Measuring colposcopy quality in Canada: development of population-based indicators.

Background: Colposcopy is a key part of cervical cancer control. As cervical cancer screening and prevention strategies evolve, monitoring colposcopy performance will become even more critical. In the present paper, we describe population-based colposcopy quality indicators that are recommended for ongoing measurement by cervical cancer screening programs in Canada. Methods: The Pan-Canadian Cervical Cancer Screening Network established a multidisciplinary expert working group to identify population-based colposcopy quality indicators. A systematic literature review was conducted to ascertain existing population and program-level colposcopy quality indicators. A systems-level cervical cancer screening pathway describing each step from an abnormal screening test, to colposcopy, and back to screening was developed. Indicators from the literature were assigned a place on the pathway to ensure that all steps were measured. A prioritization matrix scoring system was used to score each indicator based on predetermined criteria. Proposed colposcopy quality indicators were shared with provincial and territorial screening programs and subsequently revised. Results: The 10 population-based colposcopy quality indicators identified as priorities were colposcopy uptake, histologic investigation (biopsy) rate, colposcopy referral rate, failure to attend colposcopy, treatment frequency in women 18-24 years of age, re-treatment proportion, colposcopy exit-test proportion, histologic investigation (biopsy) frequency after low-grade Pap test results, length of colposcopy episode of care, and operating room treatment rate. Two descriptive indicators were also identified: colposcopist volume and number of colposcopists per capita. Summary: High-quality colposcopy services are an essential component of provincial cervical cancer screening programs. The proposed quality and descriptive indicators will permit colposcopy outcomes to be compared between provinces and across Canada so as to identify opportunities for improving colposcopy services.

A multi-centre randomised phase III trial of Dexamethasone vs Dexamethasone and diethylstilbestrol in castration-resistant prostate cancer: immediate vs deferred Diethylstilbestrol.

BACKGROUND: The role of further hormone therapy in castration-resistant prostate cancer (CRPC) remains unclear. We performed a multi-centre randomised phase III study comparing the use of Dexamethasone, Aspirin, and immediate addition of Diethylstilbestrol (DAiS) vs Dexamethasone, Aspirin, and deferred (until disease progression) addition of Diethylstilbestrol (DAdS). METHODS: From 2001 to 2008, 270 men with chemotherapy-naive CRPC were randomly assigned, in a 1 : 1 ratio, to receive either DAiS or DAdS. They were stratified for performance status, presence of bone metastases, and previous normalisation of prostate-specific antigen (PSA) to androgen deprivation. The study end points were the proportion of patients achieving a 50% PSA response, progression-free survival (PFS), overall survival, and quality of life. Intention-to-treat analysis was carried out. The effect of treatment was studied first by Kaplan-Meier curves and log-rank test, and finally through multivariable stratified Cox's proportional hazards model adjusting for the effects of possible baseline prognostic factors. Quality of life was analysed using multivariate analysis of variance. RESULTS: At study entry, the median age was 76 years (inter-quartile range: 70-80 years), the median PSA was 79 ng ml(-1), and 76% of the cohort had metastatic disease. The response rates for DAiS (68%) and DAdS (64%) were not significantly different (P=0.49). Similar to the response rate, neither the PFS (median=8.1 months for both arms) nor the overall survival (19.4 vs 18.8 months) differed significantly between the DAiS and DAdS groups (P>0.20). However, the response rate for the DAiS (68%) was significantly higher than the response rate of DA (before adding Diethylstilbestrol) (50%) (P=0.002). Similarly, the median time to progression for DAiS (8.6 months) was significantly longer than that of DA (4.5 months) (P<0.001). Multivariable analysis showed that patients with previous haemoglobin ≥11 g dl(-1) decreased the risk of death significantly (hazard ratio: 0.44, 95% CI: 0.25-0.77). Patients treated with previous anti-androgens alone had more than 5 times more risk of death compared with patients treated with gonadorelin analogues throughout their castration-sensitive phase. Treatment sequencing did not affect the quality of life but pre-treatment performance status did. The incidence of veno-thromboembolic events was 22% (n=28) in DAiS and 11% (n=14) in the DA arm (P=0.02). Painful gynaecomastia occurred in only 1% on DA, whereas in 40% on DAiS (P=0.001). CONCLUSION: Dexamethasone and immediate Diethylstilbestrol resulted in neither higher PSA response rate nor higher PFS compared with Dexamethasone with deferred Diethylstilbestrol. There was no suggestion of significantly improved overall survival or quality of life. Given the significantly higher toxicity of Diethylstilbestrol, deferring Diethylstilbestrol until failure of Dexamethasone is the preferred strategy when using these agents in CRPC.

