Comparative evaluation of human papilloma virus-DNA test verses colposcopy as secondary cervical cancer screening test to triage screen positive women on primary screening by visual inspection with 5% Acetic acid.

INTRODUCTION: Visual inspection with 5% Acetic acid (VIA) as a low cost screening method has good sensitivity with the limitation of low specificity and low positive predictive values. The present study therefore evaluates the performance of secondary testing by human papillomavirus (HPV) test and Colposcopy in a single‑visit screening approach to increase program effectiveness in limited health‑care resources settings. MATERIALS AND METHODS: In a cross‑sectional cervical cancer screening trial, 3629 women (30‑65 years) were screened by primary screening test VIA. VIA test positive women were subsequently tested for the presence of oncogenic HPV types by hybrid capture II and with colposcopy. The reference investigation histopathology was performed for all primary screen positive women. RESULTS: Data for 3613 evaluable women showed 352 (9.7%) women positive on primary screening by VIA. VIA had a sensitivity of 93% (95% confidence interval (CI): 0.76‑0.99) and specificity of 91% (95% CI: 0.90‑0.92) respectively to detect the cervical intraepithelial neoplasia grade 2+ . HPV DNA and colposcopy as secondary tests to triage VIA positive women had a sensitivity of 61% (95% CI: 0.41‑0.78), 43% (95% CI: 0.24‑0.63) and specificity of 99% (95% CI: 0.99‑1.00), 99% (95% CI: 0.99‑0.99) respectively for detecting CIN2+ lesions. CONCLUSION: Two step screening model combining highly sensitive low cost test like VIA for primary screening followed by more specific HPV DNA test as triage test for primary screen positive can be a cost‑effective cervical screening strategy in resource constrained settings.

A study of cervical cancer screening for prevention of carcinoma cervix.

To identify precursor lesions of cancer cervix and early cancer cervix in married women with primary complaint of leucorrhoea in a tertiary referral centre with reference to effectiveness of screening methods, 100 successive women attending colposcopy clinic with primary complaints of leucorrhoea were selected . All women had speculum examination, Pap smear, vaginal pH, Whiff test, visual inspection of cervix after application of acetic acid (VIA), visual inspection of cervix after application of Lugol's iodine (VIL), colposcopy done. Biopsy was taken when indicated. A total of 63 women were referred. There were 93 menstruating women. The mean age was 34.5 years. Whiff test was positive in 6 women. Downstaging showed 74 women with abnormal cervix. VIA was postive in 44 women and VIL in 53 women. The sensitivity and specificity of VIA was 77.7% and 75%, and that of VIL was 69% and 57% respectively. Diagnostic accuracy of VIA was 76%,VIL was 63%. Pap smear showed 87% accuracy. The correlation between colposcopy and histopathological examination was 93-98%. Precursor cancer cervical lesions, were found in 27% of women. Referral women with cancer precursor lesions formed the largest group of 24% (n=24) of total women. Early carcinoma cervix was detected in 3% (n=3) of which one woman was referred. The burden of carcinoma cervix in India can be brought down by screening camps and early referral.

Cervical screening by visual inspection with acetic acid (VIA) is well accepted by women--results from a community-based study in rural India.

OBJECTIVE: Among the low cost alternative screening tests Visual Inspection after Acetic Acid Application (VIA) has been found to be most promising. The objective of the present study was to evaluate the safety and acceptability of VIA done by health workers among rural Indian women. We also evaluated the level of women's satisfaction with the screening program. METHODS:Women residing in a defined geographic area were offered cervical screening using VIA by trained health workers. Women testing positive were colposcoped by a medical officer at the same sitting. Based on the feedback from a few focus group discussions a structured questionnaire was designed to interview the women after screening. A total of 498 women were selected randomly from the screened women for interview by a social worker. Besides enquiring about any discomfort they faced during or within seven days after screening, the women were also asked to indicate their level of satisfaction with the service. Their opinions to improve the quality of service were also sought. RESULTS: Most women reported no pain or only slight discomfort during screening (94.2%). The most common complaint after screening was vaginal discharge (12%). A burning sensation in the vagina was experienced by some of the women (5.8%). These complaints were mild and short-lasting in majority of cases. Most of the women were satisfied with the screening service (94.6% selected the top three of a six-point response scale) and 97% said they would recommend the test to others. The most common reasons for dissatisfaction with screening were discomfort during or after screening, long waiting time and failure to get treatment for other medical problems. CONCLUSION: VIA by trained health workers followed by colposcopy at the same sitting is an acceptable screening algorithm for Indian women. A VIA based screening program has to be integrated to the existing primary health care facility in developing countries.

VIA and cryotherapy: doing what's best.

Cervical cancer kills about 6,000 Thai women annually and has been for decades. The age-standardized incidence ratio (ASR) is 20.9 per 100,000 women-years. A multi-province survey by the Thai National Cancer Institute found that coverage of the previous cervical cancer screening program (i.e. the opportunistic Pap smear) was only 5%. Visual inspection with acetic acid (VIA) and cryotherapy, a secondary prevention program, could be a more practical approach for cervical cancer prevention, particularly in low resource, rural, and remote settings. The authors are expanding this program throughout Thailand (in conjunction with the use of the Pap smear when appropriate) with an 80% coverage target. Using both approaches in a complementary fashion should significantly reduce the incidence and mortality of cervical cancer among Thai women.

