Postoperative complications and surgical outcomes of robotic versus conventional nipple-sparing mastectomy in breast cancer: meta-analysis.

BACKGROUND: Breast cancer is the most common cancer worldwide, with remarkable advances in early diagnosis, systemic treatments, and surgical techniques. Robotic nipple-sparing mastectomy has been trialled; however, the complication rates, surgical outcomes, and oncological safety of this approach remain obscure. METHODS: A systematic search of the literature was conducted from conception until September 2022. Studies examining complications and operative variables where robotic nipple-sparing mastectomy was compared with conventional nipple-sparing mastectomy were included. Primary study outcomes were complications (Clavien-Dindo grade III complications, skin or nipple necrosis, seroma, haematoma, infection, implant loss, and wound dehiscence) and oncological safety (recurrence and positive margins). The secondary outcomes included operative variables, length of stay, cost-effectiveness, learning curve, and aesthetic outcome. RESULTS: A total of seven studies of overall fair quality, involving 1674 patients, were included in the systematic review and meta-analysis. Grade 3 complications were reduced in robotic nipple-sparing mastectomy without statistical significance (OR 0.60 (95 per cent c.i. 0.35 to 1.05)). Nipple necrosis was significantly reduced in robotic nipple-sparing mastectomy (OR 0.54 (95 per cent c.i. 0.30 to 0.96); P = 0.03; I2 = 15 per cent). Operating time (mean difference +58.81 min (95 per cent c.i. +28.19 to +89.44 min); P = 0.0002) and length of stay (mean difference +1.23 days (95 per cent c.i. +0.64 to +1.81 days); P < 0.0001) were significantly increased in robotic nipple-sparing mastectomy, whereas the opposite was true for blood loss (mean difference -53.18 ml (95 per cent c.i. -71.78 to -34.58 ml); P < 0.0001). CONCLUSION: Whilst still in its infancy, robotic breast surgery may become a viable option in breast surgery. Nonetheless, the oncological safety of this approach requires robust assessment.

Robotic nipple-sparing mastectomy has been tried, but it is still not clear how often complications happen or how much better it is for cancer patients than conventional nipple-sparing mastectomy. The aim of this study was to compare robotic nipple-sparing mastectomy with conventional nipple-sparing mastectomy. A thorough search of all articles was performed from the start to September 2022. The studies that compared robotic nipple-sparing mastectomy with conventional nipple-sparing mastectomy in terms of problems and surgical factors were included. Complications and cancer outcomes (recurrence and positive margins) were the most important things that the study looked at. Surgical time, blood loss, length of hospital stay, cost-effectiveness, learning curve, and patient-reported outcome measures were some of the other things that were studied. This systematic review and meta-analysis looked at seven studies with fair quality and included 1674 patients. Even though there were fewer major problems with robotic nipple-sparing mastectomy, the difference was not significant. In robotic nipple-sparing mastectomy, there was less nipple necrosis, but the overall time it took to operate was much longer and the cost was higher. The average amount of bleeding was less in robotic nipple-sparing mastectomy. The robotic nipple-sparing mastectomy method had a better patient-reported outcome and a steep learning curve. Robotic nipple-sparing mastectomy is a safe method, with fewer problems than other methods. Future studies should look into if it is safe for cancer patients in the long run.

Electronic aggregated data collection on cervical cancer screening in Bangladesh since 2014: what the data tells us?

