Predictor factors for conservative management of cervical intraepithelial neoplasia grade 2: Cytology and HPV genotyping.

OBJECTIVE: The purpose of this study was to evaluate the role of HPV genotyping and previous cytology result to predict the evolution of CIN2 histological lesions managed conservatively. METHODS: A prospective observational study was conducted at Hospital del Mar in Barcelona from January 2012 to May 2017. Women with new diagnosis of CIN2 were invited to undergo conservative management for 24 months. Complete regression, partial regression, persistence and progression to CIN3 were defined as final outcomes. Univariate and multivariate analyses combining HPV genotyping and cytology were used to establish progression predictors of CIN2. RESULTS: A total of 300 patients were included in the study, and 291 patients completed the 24-months follow-up. Of them, 214 patients (73.5%) showed regression; 43 (14.8%) persistence to CIN2, and 34 (11.7%) progression to CIN3. In multivariable analysis, HPV-16 infection (odds ratio [OR] 1.97, [95% confidence interval {CI} 1.13-3.43]) and previous HSIL cytology (OR 3.46, [95% CI 1.99-6.02]) significantly increased the risk of persistence or progression (CIN2+) of CIN2 lesions. In contrast, all HPV-negative lesions regressed (p < 0.001). CONCLUSIONS: The regression rate of CIN2 lesions supports conservative management in selected patients regardless of their age. Patients with a CIN2 biopsy and negative HPV test had a high rate of regression and should be offered follow-up without excisional treatment. In contrast, patients with HPV-16 and HSIL cytology had an increased risk of CIN2+, their treatment should be individualized and excisional treatment should be considered. The age may not be considered a criterion to decide the best management. New markers may help in the future to select the best management of CIN2.

The International Society for the Study of Vulvovaginal Disease Surgical Oncological Procedure Definitions Committee "Surgical Terminology for Vulvar Cancer Treatment".

OBJECTIVES: The International Society for the Study of Vulvovaginal Disease (ISSVD) Surgical Oncological Procedure Definitions Committee propose a consistent terminology based on well-defined and reproducible anatomic landmarks that can be used by all who are involved in care of patients with vulvar conditions. MATERIALS AND METHODS: The fundamental principles behind the new terminology contained descriptions of the area extension and depth of the surgical procedure. RESULTS: Vulvar Surgical Topographic Anatomy LandmarksExtension. The internal border of the vulva is the hymenal ring. The genitocrural folds are the external lateral borders.The vertical line through the clitoris and the anus defines lateral portions of the vulva.The horizontal line from the upper border of the hymenal ring defines anterior and posterior portion of the vulva.Depth. The floor of the vulva is represented by the median perineal fascia or perineal membrane of the urogenital diaphragm.A. Vulvectomy1. Extension: partial/total vulvectomy. Removal of part/entire vulvar/perineal integument independent of the depth.2. Depth: superficial/deep. Removal of the most superficial layer/removal of the vulvar tissue to the superficial aponeurosis of the urogenital diaphragm and/or pubic periosteum.B. Inguinofemoral lymphadenectomy1. Superficial inguinofemoral lymphadenectomy. Removal of the nodes located beside the inguinal ligament and along the great saphenous vein.2. Deep femoral lymphadenectomy. Removal of the nodes below the cribriform lamina and medial to the femoral vein. CONCLUSIONS: This terminology helps avoid confusion and promote better understanding and exchange of experiences among gynecologic oncologists involved in vulvar carcinoma care.

Utility of Human Papillomavirus Genotyping in the Management of Low-Grade Squamous Intraepithelial Lesions.