A phase II study investigating the re-induction of endocrine sensitivity following chemotherapy in androgen-independent prostate cancer.

When chemotherapy is used in androgen-independent prostate cancer (AIPC), androgen deprivation is continued despite its failure. In this study, we investigated whether it was possible to re-induce hormone sensitivity in previously castrate patients by stopping endocrine therapy during chemotherapy. A phase II prospective study investigated the effects of reintroduction of endocrine therapy after oral chemotherapy in 56 patients with AIPC, which was given without concurrent androgen deprivation. After chemotherapy, patients were given maximum androgen blockade until failure when treatment was switched to diethylstilbestrol and dexamethasone. Patients had already received these endocrine treatments in the same sequence before chemotherapy. All patients were castrate at the start of chemotherapy. Forty-three subsequently restarted endocrine therapy after the completion of chemotherapy. The median overall survival for these 43 patients from the time of restarting endocrine therapy was 7.7 months (95% confidence interval (CI): 3.7-10.9 months). Sixteen (37%) patients had a 50% PSA response to treatment, which was associated with improved overall survival (14.0 months vs 3.7 months P=0.003). Eight out of 12 patients who did not respond to diethylstilbestrol before chemotherapy did so post chemotherapy. Re-induction of hormone sensitivity can occur after chemotherapy in AIPC.

Pro-inflammatory alterations and status of blood plasma iron in a model of blast-induced lung trauma.

Impact of blast shock waves (SW) with the body wall produces blast lung injuries characterized by bilateral traumatic hemorrhages. Such injuries often have no external signs, are difficult to diagnose, and therefore, are frequently underestimated. Predictive assessment of acute respiratory distress syndrome outcome in SW-related accidents should be based on experimental data from appropriate animal models. Blood plasma transferrin is a major carrier of blood iron essential for proliferative "emergency" response of hematopoietic and immune systems as well as injured tissue in major trauma. Iron-transferrin complexes (Fe3+ TRF) can be quantitatively analyzed in blood and tissue samples with low-temperature EPR techniques. We hypothesized that use of EPR techniques in combination with assays for pro-inflammatory cytokines and granulocytes in the peripheral blood and BAL would reveal a pattern of systemic sequestration of (Fe3+)TRF that could be useful for development of biomarkers of the systemic inflammatory response to lung injury. With this goal we (i) analyzed time-dependent dynamics of (Fe3+)TRF in the peripheral blood of rats after impacts of SW generated in a laboratory shock-tube and (ii) assayed the fluctuation of granulocyte (PMN) counts and expression of CD11b adhesion molecules on the surface of PMNs during the first 24 h after SW induced injury. Sham-treated animals were used as control. Exposure to SW led to a significant decrease in the amount of blood (Fe3+)TRF that correlated with the extent of lung injury and developed gradually during the first 24 h. Thus, sequestration of (Fe3+)TRF occurred as early as 3 h post-exposure. At that time, the steady state concentration of (Fe3+)TRF in blood samples decreased from 19.7+/-0.6 microM in controls to 7.5+/-1.3 microM in exposed animals. The levels of (Fe3+)TRF remained decreased throughout the entire study period. PMN counts increased 5-fold and 3.5-fold over controls respectively, at 3 and 6 h postexposure. These effects were accompanied by an increase in expression of CD11b on the surface membrane of PMNs. Extensive release of cytokines IL-1, IL-6, MCP-1, and MIP-2 was observed in BAL fluid and blood plasma during 24 h postexposure. We conclude that EPR monitoring of blood (Fe3+)TRF can be a useful approach for assessment of systemic pro-inflammatory alterations due to SW-induced lung injury.

Hemoglobin stimulates the release of proinflammatory cytokines from leukocytes in whole blood.