INTRODUCTION: To reduce the high prevalence of cervical cancers among the Bangladeshi women, the Government of Bangladesh established a national cervical cancer screening programme in 2005 for women aged 30 to 60 years. The District Health Information System Version 2 (DHIS2) based electronic aggregated data collection system is used since the year 2013. This study summarises data from the year 2014 to 2022 to assess the effectiveness of the electronic data collection system in understanding the outcome of the screening programme. METHODS: This is a descriptive study based on secondary data extracted in MS Excel from the DHIS2-based electronic repository of the national cervical cancer screening programme of Bangladesh. The respondents were women aged 30-60 years, screened for cervical cancer using VIA (Visual Inspection of cervix with Acetic acid) method in 465 government health facilities. The data were collected on the participants' residential location, month and year of screening, name and type of health facilities performing VIA, and VIA screening results. RESULTS: The national screening programme reported a total 3.36 million VIA tests from 465 government hospitals in 8 years (2014 to 2022). The national average VIA-positivity rate was 3.6%, which varied from 1.4 to 9.5% among the districts. This national screening programme witnessed an exponential growth, year after year, with 83.3% increase in VIA test from 2014 to 2022. The primary and the secondary care hospitals were the highest collective contributors of VIA tests (86.2%) and positive cases (77.8%). The VIA-positivity rates in different hospital types varied widely, 7.0% in the medical university hospital, 5.7% in the medical college hospitals, 3.9% in the district/general hospitals, and 3.0% in the upazila health complexes. CONCLUSIONS: A national cervical cancer screening programme using VIA method and a DHIS2-based electronic data collection backbone, is effective, sustainable, and useful to understand the screening coverage, VIA positivity rate and geographic distribution of the participants and case load to initiate policy recommendations and actions. Decentralization of the screening programme and more efforts at the primary and secondary care level is required to increase screening performances.

Leveraging vertical COVID-19 investments to improve monitoring of cancer screening programme - A case study from Bangladesh.

Cancer screening programs from majority of the low- and middle-income countries (LMICs) report screening coverage as the only performance indicator, and that too measured through population-based sample surveys. Such information is unreliable and has very little value in assessing programmatic quality and impact. Regular monitoring of key process and outcome indicators based on data collected through a robust information system is essential to ensure quality of a screening programme. Fragmented health systems, limited resources and absence of a culture of systematic evaluation are the major hindrances for most of the LMICs to build electronic information systems to manage screening. The COVID-19 pandemic has created an impetus for the countries to customize the freely available District Health Information Software (DHIS2) to collect electronic data to track the outbreaks and manage containment measures. In the present article we present Bangladesh as an exemplar LMIC that has a (DHIS2) based integrated health information system gradually upgraded to collect individual data of the participants to the national cervical cancer screening program. Such efforts paid rich dividends as the screening program was switched from opportunistic to a population-based one. Moreover, the electronic system could report impact of the pandemic on cancer screening on a monthly basis. The aggregate number of women screened in the year 2020 was 14.1% less compared to 2019. The monthly rate of screening during peak of the outbreak was only 5.1% of the previous year. The rate rapidly recovered as the program intensified screening in the hard-to-reach regions less affected by the pandemic and expanded the outreach services. Other LMICs may emulate Bangladesh example. Customizing the information system developed for pandemic surveillance to collect cancer screening data will help them build back the screening programs better.

Population-based cancer screening programmes in low-income and middle-income countries: regional consultation of the International Cancer Screening Network in India.

The reductions in cancer morbidity and mortality afforded by population-based cancer screening programmes have led many low-income and middle-income countries to consider the implementation of national screening programmes in the public sector. Screening at the population level, when planned and organised, can greatly benefit the population, whilst disorganised screening can increase costs and reduce benefits. The International Cancer Screening Network (ICSN) was created to share lessons, experience, and evidence regarding cancer screening in countries with organised screening programmes. Organised screening programmes provide screening to an identifiable target population and use multidisciplinary delivery teams, coordinated clinical oversight committees, and regular review by a multidisciplinary evaluation board to maximise benefit to the target population. In this Series paper, we report outcomes of the first regional consultation of the ICSN held in Agartala, India (Sept 5-7, 2016), which included discussions from cancer screening programmes from Denmark, the Netherlands, USA, and Bangladesh. We outline six essential elements of population-based cancer screening programmes, and share recommendations from the meeting that policy makers might want to consider before implementation.

Evaluation of stationary colposcope and the Gynocular, by the Swede score systematic colposcopic system in VIA positive women: a crossover randomized trial.

