Time to viral clearance after successful conservative treatment for high-risk HPV-infected high-grade cervical intraepithelial neoplasia and early invasive squamous cervical carcinoma.

Two-thirds of 152 patients treated for high-grade cervical disease, free of persistence/recurrence, and followed-up both with human papillomavirus (HPV) DNA testing and HPV genotyping cleared their high-risk HPV infection within 1year. Viral clearance continued at diminishing rates during the second and the third year, at the end of which it was virtually complete.

Interpretation of colposcopy in population-based cervical screening services in north-eastern Italy: an online interregional agreement study.

OBJECTIVE: An innovative web-based colposcopy quality assurance programme was implemented in population-based cervical screening services in three north-eastern Italian administrative regions with different colposcopists' training background. In this study, the levels of intra- and interregional intercolposcopist diagnostic agreement were evaluated. STUDY DESIGN: Of the 158 registered colposcopists, 125 accessed the website of the programme, logged-in, viewed a posted set of 50 digital colpophotographs selected by an expert steering committee, and classified them for the colposcopic impression, the visibility of the squamocolumnar junction, and the need for biopsy. Anonymous data were downloaded and analysed using the crude, or observed, proportion of agreement and the kappa coefficient. RESULTS: There were 113 eligible colposcopists. Overall, crude agreement on the colposcopic impression, the visibility of the squamocolumnar junction, and the need for biopsy was 0.72, 0.72, and 0.87, with kappa values of 0.60, 0.36, and 0.69, respectively. The homologous kappa values were 0.61, 0.41, and 0.69 in one region, 0.57, 0.36, and 0.69 in another, and 0.66, 0.38, and 0.74 in the third. Total intra- and interregional agreement were nearly identical, with kappa values of 0.59 and 0.60 for the colposcopic impression, 0.38 and 0.35 for the visibility of the squamocolumnar junction, and 0.69 and 0.69 for the need for biopsy. The width of 95% confidence intervals around the above kappa values was ≤0.01. CONCLUSIONS: The levels of agreement varied between moderate and substantial both within and between regions. Regional differences in training background had minor effects. The interpretation of colposcopy is potentially well-reproducible.

Poor Folate Intake in a North Italian Pregnant Population: an Epidemiological Survey.

BACKGROUND: The association between folic acid (FA) insufficiency and congenital malformations has been demonstrated in over the past two decades. The aim of the present study was to investigate the use and timing of folate intake among a large sample of pregnant women in a north Italian region. METHODS: A multicentre prospective cohort study was conducted over a 14-month period in the maternity wards of five general hospitals (2301 women). Data were collected via a face-to-face interview. RESULTS: Seven hundred sixty women (33%) took at least one product containing FA. Seven hundred thirty-three (31.8%) women consumed multivitamins containing 413 (17.9%) consumed products containing FA only and 17 (0.7%) 15 mg of levofolinic acid. Only 0.9% of all women took FA before pregnancy 72.5% of women who consumed FA started during the first trimester. The most common dosage was 0.4 mg (19.4%). CONCLUSIONS: Very few women in the population are taking FA before pregnancy. Moreover, while most women consuming FA started in the first trimester, it is likely that they did so after closure of the neural tube. An important action is the recommendation that periconceptional supplementation programmes be promoted.

Accuracy of Colposcopically Directed Biopsy: Results from an Online Quality Assurance Programme for Colposcopy in a Population-Based Cervical Screening Setting in Italy.

PURPOSE: To report the accuracy of colposcopically directed biopsy in an internet-based colposcopy quality assurance programme in northern Italy. METHODS: A web application was made accessible on the website of the regional Administration. Fifty-nine colposcopists out of the registered 65 logged in, viewed a posted set of 50 digital colpophotographs, classified them for colposcopic impression and need for biopsy, and indicated the most appropriate site for biopsy with a left-button mouse click on the image. RESULTS: Total biopsy failure rate, comprising both nonbiopsy and incorrect selection of biopsy site, was 0.20 in CIN1, 0.11 in CIN2, 0.09 in CIN3, and 0.02 in carcinoma. Errors in the selection of biopsy site were stable between 0.08 and 0.09 in the three grades of CIN while decreasing to 0.01 in carcinoma. In multivariate analysis, the risk of incorrect selection of biopsy site was 1.97 for CIN2, 2.52 for CIN3, and 0.29 for carcinoma versus CIN1. CONCLUSIONS: Although total biopsy failure rate decreased regularly with increasing severity of histological diagnosis, the rate of incorrect selection of biopsy site was stable up to CIN3. In multivariate analysis, CIN2 and CIN3 had an independently increased risk of incorrect selection of biopsy site.

