted, TC has been the backbone of all wide hybridization studies and has made an enormous impact on the agricultural landscape spanning over the last six decades. With its intervention significant generic and specific incompatibilities have been overcome as well as allowing researchers to exploit the protocols for adding efficiency to breeding programs, facilitate operational technologies in running breeding programs and development of unique genetic stocks that preserve valuable allelic richness in user friendly forms for future free germplasmusage in global/private domains of plant improvement ventures.Plant Tissue Cult. & Biotech. 27(1): 89-140, 2017 (June)

A Comparison Between Measured Concentration of 3H in Kalpakkam Environment with Predicted Atmospheric Dispersion Model

The field measurements of 3H in the form of HTO present in air moisture carried out around Madras Atomic Power Station were compared with predicted values using atmospheric dispersion modeling. Air 3H samples were collected from different sectors at the site boundary of the operating reactors for the period of 2 y and compared with Gaussian Plume model. The predictions were comparable with the measured value. The slight variation observed between the two methods is attributed to the uncertainty involved in the measurement of air 3H concentration and in the measurement of site-specific meteorological parameters. The radiation dose imparted to members of public due to the levels observed is well within station technical specification limit for 3H.

A Rare Collision Tumour of Uterus- Squamous Cell Carcinoma and Endometrial Stromal Sarcoma

Collision tumours are defined by co-existence of two tumours in the same or adjacent organs which are topographically and histologically distinct with minimal or no histological admixture. Collision tumours have been described in many organs notably thyroid, brain, adrenal gland, stomach and rarely uterus. Most of the collision tumours reported in uterus have two components; an adenocarcinoma and a sarcoma. We report a case of a 60-year-old lady who presented with complaints of post-menopausal bleeding. A cervical biopsy was performed which showed a non-keratinizing squamous cell carcinoma of cervix. Intra-operatively the uterus was bulky with a 6 cm x 5 cm polypoidal mass in the endometrial canal along with a 2 cm friable cervical growth. The fleshy uterine cavity mass was a spindle cell tumour with moderate pleomorphism and frequent mitosis. It was immunopositive for CD10 and negative for smooth muscle actin and cytokeratin 5/6. The other growth showed non-keratinizing squamous cell carcinoma which was positive for cytokeratin 5/6. Based on the distinct topographical location and limited areas of tumour admixture of the two tumours, a diagnosis of collision tumour of uterus comprising of endometrial stromal sarcoma (high grade) uterus and squamous cell carcinoma cervix was made.

Emergency Peripartum Hysterectomy: Indications and Outcome in a Tertiary Care Setting

INTRODUCTION

Emergency Peripartum Hysterectomy (EPH) is an important lifesaving procedure, mostly reserved for conditions deemed to be serious and life threatening, and not amenable to conservative methods. In the present scenario, the advent of newer medical and conservative surgical methods for controlling obstetric haemorrhage has influenced the incidence, trend and the outcomes of the procedure.

AIM

To evaluate the demographic profile, indications, operative details, maternal morbidity and mortality and neonatal outcomes of women undergoing EPH.

MATERIALS AND METHODS

A descriptive analysis of case records of women who underwent EPH between September 2006 to July 2014, at Guru Teg Bahadur Hospital Delhi, India was done. Data were collected from the medical records department.

RESULTS

A total of 194 cases (n) were identified among 1,00712 deliveries, an incidence of 1.92 per 1000 deliveries. Majority of the women were unbooked i.e., they did not receive any form of antenatal care and were gravida 3 and above. The indications were atonic PPH in 89 (45.87%), rupture of unscarred uterus in 36 (18.56%), morbidly adhered placenta in 30 (15.46%), scar rupture in 20 (10.31%) and gangrenous uterus 19 (9.79%). The mean blood loss was around 1.6±0.45 litres. Approximately 14% cases underwent stepwise devascularisation prior to hysterectomy and in only 2% women, B-Lynch suture was applied. Thirteen (6.7%) cases had bladder injury and 22 (11.34%) needed re-laparotomy for hysterectomy. Around 76 (39%) women were shifted for ICU care. Nineteen (9.79%) women developed Disseminated Intravascular Coagulation (DIC). The case fatality rate was 7.2% and perinatal mortality was 30%.

