Assessing sociodemographic differences in human papillomavirus vaccine impact studies in the United States: a systematic review using narrative synthesis.

OBJECTIVES: Sociodemographic disparities in the incidence and mortality of human papillomavirus (HPV)-associated conditions have been well documented in the pre-HPV vaccine era. It is still unknown if the introduction of routine vaccination has been effective in reducing these prevaccine era inequalities. The purpose of this review was to determine the utilization of sociodemographic variables to assess for disparities in population-level HPV vaccine impact research and to evaluate the current evidence for disparities in the reduction of HPV-associated conditions after vaccine introduction in the United States (US). STUDY DESIGN: A systematic review of the literature from January 2007 through March 2018 was carried out to identify studies evaluating the impact HPV vaccines have had on the rates of HPV infection, genital warts, and cervical dysplasia (cervical intraepithelial neoplasia grades 1+) in the US. An in-depth review was then performed to synthesize these data and to assess the way prior studies have reported and evaluated for potential disparities in the vaccine's impact within various racial, ethnic, and/or socio-economic subgroups of the population. METHODS: Vaccine impact studies measure the change in the population-level burden of disease prelicensure versus postlicensure of the vaccine. We systematically searched PubMed/Medline and Embase, combining search terms related to the HPV vaccine, sentinel surveillance, and HPV-associated conditions. Eligible studies were those with population-level, postvaccine introduction data that were conducted in the US. Finally, a cited reference search was conducted for all included articles using the Web of Science platform that accesses three major citation indexes: Science Citation Index, Social Sciences Citation Index, and Arts and Humanities Citation Index. This allowed us to screen not only the articles that were cited by our final collection of studies but also the articles that used our selected studies as one of their references. The study protocol is registered in PROSPERO (#CRD42018107579). RESULTS: Overall, 23 of the 4139 references retrieved assessed the population-level impact of HPV vaccines between January 1, 2007, and March 29, 2018. Among these, 13 (57%) reported sociodemographic data. Only two articles reported stratified results by sociodemographic factors, thereby allowing assessment for potential disparate impact. One of these studies described differences in the impact of the vaccine by race, ethnicity, and income. CONCLUSION: Although approximately half of the studies that assessed the impact of the HPV vaccine measured sociodemographic characteristics, few presented results in a way that allowed for the identification of potential differences in impact between the relevant subgroups of the population. Determining to what extent, if any, vaccines are reducing known sociodemographic disparities is an important public health priority and an essential step in developing immunization strategies that are beneficial for all.

Severe adenomyosis and CA125.

A total of 50 women having uterine enlargement of > 12 weeks' size due to severe adenomyosis with raised CA125, were carefully studied and compared with other cases. The greater the enlargement of the uterus over 240 cm(3) volume or 12 weeks' uterine size due to severe adenomyosis, the greater was the rise of CA125 levels and these were disturbingly high in some cases. However, similarly enlarged uteri due to fibroids did not show a rise in CA125 levels above normal. Raised CA125 thus need not instil anxiety, when the clinical findings are benign.

Vaginal route for breast cancer induced hysterectomy with oophorectomy.

A previous history of breast cancer can induce problems in some women, which may necessitate hysterectomy as well as oophorectomy. This study included 20 women with a history of breast cancer with endometrial hyperplasia and recurrent vaginal bleeding or the need for oophorectomy because of metastatic breast cancer along with concomitant hysterectomy. The aim of this study is to show that benign indications for hysterectomy with oophorectomy, arising out of management of breast cancer in the past, can be dealt with by the least invasive approach via the vaginal route, provided vaginal hysterectomy is not contraindicated and the abdomino-pelvic area is free of metastasis. All 20 women had an uneventful postoperative period with rapid recovery, economic benefit and short hospital stay.

Hepatocellular carcinoma in Txnip-deficient mice.