OBJECTIVE: The aim of the study was to determine the usefulness of human papillomavirus (HPV) partial genotyping test in the triage of newly diagnosed low-grade squamous intraepithelial lesions (LSILs). MATERIALS AND METHODS: We analyzed 143 patients with LSIL diagnosed de novo. Lesions were classified as positive for HPV 16 or HPV 18, positive for HPV but not HPV 16 or HPV 18 (HPVno16no18) or no HPV detected (HPVneg). Patients were followed for a period of 2 years or until the lesion progressed. We calculated absolute and relative risks for progression and regression according to the HPV result. RESULTS: The mean (SD) age was 33.8 (11.1) years. A total of 19.6% were positive for HPV 16, 4.9% for HPV 18, and 63.6% for HPVno16no18. The absolute risk of HPV 16 for progression to cervical intraepithelial neoplasia grade 2 or more (CIN 2+) was 32.1%, 14.3% for HPV 18, and 5.8% for HPVno16no18. None of the HPVneg cases evolved to CIN 2+. The presence of HPV 16 conferred a 7.4 (95% CI = 2.7-20.3) times greater risk of developing CIN 2+ than its absence. The absolute risks for HPV 16, HPV 18, HPVno16no18, and HPVneg for regression were 53.6%, 57.1%, 75.4%, and 87.5%, respectively. Relative risks for regression were 0.7 (95% CI = 0.5-0.9) for HPV 16 and 1.3 (95% CI = 1.1-1.5) for HPVneg. CONCLUSIONS: The HPV 16 LSILs are more likely to progress to CIN 2+, so tight control and immediate colposcopy are crucial, whereas when HPV 16 is not present, follow-up could be less strict. Low-grade squamous intraepithelial lesions in which high-risk HPV is not detected do not progress to CIN 2+, so its control should be different from other LSIL, and conservative management could be an acceptable strategy.

Protein Supplementation in a Prehabilitation Program in Patients Undergoing Surgery for Endometrial Cancer.

Enhanced recovery after surgery (ERAS) and prehabilitation programs are multidisciplinary care pathways to reduce stress response and improve perioperative outcomes, which also include nutritional interventions. The aim of this study is to assess the impact of protein supplementation with 20 mg per day before surgery in a prehabilitation program in postoperative serum albumin, prealbumin, and total proteins in endometrial cancer patients undergoing laparoscopic surgery. METHODS: A prospective study including patients who underwent laparoscopy for endometrial cancer was conducted. Three groups were identified according to ERAS and prehabilitation implementation (preERAS, ERAS, and Prehab). The primary outcome was levels of serum albumin, prealbumin, and total protein 24-48 h after surgery. RESULTS: A total of 185 patients were included: 57 in the preERAS group, 60 in the ERAS group, and 68 in the Prehab group. There were no basal differences in serum albumin, prealbumin, or total protein between the three groups. After surgery, regardless of the nutritional intervention, the decrease in the values was also similar. Moreover, values in the Prehab group just before surgery were lower than the initial ones, despite the protein supplementation. CONCLUSIONS: Supplementation with 20 mg of protein per day does not impact serum protein levels in a prehabilitation program. Supplementations with higher quantities should be studied.

Obesity, Mediterranean Diet, and Public Health: A Vision of Obesity in the Mediterranean Context from a Sociocultural Perspective.

Obesity is a disease that straddles medico-nutritional, psychological, and socio-cultural boundaries. There is a clear relationship between lifestyle and obesity, and today the Mediterranean diet in the Mediterranean area may represent an interesting corrective asset. However, we should not be under any misapprehension about the model's capacity for action in non-nutritional terms. Our societies are experiencing a process of rapid change, and the Mediterranean area is no exception. The aim of this article is to present a view of obesity in the Mediterranean context from an open, mainly socio-cultural perspective, but from different points of view (medical, nutritional), seeking points of convergence and elements that contribute to the understanding of and approach to the disease in the context of the Mediterranean diet. As a public health and a multidimensional social problem, obesity must be dealt with in a holistic, open, and cross-disciplinary manner to ensure that it can be understood coherently. The only way to keep the usefulness of the Mediterranean diet within desirable limits will be our societies' vitality and interest in rapidly adapting the Mediterranean diet to social change, thus providing valid answers to today's needs.

Resident memory T cells are a cellular reservoir for HIV in the cervical mucosa.

HIV viral reservoirs are established very early during infection. Resident memory T cells (TRM) are present in tissues such as the lower female genital tract, but the contribution of this subset of cells to the pathogenesis and persistence of HIV remains unclear. Here, we show that cervical CD4+TRM display a unique repertoire of clusters of differentiation, with enrichment of several molecules associated with HIV infection susceptibility, longevity and self-renewing capacities. These protein profiles are enriched in a fraction of CD4+TRM expressing CD32. Cervical explant models show that CD4+TRM preferentially support HIV infection and harbor more viral DNA and protein than non-TRM. Importantly, cervical tissue from ART-suppressed HIV+ women contain high levels of viral DNA and RNA, being the TRM fraction the principal contributor. These results recognize the lower female genital tract as an HIV sanctuary and identify CD4+TRM as primary targets of HIV infection and viral persistence. Thus, strategies towards an HIV cure will need to consider TRM phenotypes, which are widely distributed in tissues.

