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Abstract Background Cervical cancer is the fourth most frequent cancer among women, with 90% of cervical cancer-related deaths occurring in low- and middle-income countries like Cameroon. Visual inspection with acetic acid is often used in low-resource settings to screen for cervical cancer; however, its accuracy can be limited. To address this issue, the Swiss Federal Institute of Technology Lausanne and the University Hospitals of Geneva are collaborating to develop an automated smartphone-based image classifier that serves as a computer aided diagnosis tool for cancerous lesions. The primary objective of this study is to explore the acceptability and perspectives of women in Dschang regarding the usage of a screening tool for cervical cancer relying on artificial intelligence. A secondary objective is to understand the preferred form and type of information women would like to receive regarding this artificial intelligence-based screening tool. Methods A qualitative methodology was employed to gain better insight into the women’s perspectives. Participants, aged between 30 and 49 were invited from both rural and urban regions and semi-structured interviews using a pre-tested interview guide were conducted. The focus groups were divided on the basis of level of education, as well as HPV status. The interviews were audio-recorded, transcribed, and coded using the ATLAS.ti software. Results A total of 32 participants took part in the six focus groups, and 38% of participants had a primary level of education. The perspectives identified were classified using an adapted version of the Technology Acceptance Model. Key factors influencing the acceptability of artificial intelligence include privacy concerns, perceived usefulness, and trust in the competence of providers, accuracy of the tool as well as the potential negative impact of smartphones. Conclusion The results suggest that an artificial intelligence-based screening tool for cervical cancer is mostly acceptable to the women in Dschang. By ensuring patient confidentiality and by providing clear explanations, acceptance can be fostered in the community and uptake of cervical cancer screening can be improved. Trial registration Ethical Cantonal Board of Geneva, Switzerland (CCER, N°2017–0110 and CER-amendment n°4) and Cameroonian National Ethics Committee for Human Health Research (N°2022/12/1518/CE/CNERSH/SP). NCT: 03757299.

Abstract Objective To determine whether knowledge of cytology affects the colposcopist’s diagnostic accuracy in the identification of cervical intraepithelial neoplasia grade 2 and worse (≥ CIN2). Method In this cross-over study, healthcare professionals interpreted colposcopy images from 80 patient cases with known histological diagnoses. For each case, 2 images taken with a colposcope were provided (native and after acetic acid application). Inclusion criteria consisted of women with a transformation zone type 1 or 2, who had both a cytological and histological diagnosis. Cases were distributed across two online surveys, one including and one omitting the cytology. A wash-out period of six weeks between surveys was implemented. Colposcopists were asked to give their diagnosis for each case as

Clear cell carcinoma is a rare and very aggressive subset of cervical cancer, with poor outcome if diagnosed at advanced stage. There are few data available on the optimal management of this histotype, and treatment recommendations that include surgery and chemoradiotherapy, are essentially based on those for squamous cell carcinoma. Here we report the case of a young patient newly diagnosed with advanced stage (FIGO IIB) clear cell carcinoma of the uterine cervix who received a window of opportunity one injection of nivolumab followed by standard chemoradiotherapy. She showed a persistent complete remission after 28 months of follow-up, but developed hypothyroidism, as a consequence of immunotherapy, and required lifelong thyroid hormone replacement.

Abstract Background Screening participation at recommended intervals is a crucial component of cervical cancer prevention effectiveness. However, little is known regarding the rate of re-screening in a Sub-Saharan context. This study aimed to estimate the re-screening rate of women in a semi-rural after an initial HPV-based screening and identify factors that influence adherence. Methods This cohort study at the Annex Regional Hospital of Dschang enrolled women screened for cervical cancer over 5 years ago and due for re-screening. Women who initially tested HPV-positive (n = 132) and a random sample of HPV-negative women (n = 220) participated in a telephone survey between October 2021 and March 2022 to assess re-screening participation and reasons. Sociodemographic factors were collected, and associations with rescreening were evaluated. Results A total of 352 participants aged under 50 years (mean age 37.4 years) were contacted, and 203 (58.0%) completed the survey. The proportion of women who complied with the screening recommendation was 34.0% (95% CI 27.5% − 40.5%), The weighted re-screening proportion was 28.4%. Age, marital status, education level, type of employment, and place of residence were not associated with the rate of re-screening. Main reported barriers to re-screening were lack of information (39.0%), forgetfulness (39.0%), and impression of being in good health (30.0%). Women who remembered the recommended screening interval were 2 to 3 times more likely to undergo re-screening (aOR (adjusted odds ratio) = 2.3 [1.2–4.4], p = 0.013). Human papilloma virus- positive status at the initial screening was also associated with the re-screening((aOR) (95% CI): 3.4 (1.8–6.5). Conclusion Following an initial Human Papilloma Virus-based screening campaign in the West Region of Cameroon, one third of women adhered to re-screening within the recommended timeframe. Existing screening strategies would benefit from developing better information approaches to reinforce the importance of repeated cervical cancer screening.

Introduction Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) has already proven its non-inferiority to conventional abdominal laparoscopy (CAL) for hysterectomy without conversion. The results in terms of efficacy and safety are promising. However, we note a lack of medical literature and no specific randomised controlled trial assessing women’s sexual function after vNOTES for benign adnexal surgery. The aim of this RCT is to confirm the non-inferiority of the vNOTES approach for benign adnexal pathology compared with CAL on women’s sexual function. Secondary outcomes will evaluate vNOTES’s efficiency, morbidity and postoperative complications compared with CAL for benign adnexal surgery. The relationship between adnexal mass morcellation and the quality of the histological analysis will also be evaluated as secondary outcome.Methods and analysis Women aged 18–70 years undergoing a benign adnexal surgery at the Geneva University Hospitals will be eligible and randomised with a 1:1 ratio to the CAL arm or the vNOTES arm, if inclusion criteria are met. Participants will complete the Female Sexual Function Index, the Couple Satisfaction Index-16 and a self-reported questionnaire on dyspareunia within 4 weeks prior to randomisation and at 3+6 months after surgery. General and clinical data will be collected when the patient is enrolled in the study, during hospitalisation and at 1 month postoperative to assess secondary outcomes.An absence of impairment on sexual function will be confirmed with a stability or an improvement of the evaluated scores in each group at 3 and 6 months postoperative compared with the preoperative scores. We expect to have no statistically significant difference in sexuality questionnaires scores between the two groups.Ethics and dissemination Protocol of this study was validated by the Cantonal Research Ethics Commission of Geneva, Switzerland, on 9 August 2022. We aim to publish the study’s results in peer-reviewed journals within 3 years.Trial registration number NCT05761275.