The molecular pathogenesis and the genetic aberrations that lead to the progression of hepatocellular carcinoma (HCC) are largely unknown. Here, we demonstrate that the thioredoxin interacting protein (Txnip) gene is a candidate tumor suppressor gene in vivo. We previously showed that the recombinant inbred congenic strain HcB-19 has a spontaneous mutation of the Txnip gene, and we now show that the strain has dramatically increased incidence of HCC, and that the HCC cosegregates with the Txnip mutation. Approximately 40% of the Txnip-deficient mice developed hepatic tumors with an increased prevalence in male mice. Visible tumors develop as early as 8 months of age. Histological analysis confirmed the morphology of HCC in the Txnip-deficient mice. Molecular markers of HCC, alpha-fetoprotein and p53, were increased in tumors of Txnip-deficient mice. The upregulation of p53 preceded tumor development; however, bromodeoxyuridine (BrdU) labeling of normal hepatic tissue of Txnip-deficient mice did not reveal increased cell proliferation. Finally, microarray analyses of tumor, non-tumor adjacent, and normal tissue of Txnip-deficient mice highlighted the genetic differences leading to the predisposition and onset of HCC. Our findings suggest that Txnip deficiency is sufficient to initiate HCC and suggest novel mechanisms in hepatocarcinogenesis.

Management of ovarian dermoids without laparoscopy or laparotomy.

OBJECTIVE: To report experience of managing ovarian dermoids via the vaginal route. STUDY DESIGN: A series of 26 cases managed this way either with or without hysterectomy and for comparison 10 women managed by laparotomy and 6 who underwent laparoscopic ovarian cystectomy or oophorectomy were considered. RESULTS: The vaginal approach was successful in all patients, without need for laparoscopic assistance or a switch over to laparotomy. Spill was minimal or absent in the vaginal group and recovery significantly faster in the vaginal and laparoscopic groups compared to the laparotomy group. Hospital stay was slightly shorter in the vaginal than the laparoscopic group. No disposable material or equipment was used in the vaginal or laparotomy group. CONCLUSION: For mobile, benign ovarian teratoma, the vaginal route should be strongly considered to minimise invasive surgery, particularly when the operator is an experienced vaginal surgeon or laparoscopic equipment or laparoscopic surgeons are not easily available. Reduced spillage and speedier recovery are important advantages.

FIGO and women's health 2000-2003.

The International Federation of Gynecology and Obstetrics--FIGO--has been striving hard to carefully attend to women's well-being, and respect and implement their rights, the status and their health, which is well beyond the basic obstetric and gynecological requirement. FIGO is deeply involved in acting as a catalyst for the all-round activities of national obstetric and gynecologic societies to mobilise their members to participate in and contribute to, all of their endeavours. FIGO's committees strengthen these objectives and FIGO's alliance with WHO provides a springboard. The task is gigantic, but FIGO, through national obstetric and gynecological societies and with the strength of obstetricians and gynecologists as its battalion, can offer to combat and meet the demands.

Elevated CA 125 in advanced abdominal or pelvic tuberculosis.

Three cases with advanced pelvic or abdominal tuberculosis showed marked elevation of CA 125. This observation should help clinicians to entertain a possible diagnosis of abdominopelvic tuberculosis and undertake diagnostic laparoscopy, thus avoiding laparotomy where possible. It is suggested that all women who present with adnexal or abdominopelvic mass and/or ascites be tested for CA 125; raised levels may not be due to ovarian malignancy but could be due to tuberculosis.

Transvaginal trucut biopsy in patients with abdominopelvic mass.

OBJECTIVE: To perform an abdominopelvic or pelvic mass biopsy as an office procedure, as an alternative to laparoscopic biopsy. METHODS: A transvaginal trucut biopsy using a disposable biopsy needle was carried out in 5 cases. RESULTS: The biopsy gave a clear diagnosis of ovarian cancer in 2 cases, non-tubercular inflammation in 2 cases and tuberculosis in 1 case. CONCLUSIONS: In the developing world, transvaginal trucut biopsy is an important method for diagnosis.

Vaginal hysterectomy following previous cesarean section.

OBJECTIVE: To determine whether hysterectomy by the vaginal route is safe and feasible in patients with previous cesarean section. METHODS: A retrospective study of the records of private and public hospital patients who underwent vaginal hysterectomy performed by the senior author. Two hundred twenty patients who had had previous cesarean sections were compared with a control group of 200 patients who had not had previous pelvic surgery, with special reference to operative difficulties, intraoperative complications, surgical time and length of hospital stay. RESULTS: It was possible to perform vaginal hysterectomy safety in patients with previous cesarean sections. Three of 200 (1.5%) patients had inadvertent intraoperative urological trauma because of dense adhesions. CONCLUSIONS: The vaginal route is the route of choice for performing a hysterectomy in patients with previous cesarean section.