CONCLUSION

Atonic PPH remains the leading cause of EPH in our analysis. Surprisingly rupture of unscarred uterus was more common compared to scar rupture. Creating awareness among women to seek health services in time with facilities for early referral, teaching younger obstetricians with conservative surgical procedures like stepwise devascularisation steps and compressive sutures should be of utmost priority.

A Ten Year Audit of Maternal Mortality: Millennium Development Still a Distant Goal

OBJECTIVE

To assess various causes of maternal mortality over a ten year period.

DESIGN

Retrospective audit of hospital case records.

SETTING

Tertiary care hospital.

POPULATION

Pregnant women who expired in the premises of GTB Hospital.

MATERIALS AND METHODS

A retrospective audit of case records of maternal deaths was conducted for a ten year period (January 2005 to December 2014).

RESULTS

There were a total of 647 maternal deaths out of 1,16,641 live births. Sixty-eight percent (n = 445) of women were aged 21-30 years, while 10.5% (n = 68) were <20 years of age. The most common direct causes of maternal mortality were preeclampsia/eclampsia in 24.4% (n = 158), obstetric hemorrhage in 19.1% (n = 124) and puerperal sepsis in 14.5% (n = 94). With regards to indirect causes, anemia accounted for 15.3% (n = 99) mortality. There was only 1 (0.1%) mortality because of HIV/AIDS. Other notable causes of maternal mortality were infective hepatitis in 7.1% (n = 46). Tuberculosis, that is a disease of tropical countries, accounted for 3.0% (n = 20) of the total deaths.

CONCLUSION

High maternal mortality in GTB hospital can be due to it being a tertiary hospital with referrals from all neighbouring states. Accessible antenatal care can help prevent these maternal deaths. Female education can be of immense help in dealing with the problem and improving the utilization of public health facilities.

KEY MESSAGE

Preeclampsia/eclampsia and obstetric hemorrhage have been the main causes of maternal mortality for ages. Regular antenatal visits and the judicious training of grassroot level workers to pick-up complications early on in the pregnancy can be an effective way to deal the morbidity and mortality associated with these problems. The Janani Suraksha Yojana (JSY) and Janani Shishu Suraksha Karyakaram (JSSK) in India are pioneer steps in this direction.

Conventional cytology, visual tests and evaluation of P16(INK4A) as a biomarker in cervical intraepithelial neoplasia

OBJECTIVES

(1) To detect cervical intraepithelial neoplasia (CIN) using Papanicolaou test (PAP test), visual tests (visual inspection after the application of acetic acid [VIA], visual inspection after the application of Lugol's iodine [VILI]), colposcopy, and biopsy. (2) To study the biomarker p16(INK4A) expression by immunostaining.

MATERIALS AND METHODS

Experimental study was conducted from November 2009 to April 2011. 1500 women were screened for cancer cervix using conventional PAP test, VIA, and VILI. Sensitivity, specificity, positive, and negative predictive values of these tests were calculated individually, sequentially, and in parallel. Women having positive results underwent colposcopy and biopsy if required. p16(INK4A) expression in biopsy samples was studied using immunohistochemistry.

RESULTS

All test positive cases (n = 235) underwent colposcopy. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of PAP with atypical squamous cells of undetermined significance (ASCUS) as cut-off was 40%, 99.25%, 35.25%, and 99.39%; VIA was 60%, 93.06%, 8.03%, and 99.56% and VILI was 80%, 86.06%, 5.4%, and 99.76%, respectively. When PAP, VIA, and VILI were used in parallel sensitivity, specificity, PPV, and NPV improved to 100%, 85.18%, 6.38%, and 100%, respectively. Colposcopic abnormalities were detected in 83 and biopsy proven CIN in 15. p(16INK4A) expression was seen in eight of 15 CIN cases.

CONCLUSIONS

(1) PAP test and visual techniques are complementary. (2) p(16INK4A) expression was seen in majority of CIN 2 lesions suggesting a higher grade lesion.

Randomized controlled trial of thermal balloon ablation versus vaginal hysterectomy for leiomyoma-induced heavy menstrual bleeding

OBJECTIVE

To compare the efficacy of thermal balloon ablation (TBA) with that of vaginal hysterectomy in the treatment of leiomyoma-induced heavy menstrual bleeding (HMB).