OBJECTIVE: This study aimed to evaluate cervical lesions by the Swede coloscopy system, histologic finding, liquid-based cytology, and human papillomavirus (HPV) in women who resulted positive for visual inspection of the cervix with acetic acid (VIA) by using a pocket-sized battery-driven colposcope, the Gynocular (Gynius AB, Sweden). METHODS: This study was a crossover, randomized clinical trial at the colposcopy clinic of Bangabandhu Sheikh Mujib Medical University in Dhaka, Bangladesh, with 540 VIA-positive women. Swede scores were obtained by the Gynocular and stationary colposcope, as well as samples for liquid-based cytology, HPV, and cervical biopsies. The Swede scores were compared against the histologic diagnosis and used as criterion standard. The percentage agreement and the κ statistic for the Gynocular and standard colposcope were also calculated. RESULTS: The Gynocular and stationary colposcope showed high agreement in Swede scores with a κ statistic of 0.998, P value of less than 0.0001, and no difference in detecting cervical lesions in biopsy. Biopsy detected cervical intraepithelial neoplasia (CIN) 2+ (CIN2, CIN3, and invasive cancer) in 38 (7%) of the women, whereas liquid-based cytology detected CIN2+ in 13 (2.5%) of the women. Forty-four (8.6%) women who were tested resulted positive for HPV; 20 (3.9%) women had HPV-16, 2 (0.4%) had HPV-18, and 22 (4.3%) had other high-risk HPV. CONCLUSIONS: Our study showed that few VIA-positive women had CIN2+ lesions or HPV infection. Colposcopy by Swede score identified significantly more CIN2+ lesions than liquid-based cytology and could offer a more accurate screening and selection for immediate treatment of cervical lesions in low-resource settings.

A surgical case report of an epiploic hernia - A mobile right colon herniating through the foramen of Winslow.

INTRODUCTION: An Epiploic Hernia is an extremely rare type of abdominal hernia with <0.1 % incidence where the bowel or other intra-abdominal contents herniate through the Foramen of Winslow. A case of an Epiploic hernia in a middle-aged female is presented here. PRESENTATION OF CASE: A woman in her 60s was admitted to a tertiary level hospital with severe right sided intermittent upper abdominal pain associated with nausea, bloating and constipation. The symptoms were thought to be due to biliary colic and managed conservatively. Since the symptoms persisted and a computed tomography scan of abdomen was organized. CT scan showed that the caecum was in the upper left quadrant. A laparoscopy was performed and demonstrated that her right colon was mobile herniating through the Foramen of Winslow into the lesser sac. The hernia was reduced, and the bowel was viable. The patient was discharged with no complications. DISCUSSION: There have been case reports of small bowel as the content of the hernia with lesser occurrences of caecum, ascending colon, transverse colon, gall bladder, omentum, or Meckel's diverticulum. A caecal herniation through the Foramen of Winslow is reported only with an incidence of 0.02 %. <10 % of these Epiploic hernias are diagnosed preoperatively making it a potentially life-threatening condition if not treated promptly due to high risk of bowel strangulation and mortality of up to 50 %. CONCLUSION: A high index of suspicion is needed for the diagnosis of this internal hernia and radiological investigation is fundamental in making this diagnosis for allowing prompt surgical treatment.

Staging and Management of Cervical Cancer at the Colposcopy Clinic of Bangabandhu Sheikh Sheikh Mujib Medical University (BSMMU), Bangladesh.

Anjuman SultanaCervical cancer (CC) ranks as the second most common cancer among women in Bangladesh. Unfortunately, due to late-stage diagnosis and inadequate treatment facilities, the mortality rate remains high. The stage at which CC is diagnosed plays a crucial role in predicting a woman's survival. This study aimed to determine the staging patterns of CC at presentation in the colposcopy clinic of Bangabandhu Sheikh Mujib Medical University (BSMMU) and the subsequent management provided to these women. This retrospective study was conducted at the BSMMU colposcopy clinic from January 2019 to June 2020. It included CC cases with known staging, spanning from January 2016 to June 2019. Data were collected from the colposcopy registry book, telephone interviews, and face-to-face discussions during follow-up appointments. The mean age of women diagnosed with CC was 48.59 years (±2 standard deviations). Among the 523 women studied, 107 (20.5%) were diagnosed at stage I, 124 (23.7%) at stage IIA, 240 (45.9%) at stage IIB, while the remaining 52 (9.90%) were diagnosed with Stage III and IV disease. Within the study population, 39 (7.5%) women underwent radical hysterectomy alone, 110 (21.00%) underwent radical hysterectomy followed by adjuvant therapy, and 184 (35.14%) received primary radiotherapy or concurrent chemoradiation. A significant portion of CC cases presented at an early stage, underscoring the importance of an effective screening program to prevent advanced-stage disease and enhance early detection rates. Establishing a patient navigation system immediately after diagnosis is crucial to prevent the loss of follow-up and ensure timely treatment. It is imperative to enhance the healthcare system's capacity to ensure timely treatment for cancer patients.