Abstract Background In low-resource countries, interpretation of the transformation zone (TZ) using the classification of the International Federation for Cervical Pathology and Colposcopy (IFCPC), adopted by the World Health Organization, is critical for determining if visual inspection with acetic acid (VIA) screening and thermal ablation treatment are possible. We aim to assess inter- and intra-observer agreement in TZ interpretation. Methods We performed a prospective multi-observer reliability study. One hundred cervical digital images of Human papillomavirus positive women (30–49 years) were consecutively selected from a Cameroonian cervical cancer screening trial. Images of the native cervix and after VIA were obtained. The images were evaluated for the TZ type at two time points (rounds one and two) by five VIA experts from four countries (Côte d’Ivoire, Cameroon, Peru, and Zambia) according to the IFCPC classification (TZ1 = ectocervical fully visible; TZ2 = endocervical fully visible; TZ3 = not fully visible). Intra- and inter-observer agreement were measured by Fleiss’ kappa. Results Overall, 37.0% of images were interpreted as TZ1, 36.4% as TZ2, and 26.6% as TZ3. Global inter-observer reliability indicated fair agreement in both rounds (kappa 0.313 and 0.288). The inter-observer agreement was moderate for TZ1 interpretation (0.460), slight for TZ2 (0.153), and fair for TZ3 (0.329). Intra-observer analysis showed fair agreement for two observers (0.356 and 0.345), moderate agreement for two other (0.562 and 0.549), and one with substantial agreement (0.728). Conclusion Interpretation of the TZ using the IFCPC classification, adopted by the World Health Organization, is critical for determining if VIA screening and thermal ablation treatment are possible. However, the low inter- and intra-observer agreement suggest that the reliability of the referred classification is limited in the context of VIA. It’s integration in treatment recommendations should be used with caution since TZ3 interpretation could lead to an important referral rate for further evaluation. Trial registration Cantonal Ethics Board of Geneva, Switzerland: N°2017–0110. Cameroonian National Ethics Committee for Human Health Research N°2018/07/1083/CE/CNERSH/SP.

Abstract Background Polyploid giant cancer cells (PGCCs) have been observed in epithelial ovarian tumors. They can resist antimitotic drugs, thus participating in tumor maintenance and recurrence. Although their origin remains unclear, PGCC formation seems to be enhanced by conditions that trigger the unfolded protein response (UPR) such as hypoxia or chemotherapeutic drugs like paclitaxel. Hypoxia has been shown to promote the formation of ovarian PGCCs by cell fusion. We thus hypothesized that the UPR could be involved in EOC cell fusion, possibly explaining the occurrence of PGCCs and the aggressiveness of EOC. Methods The UPR was induced in two ovarian cancer cell lines (SKOV3 and COV318). The UPR activation was assessed by Western blot and polyploidy indexes were calculated. Then, to confirm the implication of cell fusion in PGCC formation, two populations of SKOV3 cells were transfected with plasmids encoding for two distinct nuclear fluorescent proteins (GFP and mCherry) associated with different antibiotic resistance genes, and the two cell populations were mixed in co-culture. The co-culture was submitted to a double-antibiotic selection. The resulting cell population was characterized for its morphology, cyclicity, and proliferative and tumorigenic capacities, in addition to transcriptomic characterization. Results We demonstrated that cell fusion could be involved in the generation of ovarian PGCCs and this process was promoted by paclitaxel and the UPR activation. Double-antibiotic treatment of PGCCs led to the selection of a pure population of cells containing both GFP- and mCherry-positive nuclei. Interestingly, after 3 weeks of selection, we observed that these cells were no longer polynucleated but displayed a single nucleus positive for both fluorescent proteins, suggesting that genetic material mixing had occurred. These cells had reinitiated their normal cell cycles, acquired an increased invasive capacity, and could form ovarian tumors in ovo. Conclusions The UPR activation increased the in vitro formation of PGCCs by cell fusion, with the newly generated cells further acquiring new properties. The UPR modulation in ovarian cancer patients could represent an interesting therapeutic strategy to avoid the formation of PGCCs and therefore limit cancer relapse and drug resistance.

Plain Language Summary Cervical cancer is the second leading cause of cancer-related death among women in Cameroon. This is mainly due to the absence of routine cervical cancer screening programs and the lack of treatment. However, even in case of availability of cervical cancer screening programs, barriers exist. Therefore, community healthcare workers have been involved successfully to increase the screening coverage. As retention of these actors remains a challenge, the main objective of this study was to identify key factors affecting their motivation aiming to suggest interventions to address motivational factors. 11 qualitative interviews with individual community healthcare workers were conducted at a cervical cancer screening program in Dschang, Cameroon. Motivation was generally high and affecting factors were divided into the individual and the environmental level. Factors with a positive influence on motivation were mainly on the individual side while impeding factors were mainly associated with the environmental level. Ongoing collaboration with community healthcare workers is beneficial for cervical cancer screening programs, and key interventions should therefore include: (i) more training and supportive supervision; (ii) evaluation of remuneration systems by workload; and (iii) provision of job-enabling resources such as uniforms, cellphone cards and transport.

Uterine leiomyoma is the most common benign tumour of the uterus in women of reproductive age. When removed surgically, a mini-invasive procedure is preferentially used (laparoscopic or robotic) and the extraction of the specimen can be managed by power morcellation. In this consecutive case-series, we present three cases of parasitic leiomyoma that appeared following previous surgical management of leiomyoma using the technique of laparoscopic myomectomy with uncontained power morcellation. The time frame in between the initial surgery and the diagnosis of the parasitic leiomyoma was 5.7 years. All three patients were diagnosed with endometriosis: 2 cases prior to the initial surgery and 1 case after the initial surgery. One hypothesis could be that, due to pelvic inflammation, endometriosis is a risk factor for iatrogenic parasitic leiomyoma development in case of uncontained morcellation of leiomyoma during myomectomy.

PURPOSEThermal ablation (TA) has become the conventional method for treatment of precancerous cervical lesions in low-resource settings. After TA, both the squamocolumnar junction (SCJ) and the transformation zone (TZ) may be subject to change. Our aim was to evaluate SCJ and TZ variability after TA.METHODSStudy data were collected in a large prospective trial of a cervical cancer screening campaign in Cameroon. For each patient, two sets of cervical photos (native and with acetic acid) were taken before and 6-12 months after TA. The SCJ and TZ were evaluated independently by three observers according to the WHO nomenclature. When discordances were observed between the type of TZ and SCJ selected by each observer, a corrected TZ was established on the basis of the SCJ categorization. Interobserver agreement for TZ interpretation was evaluated using Cohen's kappa coefficient for agreement between two observers and Fleiss' kappa between three observers.RESULTSFifty consecutive participants were included in the analysis. Seventy-six percent were interpreted as TZ1-2, and 24% as TZ3 before TA. In 56% of cases, the entire SCJ could not be entirely visualized after TA, thus being recategorized as TZ3. Interobserver agreement was fair for diagnosis before TA (Kappa coefficient, 0.34; 95% CI, 0.27 to 0.45) and moderate for diagnosis after TA (Kappa coefficient, 0.40; 95% CI, 0.30 to 0.50). After TA, 36% progressed from TZ1-2 to TZ3, with a moderate interobserver agreement (Kappa coefficient, 0.44; 95% CI, 0.40 to 0.54).CONCLUSIONWe observed a shift of the SCJ into the endocervical canal after TA. A significant proportion of participants had TZ 3 after treatment, raising the question of visual inspection with acetic acid's applicability as a first-line follow-up examination method after TA.

Pigment epithelium-derived factor (PEDF) is a secreted glycoprotein involved in various biological processes. Its expression declines during ovarian carcinogenesis where it could decrease macrophages polarization, inhibit angiogenesis and induce apoptosis. Altogether, PEDF represents an ideal anti-cancer agent against ovarian cancer. We previously proposed the non-viral Sleeping Beauty transposon (SBT) system to stably integrate the PEDF transgene into ovarian cancer cells. Here, we report the development of liposomes and lipid nanoparticles for SBT-PEDF gene therapy. We determined that the SBT-PEDF nanolipid delivery system was the best system to increase the expression of PEDF in ovarian cancer spheroids. We also developed an ex vivo model of ovarian tumors which allowed us to show that nanolipoplexe in combination to paclitaxel exhibits synergistic and effective anti-tumor efficacy on ovarian tumors. These findings demonstrate that lipid nanoparticle for SBT-PEDF gene therapy may be a promising therapeutic approach for ovarian cancer.