METHODS

An open-label randomized controlled trial was conducted between November 1, 2012, and October 31, 2014, in a tertiary care hospital in Delhi, India. Eligible women with HMB (aged ≥40 years, uterus size ≤14 weeks of pregnancy, leiomyoma ≤5 cm, uterocervical length ≤12 cm) were randomly assigned (1:1) to undergo TBA or vaginal hysterectomy using computer-generated random number tables. The primary outcome was the number of women in the TBA group with HMB 6 months after surgery. Analyses were by intention to treat.

RESULTS

Each group contained 20 women. No women in the TBA group had HMB at 6 months. Nineteen women were amenorrheic by 6 months and one was hypomenorrheic.

CONCLUSION

TBA can replace vaginal hysterectomy in some perimenopausal women with uterine leiomyomas. Clinical Trials Registry India: CTRI/2016/07/007119.

Materno-Fetal Outcomes with Viral Hepatitis in Pregnancy

OBJECTIVE

To evaluate materno-fetal outcomes in pregnant women with jaundice.

METHODS

A prospective study was conducted over a period of 6 months in a tertiary care hospital of Delhi, India. 82 pregnant women with jaundice were included. The serum was screened for viral markers, liver function tests, and coagulation status.

RESULTS

The mean age of women was 27.3 ± 4.3 years. 43.9 % (n = 36) women were HEV positive, 36 % (n = 27) HBsAg positive, 4 % (n = 3) HAV positive and 1.3 % (n = 1) HCV positive. Intrahepatic cholestasis was diagnosed in 10.8 % (n = 8) of women. Maternal morbidity was evaluated in terms of chorioamnionitis (5.4 %, n = 3), encephalopathy (26.8 %, n = 15), and coagulopathy (67.9 %, n = 38). There were five maternal deaths, and all were unbooked with HEV-positive status and a bilirubin >15 mg/dl with deranged coagulogram and encephalopathy and IUDs. 79 women delivered vaginally, and three had cesarean section. Of the vaginal deliveries, 59.8 % (n = 49) went into spontaneous labor, and 25.5 % (n = 21) were induced for varied reasons (BPS < 6/10 (38 %, n = 8)) and progressive derangement of LFT (38 %, n = 8). Among the 71 deliveries, 29 (40.8 %) were IUD and 42 (59.1 %) were live born. On analyzing the morbidity data, it was found that HEV-positive women (deranged coagulogram 71.05 %, IUD 75.86 %, encephalopathy 80 %) had a poorer outcome as compared to their HBsAg positive counterparts (deranged coagulogram 10.52 %, IUD 13.79 %, encephalopathy 6.66 %).

CONCLUSION

Urgent redressal of issues pertaining to sanitation and provision for clean drinking water for citizens of India is the need of the hour as HEV is fecooral in transmission.

Genome-Wide Association Mapping of Yield and Grain Quality Traits in Winter Wheat Genotypes

The main goal of this study was to investigate the genetic basis of yield and grain quality traits in winter wheat genotypes using association mapping approach, and identify linked molecular markers for marker assisted selection. A total of 120 elite facultative/winter wheat genotypes were evaluated for yield, quality and other agronomic traits under rain-fed and irrigated conditions for two years (2011–2012) at the Tel Hadya station of ICARDA, Syria. The same genotypes were genotyped using 3,051 Diversity Array Technologies (DArT) markers, of which 1,586 were of known chromosome positions. The grain yield performance of the genotypes was highly significant both in rain-fed and irrigated sites. Average yield of the genotypes ranged from 2295 to 4038 kg/ha and 4268 to 7102 kg/ha under rain-fed and irrigated conditions, respectively. Protein content and alveograph strength (W) ranged from 13.6–16.1% and 217.6–375 Jx10-4, respectively. DArT markers wPt731910 (3B), wPt4680 (4A), wPt3509 (5A), wPt8183 (6B), and wPt0298 (2D) were significantly associated with yield under rain-fed conditions. Under irrigated condition, tPt4125 on chromosome 2B was significantly associated with yield explaining about 13% of the variation. Markers wPt2607 and wPt1482 on 5B were highly associated with protein content and alveograph strength explaining 16 and 14% of the variations, respectively. The elite genotypes have been distributed to many countries using ICARDA’s International system for potential direct release and/or use as parents after local adaptation trials by the NARSs of respective countries. The QTLs identified in this study are recommended to be used for marker assisted selection after through validation using bi-parental populations.