Feasibility of monitoring Global Breast Cancer Initiative Framework key performance indicators in 21 Asian National Cancer Centers Alliance member countries.

Background: The Global Breast Cancer Initiative (GBCI) Framework, launched by the World Health Organisation (WHO) in 2023, emphasises assessing, strengthening, and scaling up services for the early detection and management of breast cancer. This study aims to determine the feasibility of monitoring the status of breast cancer control in the 21 Asian National Cancer Centers Alliance (ANCCA) countries based on the three GBCI Framework key performance indicators (KPIs): stage at diagnosis, time to diagnosis, and treatment completion. Methods: We reviewed published literature on breast cancer control among 21 ANCCA countries from May to July 2023 to establish data availability and compiled the latest descriptive statistics and sources of the indicators using a standardised data collection form. We performed bivariate Pearson's correlation analysis to measure the strength of correlation between stage at diagnosis, mortality and survival rates, and universal health coverage. Findings: Only 12 (57%) ANCCA member countries published national cancer registry reports on breast cancer age-standardised incidence rate (ASIR) and age-standardised mortality rate (ASMR). Indonesia, Myanmar, and Nepal had provincial data and others relied on WHO's Global Cancer Observatory (GLOBOCAN) estimates. GLOBOCAN data differed from the reported national statistics by 5-10% in Bhutan, Indonesia, Iran, the Republic of Korea, Singapore, and Thailand and >10% in China, India, Malaysia, Mongolia, and Sri Lanka. The proportion of patients diagnosed in stages I and II strongly correlated with the five-year survival rate and with the universal health coverage (UHC) index. Three countries (14%) reported national data with >60% of invasive breast cancer patients diagnosed at stages I and II, and a five-year survival rate of >80%. Over 60% of the ANCCA countries had no published national data on breast cancer staging, the time interval from presentation to diagnosis, and diagnosis to treatment. Five (24%) countries reported data on treatment completion. The definition of delayed diagnosis and treatment completion varied across countries. Interpretation: GBCI's Pillar 1 KPI correlates strongly with five-year survival rate and with the UHC index. Most ANCCA countries lacked national data on cancer staging, timely diagnosis, and treatment completion KPIs. While institutional-level data were available in some countries, they may not represent the nationwide status. Strengthening cancer surveillance is crucial for effective breast cancer control. The GBCI Framework indicators warrant more detailed definitions for standardised data collection. Surrogate indicators which are measurable and manageable in country-specific settings, could be considered for monitoring GBCI indicators. Ensuring UHC and addressing health inequalities are essential to early diagnosis and treatment of breast cancer. Funding: Funding for this research article's processing fee (APC) will be provided by the affiliated institution to support the open-access publication of this work. The funding body is not involved in the study design; collection, management, analysis and interpretation of data; or the decision to submit for publication. The funding body will be informed of any planned publications, and documentation provided.

Screening for and management of high-grade cervical intraepithelial neoplasia in Bangladesh: a cross-sectional study comparing two protocols.

AIM: To evaluate the feasibility of the 'see and treat' protocol for the management of high-grade cervical intraepithelial neoplasia (CIN) at a colposcopy clinic in Bangladesh. MATERIAL AND METHODS: A cross-sectional and comparative study was carried out between two periods on 358 colposcopy-diagnosed high-grade CIN at the colposcopy clinic of Bangabandhu Sheikh Mujib Medical University (BSMMU). During the first period (January 2005 to June 2008), 181 colposcopy-diagnosed high-grade CIN patients had cervical biopsy by punch biopsy forceps and histology-confirmed high-grade CIN were treated by loop electrosurgical excision procedure (LEEP). During the second period (July 2008 to December 2009), 177 colposcopy-diagnosed high-grade CIN were treated by LEEP at their first visit. RESULTS: During the first and second periods, 48 of 87 and 55 of 73 histology-proven high-grade CIN cases, respectively, received treatment. Among the study population, 37.3% women who had normal or CIN-I in histology were treated unnecessarily in the second period. The compliance of treatment improved by 20% and failure to receive treatment fell by 20%; these changes were statistically significant (P=0.006). CONCLUSION: 'See and treat' protocol is a well-accepted, feasible and useful option for management of high-grade CIN in Bangladesh. It reduces the number of visits to the clinic and failure to receive treatment.