Abstract Objectives The World Health Organization’s (WHO) global strategy for cervical cancer elimination has set the target of 70% of women screened in all countries by 2030. Community sensitization through media is often used, but community health workers’ (CHW) involvement may contribute to improving screening coverage. We aimed to assess effectiveness and costs of two cervical cancer screening recruitment strategies conducted in a low-resource setting. Methods The study was conducted in the West Region of Cameroon, in the Health District of Dschang, a community of 300,000 inhabitants. From September 2018 to February 2020, we recruited and screened women for cervical cancer in a single-visit prevention campaign at Dschang District Hospital. During the first 9 months, recruitment was only based on Community Information Channels (CIC) (e.g.. street banners). From the tenth month, participation of CHW was added in the community after training for cervical cancer prevention counselling. Population recruitment was compared between the two strategies by assessing the number of recruited women and direct costs (CHW costs included recruitment, teaching, certification, identification badge, flyers, transport, and incentives). The intervention’s cost-effectiveness was expressed using an incremental cost-effectiveness ratio (ICER). Results and discussion During the period under study, 1940 women were recruited, HPV positive rate was 18.6% (n = 361) and 39 cases of cervical intraepithelial neoplasia grade 2 or worse (CIN2+) were diagnosed. Among included participants, 69.9% (n = 1356) of women were recruited through CIC as compared to 30.1% (n = 584) by CHW. The cost per screened woman and CIN2+ diagnosed was higher in the CHW group. The ICER was 6.45 USD or 16.612021Int’l$ per screened woman recruited by CHW. Recruitment in rural areas increased from 12.1 to 61.4% of all women included between CIC-led and CHW-led interventions. These outcomes highlight the importance of training, preparing, and deploying CHW to screen hard-to-reach women, considering that up to 45% of Cameroon’s population lives in rural areas. Conclusion CHW offer an important complement to CIC for expanding coverage in a sub-Saharan African region such as the West Region of Cameroon. CHW play a central role in building awareness and motivation for cervical cancer screening in rural settings.

Abstract Background The World Health Organization recommends thermal ablation as an alternative to cryotherapy to treat women with precancerous lesions in low-resource settings. However, limited data are available on women’s experience and adverse events (AEs) of the procedure in the context of Sub-Saharan Africa. The objective of this study was to evaluate the acceptability and safety of thermal ablation in women screened positive for precancerous cervical lesions. Methods Asymptomatic women aged 30–49 years old living in the Dschang Health District were invited to participate in a cervical cancer screening campaign termed “3 T-Approach” (for Test-Triage and Treat). Recruited women were asked to perform HPV self-sampling followed by triage with visual assessment and treatment with thermal ablation if required. After treatment and 4–6 weeks later, interviews were conducted to assess women’s experience on anxiety, discomfort, and pain during thermal ablation. AEs were recorded on pre-defined electronic forms 4–6 weeks after treatment to assess the procedure’s safety. Results Between September 2018 and December 2020, 399 HPV-positive women (18.7% of women screened) were recruited, 236 (59.1%) had a positive visual assessment, 234 were treated by thermal ablation and 198 (84.6%) received therapy in the same visit. Treatment was not considered as painful (score ≤ 4/10) by 209 (90.9%) patients while 5 (2.5%) reported high pain (score 8–10/10). During post-treatment interviews 4–6 weeks later, most reported AEs were graded mild or moderate (grade I-II). The most frequent symptoms reported as mild AEs (grade 1–2) were vaginal watery discharge (75.5%), vaginal bloody-stained discharge (21.5%) and malodourous discharge (14.5%). None of the participants experienced serious AEs (grade 3–4) or AEs requiring admission to hospital or emergency consultation. The vast majority of women (99.6%) would agree to repeat the procedure if necessary and (99.6%) would recommend it to friends or family. Conclusion Thermal ablation is widely accepted by women and appears as a safe procedure. It may contribute to improving the link between screening and treatment in a single visit and to optimizing cervical cancer control in low-resource settings. Trial registration The study was registered on clinicaltrials.gov ( NCT03757299 ) in November 2018 (28/11/2018).

Introduction Intraperitoneal dissemination is a major problem resulting in very poor prognosis and a rapid marked deterioration in the quality of life of patients. Pressurised intraperitoneal aerosol chemotherapy (PIPAC) is an emergent laparoscopic procedure aiming to maximise local efficacy and to reduce systemic side effects.Methods and analysis Nab-PIPAC, a bicentre open-label phase IB, aims to evaluate safety of nab-paclitaxel and cisplatin association using in patients with peritoneal carcinomatosis (PC) of gastric, pancreatic or ovarian origin as ≥1 prior line of systemic therapy. Using a 3+3 design, sequential intraperitoneal laparoscopic application of nab-paclitaxel (7.5, 15, 25, 37.5, 52.5 and 70 mg/m2) and cisplatin (10.5 mg/m2) through a nebuliser to a high-pressure injector at ambient temperature with a maximal upstream pressure of 300 psi. Treatment maintained for 30 min at a pressure of 12 mm Hg and repeated4–6 weeks intervals for three courses total.A total of 6–36 patients are expected, accrual is ongoing. Results are expected in 2024.The primary objective of Nab-PIPAC trial is to assess tolerability and safety of nab-paclitaxel and cisplatin combination administered intraperitoneally by PIPAC in patients with PC of gastric, pancreatic or ovarian origin. This study will determine maximum tolerated dose and provide pharmacokinetic data.Ethic and dissemination Ethical approval was obtained from the ethical committees of Geneva and Vaud (CCER-2018-01327). The study findings will be published in an open-access, peer-reviewed journal and presented at relevant conferences and research meetings.Trial registration number NCT04000906.

Objective To explore the utility of extended Human Papillomavirus (HPV) genotyping to detect cervical intraepithelial neoplasia grade 2 or more (CIN2+) in a ‘screen-and-treat’ strategy for HPV-positive women in low-resource settings.Design Prospective study of diagnostic accuracy.Setting The study took place in West Cameroon between September 2018 and March 2020.Participants 2014 women were recruited. Asymptomatic, non-pregnant women aged 30–49 years without history of CIN treatment, anogenital cancer or hysterectomy were eligible.Interventions Participants performed self-sampling for HPV testing with GeneXpert followed by visual inspection with acetic acid and Lugol’s iodine (VIA) triage before treatment if required.Main outcome measures Liquid-based cytology, biopsies and endocervical brushing were performed in HPV-positive women as quality control. We assessed the detection rate of CIN2+ by HPV genotyping (two pools of genotypes obtained from the Xpert system, pool_1 (HPV 16, 18, 45) and pool_2 (HPV 16, 18, 45, 31, 33, 35, 52, 58)), VIA and cytology.Results 382 (18.2%) women were HPV-positive among which 11.5% (n=44) were CIN2+. Of those 44 participants, 41 were triaged positive by extended genotyping, versus 35 by VIA and 33 by cytology. Overall, triage positivity was of 68.4% for extended genotyping, 59.3% for VIA and 14.8% for cytology, with false positive rates of 83.4%, 84.1% and 37.7%, respectively. Extended genotyping had a higher sensitivity for CIN2+ detection (93.2%, CI: 81.3 to 98.6) than VIA (79.5%, CI: 64.7 to 90.2, p=0.034) and cytology (75.0%, CI: 59.7 to 86.8, p=0.005). No significant difference was observed in the overtreatment rate in triaged women by extended genotyping or VIA (9.9%, CI: 8.6 to 11.3, and 8.8%, CI: 7.7 to 10.1), with a ratio of 6.0 and 6.3 women treated per CIN2+ diagnosed.Conclusion Triage of HPV-positive women with extended HPV genotyping improves CIN2+ detection compared with VIA with a minor loss of specificity and could be used to optimize the management of HPV-positive women.Trial registration number NCT03757299.