Accuracy of visual inspection with acetic acid (VIA) for early detection of cervical dysplasia in Tehran, Iran.

OBJECTIVE: To evaluate the accuracy of visual inspection with 5% acetic acid (VIA) when used to detect cervical cancer and its precursors. METHODS: The study population included women attended Family Planning and Gynecological Clinic in Bagher Abad Health Center and Mirza Koochak Khan Hospital for regular cervical screening tests. After obtaining informed consent from each woman, VIA was performed. One hundred with a positive VIA test and 100 women with a negative VIA test were randomly selected for this study. Cytology and colposcopy examination were performed for all 200 cases and cervical biopsies were conducted for those individuals showing abnormal colposcopic findings. RESULTS: Nine cases in VIA-positive group and two cases in VIA-negative group had an abnormal cytology. Ninety five women in the VIA-positive group and 25 in the VIA-negative group had abnormal colposcopic findings. From biopsy examination, 67 (71%) of cases in the VIA-positive group and 3 (12%) cases in the VIA-negative group had a final diagnosis of dysplasia. Among biopsied samples, only 7 cases of VIA-positive group showed abnormal result and the remaining were normal. Based on these results, VIA test sensitivity and specificity were 95.7% and 44.0% respectively, while they were 10% and 92% for cytology tests. CONCLUSIONS: The results of this study indicate that although VIA is a sensitive screening test for detection of cervical dysplasia, it can not be used by itself. Applying VIA along with Pap smears helps to detect a higher number of cases with cancer precursor lesions.

Visual inspection for cervical cancer screening: evaluation by doctor versus paramedical worker.

BACKGROUND: In the absence of an effective cervical cancer screening programme, efforts are being made to explore the feasibility of using the existing infrastructure to develop effective low-cost screening methods. AIMS: To evaluate and compare test performance of visual inspection of the cervix by a doctor and a paramedical worker. SETTING AND DESIGN: Gynaecology outpatient department (OPD), All India Institute of Medical Sciences, New Delhi; cross-sectional study. MATERIAL AND METHODS: One hundred women with complaints of vaginal discharge, irregular bleeding, post coital bleeding or unhealthy cervix underwent visual inspection with acetic acid (VIA) and Lugol's iodine (VILI) by a doctor and nurse, followed by colposcopy and biopsy. STATISTICAL ANALYSIS USED: Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated for each test and compared. Concordance was determined by kappa statistics. RESULTS: VIA by nurse had a higher sensitivity (100% versus 87.5%), but lower specificity (53% versus 63%) when compared with the doctor, but it was not statistically significant. There was moderate agreement between their VIA findings (kappa=0.56). VILI findings were comparable to that of the VIA, both by the doctor and nurse. There was almost perfect agreement (kappa=0.89) between VILI by the doctor and nurse. CONCLUSION: Visual inspection can be performed reliably by trained paramedical workers and doctors and is an effective screening option in low resource settings.

The applied physiology of cough.

The cough reflex is such an important defense mechanism of the respiratory tract that a thorough knowledge of its applied physiology in respiratory disease is essential for clinicians. It is a well-integrated reflex, which has afferent limb consisting of receptors and afferent nerves, the central cough center in the brainstem and the efferent limb consisting of motor nerves supplying the muscles of coughing. The cough process consists of inspiratory phase, compressive phase and expiratory phase. Stimuli that can initiate the cough process can be central or peripheral in the lungs or outside the lungs. The important function of the cough reflex is to maintain the airways and alveoli clear and healthy. The mechanisms by which it achieves this are (i) high velocity of expiratory gas flows produced in the expiratory phase (ii) the compression of the lungs and airways by high positive pleural pressure generated in the compressive phase. Cough threshold can be determined by giving acetic acid, citric acid or capsaicin inhalation challenge test. This has practical application in clinical research. The pathophysiological basis of different types of cough encountered in clinical practice is discussed.

Detection of CIN by naked eye visualization after application of acetic acid.

A prospective study was undertaken to determine the sensitivity and specificity of acetic application to the cervix followed by naked eye visualization as a screening test for detection of cervical intraepithelial neoplasia. Three hundred and seventy two sexually active woman in the reproductive age group were studied. All the women underwent Papanicolaou test, acetic acid test and colposcopy. One hundred and seventy five woman were acetic acid test negative, 197 women were acetic acid test positive. The sensitivity of acetic acid test was 72.4%, specificity 54% and false negative rate 15.2%, as compared to papanicolaou test which had a sensitivity of 13.2%, specificity of 96.3% and false negative rate of 24.4%. The advantage of the acetic acid test lies in its easy technique, low cost and high sensitivity which are important factors for determining the efficacy of any screening programme in developing countries.