Quantification of impact of COVID-19 pandemic on cancer screening programmes - a case study from Argentina, Bangladesh, Colombia, Morocco, Sri Lanka, and Thailand.

It is quite well documented that the COVID-19 pandemic disrupted cancer screening services in all countries, irrespective of their resources and healthcare settings. While quantitative estimates on reduction in volume of screening tests or diagnostic evaluation are readily available from the high-income countries, very little data are available from the low- and middle-income countries (LMICs). From the CanScreen5 global cancer screening data repository we identified six LMICs through purposive sampling based on the availability of cancer screening data at least for the years 2019 and 2020. These countries represented those in high human development index (HDI) categories (Argentina, Colombia, Sri Lanka, and Thailand) and medium HDI categories (Bangladesh and Morocco). No data were available from low HDI countries to perform similar analysis. The reduction in the volume of tests in 2020 compared to the previous year ranged from 14.1% in Bangladesh to 72.9% in Argentina (regional programme) for cervical screening, from 14.2% in Bangladesh to 49.4% in Morocco for breast cancer screening and 30.7% in Thailand for colorectal cancer screening. Number of colposcopies was reduced in 2020 compared to previous year by 88.9% in Argentina, 38.2% in Colombia, 27.4% in Bangladesh, and 52.2% in Morocco. The reduction in detection rates of CIN 2 or worse lesions ranged from 20.7% in Morocco to 45.4% in Argentina. Reduction of breast cancer detection by 19.1% was reported from Morocco. No association of the impact of pandemic could be seen with HDI categories. Quantifying the impact of service disruptions in screening and diagnostic tests will allow the programmes to strategize how to ramp up services to clear the backlogs in screening and more crucially in further evaluation of screen positives. The data can be used to estimate the impact on stage distribution and avoidable mortality from these common cancers.

Apis mellifera Solinvivirus-1, a Novel Honey Bee Virus That Remained Undetected for over a Decade, Is Widespread in the USA.

A metagenomic analysis of the virome of honey bees (Apis mellifera) from an apiary with high rates of unexplained colony losses identified a novel RNA virus. The virus, which was named Apis mellifera solinvivirus 1 (AmSV1), contains a 10.6 kb positive-strand genomic RNA with a single ORF coding for a polyprotein with the protease, helicase, and RNA-dependent RNA polymerase domains, as well as a single jelly-roll structural protein domain, showing highest similarity with viruses in the family Solinviviridae. The injection of honey bee pupae with AmSV1 preparation showed an increase in virus titer and the accumulation of the negative-strand of AmSV1 RNA 3 days after injection, indicating the replication of AmSV1. In the infected worker bees, AmSV1 was present in heads, thoraxes, and abdomens, indicating that this virus causes systemic infection. An analysis of the geographic and historic distribution of AmSV1, using over 900 apiary samples collected across the United States, showed AmSV1 presence since at least 2010. In the year 2021, AmSV1 was detected in 10.45% of apiaries (95%CI: 8.41-12.79%), mostly sampled in June and July in Northwestern and Northeastern United States. The diagnostic methods and information on the AmSV1 distribution will be used to investigate the connection of AmSV1 to honey bee colony losses.

Towards elimination of cervical cancer - human papillomavirus (HPV) vaccination and cervical cancer screening in Asian National Cancer Centers Alliance (ANCCA) member countries.