Value of p16(INK4a) and Ki-67 Immunohistochemical Staining in Cervical Intraepithelial Neoplasia Grade 2 Biopsies as Biomarkers for Cervical Intraepithelial Neoplasia Grade 3 in Cone Results.

OBJECTIVE: To evaluate the usefulness of p16(INK4a) (p16) and Ki-67 staining in high-grade cervical intraepithelial neoplasia (CIN2) biopsies in order to predict CIN3 results in cone specimens, thereby sparing those not likely at risk for CIN3 from unnecessary cone excision. STUDY DESIGN: We retrospectively recruited patients with CIN2 colposcopy-directed biopsy treated by loop electrosurgical excision procedure. The expression of p16 and Ki-67 was qualitatively and quantitatively analyzed in all biopsies and cone specimens. RESULTS: A total of 123 patients from January 2009 to December 2010 were included in the study. CIN3 in cone specimens was observed in 35 patients (28.5%). Ki-67 positive immunostaining in > 50% of epithelial cells was related to CIN3 diagnoses in cone specimens (p = 0.043). However, p16+ and Ki-67+ evaluated by thirds of the epithelial thickness in CIN2 biopsies did not show a significant correlation with the cone results. In multivariate analysis, Ki-67 cell expression over 50% in CIN2 biopsies and high-grade squamous intraepithelial lesion (HSIL) in the previous cytology were statistically associated with CIN3 results in the cone (odds ratio [OR] 2.55, 95% confidence interval [CI] 1.04-6.29; OR 2.68, 95% CI 1.07-6.72, respectively). CONCLUSION: Patients with HSIL in the previous cytology and Ki-67 cell expression over 50% in their CIN2 biopsies could be considered in need of treatment by cone for their higher risk of underlying CIN3 lesions.

Use of mobile phones as a tool for weight loss: a systematic review.

We conducted a systematic review of the literature on the use of mobile phones for weight loss. A total of 43 studies were identified on obese or overweight adults, aged 18 years or over. After review, ten articles met the inclusion criteria. There were 19-534 participants per study. Participants were from European, Asian and North American regions. The mean body mass index (BMI) of the subjects varied from 22 to 36 kg/m(2). Two studies used text messaging or multimedia messaging. All the other studies used mobile-phone apps or web-based programmes that could be accessed from mobile phones as a part of a weight-loss intervention or for evaluating their potential for use and their acceptance. Most studies lasted 2-4 months and the maximum duration was 1 year. All but two studies showed reductions in the participants' bodyweight, BMI, waist circumference and body fat in the various interventions. There appeared to be a proportional relationship between weight loss and programme use. The programmes most benefited those who took a pro-active approach to everyday problems. Frequent self-recording of weight seemed to be important, as was the personalisation of the intervention (counselling and individualized feedback). Finally, a social support system acted as a motivational tool.

Feasibility of a new two-step procedure for office hysteroscopic resection of submucous myomas: results of a pilot study.

OBJECTIVE: To assess the feasibility of a new two-step technique for office hysteroscopic resection of submucous myomas. STUDY DESIGN: Between January 2010 and December 2011, all consecutive patients of reproductive age with symptomatic lesions sonographically diagnosed as single mainly intracavitary (G1 or G2) myoma ≤4.0 cm were eligible to participate in a prospective study. They underwent a two-step hysteroscopic procedure, which included preparation of partially intramural myomas with incision of the endometrial mucosa and the pseudocapsule covering the myoma in the first step, and excision of the myoma by means of diode laser four weeks later. All procedures were performed on an outpatient basis and without anesthesia. RESULTS: A total of 43 women (mean age 36.7 years) were included. The two-step myomectomy technique was successfully performed in 34 (79.1%) patients. All myomas ≤18 mm were successfully enucleated as compared with 85% of 19-30 mm, and 0% of ≥30 mm (P<0.001). Also, myomas located in the anterior/posterior walls and those located in the fundus/lateral walls were enucleated in 87.9% and 50% of cases, respectively (P=0.020). Success of surgery was not influenced by the initial type of myoma. CONCLUSION: The new two-step hysteroscopic myomectomy carried out as an outpatient procedure and without anesthesia is feasible for the excision of symptomatic submucous fibroids.