Upscaling cervical cancer screening and treatment for women living with HIV at a rural referral hospital in Tanzania: protocol of a before-and-after study exploring HPV testing and novel diagnostics.

BACKGROUND: Cervical cancer (CC) is nearly always caused by persistent human papillomavirus (HPV) infection. It is the most common cancer among women living with HIV (WLWH) and is the leading cause of cancer-related death in women in East Africa, with 10,241 new cases reported in Tanzania in 2020. In 2019, the World Health Organization (WHO) presented a global strategy for the elimination of CC as a public health problem, proposing targets to meet by 2030 for HPV vaccine coverage (90% of all 15-year-old girls), CC screening (70% of all women once at 35 and again at 45 years of age) and treatment delivery, to be scaled at national and subnational levels with a context-sensitive approach. This study aims to evaluate the upscaling of screening and treatment services at a rural referral hospital in Tanzania in order to address the second and third WHO targets. METHODS: This is an implementation study with a before-and-after design performed at St. Francis Referral Hospital (SFRH) in Ifakara (south-central Tanzania). CC screening and treatment services are integrated within the local HIV Care and Treatment Center (CTC). The standard of care, consisting of visualization of the cervix with acetic acid (VIA) and cryotherapy has been up-scaled with self-sampled HPV testing and also involved the introduction of mobile colposcopy, thermal ablation and loop electrosurgical excision procedure (LEEP). Participants are WLWH aged 18 to 65 years. Outcome measures included the percentage of women screened, HPV prevalence and genotype, and adherence to screening, treatment and follow-up plan. Additionally, we will explore the performance of novel diagnostic tests (QG-MPH®, Prevo-Check® and PT Monitor®), which share the features of being manageable and inexpensive, and thus a potential tool for effective triage in HPV high-prevalence cohorts. DISCUSSION: The study will provide relevant information about HPV prevalence and persistence, as well as reproductive and lifestyle indicators in a CC high-risk cohort of WLWH and about upscaling screening and treatment services at the level of a rural referral hospital in Tanzania. Furthermore, it will provide exploratory data on novel assays. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05256862, date of registration 25/02/2022. Retrospectively registered.

Group B streptococcal colonization in elderly women.

BACKGROUND: In non-pregnant adults, the incidence of invasive Group B Streptococcus (GBS) disease is continuously increasing. Elderly and immunocompromised persons are at increased risk of infection. GBS commonly colonizes the vaginal tract, though data on colonization in the elderly are scarce. It is unknown whether the prevalence of GBS colonization is increasing in parallel to the observed rise of invasive infection. We conducted a three-year (2017-2019) prospective observational cross-sectional study in two teaching hospitals in Switzerland to determine the rate of GBS vaginal colonization in women over 60 years and i) to compare the proportions of known risk factors associated with invasive GBS diseases in colonized versus non-colonized women and ii) to evaluate the presence of GBS clusters with specific phenotypic and genotypic patterns in this population. METHODS: GBS screening was performed by using vaginal swabs collected during routine examination from women willing to participate in the study and to complete a questionnaire for risk factors. Isolates were characterized for antibiotic resistance profile, serotype and sequence type (ST). RESULTS: The GBS positivity rate in the elderly was 17% (44/255 positive samples), and similar to the one previously reported in pregnant women (around 20%). We could not find any association between participants' characteristics, previously published risk factors and GBS colonization. All strains were susceptible to penicillin, 22% (8/36) were not susceptible to erythromycin, 14% (5/36) were not susceptible to clindamycin and 8% (3/36) showed inducible clindamycin resistance. Both M and L phenotypes were each detected in one isolate. The most prevalent serotypes were III (33%, 12/36) and V (31%, 11/36). ST1 and ST19 accounted for 11% of isolates each (4/36); ST175 for 8% (3/36); and ST23, ST249 and ST297 for 6% each (2/36). Significantly higher rates of resistance to macrolides and clindamycin were associated with the ST1 genetic background of ST1. CONCLUSIONS: Our findings indicate a similar colonization rate for pregnant and elderly women. TRIAL REGISTRATION: Current Controlled Trial ISRCTN15468519 ; 06/01/2017.

Vaginal-perineal cultures for detecting group B streptococci and extended spectrum ß-lactamase producing bacteria in pregnancy.