About 95% of cervical cancers worldwide are caused by human papillomavirus (HPV). Cervical cancer is preventable and curable if it is detected and treated early. We reviewed the latest national cervical cancer indicators, and barriers to HPV vaccination and cervical cancer screening in 21 Asian National Cancer Centers Alliance (ANCCA) member countries. Half (n = 11, 52%) of the countries have introduced HPV vaccination for girls as part of their national vaccination programme, three countries reported coverage of over 90%. Most ANCCA member countries have cervical cancer screening programmes, only five countries reported screening uptake of over 50%. The barriers to HPV vaccination coverage and cervical cancer screening participation have been identified. Ensuring health service accessibility and affordability for women, addressing sociocultural barriers, and strengthening the healthcare system and continuum of care are essential to increase HPV vaccination and cervical cancer screening coverage.

Seroprevalence of Treponema Pallidum antibody among pregnant population of Bangladesh.

AIM: The aim of this study was to investigate the seroprevalence of antibody to Treponema pallidum among pregnant women and its association with age, sexual behavior and socioeconomic status. MATERIALS AND METHODS: In this cross-sectional study, 1266 sera were collected from pregnant women attending Bangabandhu Sheikh Mujib Medical University and Rajshahi, Khulna and Chittagong Medical College Hospitals between February 2007 and April 2008. From each hospital, samples were collected from about a quarter of the total recruited pregnant women. Sera were tested to identify the antibody to T. pallidum using Treponema pallidum hemagglutination at the Virology Department of Bangabandhu Sheikh Mujib Medical University. Logistic regression was used to explore potential risk factors for syphilis. RESULTS: Among 1250 sera tested (16 sera were discarded due to hemolysis), 37 (2.96%) were positive for T. pallidum antibody. Higher seropositivity was associated with couples with no formal education, low socioeconomic status (P = 0.006), marriage at or before 18 years of age (P = 0.002), multiple marriages of the husband (P = 0.031) and sexual activity for more than 10 years (P = 0.007). Among these factors, low education level of women, early age of marriage and multiple marriages of the husband showed individual effects on high seropositivity to T. pallidum. CONCLUSIONS: The high seroprevalence of syphilis among pregnant women attending the antenatal clinics of these hospitals indicates the need for the incorporation of screening for syphilis in routine antenatal screening in Bangladesh. Improvement of education level in the female population, prevention of early marriage and preventing polygamy of husbands may play an important role in prevention of syphilis among women.

Human papillomavirus genotype attribution in invasive cervical cancer: a retrospective cross-sectional worldwide study.

BACKGROUND: Knowledge about the distribution of human papillomavirus (HPV) genotypes in invasive cervical cancer is crucial to guide the introduction of prophylactic vaccines. We aimed to provide novel and comprehensive data about the worldwide genotype distribution in patients with invasive cervical cancer. METHODS: Paraffin-embedded samples of histologically confirmed cases of invasive cervical cancer were collected from 38 countries in Europe, North America, central South America, Africa, Asia, and Oceania. Inclusion criteria were a pathological confirmation of a primary invasive cervical cancer of epithelial origin in the tissue sample selected for analysis of HPV DNA, and information about the year of diagnosis. HPV detection was done by use of PCR with SPF-10 broad-spectrum primers followed by DNA enzyme immunoassay and genotyping with a reverse hybridisation line probe assay. Sequence analysis was done to characterise HPV-positive samples with unknown HPV types. Data analyses included algorithms of multiple infections to estimate type-specific relative contributions. FINDINGS: 22,661 paraffin-embedded samples were obtained from 14,249 women. 10,575 cases of invasive cervical cancer were included in the study, and 8977 (85%) of these were positive for HPV DNA. The most common HPV types were 16, 18, 31, 33, 35, 45, 52, and 58 with a combined worldwide relative contribution of 8196 of 8977 (91%, 95% CI 90-92). HPV types 16 and 18 were detected in 6357 of 8977 of cases (71%, 70-72) of invasive cervical cancer. HPV types 16, 18, and 45 were detected in 443 of 470 cases (94%, 92-96) of cervical adenocarcinomas. Unknown HPV types that were identified with sequence analysis were 26, 30, 61, 67, 69, 82, and 91 in 103 (1%) of 8977 cases of invasive cervical cancer. Women with invasive cervical cancers related to HPV types 16, 18, or 45 presented at a younger mean age than did those with other HPV types (50·0 years [49·6-50·4], 48·2 years [47·3-49·2], 46·8 years [46·6-48·1], and 55·5 years [54·9-56·1], respectively). INTERPRETATION: To our knowledge, this study is the largest assessment of HPV genotypes to date. HPV types 16, 18, 31, 33, 35, 45, 52, and 58 should be given priority when the cross-protective effects of current vaccines are assessed, and for formulation of recommendations for the use of second-generation polyvalent HPV vaccines. Our results also suggest that type-specific high-risk HPV-DNA-based screening tests and protocols should focus on HPV types 16, 18, and 45.