Human papillomavirus (HPV) testing is replacing cytological screening for cervical cancer. Our aim was to assess the expected benefits and harms of different cervical screening strategies. This study is sub-analysis of a previous cost-effectiveness study with a target population of unscreened women without cervical cancer aged ≥ 25 years. A recursive decision-tree with one-year cycles was used to model the life-long natural HPV history. Markov cohort simulations were used to assess the expected outcomes from the model. The outcomes of three strategies were compared with the absence of screening: HPV-testing on self-collected vaginal samples (Self-HPV) followed by colposcopy (Self-HPV/colpo), Self-HPV and triage with cytology (Self-HPV/PAP), cytology and triage with HPV (PAP/HPV). All screening strategies resulted in reductions in cancer cases and deaths. Self-HPV strategies were associated with a lower cancer incidence and mortality life-long, not only when performed every 3 years but also when Self-HPV was performed every 5 years vs cytology every 3 years. The gain in life expectancy obtained was 82 days with Self-HPV/colpo, 81 days with Self-HPV/PAP and 75 days with PAP/HPV compared to no screening. The number of lifetime total visits was greater with PAP/HPV compared with the Self-HPV strategies (13.13 vs

Plain Language Summary Cervical cancer is the second leading cause of cancer-related death among women in sub-Saharan countries, constituting a major public health concern. In Cameroon, cervical cancer ranks as the second most common type of cancer among women and is the leading cause of cancer-related deaths, mainly due to the lack of prevention measures, such as cervical cancer screening. The main aim of the current study was to understand barriers that affect women’s decision-making processes regarding participation in a cervical cancer screening program in the Dschang district in West Cameroon. A qualitative study methodology using focus group discussions was conducted from February to March 2020. Female participants aged between 30 and 49 years and their male partners were invited to participate. In total, six discussion groups with 43 participants (31 women and 12 men) were conducted. The most important barriers were a lack of health literacy, limited access to the program because of cost and distance, and disrespectful treatment by healthcare workers. Our results identified three key areas for improvement: first, increasing health literacy; second, providing cervical cancer screening in rural areas; and third, training healthcare providers and community healthcare workers in better patient-provider-communication.

Visual inspection with acetic acid (VIA) is one of the methods recommended by the World Health Organization for cervical cancer screening. VIA is simple and low-cost; it, however, presents high subjectivity. We conducted a systematic literature search in PubMed, Google Scholar and Scopus to identify automated algorithms for classifying images taken during VIA as negative (healthy/benign) or precancerous/cancerous. Of the 2608 studies identified, 11 met the inclusion criteria. The algorithm with the highest accuracy in each study was selected, and some of its key features were analyzed. Data analysis and comparison between the algorithms were conducted, in terms of sensitivity and specificity, ranging from 0.22 to 0.93 and 0.67 to 0.95, respectively. The quality and risk of each study were assessed following the QUADAS-2 guidelines. Artificial intelligence-based cervical cancer screening algorithms have the potential to become a key tool for supporting cervical cancer screening, especially in settings where there is a lack of healthcare infrastructure and trained personnel. The presented studies, however, assess their algorithms using small datasets of highly selected images, not reflecting whole screened populations. Large-scale testing in real conditions is required to assess the feasibility of integrating those algorithms in clinical settings.

Objectives A simple system for visual inspection with acetic acid assessment, named ABCD criteria, has been developed to increase accuracy for triaging of high-risk human papillomavirus (HPV)-positive women. This study aimed to determine the accuracy of ABCD criteria for the detection of histologically confirmed cervical intraepithelial neoplasia grade two or worse (CIN2+) in HPV-positive women living in a low-resource setting.Design Prospective study of diagnostic accuracy.Setting Cervical cancer screening programme based on a 3T-Approach (test, triage and treat) in the Health District of Dschang, West Cameroon.Participants Asymptomatic non-pregnant women aged 30–49 years were eligible to participate. Exclusion criteria included history of CIN treatment, anogenital cancer or hysterectomy. A total of 1980 women were recruited (median age, 40 years; IQR 35–45 years), of whom 361 (18.4%) were HPV-positive and 340 (94.2%) completed the trial.Interventions HPV-positive women underwent a pelvic examination for visual assessment of the cervix according to ABCD criteria. The criteria comprised A for acetowhiteness, B for bleeding, C for colouring and D for diameter. The ABCD criteria results were codified as positive or negative and compared with histological analysis findings (reference standards).Primary outcome measure Diagnostic performance of ABCD criteria for CIN2+, defined as sensitivity, specificity, negative and positive predictive values.Results ABCD criteria had a sensitivity of 77.5% (95% CI 61.3% to 88.2%), specificity of 42.0% (95% CI 36.5% to 47.7%), positive predictive value of 15.1% (95% CI 10.8% to 20.8%), and negative predictive value of 93.3% (95% CI 87.6% to 96.5%) for detection of CIN2 +lesions. Most (86.7%) of the ABCD-positive women were treated on the same day.Conclusions ABCD criteria can be used in the context of a single-visit approach and may be the preferred triage method for management of HPV-positive women in a low-income context.Trial registration number NCT03757299.

BackgroundDeveloping human resource capacity and efficient deployment of skilled personnel are essential for cervical cancer screening program implementation in resource-limited countries. Our aim was to provide a context-specific training framework, supervision, and effectiveness evaluation of health care providers in a cervical cancer screening program.MethodsA 5-year cervical cancer screening program was implemented in Dschang, West Cameroon. Women were invited to perform human papillomavirus self-sampling (Self-HPV), followed by triage using visual inspection with acetic acid (VIA) and thermal ablation if needed. Health care providers were trained in four key learning phases to perform counseling, screening, and treatment process in a single visit. Training included (i) a 3-day basic course, (ii) 3-day advanced practical training, (iii) 2 weeks of supervision, and (iv) bi-monthly supervision by a mentor. The diagnostic performance of health care providers was compared between two time periods, period I (September 2018 to April 2019) and period II (May 2019 to January 2020), for an overall 17-month study period.ResultsFourteen health care providers were recruited for the training course and 12 of them completed the training objectives. Follow-up and evaluations were conducted for three health care providers working in the screening unit at Dschang District Hospital. During the study period, 1,609 women performed Self-HPV, among which 759 were screened during period I and 850 during period II. HPV positivity was 18.2 and 17.1%, and VIA positivity was 45.7 and 71.0% in period I and II, respectively. VIA sensitivity was 60.0% (95% confidence interval [CI] 26.2–87.8) and 80.8% (95% CI 60.6–93.4) in period I and II, respectively (p = 0.390). VIA specificity decreased between period I (57.4, 95% CI 48.1–66.3) and II (30.8, 95% CI 22.6–40.0) (p < 0.001). Health care providers demonstrated substantial agreement with their mentor in their diagnoses during both periods (period I: Cohen's kappa coefficient [k] = 0.73, 95% CI 0.62–0.85, and period II: k = 0.62 0.47–0.76; p = 0.0549).DiscussionTraining, supervision, and a focus on effectiveness in cervical cancer screening are interventions that contribute to improving frontline provider competencies and maintaining a high quality of health care service delivery.