Isolated mononuclear leukocytes, when incubated with purified hemoglobin Ao (HbAo), release the proinflammatory cytokines interleukin-8 (IL-8) and tumor necrosis factor-alpha (TNF-alpha). In this study we examined whether leukocytes in whole blood, when incubated with HbAo, release IL-8, TNF-alpha, and IL-6. Leukocytes in whole blood incubated with HbAo for 4 hours at 37 degrees C, 5% CO2, and 95% humidity released 187, 1313, and 50 pg/mL of IL-6, IL-8, and TNF-alpha, respectively, as compared with 6, 192, and 2 pg/mL released by leukocytes in blood incubated with human serum albumin (HSA). Furthermore, plasma from blood incubated with HbAo exhibited chemotactic activity and stimulated human umbilical vein endothelial cells to become adherent to neutrophils. These activities were 3.3 and 2.6 times those measured in plasma from blood incubated with HSA. Hydrocortisone (0.05 micromol/L to 50 micromol/L) inhibited cytokine release in a dose-dependent manner with ED50 values of 0.23 micromol/L, 0.19 micromol/L, and 0.10 micromol/L for IL-6, IL-8, and TNF-alpha, respectively. The release of proinflammatory cytokines in whole blood after exposure to hemoglobin solutions is consistent with the possibility that an inflammatory reaction could develop on infusion of hemoglobin, whereas inhibition of cytokine release by hydrocortisone suggests that the inclusion of anti-inflammatory compounds in hemoglobin solutions may prevent undesirable effects caused by inflammation after infusion.

Hemoglobin stimulates mononuclear leukocytes to release interleukin-8 and tumor necrosis factor alpha.

Incubation of human mononuclear leukocytes (MNL) with human stroma-free hemolysate (SFH), purified adult hemoglobin Ao (HbAo), and oxidized HbAo (METHb) caused MNL to release compounds into the supernate that mediated neutrophil (polymorphonuclear leukocytes, PMN) chemotaxis and PMN adherence to human umbilical vein endothelial cells (HUVEC). Chemotaxis and PMN adherence to HUVEC were reduced significantly when supernates were preincubated with neutralizing antibodies to interleukin-8 (IL-8) and tumor necrosis factor alpha (TNF-alpha), respectively, suggesting that IL-8 and TNF-alpha played significant roles in mediating these activities. Greatest chemotactic activity was observed in supernates of MNL treated with HbAo; while greatest PMN/endothelial cell (EC) adherence activity was observed in supernates of MNL treated with METHb. Furthermore, PMN/EC adherence activity was a function of METHb content in each hemoglobin solution. PMN chemotaxis, PMN adherence to HUVEC, and cytokine release increased as a function of increasing incubation time. Chemotactic activity was detected in HbAo-treated and METHb-treated MNL supernates after incubation for 6 hours and was maximal by 10 hours. IL-8 was detected in both HbAo and METHb-MNL supernates by 4 hours. PMN/EC adherence activity was detected in HbAo-MNL supernates at 10 hours and in METHb-MNL supernates at 4 hours. TNF-alpha was detected in METHb and HbAo-MNL supernates at 4 and 12 hours, respectively. These results suggest that hemoglobin solutions stimulate MNL to release IL-8 and TNF-alpha in quantities sufficient to induce PMN chemotaxis and PMN adherence to HUVEC. This is a US government work. There are no restrictions on its use.

Quantitation of polymorphonuclear leukocyte adherence to endothelial cells by electronic particle size discrimination.

A method for quantitating the number of polymorphonuclear leukocytes (PMNs) adhering to endothelial cells in vitro is presented. Confluent human umbilical vein endothelial cells cultured in 24-well multiplates and treated with tumor necrosis factor alpha (TNF alpha) were incubated subsequently with PMNs which adhere to the endothelial cell as a function of TNF alpha concentration. Adherent PMNs and endothelial cells were proteolytically dissociated from the multiwell and, using an electronic particle counter, the number of endothelial cells and PMNs were determined simultaneously on the basis of size. The average number of PMNs adhering per endothelial cell was then calculated. The method is rapid and precise and offers an alternative to both tedious microscopic counting and the hazardous radiolabeling of PMNs.

Laser treatment of cervical intraepithelial neoplasia and the endocervical button.