OBJECTIVE: To compare the detection rates of vaginal-perineal cultures for group B streptococci (GBS) with the standard vaginal and rectal cultures and evaluate the diagnostic yield of vaginal-perineal vs. rectal swabs for extended spectrum ß-lactamase producing Enterobacterales (ESBL-E) during the third trimester of pregnancy. STUDY DESIGN: Vagino-perineal and rectal swabs were collected cross-sectionally from pregnant women between 35-37 weeks gestation and tested for the presence of GBS and ESBL-E. Accuracy of the vagino-perineal swab was compared to the combined vagino-perineal/rectal swab. Risk factors for ESBL carriage were examined. Degrees of pain, discomfort and stress related to the rectal swab were analyzed on visual analogue scales. RESULTS: 48 out of 250 participants (19.2%) were GBS positive. The vagino-perineal swab was positive in 44 of 48 women (91.7%) yielding a negative predictive value of 98.1%. Agreement (kappa) between the two methods was 0.95. Six out of 190 women with additional ESBL-E screening (3.2%) tested positive by rectal swab. Of these, only two had also a positive vagino-perineal swab. The rectal swab caused overall little subjective discomfort, pain or stress, as indicated by low scores indicated on the visual scales. CONCLUSIONS: The GBS detection rate of the vagino-perineal swab was lower compared to the reference standard. However, agreement between the two screening methods was high and there were no cases of GBS neonatal sepsis in the recruited population, supporting this less invasive screening strategy. In contrast, the vaginal-perineal swab was inferior to the rectal swab for detecting ESBL-E, indicating that this less invasive method for detecting antibiotic resistant bacteria that may be potentially transferred to the neonate during labor and delivery would be inappropriate for ESBL-E screening in pregnant women. The low ESBL-E carriage rate among pregnant women likely reflects the prevalence in the general population.

Breast cancer screening attendance in two Swiss regions dominated by opportunistic or organized screening.

BACKGROUND: In Switzerland, the French-speaking region has an organized breast cancer (BC) screening program; in the German-speaking region, only opportunistic screening until recently had been offered. We evaluated factors associated with attendance to breast cancer screening in these two regions. METHODS: We analyzed the data of 50-69 year-old women (n = 2769) from the Swiss Health Survey 2012. Factors of interest included education level, place of residence, nationality, marital status, smoking history, alcohol consumption, physical activity, diet, self-perceived health, history of chronic diseases and mental distress, visits to medical doctors and cervical and colorectal cancer screening. Outcome measures were dichotomized into ≤2 years since most recent mammography versus >2 years or never. RESULTS: In the German- and French-speaking regions, mammography attendance within the last two years was 34.9 % and 77.8 %, respectively. In the French region, moderate alcohol consumption (adjusted OR 2.01, 95 % CI 1.28-3.15) increased screening attendance. Compared to those with no visit to a physician during the recent year, women in both regions with such visits attended statistically significantly more often BC screening (1-5 times vs. no visit: German (adjusted OR 3.96, 95 % CI 2.58-6.09); French: OR 7.25, 95 % CI 4.04-13.01). Non-attendance to cervical screening had a negative effect in both the German (adjusted OR 0.44, 95 % CI 0.25-0.79) and the French region (adjusted OR 0.57, 95 % CI 0.35-0.91). The same was true for colorectal cancer screening (German (adjusted OR 0.66, 95 % CI 0.52-0.84); French: OR 0.52, 95 % CI 0.33-0.83). No other factor was associated with BC screening and none of the tests of interaction comparing the two regions revealed statistically significant results. CONCLUSION: The effect of socio-demographic characteristics, lifestyle, health factors and screening behavior other than mammography on non-attendance to BC screening did not differ between the two regions with mainly opportunistic and organized screening, respectively, and did not explain the large differences in attendance between regions. Other potential explanations such as public promotion of attendance for BC screening, physicians' recommendations regarding mammography participation or women's beliefs should be further investigated.

Lifestyle and health-related predictors of cervical cancer screening attendance in a Swiss population-based study.