Abstract Option recommended by World Health Organization (WHO) includes human papillomavirus (HPV) primary screening followed by visual inspection with acetic acid (VIA) triage. We implemented a program based on a 3T‐approach (Test‐Triage and Treat). Our objective was to verify the effectiveness of the program by defining a set of performance indices. A sensitization campaign was performed in Dschang (Cameroon) and women aged 30‐49 years were invited to participate for screening based on the 3T‐approach. Participants performed HPV self‐sampling (Self‐HPV), analyzed with the point‐of‐care Xpert HPV assay followed by VIA/VILI triage and treatment if required. Key performance indicators (KPIs) for screening, diagnosis, treatment and follow‐up were defined, and achievable targets were described for which the approach is likely to be running optimally. A total of 840 women with a mean age of 39.4±5.9 years participated. The KPIs included (i) the screening rate (8.4% at 7 months, target =20% at 12 months), (ii) HPV positivity rate (19.8%, expected range 18‐25%), (iii) compliance to referral to VIA/VILI and complete test (100%, target >90%), (iv) compliance to referral to thermal ablation (100%, target >90%), (v) VIA/VILI positivity rate (50.6%, expected range 45‐55%), (vi) a single visit from diagnostic to treatment (79.8%, target >80%), (vii) compliance to follow‐up at 1 month (96.4%, target >80%) and (viii) at 6 months (70.6%, target >80%). Program performance based on the single‐visit 3T‐approach corresponded to defined targets and preliminary results support adequateness of KPIs for periodic monitoring.

Abstract Background Extrauterine leiomyomata is an uncommon lesion that can lead to several problems of differential diagnosis, especially when localized in the external genitalia. There are few reports in the English literature and a novel association with Alport’s syndrome has been investigated since the 1980s. Case presentation Here, we describe the case of a premenopausal woman who presented with an indolent swelling of the right interlabial fossa that resulted in a Bartholin cyst. In addition to this cyst, a benign leiomyoma of the right side of the clitoris was also found and removed. Our patient refused any further examination, although she was informed that genetic counselling could be organized to rule out an association with Alport’s syndrome. Conclusions Extrauterine leiomyomata localized in the external genitalia is an uncommon lesion arising from smooth muscle cells around vascular epithelium or erectile tissue. Since an association between extrauterine leiomyomata and Alport’s syndrome has been described, genetic testing can be proposed to these patients. Upper intestinal tract symptoms such as dysphagia should prompt a gastroenterological evaluation as an association with an esophageal leiomyomatosis has been described.

BackgroundWorld Health Organization guidelines for cervical cancer screening recommend HPV testing followed by visual inspection with acetic acid (VIA) for triage if HPV positive. In order to improve visual assessment and identification of cervical intraepithelial neoplasia grade 2 and worse (CIN2+), providers may use visual aids such as digital cameras.ObjectivesTo determine whether combined examination by naked-eye and digital VIA (D-VIA) and VILI (D-VILI) improves detection of CIN2+ as compared to the conventional evaluation.Materials and methodsWomen (30-49 years) living in Dschang (West Cameroon) were prospectively invited to a cervical cancer screening campaign. Primary HPV-based screening was followed by VIA/VILI and D-VIA/VILI if HPV-positive. Health care providers independently defined diagnosis (pathological or non-pathological) based on naked-eye VIA/VILI and D-VIA/VILI. Decision to treat was based on combined examination (VIA/VILI and D-VIA/VILI). Cervical biopsy and endocervical curettage were performed in all HPV-positive participants and considered as reference standard. Diagnostic performance of individual and combined naked-eye VIA/VILI and D-VIA/VILI was evaluated. A sample size of 1,500 women was calculated assuming a prevalence of 20% HPV positivity and 10% CIN2+ in HPV-positive women.ResultsDue to the COVID-19 pandemic, the study had to terminate prematurely. A total of 1,081 women with a median age of 40 (IQR 35.5-45) were recruited. HPV positivity was 17.4% (n = 188) and 26 (14.4%) had CIN2+. Naked-eye VIA and D-VIA sensitivities were 80.8% (95% CI 60.6-93.4) and 92.0% (95% CI 74.0-99.0), and specificities were 31.2% (95% CI 24-39.1) and 31.6% (95% CI 24.4-39.6), respectively. The combination of both methods yielded a sensitivity of 92.3% (95% CI 74.9-99.1) and specificity of 23.2% (95% CI 16.8-30.7). A trend towards improved sensitivity was observed, but did not reach statistical significance.ConclusionAddition of D-VIA/VILI to conventional naked-eye examination may be associated with improved CIN2+ identification. Further studies including a larger sample size are needed to confirm these results.

Current follow-up strategy for women after large loop excision of the transformation zone (LLETZ) for cervical intra-epithelial neoplasia (CIN) is burdened by a low compliance. We evaluated the performance of home-based Human Papillomavirus (HPV) self-sampling (Self-HPV) after treatment for CIN with the aim to assess the (i) feasibility and (ii) follow-up compliance. This study took place at the Geneva University Hospitals between May 2016 and September 2020. Women aged 18 years or older, undergoing LLETZ for a biopsy-proven cervical intraepithelial neoplasia grade 1 or worse (CIN1 + ) were invited to participate. Agreement statistics, interpreted according to the scale of κ values, were calculated for Self-HPV and HPV performed by the physician (Dr-HPV). The samples were analyzed using GeneXpert and Cobas. Sample size was calculated to provide a 10% precision to estimate the kappa coefficient. A total of 127 women were included, with a median age of 35 years (interquartile range 30–41 years). There was a substantial agreement between Self-HPV and Dr-HPV using GeneXpert at 6 and 12 months, with a κ value of 0.63 (95%CI: 0.47–0.79) and 0.66 (95%CI: 0.50–0.82), respectively. Up to 9/10 (90%) women who did not come to their follow-up visit did not send their Self-HPV, either. In the follow-up after LLETZ treatment, home-based self-HPV is feasible, with substantial agreement between the two groups, however, concern remains regarding adherence to Self-HPV performance at home and loss to follow-up.The trial was registered on clinicaltrials.gov with the identifier NCT02780960.