Inappropriate use of new technology: impact on women's health.

While medical technology is very useful we need to be aware of its inappropriate use. Examples are given, such as: continuous vs. intermittent electronic fetal monitoring; widespread use of magnetic resonance image technology where simple methods could be as effective; laparoscopically assisted vaginal hysterectomies replacing simple vaginal hysterectomies and increasing the cost; ultrasound to provide the first pictures of the baby or to detect female fetuses for female feticide; use of technology for defensive medicine rather than using it for the patient's welfare, and pecuniary indications. Woe betide the doctor who does not make enough money--he may find that his contract is not renewed. We need to empower patients with information, so that they can judge the technology and its appropriateness as it relates to them. Opinion programs have helped to curb the misuse of unnecessary surgery, and audit and peer review programs also provide a check on the misuse of technology. The provision of consensus statements, e.g. by the National Institutes of Health, USA, have helped to clarify issues and to guide doctors as to the appropriateness of the newer technologies, and practice guidelines formulated by experts are also very helpful. We need to teach medical students and residents how to be critical, how to evaluate claims and study the literature, so that they are not hoodwinked by 'authority' or misled by manufacturer's claims.

Uterine septum misdiagnosed on hysterosalpingogram.

OBJECTIVE: To evaluate the correctness of diagnosis of bicornuate uterus made on hysterosalpingogram. METHOD: Thirty-six women diagnosed on hysterosalpingogram to have bicornuate uterus were subjected to laparoscopy and hysteroscopy. RESULT: Two out of 36 women had bicornuate uterus whereas the remaining 34 had intrauterine septum. CONCLUSION: Diagnosis of bicornuate uterus made on hysterosalpingogram by radiologists is often incorrect and needs to be revised.

The Mantoux test in the diagnosis of genital tuberculosis in women.

OBJECTIVE: To analyze the usefulness of the Mantoux test in the diagnosis of genital tuberculosis in women of childbearing age. METHOD: In this report, the investigators studied the ability of a tuberculosis (TB) Mantoux test to diagnose pelvic tuberculosis. A positive TB Mantoux test was clearly defined. The positive control group was of 100 women treated for TB (study group C). The negative control group was of 100 postpartum women (study group B). The study group was 100 infertile women undergoing laparoscopy, in some of whom the diagnosis of TB was made (study group A). RESULT: The Mantoux test had a sensitivity of only 55% and a specificity of 80% in women with laparoscopically diagnosed tuberculosis. Pelvic focal reaction was absent in all groups including infertile women with a positive Mantoux test. CONCLUSION: Mantoux test has limited utility in diagnosing active genital tuberculosis during the childbearing age. However, in infertile women with positive a Mantoux test, laparoscopy may be advocated early.

Cerebrospinal dehydrogenases in central nervous system infections.

Cerebrospinal fluid (CSF) dehydrogenases were studied in 42 controls, 23 children with pyogenic meningitis, 22 with tuberculous meningitis and 19 with encephalitis to assess their usefulness in differentiating between the different central nervous system infections. CSF-LDH and ICD activity was increased in CNS infections (p less than 0.0001), LDH being significantly higher (p less than 0.001) in pyogenic meningitis than in tuberculous meningitis or encephalitis. However, ICD activity was significantly different in each of these conditions (p less than 0.001). The dehydrogenase activity declined with subsequent clinical improvement, in all children with meningitis. A significant direct relationship was found between the enzyme activity and CSF protein content as well as total cell count. The 95% confidence interval confirms the utility of assaying CSF dehydrogenase activity to differentiate various CNS infections, thus improving the diagnostic ability.

Vaginal hysterectomy for myomatous polyp.

Vaginal hysterectomy was performed in 28 perimenopausal women with large myomatous polyps protruding from the cervix. The vaginal route was selected for hysterectomy instead of the usual abdominal approach, based on assessment made after examination under anesthesia following polypectomy. All patients made an uneventful recovery. In women who need hysterectomy, we recommend that removal of myomatous polyps vaginally should be followed by a thorough assessment for deciding the route of hysterectomy. In most cases, the choice would be vaginal hysterectomy, sparing the women the trauma of an abdominal operation.