BACKGROUND: Since the implementation of cervical cancer (CC) screening, incidence and mortality rates have decreased worldwide. Little is known about lifestyle and health-related predictors of cervical cancer screening attendance in Switzerland. Our aim was to examine the relationship between lifestyle and health-related factors and the attendance to CC screening in Switzerland. METHODS: We analyzed data of 20-69 years old women (n=7319) of the Swiss Health Survey (SHS) 2012. Lifestyle factors included body mass index, smoking status, alcohol consumption, physical activity and attention to diet. Health-related factors of interest were diabetes, hypertension, high cholesterol levels, chronic diseases, self-perceived health, and psychological distress. We performed multivariable logistic regression analyses with the dichotomized CC screening status as outcome measure and adjusted for demographic factors. RESULTS: Obesity, low physical activity, and not paying attention to diet were statistically significantly associated with lower CC screening participation. High cholesterol levels and history of chronic diseases were statistically significantly positively associated with screening participation. CONCLUSION: Being obese, physically inactive and non-attention to diet are risk factors for CC screening attendance. These findings are of importance for improving the CC screening practices of low-user groups.

Pyoderma gangrenosum of the vaginal vault after vaginal hysterectomy: only the correct diagnosis of a rare entity can prevent long-term morbidity.

INTRODUCTION: Pyoderma gangrenosum (PG) is a rare ulcerative skin disease characterized by a wide variety in its clinical presentation and outcome. The etiology is unknown and the pathogenesis is poorly understood, but autoimmune mechanisms have been suggested. Gynecological reports about PG are particularly scarce. As gynecologists rarely encounter this disorder, the correct diagnosis can easily be missed. PATIENTS AND METHODS: This paper presents the first case to our knowledge of an idiopathic PG of the vaginal vault as a late complication after vaginal hysterectomy. CONCLUSION: We demonstrate how PG, a rare disorder, might be misdiagnosed and how only the correct diagnosis and treatment involving systemic glucocorticoids and wound care can spare the patients from long-term morbidity.

Impact of body mass index on prognostically relevant breast cancer tumor characteristics.

BACKGROUND: This study analyzes the association of body mass index (BMI) and prognostically relevant breast cancer (BC) characteristics in a country that has been rather spared of the global obesity epidemic. PATIENTS AND METHODS: Based on 20-year data (1999-2009, n = 1,414) of the prospective relational BC database of the University Hospital Basel, Switzerland, the associations between BMI, tumor size and stage, histological subtype, grading, hormonal receptor status, HER2 status and 'triple-negative' status were evaluated. Multivariate analysis considered BMI and patient's age. RESULTS: The association between increasing BMI and the above-mentioned variables were as follows (results described in each case: Beta-coefficient or odds ratio, 95% confidence interval, p value): tumor size, (1) entire cohort: 0.03 (0.01-0.05), p < 0.001, (2) tumor found by self-palpation: 0.05 (0.03-0.07), p < 0.001, (3) tumor found by radiological examination: 0.03 (0-0.07), p = 0.044; advanced TNM stage: 1.16 (1.02-1.31), p = 0.022; histological subtype: 1.04 (0.89-1.22), p = 0.602; unfavorable grading: 1.11 (1.00-1.25), p = 0.057; positive estrogen receptor status: 0.95 (0.83-1.09), p = 0.459; positive HER2 status: 0.92 (0.74-1.15), p = 0.467; presence of a 'triple-negative' carcinoma: 1.19 (0.93-1.52), p = 0.165. Consideration of only postmenopausal BC patients (n = 1,063) did attenuate the results, but did not change the direction of the associations with BMI. CONCLUSION: BMI was positively associated with TNM stage, grading and tumor size for tumors that were found by self-detection, as well as for those lesions detected by radiological breast examinations.

Cannabinoid hyperemesis syndrome: an underreported entity causing nausea and vomiting of pregnancy.

INTRODUCTION: In the western world, cannabis is the most widely used drug of abuse. Cannabinoid hyperemesis syndrome, which seems to be a rare paradoxical reaction in individuals with a particular predisposition, is characterized by cyclic severe nausea and vomiting in long-term cannabis users. While the symptoms are unresponsive to antiemetic drugs, compulsive hot baths result in a considerable symptom relief. METHODS: We report the first case of cannabinoid hyperemesis syndrome in pregnancy. A 26-year-old patient was admitted to our clinic in the 10th week of gestation. CONCLUSION: Before undertaking time-consuming and expensive medical examinations to rule out other medical reasons for therapy-resistant hyperemesis in pregnancy, obstetricians should determine whether compulsive bathing or showering provides symptomatic relief and ask specific questions regarding possible/suspected cannabis consumption.

Maldi-TOF mass spectrometry for trisomy detection.