Study Objective: Evaluate the effects of a fast-track (FT) protocol on costs and post-operative recovery.Methods: One hundred and seventy women undergoing total laparoscopic hysterectomy for a benign indication were randomized in a FT protocol or a usual care protocol. A FT protocol included the combination of minimally invasive surgery, analgesia optimization, early oral refeeding and rapid mobilization of patients was compared to a usual care protocol. Primary outcome was costs. Secondary outcomes were length of stay, post-operative morbidity and patient satisfaction.Main Results: The mean total cost in the FT group was 13,070 ± 4,321 Euros (EUR) per patient, and that in the usual care group was 3.5% higher at 13,527 ± 3,925 EUR (p = 0.49). The FT group had lower inpatient surgical costs but higher total ambulatory costs during the first post-operative month. The mean hospital stay in the FT group was 52.7 ± 26.8 h, and that in the usual care group was 20% higher at 65.8 ± 33.7 h (p = 0.006). Morbidity during the first post-operative month was not significantly different between the two groups. On their day of discharge, the proportion of patients satisfied with pain management was similar in both groups [83% in FT and 78% in the usual care group (p = 0.57)]. Satisfaction with medical follow-up 1 month after surgery was also similar [91% in FT and 88% in the usual care group (p = 0.69)].Conclusion: Implementation of a FT protocol in laparoscopic hysterectomy for benign indications has minimal non-significant effects on costs but significantly reduces hospital stay without increasing post-operative morbidity nor decreasing patient satisfaction.Clinical Trial Registration:www.ClinicalTrials.gov, identifier: NCT04839263.

Study Objective: This study was performed to evaluate the association between uterine weight and operative outcomes in women undergoing laparoscopic hysterectomy for a benign indication.Methods: This is a secondary analysis of a randomized trial with data collected prospectively and retrospectively. The data of 159 women undergoing laparoscopic hysterectomy for a benign indication were analyzed. Women were divided in two groups according to the postoperative uterine weight: small uterus group (

Objective: To report a case of direct in vivo oocytes retrieval for fertility preservation before oophorectomy by open surgery in a young patient with ovarian cancer. Design: case report and literature review. Setting: University hospital. Patients: A 29-year-old nulliparous patient, recently diagnosed with low grade serous ovarian carcinoma.The patient consented to the removal of her remaining ovary but wished to preserve oocytes and declined hysterectomy. Conventional trans-vaginal US-guided oocyte retrieval was contra-indicated because of the risk of malignant cell dissemination to the abdomen and the vaginal puncture sites. Interventions: Controlled ovarian stimulation with gonadotrophins was realized. Comprehensive surgical staging was performed 35 h after ovulation triggering using rHCG. The oocytes retrieval was performed in vivo with ultrasound guidance at time of laparotomy before oophorectomy without any time of ischemia. Results: Seven mature oocytes were obtained and vitrified. Conclusions: This case highlights the feasibility of in vivo oocytes retrieval of mature oocytes during open surgery for gynecologic cancers. By avoiding transvaginal follicular retrieval, the risk of malignant cell contamination to vaginal and parametrial tissues is reduced, limiting cancer upstaging.

An amendment to this paper has been published and can be accessed via the original article.

Abstract Background Human Papillomavirus (HPV) vaccination, intended for young women aged 11–14 years old, has been introduced in Switzerland in 2007. Ten years after its introduction, only a few studies have explored the reasons associated with uptake and non-uptake of the vaccination. Our objective was to identify the sociodemographic characteristics of a population of vaccinated and unvaccinated undergraduate healthcare female students, to define the reasons of non-uptake of vaccination, and compare our findings with those found in other Swiss cantons. Methods Between January and November 2017, women studying in Health Sciences School and Medical School in Geneva, aged 18–31 years old, were recruited in a large trial assessing HPV prevalence. As part of a smaller, observational study nested in this larger trial, women were invited to complete a questionnaire. Self-reported HPV vaccination uptake or non-uptake, as well as knowledge and attitude about HPV vaccination were assessed. T-Test and Chi square test were used to compare characteristics of vaccinated and unvaccinated women. Results Overall, 409 women were recruited in the study. The majority of them (69.1%) reported having been vaccinated for HPV, while 30.9% of them had never received any dose of the HPV vaccine. The only factor associated with a higher vaccination rate was the participants’ origin, as women from Geneva were more represented in the vaccinated group than women from other Swiss regions or countries. Unvaccinated women were more likely to consider HPV vaccination as less important than the vaccinated ones (50.4% vs 3.5% p

Abstract Background The Swiss Federal Office of Public Health has recommended vaccination against human papillomavirus (HPV) to prevent cervical cancer since 2008. To establish monitoring of the future public health impact of vaccination, baseline population-based data are required. The objectives of this study were to examine the distribution of oncogenic HPV genotypes in biopsies with cervical intraepithelial neoplasia stage 3 or more severe lesions (CIN3+) at the beginning of HPV vaccination programmes and to compare sociodemographic and behavioural factors of women with CIN3+ with women in the Swiss general population. Methods We conducted a retrospective and prospective cross-sectional study with women diagnosed with CIN3+ in Switzerland. Ten pathology institutes from six cantons and three language regions participated. We conducted HPV typing on formaldehyde fixed-paraffin embedded specimens from 2014 and 2015. Women enrolled in 2015 were asked to complete a questionnaire. We described frequencies of HPV types. We also compared demographic characteristics and socioeconomic status in the CIN3 + plus group with the Swiss National Cohort in 2014 and compared risk factors for HPV infection with the Swiss Health Survey in 2012. Results We included 768 biopsies from 767 women. Four hundred and seventy-five (61.8%) biopsies were positive for HPV 16 and/or 18, 687 (89.5%) were positive for oncogenic HPV genotypes 16, 18, 31, 33, 45, 52, and/or 58 and five (0.7%) were HPV negative. Twenty-eight (10.3%) of the 273 women who completed the patient questionnaire reported having received at least one dose of an HPV vaccine. When compared with Swiss women in the six study cantons, fewer women in the CIN3+ plus study group were of Swiss nationality, more were born abroad and more were single. The study group also had a higher proportion of women with ≥2 partners in the last year, current smokers and was younger at age of first sexual intercourse. Conclusions Introduction of the nonavalent vaccine could cover approximately 90% of CIN3+ lesions in Swiss women compared with around 60% with the quadrivalent vaccine. Surveillance of HPV genotype distribution in CIN3+, together with information about vaccination and CIN3+ incidence will allow monitoring of the public health impact of vaccination programmes. Trial Registration ClinicalTrials.gov, NCT02323997. Registered 24 December 2014.

AIMS OF THE STUDY The European Society of Medical Oncology (ESMO) recommends that countries should have reference centres to provide adequate diagnosis and treatment of gestational trophoblastic disease. A trophoblastic disease centre in the French-speaking part of Switzerland was inaugurated in 2009. The objectives of this study were to report the activity of the centre during the last 10 years and analyse gestational trophoblastic disease outcomes. METHODS This was a retrospective study with data collected from all cases of gestational trophoblastic disease referred to the centre from 2009 to 2018. All histological specimens as well as data for treatment and follow-up of gestational trophoblastic disease and neoplasia were reviewed. Clinical features, including age, prognostic score and International Federation of Gynecology and Obstetrics (FIGO) stages (in the case of gestational trophoblastic neoplasia), human chorionic gonadotropin (hCG) follow-up, treatment and outcome were reported. RESULTS The centre registered 354 patients, and these patients presented 156 cases of partial hydatidiform moles, 163 cases of complete hydatidiform moles and 14 cases of gestational trophoblastic neoplasia. During follow-up, 35 gestational trophoblastic neoplasms were diagnosed after hCG persistence. After pathology review, the overall agreement rates between our centre and a participating provider hospital was 82%. Methotrexate was the first line of single-agent chemotherapy for most patients, with resistance rates of 23%. Multi-agent chemotherapy was used as first-line treatment for five patients. None of the patients followed up by the centre died from gestational trophoblastic disease. CONCLUSIONS This study reflects the activity of the Swiss trophoblastic disease centre from the French-speaking part of Switzerland created in 2009, and its role as local and national reference centre, in terms of global health, for women with gestational trophoblastic disease.