Gene expression changes in progression of cervical neoplasia revealed by microarray analysis of cervical neoplastic keratinocytes.

To evaluate the gene expression changes involved in neoplastic progression of cervical intraepithelial neoplasia. Using microarray analysis, large-scale gene expression profile was carried out on HPV16-CIN2, HPV16-CIN3, and normal cervical keratinocytes derived from two HPV16-CIN2, two HPV-CIN3 lesions, and two corresponding normal cervical tissues, respectively. Differentially expressed genes were analyzed in normal cervical keratinocytes compared with HPV16-CIN2 keratinocytes and in HPV16-CIN2 keratinocytes compared with HPV16-CIN3 keratinocytes; 37 candidate genes with continuously increasing or decreasing expression during CIN progression were identified. One of these genes, phosphoglycerate dehydrogenase, was chosen for further characterization. Quantitative reverse transcription-polymerase chain reaction and immunohistochemical analysis confirmed that expression of phosphoglycerate dehydrogenase consistently increases during progression of CIN toward cancer. Gene expression changes occurring during CIN progression were investigated using microarray analysis, for the first time, in CIN2 and CIN3 keratinocytes naturally infected with HPV16. Phosphoglycerate dehydrogenase is likely to be associated with tumorigenesis and may be a potential prognostic marker for CIN progression.

An online quality assurance program for colposcopy in a population-based cervical screening setting in Italy: results on colposcopic impression.

OBJECTIVE: To report the results of an Internet-based colposcopy quality assurance program from a population-based cervical screening service in a large region of northern Italy. METHODS: In 2010 to 2011, a Web application was made accessible on the Web site of the regional administration. Fifty-nine colposcopists of the registered 65 participated. They logged-in, viewed a posted set of 50 high-quality digital colpophotographs selected by an expert committee, and rated them for colposcopic impression using a 4-tier classification (Negative; abnormal, grade 1 [G1]; abnormal, grade 2 [G2]; suspected invasive cancer [Cancer]) derived from the International Federation for Cervical Pathology and Colposcopy 2002 classification. kappa (κ) coefficients for intercolposcopist agreement and colposcopist-committee agreement were calculated. RESULTS: Colposcopist-committee agreement was greater than intercolposcopist agreement (overall κ 0.69 vs 0.60, p<.001). The κ values for colposcopist-committee agreement were 0.83 on Negative, 0.53 on G1, 0.66 on G2, and 0.80 on Cancer (all p values for pairwise comparisons<.001, except for Negative vs Cancer [p=.078]). There was no systematic tendency for colposcopists to underestimate or overestimate the colposcopic findings (2-tailed sign test, p=.13). Overall colposcopist-committee agreement was greater among patients 35 years or older (p<.001) and for colposcopists with previous quality assurance experiences (p<.01). Only 0.2% of Negative impressions were formulated for a cervical intraepithelial neoplasia grade 2 or worse. As a parallel finding, the impression of Cancer predicted cervical intraepithelial neoplasia grade 2 or less in 0.5% of cases. The histologic substrates of G1 were dispersed over a large spectrum. CONCLUSIONS: The reproducibility of colposcopic impression, when classified by trained colposcopists examining high-quality images, is higher than is generally thought.

Rationale and development of an on-line quality assurance programme for colposcopy in a population-based cervical screening setting in Italy.