Matrix-associated laser desorption/ionization time-of-flight (MALDI-TOF) mass spectrometry is a tool currently under investigation for use in prenatal detection of abnormalities in chromosome number, such as trisomy 21. Because of its ability to detect extremely small differences in mass, even to the level of a single nucleotide difference, this method can be applied to the detection of single-nucleotide polymorphisms (SNPs), which when present in a heterozygous state, can yield quantitative information regarding chromosome status from diagnostic specimens such as amniotic fluid or chorionic villus samples. MALDI-TOF mass spectrometry has several potential advantages over traditional karyotyping methods, including its amenability to high-throughput analyses and its nonreliance on prior cell culture. The method described here is based on the MassEXTEND protocol developed by Sequenom, Inc., although any mass spectrometry platform sensitive enough to detect the small difference in mass between SNPs could be applied for this purpose.

Isolation of cell-free DNA from maternal plasma using manual and automated systems.

Cell-free fetal DNA present in the maternal circulation holds great potential for noninvasive prenatal diagnosis and analysis of fetal genetic traits. However, only approximately 3-6% of total DNA in the maternal plasma is of fetal origin. Because of its scarcity in the maternal circulation, various methods have been developed and tested to optimize the extraction of this rare material from plasma. Here, we first describe the commonly used protocol for separating plasma from whole blood samples. We also describe two commercially available methods for the extraction of cell-free DNA from maternal plasma, which we have found particularly straightforward and easy to use: a manual method using the High Pure PCR Template Preparation kit (Roche Diagnostics) and an automated system using the MagNA Pure LC instrument (Roche Diagnostics). Use of the methods described here will help to ensure maximum yield and purity of cell-free fetal DNA extracted from maternal plasma samples for downstream analyses.

Isolation of cell-free RNA from maternal plasma.

The discovery of cell-free RNA in plasma and serum samples provides possibilities for noninvasive prenatal diagnosis. Quantitative alterations of cell-free placental-derived mRNA in the maternal circulation are associated with many pregnancy-related disorders, such as preeclampsia and preterm labor. Obtaining circulating cell-free RNA is the first and often the most critical step for analyzing the placental-derived mRNA in maternal blood. We have compared different protocols for the extraction of cell-free RNA from plasma samples, and we have found the protocol using TRIzol LS reagent (Invitrogen) as lysis buffer combined with RNeasy Mini kit (QIAGEN) to be the optimal method for extracting high-quality cell-free RNA in the highest quantities possible. This method is also amenable to the simultaneous extraction of cell-free RNA from many different samples, by use of the QIAGEN Vacuum Manifold QIAvac 24 Plus.

Improvement of methods for the isolation of cell-free fetal DNA from maternal plasma: comparison of a manual and an automated method.

The low amount of cell-free fetal DNA present in the maternal circulation poses significant challenges to its use in future diagnostic applications, and ways of increasing the yield of this potential marker extracted from maternal plasma are constantly being explored. In this study, we compared two methods of DNA extraction, a manual and an automated method. Our analysis revealed that although the manual method yielded overall more total cell-free DNA, the automated system yielded higher quantities of cell-free DNA of fetal origin. Furthermore, the DNA isolated using the automated system appeared to be of greater purity than that isolated by the manual method, with fewer inhibitors to downstream real-time PCR reactions.

Reliable detection of trisomy 21 using MALDI-TOF mass spectrometry.

PURPOSE: Current diagnostic methods for chromosomal abnormalities rely mainly on karyotyping and occasionally fluorescent in situ hybridization or quantitative polymerase chain reaction. We describe an alternative molecular method for the detection of trisomy 21 involving mass spectrometric analysis of single nucleotide polymorphisms. METHODS: In collaboration with Sequenom, Inc., 350 blinded amniotic fluid, amniocyte culture, chorionic villus, or amniotic fluid supernatant samples were analyzed for trisomy 21 using SNP analysis and matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) mass spectrometry. Peak ratios were calculated for heterozygous genotypes and compared to control values generated from known euploid samples. An analytical algorithm using standard deviations from control values was used to determine the probability of a sample being affected or unaffected. RESULTS: Seventy-three trisomy 21 samples from among the 350 blinded samples were correctly identified. There were no false-positive or false-negative results among the complete trisomy 21 samples. One sample exhibiting mosaicism for trisomy 21 was identified as being unaffected. CONCLUSIONS: MALDI-TOF mass spectrometry is a robust and reproducible method for the detection of trisomy 21. Its amenability to high-throughput analysis and high degree of multiplexing make it a potential future diagnostic tool for the detection of other aneuploidies as well.