IntroductionCervical cancer remains a major public health challenge in low- and middle-income countries (LMICs) due to financial and logistical issues. WHO recommendation for cervical cancer screening in LMICs includes HPV testing as primary screening followed by visual inspection with acetic acid (VIA) and treatment. However, VIA is a subjective procedure dependent on the healthcare provider's experience. Its accuracy can be improved by computer-aided detection techniques. Our aim is to assess the performance of a smartphone-based Automated VIA Classifier (AVC) relying on Artificial Intelligence to discriminate precancerous and cancerous lesions from normal cervical tissue.MethodsThe AVC study will be nested in an ongoing cervical cancer screening program called "3T-study" (for Test, Triage and Treat), including HPV self-sampling followed by VIA triage and treatment if needed. After application of acetic acid on the cervix, precancerous and cancerous cells whiten more rapidly than non-cancerous ones and their whiteness persists stronger overtime. The AVC relies on this key feature to determine whether the cervix is suspect for precancer or cancer. In order to train and validate the AVC, 6000 women aged 30 to 49 years meeting the inclusion criteria will be recruited on a voluntary basis, with an estimated 100 CIN2+, calculated using a confidence level of 95% and an estimated sensitivity of 90% +/-7% precision on either side. Diagnostic test performance of AVC test and two current standard tests (VIA and cytology) used routinely for triage will be evaluated and compared. Histopathological examination will serve as reference standard. Participants' and providers' acceptability of the technology will also be assessed. The study protocol was registered under ClinicalTrials.gov (number NCT04859530).Expected resultsThe study will determine whether AVC test can be an effective method for cervical cancer screening in LMICs.

Visual inspection with acetic acid (VIA) is recommended by the World Health Organization for primary cervical cancer screening or triage of human papillomavirus-positive women living in low-resource settings. Nonetheless, traditional VIA with the naked-eye is associated with large variabilities in the detection of pre-cancer and with a lack of quality control. Digital-VIA (D-VIA), using high definition cameras, allows magnification and zooming on transformation zones and suspicious cervical regions, as well as simultaneously compare native and post-VIA images in real-time. We searched MEDLINE and LILACS between January 2015 and November 2021 for relevant studies conducted in low-resource settings using a smartphone device for D-VIA. The aim of this review was to provide an evaluation on available data for smartphone use in low-resource settings in the context of D-VIA-based cervical cancer screenings. The available results to date show that the quality of D-VIA images is satisfactory and enables CIN1/CIN2+ diagnosis, and that a smartphone is a promising tool for cervical cancer screening monitoring and for on- and off-site supervision, and training. The use of artificial intelligence algorithms could soon allow automated and accurate cervical lesion detection.

INTRODUCTION : cervical cancer is an illness that causes 250,000 deaths worldwide. Data on Health professional's skills is highly important for the elaboration of prevention strategies. Objective: assess the knowledge, attitudes and practices (KAP) among Brazzaville midwives on cervical cancer screening.Methods: analytical KAP Study, from May 2nd to August 10th 2018. Participants are midwives working in the Gynaecology-Obstetrics departments of six hospitals in Brazzaville (Republic of Congo). Variables were related to their socio-demographic and occupational characteristics, as well as to their knowledge, attitudes and practices. Analyses were done using the Epi Info 7.2.2.6 software. Frequencies, central trend parameters, as well as rib ratios were calculated. Pearson, Fisher and Wald statistical tests with a significance level of 5% where used.Results: the study included 114 midwives aged 43.07 (± 7.40) years. They had an unsatisfactory level of knowledge (59.64%), favourable attitudes (92.98%) and poor practices (71.05%). The factors linked with best (satisfactory) knowledge were, seniority at workplace (10-27 years) [29.31%] vs. 51, 79%; OR; 2.59 (1.19-5.60)] and age (42-60 years) [31.81% vs. 52.08%; OR 2.32 (1.08-5.01)]. The best knowledge were related to the best practices (good) [16.18% vs. 47.83%; OR a = 2.95 (1.87-4.67)]; Midwives attitudes seem to not impact on their practices (p = 0.53).Conclusion: Brazzaville midwives have little knowledge and practices on cervical cancer screening. Therefore, the need of training them and equipping cervical cancer screening.

Objective: The aim of this study was to review the characteristics of patients who underwent laparoscopic removal of giant ovarian cysts using the Alexis Laparoscopic System® and confirm the safety and feasibility of this technique.Method: We conducted a retrospective review of data of women undergoing the procedure from March 2014 to February 2019. Inclusion criteria were ovarian cysts of at least 15 cm. Exclusion criteria were the presence of solid components and suspicion of neoplasia on imaging.Results: Six patients were included in the series. Median size of the cysts at imaging was 22.8 cm (range 15–30 cm), while median volume was 5.9 L (range 1.9–15.6 L). Mean age of operated women was 59 years (range 21–88 years). All patients underwent exclusive laparoscopic management except one patient who underwent a conversion into midline laparotomy. The size of the skin incision initially performed to puncture the cyst ranged from 2.5 to 4 cm. On final pathological reports, two cysts were mucinous cystadenomas, and four were serous cystadenomas. There was no epithelial ovarian cancer or borderline tumor in any of the specimen operated.Conclusion: Laparoscopic management of giant ovarian cysts using the Alexis Laparoscopic System® is safe and feasible in well-selected cases. Midline laparotomy can thus be avoided, decreasing the risk of post-operative complications and increasing quality of life of patients.

Abstract Background Antenatal care (ANC) has the potential to identify and manage obstetric complications, educate women about risks during pregnancy and promote skilled birth attendance during childbirth. The aim of this study was to assess women’s knowledge of obstetric danger signs and factors associated with this knowledge in Ambanja, Madagascar. It also sought to evaluate whether the participation in a mobile health (mHealth) project that aimed to provide comprehensive ANC to pregnant women in remote areas influenced women’s knowledge of obstetric danger signs. Methods From April to October 2015, a non-random, convenience sample of 372 women in their first year postpartum were recruited, including 161 who had participated in the mHealth project. Data were analyzed using bivariate and multivariate logistic regression. Results Knowledge of at least one danger sign varied from 80.9% of women knowing danger sign(s) in pregnancy, to 51.9%, 50.8% and 53.2% at delivery, postpartum and in the newborn, respectively. Participation in the mHealth intervention, higher household income, and receipt of information about danger signs during pregnancy were associated with knowledge of danger signs during delivery, in bivariate analysis; only higher household income and mHealth project participation were independently associated. Higher educational attainment and receipt of information about danger signs in antenatal care were associated with significantly higher odds of knowing danger sign(s) for the newborn in both bivariate and multivariate analysis. Conclusions Knowledge of obstetric danger signs is low. Information provision during pregnancy and with mHealth is promising. Trial registration This trial was retrospectively registered at the International Standard Randomized Controlled Trial Register (identifier ISRCTN15798183; August 22, 2015).