BACKGROUND: Colposcopy, the key step in the management of women with abnormal Pap smear results, is a visual technique prone to observer variation, which implies the need for prolonged apprenticeship, continuous training, and quality assurance (QA) measures. Colposcopy QA programmes vary in level of responsibility of organizing subjects, geographic coverage, scope, model, and type of actions. The programmes addressing the clinical standards of colposcopy (quality of examination and appropriateness of clinical decisions) are more limited in space and less sustainable over time than those focused on the provision of the service (resources, accessibility, etc.). This article reports on the protocol of a QA programme targeting the clinical quality of colposcopy in a population-based cervical screening service in an administrative region of northern Italy. METHODS/DESIGN: After a situation analysis of local colposcopy audit practices and previous QA initiatives, a permanent web-based QA programme was developed. The design places more emphasis on providing education and feedback to participants than on testing them. The technical core is a log-in web application accessible on the website of the regional Administration. The primary objectives are to provide (1) a practical opportunity for retraining of screening colposcopists, and (2) a platform for them to interact with colposcopists from other settings and regions through exchange and discussion of digital colposcopic images. The retraining function is based on repeated QA sessions in which the registered colposcopists log-in, classify a posted set of colpophotographs, and receive on line a set of personal feedback data. Each session ends with a plenary seminar featuring the presentation of overall results and an interactive review of the test set of colpophotographs. This is meant to be a forum for an open exchange of views that may lead to more knowledge and more diagnostic homogeneity. The protocol includes the criteria for selection of colpophotographs and the rationale for colposcopic gold standards. DISCUSSION: This programme is an ongoing initiative open to further developments, in particular in the area of basic training. It uses the infrastructure of the internet to give a novel solution to technical problems affecting colposcopy QA in population-based screening services.

Establishment of keratinocyte colonies from small-sized cervical intraepithelial neoplasia specimens.

The size of human cervical intraepithelial neoplasia (CIN) biopsies is usually very small and standard methods do not allow an adequate number of keratinocytes to be isolated for culturing purposes. In this study, a new approach to establish keratinocyte cultures from small CIN a tissue fragments was developed. Neoplastic specimens and corresponding normal tissues, which were used as controls, were digested with collagenase. Tissue-derived fibroblasts and keratinocytes were co-cultured in calcium and serum medium. Single keratinocyte colonies from primary cultures were expanded using a culture medium optimized in our laboratory. Primary keratinocyte colonies, as well as expanded colonies, were tested for epithelial and cervical markers such as 5, 14, 17, and 19 keratins, and p63 by immunofluorescence. Our results indicate that a variable number of primary keratinocyte colonies could be detected in neoplastic cultures, depending on the grade of cervical lesions from which the colonies originated. Single colonies, when cultured with our new medium, grew at a high rate with uniform size and morphology for some passages. Epithelial and p63 markers were expressed in keratinocyte colonies, as well as in expanded colonies. In conclusion, our study reports a rapid and easy culturing system which enables keratinocyte colonies from minute cervical tumor tissues to be obtained. Moreover, using the new culture medium, keratinocyte colonies can be expanded at a high proliferative rate.

Fluconazole 150 mg single dose versus itraconazole 200 mg per day for 3 days in the treatment of acute vaginal candidiasis: a double-blind randomized study.

OBJECTIVE: To compare the safety and efficacy of fluconazole 150mg single dose and itraconazole 200mg per day for 3 days in the treatment of the acute episode of vulvovaginal candidiasis (VVC). METHODS: Double-blind randomized study conducted in three University centers. Patients with acute clinically and mycologically confirmed VVC were enrolled. RESULTS: A total of 86 patients were enrolled; of them, 38 fluconazole and 32 itraconazole patients were evaluable. At the Day 7 visit, all but one fluconazole patients were cured or improved with eradication of the baseline pathogen obtained in all but two itraconazole patients. At the Day 21 visit, a 13% relapse rate was observed in both groups with all other patients cured or improved; eradication rates were 76% for fluconazole and 66% for itraconazole. Global symptom scores (GSS) were significantly more severe at baseline in fluconazole patients (P=0.003). Nevertheless, the slope of the GSS decrease between baseline and Day 7 was similar for both groups whilst GSS were identical at the last visit. Nineteen fluconazole patients reported 31 adverse events and 15 itraconazole patients reported 30 adverse events. CONCLUSIONS: Both oral antifungal treatments showed good clinical and mycological efficacy on the acute episode of VVC with a dramatic decrease of signs and symptoms 7 days after treatment initiation. Fluconazole in single dose warrants optimal compliance in patients who frequently experience more than one episode of VVC.