Implementation of NICE recommendations on abdomino-pelvic CT, following unprovoked venous thromboembolism, in a UK teaching hospital: no additional detection of occult malignancy and high numbers of incidental findings.

INTRODUCTION: NICE Clinical Guideline 144 recommends that patients with an unprovoked VTE, who do not have signs or symptoms of cancer on initial investigation, be considered for further investigation with an abdomino-pelvic CT to exclude occult malignancy. This study aimed to evaluate numbers of scans performed in a UK teaching hospital and outcomes, following this recommendation. METHODS: Retrospective review of CT scans performed before and after publication of the NICE guidance in 2012. CT reports and case notes were analysed. Type and stage of malignancy, treatment and other relevant findings were documented. For the 2014 data set, all incidental radiological findings and follow-up recommendations were reviewed. RESULTS: The annual number of CT scans requested for "unprovoked VTE", rose by 142% following publication of NICE Clinical Guideline 144. In the 2011 - 2012 data set, 21 patients were included, one of which was found to have a malignancy, which was clinically overt at the time of diagnosis i.e. not occult. Five patients (23.8%) had incidental findings requiring further investigation. In the 2014 - 2015 data set, 51 patients were included, five (9.8%) of which were found to have malignancy. In retrospect, all showed signs/symptoms of potential malignancy on initial investigation. No occult malignancies were detected in the patients correctly referred. Incidental findings warranting further investigation were reported in ten cases (19.6%). On review, follow-up advice was deemed incorrect in four of these. CONCLUSION: Addition of an abdomino-pelvic CT scan in patients with a first unprovoked VTE and no signs or symptoms of cancer on initial investigation, significantly increased the number of scans and incidental findings, but did not pick up any additional occult malignancies.

High-risk and multiple human papillomavirus (HPV) infections in cancer-free Jamaican women.

BACKGROUND: Vaccines, that target human papillomavirus (HPV) high risk genotypes 16 and 18, have recently been developed. This study was aimed at determining genotypes commonly found in high-risk and multiple-HPV infections in Jamaican women. Two hundred and fifty three (253) women were enrolled in the study. Of these, 120 pregnant women, aged 15-44 years, were recruited from the Ante Natal Clinic at the University Hospital of the West Indies and 116 non-pregnant, aged 19-83, from a family practice in Western Jamaica. Cervical cell samples were collected from the women and HPV DNA was detected using Polymerase Chain Reaction and Reverse Line Hybridization. HPV genotypes were assessed in 236 women. Data were collected from January 2003 to October 2006. RESULTS: HPV DNA was detected in 87.7% (207/236) and of these 80.2% were positive for high-risk types. The most common high-risk HPV types were: HPV 45 (21.7%), HPV 58 (18.8%), HPV 16 (18.4%), HPV 35 (15.0%), HPV 18 (14.5%), HPV 52 (12.0%) and HPV 51(11.1%). Other high-risk types were present in frequencies of 1.4% - 7.2%.Multivariate regression analyses showed that bacterial vaginosis predicted the presence of multiple infections (OR 3.51; CI, 1.26-9.82) and that alcohol use (OR 0.31; CI, 0.15-0.85) and age at first sexual encounter (12-15 years: OR 3.56; CI, 1.41-9.12; 16-19 years, OR 3.53, CI, 1.22-10.23) were significantly associated with high risk infections. Cervical cytology was normal in the majority of women despite the presence of high-risk and multiple infections. CONCLUSION: HPV genotype distribution in this group of Jamaican women differs from the patterns found in Europe, North America and some parts of Asia. It may be necessary therefore to consider development of other vaccines which target genotypes found in our and similar populations. HPV genotyping as well as Pap smears should be considered.

Comparisons of high-risk cervical HPV infections in Caribbean and US populations.

BACKGROUND: Disparities in cervical cancer incidence and mortality rates exist among women of African ancestry (African-American, African-Caribbean and African). Persistent cervical infection with Human papillomavirus (HPV) is associated with cervical dysplasia and if untreated, could potentially progress to invasive cervical cancer. Very few studies have been conducted to examine the true prevalence of HPV infection in this population. Comparisons of cervical HPV infection and the type-specific distribution of HPV were performed between cancer-free Caribbean and US women. RESULTS: The Caribbean population consisted of 212 women from Tobago and 99 women from Jamaica. The US population tested, consisted of 82 women from Pittsburgh. The majority of the US subjects was Caucasian, 74% (61/82) while 12% (10/82) and 13% (11/82) were African-American or other ethnic groups, respectively. The age-adjusted prevalence of any HPV infection among women from Tobago was 35%, while for Jamaica, it was 81% (p < 0.0001). The age-adjusted prevalence of HPV infection for Caribbean subjects was not statistically significantly different from the US (any HPV: 47% vs. 39%, p > 0.1; high-risk HPVs: 27% vs. 25%, p > 0.1); no difference was observed between US-Blacks and Jamaicans (any HPV: 92% vs. 81%, p > 0.1; high-risk HPV: 50% vs. 53%, p > 0.1). However, US-Whites had a lower age-adjusted prevalence of HPV infections compared to Jamaican subjects (any HPV: 29% vs. 81%, p < 0.0001; high-risk HPV: 20% vs. 53%, p < 0.001). Subjects from Jamaica, Tobago, and US-Blacks had a higher proportion of high-risk HPV infections (Tobago: 20%, Jamaica: 58%, US-Blacks: 40%) compared to US-Whites (15%). Similar observations were made for the presence of infections with multiple high-risk HPV types (Tobago: 12%, Jamaica: 43%, US-Blacks: 30%, US-Whites: 8%). Although we observed similar prevalence of HPV16 infections among Caribbean and US-White women, there was a distinct distribution of high-risk HPV types when comparisons were made between the ethnic groups. CONCLUSION: The higher prevalence of cervical HPV infections and multiple high-risk infections in Caribbean and US-Black women may contribute to the high incidence and prevalence of cervical cancer in these populations. Evaluation of a larger sample size is currently ongoing to confirm the distinct distribution of HPV types between ethnic groups.