Program organization rather than choice of test determines success of cervical cancer screening: Case studies from Bangladesh and India.

The call for elimination of cervical cancer as a public health problem by the World Health Organization has led to intense focus on the burden of disease, available resources, and the possibility of introducing efficient systems for screening and treatment that allow effective cancer control in limited-resource settings. Presently, the focus is on the introduction of rapid, technologically less-demanding, affordable HPV testing. However, until such tests become widely available, the momentum that has been gained using visual inspection with acetic acid (VIA) should not be lost. Countries with limited resources and a heavy burden of cervical cancer, such as Bangladesh and India, introduced and scaled up VIA-based programs with varying degrees of programmatic organization and performance. Despite its limitations, VIA's simplicity and affordability has allowed these countries to build infrastructure, increase numbers of trained healthcare personnel, and develop a system of multilevel coordination within the health system. Such efforts will have long-term advantages provided that countries have access to an appropriate HPV test and build on their efforts to improve program organization through a strengthened health system, translating lessons learned in program implementation, logistics, and compliance with the new paradigm.

Genotypic distribution and prevalence of human papillomavirus infection in an apparently healthy female population in Bangladesh.

Objective: Human papillomavirus (HPV) comprises around 120 genotypically related viruses, classified into low- and high-risk HPVs, which are capable of replicating inside the keratinocytes of skin or mucous membranes. Studies suggest that infections with HPV-16 or HPV-18 have a higher rate of developing cancer. The aim of our study was to detect HPV early, and to estimate the genotype-specific prevalence of HPV in apparently healthy and asymptomatic females in Bangladesh. Method: After cervical swab specimen collection, a VIA test was performed to identify any type of abnormality in the cervix. A multiplex PCR amplification of HPV DNA, using L1 consensus primer systems, was performed with type-specific primers, followed by sequencing to detect HPV genotypes. Result: Of the 417 females, 121 were found to be HPV positive. The most prevalent high-risk HPV genotypes were found to be HPV-16 and HPV-18. Different patient demographic parameters, such as age, socioeconomic status, education, and history of first intercourse, were also studied to establish correlations with HPV infection. Conclusion: Our results might provide some insights into factors that influence the development of cervical cancer. They might also help in guiding better patient management, increased public health awareness, further testing, and the implementation of existing vaccines.

Evaluation of the National Cervical Cancer Screening Programme of Bangladesh and the formulation of quality assurance guidelines.

UNLABELLED: BACKGROUND/METHODOLOGY: External quality assurance for the National Cervical Cancer Screening Programme of Bangladesh was done in June 2008 by the United Nations Population Fund (UNFPA). The programme, initiated in 2004, has set up screening facilities in 44 districts of Bangladesh. Women aged over 29 years are screened using visual inspection after acetic acid application (VIA) by trained paramedics. Independent consultants not involved in strategic planning or implementation of the programme were engaged to review the ongoing activities. They visited different service delivery set-ups, collected data using a structured proforma, interviewed the service providers, and held discussions with the programme managers. This paper summarises the observations and recommendations of the experts performing the quality control process. RESULTS/CONCLUSIONS: The consultants observed that the programme was based on largely opportunistic screening with good central co-ordination and some elements of organised screening. The coverage of the target population at the end of 4 years was very low. The compliance to colposcopy was good, though nearly half of the patients with high-grade precancers did not receive treatment. Cryotherapy was infrequently used and a 'see and treat' policy was rarely followed. No strategy for internal monitoring and quality control was built into the programme. The reviewers enumerated the quality assurance standards at various levels of service delivery based on which the performance assessment can be done periodically. This is the first evaluation report of a VIA-based national cervical screening programme.