A prospective randomized clinical trial was undertaken to investigate the relationship between the shape of cervical tissue vaporized with CO 2 laser and the postoperative location of the squamocolumnar junction. It has been suggested that a button of columnar epithelium may be everted onto the exocervix by vaporizing a shallow 1 mm trench around the endocervical canal after the evaporization cone has been completed. Eighty-eight patients with cervical intraepithelial neoplasia (CIN) suitable for treatment by CO 2 laser were randomized into two groups. The transformation zone was ablated to 6 mm in all patients. In the flat group (n = 45), the base of the cervical defect was flat. In the contour group (n = 43), an additional 1 mm trench was vaporized at the periphery of the defect. Both groups were similar with respect to age, use of oral contraceptives, parity, operative complications, degree of CIN, and volume of tissue ablated. On follow-up at 6 months, significantly more patients in the contour group had an endocervical button of columnar epithelium compared to the flat group. No difference was seen at 3 and 12 months. There was a moderate relationship between the volume of tissue vaporized and the area of the button in the contour groups (p less than 0.001) but not in the flat group. The presence of squamous metaplasia tends to increase with time. There were 2 recurrences of CIN at 1 year follow-up.

Studies on the mechanism of carbon monoxide-induced vasodilation in the isolated perfused rat heart.

We investigated the effects of dissolved CO on isolated potassium-arrested (K+) perfused rat hearts. Hearts from male Sprague-Dawley rats were perfused via the aorta with oxygenated Krebs-Henseleit solution containing 20 mM K+. Coronary flow (Qt) averaged 48.8 +/- 1.6 (SE), 48.1 +/- 1.7, and 55.6 +/- 1.7 ml/min/g dry wt when the perfusate was equilibrated with 95% O2-5% CO2, 5% N2-90% O2-5% CO2, and 5% CO-90% O2-5% CO2, respectively. The change in Qt was statistically significant when CO was present in the perfusion medium, but was not significant when N2 was present. Furthermore, the effect was reversible because coronary flow returned to control levels when CO was removed. Myocardial oxygen consumption (MVO2) did not change significantly when hearts were perfused with either N2 or CO. The magnitude of CO-induced vasodilation was not affected significantly by the addition of either 5 microM propranolol, 2 microM phentolamine, 1 unit of adenosine deaminase, or 0.1 mM indomethacin to the perfusate. In addition, CO reversed the vasoconstrictive effects of the alpha-agonist methoxamine. These results indicate that CO exerts a vasodilatory effect on coronary vasculature that is not the result of decreased O2 content in the perfusate and is not mediated by adrenergic influences, adenosine, or prostaglandins.

The mechanism of peroxidase-mediated cytotoxicity. I. Comparison of horseradish peroxidase and lactoperoxidase.

The kinetics of the cytolytic activity expressed by lactoperoxidase and horseradish peroxidase toward erythrocytes in the presence of H2O2 and iodide have been investigated at physiological pH. The action of both enzymes was found to be very similar with respect to their kinetic mechanisms. Both enzymes showed saturation kinetics at higher enzyme concentrations under conditions where substrate concentrations were not limiting. Optimal concentrations of H2O2 and iodide were found to be 40 and 25 microM, respectively, for both enzymes. Higher concentrations of H2O2 inhibited the cytolytic activity. The pH dependence of the cytolytic reaction is also very similar for both enzymes, showing maximal activity at about pH 6.3. Moreover, the cytolytic activities of both enzymes were inhibited by tyrosine, tryptophan, cysteine, and to a lesser extent by histidine. We conclude from these data that the mechanisms of horseradish peroxidase and lactoperoxidase in promoting the lysis of erythrocytes are closely related if not identical.

Observations on the cytolytic activity of lactoperoxidase using a continuous assay.

A turbidometric assay that allows continuous monitoring of the cytolytic activity of toxic agents toward various target cells has been developed. This assay monitors the change in absorbance at 600 nm (due to light scattering) of a suspension of human red blood cells as a function of time. The rate of cell lysis, delta A600/delta t, can be expressed as the number of cells lysed per minute, which facilitates the determination of kinetic constants. Using this procedure we observed that the cytolytic activity exerted by various peroxidases in the presence of hydrogen peroxide and a halide ion proceeds in at least two stages. During the first stage no lysis occurs, but scanning electron microscopy showed that alterations in the target cell membrane take place. During the second stage the target cells lyse, resulting in a simultaneous release of metabolites and macromolecules. We conclude that the lytic action of peroxidases is directed toward the target cell membrane, which appears to acquire an increased rigidity and subsequently disintegrates.