Influence of Demographic and Reproductive Factors on Cervical Pre-Cancer and Cancer in Bangladesh.

BACKGROUND: In Bangladesh, cervical cancer (CC) is the 2nd most common cancer with estimated 8068 new cases and 5,214 deaths every year. It is also revealed that different socio-demographic factors have association with CC. This study was performed to evaluate the colposcopy outcomes and the association of different demographic and reproductive risk factors with cervical pre-cancer and cancer. METHODS: This retrospective cross-sectional study was carried out at the colposcopy clinic of Bangabandhu Sheikh Mujib Medical University (BSMMU) between January 2010 and December 2016. RESULTS: A total 16147 women attended the colposcopy clinic of BSMMU with VIA positive reports. Among them, 65.73% women were referred from different VIA centers of Dhaka district. Mean age of marriage of the subjects was 16. 93 (± 1) and mean age of 1st delivery was 18.45 years (± 4.10). Almost three-fourth of them were married before 18 years and had their 1st delivery by 20 years. Colposcopy examination of the VIA positive women revealed that 36.7% had CINI, 10.6% had CINII/ III and 7.1% had carcinoma of cervix. Considering CIN as disease the Sensitivity, Specificity, PPV and NPV of colposcopy were found 99.7%, 75.3%, 70.3% and 99.8% respectively. On other hand considering CIN2+ as disease the Sensitivity, Specificity, PPV and NPV of colposcopy were found 73.8%, 92.7%, 64.4% and 95.2% respectively. Statistical analysis revealed that higher age (p=0.000), lower level of education (p=0.007), lower socioeconomic status (p=0.014), higher parity (p=0.001) had individual influence on cervical pre-cancer and cancer. CONCLUSIONS: This study indicated higher age, low level of education, lower socio-economic condition and higher parity as most important socio-demographic factors for developing cervical pre-cancer and cancer in Bangladesh.

Scaling up proven innovative cervical cancer screening strategies: Challenges and opportunities in implementation at the population level in low- and lower-middle-income countries.

The problem of cervical cancer in low- and lower-middle-income countries (LLMICs) is both urgent and important, and calls for governments to move beyond pilot testing to population-based screening approaches as quickly as possible. Experiences from Zambia, Bangladesh, Guatemala, Honduras, and Nicaragua, where scale-up of evidence-based screening strategies is taking place, may help other countries plan for large-scale implementation. These countries selected screening modalities recommended by the WHO that are within budgetary constraints, improve access for women, and reduce health system bottlenecks. In addition, some common elements such as political will and government investment have facilitated action in these diverse settings. There are several challenges for continued scale-up in these countries, including maintaining trained personnel, overcoming limited follow-up and treatment capacity, and implementing quality assurance measures. Countries considering scale-up should assess their readiness and conduct careful planning, taking into consideration potential obstacles. International organizations can catalyze action by helping governments overcome initial barriers to scale-up.

Recent spread of Varroa destructor virus-1, a honey bee pathogen, in the United States.

RNA viruses impact honey bee health and contribute to elevated colony loss rates worldwide. Deformed wing virus (DWV) and the closely related Varroa destructor virus-1 (VDV1), are the most widespread honey bee viruses. VDV1 is known to cause high rates of overwintering colony losses in Europe, however it was unknown in the United States (US). Using next generation sequencing, we identified VDV1 in honey bee pupae in the US. We tested 603 apiaries the US in 2016 and found that VDV1 was present in 66.0% of them, making it the second most prevalent virus after DWV, which was present in 89.4% of the colonies. VDV1 had the highest load in infected bees (7.45*1012 ± 1.62*1012 average copy number ± standard error) compared to other tested viruses, with DWV second (1.04*1012 ± 0.53*1012). Analysis of 75 colonies sourced in 2010 revealed that VDV1 was present in only 2 colonies (2.7%), suggesting its recent spread. We also detected newly emerged recombinants between the US strains of VDV1 and DWV. The presence of these recombinants poses additional risk, because similar VDV1-DWV recombinants constitute the most virulent honeybee viruses in the UK.