Objective: The objective of this study was to review the records of patients with excised abdominal wall endometriosis (AWE) to determine patient characteristics, diagnostic methods, presence of concurrent pelvic endometriosis and type of surgery. Study design: Medical records from an 11-year period were searched to identify histologically confirmed AWE cases. Descriptive data were collected and analyzed. Two subgroups were differentiated: isolated AWE and pelvic endometriosis-associated AWE. Results: Thirty-five women with AWE were included. The most common symptom was cyclic abdominal or parietal pain (68.6%); 17.1% of the women had no symptoms. Twenty-nine women (82.8%) had a history of gynecological or obstetrical surgery, most commonly cesarean section (CS). The mean interval between prior surgery and appearance of symptoms was 5.3 years. Six women (17.1%) had no prior surgery; all six presented with umbilical nodules, nulliparity and confirmed mild to severe pelvic endometriosis. Among all patients, 34.3% had concurrent pelvic endometriosis, 40% presented with isolated AWE and 25.7% had no pelvic exploration. Women with concurrent pelvic endometriosis had significantly lower parity, smaller nodule size and a higher likelihood of umbilical location than those with isolated AWE (p

ObjectiveTo assess triage compliance and the effect of the time from screening to triage on follow-up among HPV-positive women.MethodsWe recruited 1232 women in a screening campaign in Madagascar from February to October 2015. In the first period (February-May), HPV tests were performed remotely using the cobas test. In the second period (May-October), testing was performed on-site using the Xpert HPV assay. HPV-positive women were invited for triage with visual inspection with acetic acid (VIA) and Lugol's iodine (VILI). Systematic biopsy and endocervical brushing were performed on all HPV-positive women for quality control. Three groups were defined according to time from HPV testing to triage invitation for HPV-positive women-Group I: delayed (> 3 months), Group II: prompt (24-48 hours), and Group III: immediate (< 24 hours).ResultsA total 1232 self-sampled HPV tests were performed in the study period (496 in Group I, 512 in Group II, and 224 in Group III). Participants' mean age was 43.2 ± 9.3 years. Mean time from screening to VIA/VILI testing was 103.5 ± 43.6 days. Overall HPV prevalence was 28.0%. HPV prevalence was 27.2% in Group I (cobas test), 29.2% in Group 2 (Xpert test), and 26,7% in Group III (Xpert test). The VIA/VILI compliance rate was 77.8% for Group I, 82.7% for Group II, and 95.0% for Group III. Of women undergoing VIA/VILI, 56.3% in Group I and 43.5% in Groups II/III had positive results. Prevalence of cervical intraepithelial neoplasia grade 2 or worse among HPV-positive women was 9.8% for Group I and 6.8% for Groups II/III. Non-adherence was higher among rural women, uneducated women, and women in Group I.ConclusionHPV-positive women with immediate VIA/VILI triage invitation had the best triage compliance. A single-day test and triage strategy is preferred for low-resource settings.

Cervical cancer remains a major public health concern in developing countries due to financial and human resource constraints. Visual inspection with acetic acid (VIA) of the cervix was widely promoted and routinely used as a low-cost primary screening test in low- and middle-income countries. It can be performed by a variety of health workers and the result is immediate. VIA provides a transient whitening effect which appears and disappears differently in precancerous and cancerous lesions, as compared to benign conditions. Colposcopes are often used during VIA to magnify the view of the cervix and allow clinicians to visually assess it. However, this assessment is generally subjective and unreliable even for experienced clinicians. Computer-aided techniques may improve the accuracy of VIA diagnosis and be an important determinant in the promotion of cervical cancer screening. This work proposes a smartphone-based solution that automatically detects cervical precancer from the dynamic features extracted from videos taken during VIA. The proposed solution achieves a sensitivity and specificity of 0.9 and 0.87 respectively, and could be a solution for screening in countries that suffer from the lack of expensive tools such as colposcopes and well-trained clinicians.

Objective: Persistent infection with human papillomavirus is the prerequisite for the development of cervical precancerous and cancerous lesions. The aim of this study was to determine the time-to-viral clearance in a population of human papillomavirus–infected Cameroonian women and to examine the possible predictors of viral persistence. Methods: We conducted a prospective cohort study based on a population of human papillomavirus–positive women having previously been recruited in a self-human papillomavirus-based cervical cancer screening campaign, who were invited for a control visit at 6 and 12 months. We determined human papillomavirus clearance using self-sampling (Self-HPV) and physician-sampling (Dr-HPV), which were analyzed with a point-of-care assay (GeneXpert ® IV; Cepheid, Sunnyvale, CA, USA). Logistic regression was performed to assess the relationship between sociodemographic and clinical characteristics with HPV clearance according to the two sampling techniques. Results: A total of 187 participants were included in the study. At the 12 months follow-up, 79.5% (n = 104) and 65.3% (n = 86) had cleared their human papillomavirus infection according to Dr-HPV and self-HPV, respectively (p = 0.001). Only parity (>5 children) was statistically associated with viral persistence (p = 0.033). According to Dr-HPV, clearance of women treated with thermoablation at 12 months was of 84.1% versus 70.2% for non-treated women (p = 0.075). Conclusion: The human papillomavirus clearing rates found in our study are close to those found in other studies worldwide. Parity was significantly associated with human papillomavirus persistence. Larger, prospective studies are needed to confirm our results.

Polymerase chain reaction-based Xpert human papillomavirus (HPV) assay is a rapid test that detects high-risk HPV (hrHPV) infection. This point-of-care test is usually performed by collecting a cervical specimen in a vial of PreservCyt® transport medium. We compared HPV test positivity and accuracy between self-collected sample with a dry swab (s-DRY) versus physician-collected cervical sampling using a broom like brush and immediate immersion in PreservCyt (dr-WET).In this cross-sectional study, we recruited 150 women ≥ 18 years old attending the colposcopy clinic in the University Hospital of Geneva. Each participant first self-collected a vaginal sample using a dry swab and then the physician collected a cervical specimen in PreservCyt. HPV analysis was performed with Xpert. Part of the PreservCyt-collected sample was used for hrHPV detection with the cobas® HPV test. HPV test positivity and performance of the two collection methods was compared.HPV positivity was 49.1% for s-DRY, 41.8% for dr-WET and 46.2% for cobas. Good agreement was found between s-DRY and dr-WET samples (kappa±Standard error (SE) = 0.64±0.09,), particularly for low-grade squamous intraepithelial lesions (LSIL+) (kappa±SE = 0.80±0.17). Excellent agreement was found between the two samples for HPV16 detection in general (kappa±SE = 0.91±0.09) and among LSIL+ lesions (kappa±SE = 1.00±0.17). Sensitivities and specificities were, respectively, 84.2% and 47.1%(s-DRY), 73.1% and 58.7%. (dr-WET) and 77.8% and 45.7% (cobas) for CIN2+ detection. The median delay between sampling and HPV analysis was 7 days for the Xpert HPV assay and 19 days for cobas. There were 36 (24.0%) invalid results among s-DRY samples and 4 (2.7%) among dr-WET (p = 0.001). Invalid results happened due to the long interval between collection and analysis.Self-collected vaginal dry swabs are a valid alternative to collecting cervical samples in PreservCyt solution for HPV testing with the Xpert HPV assay.HPV self-collection with dry cotton swabs might assist in the implementation of an effective screening strategy in developing countries.International Standard Randomized Controlled Trial Number Registry ISRCTN83050913.

To evaluate whether the endocervical brush (ECB) is better accepted by patients and health care providers for endocervical evaluation when compared to the endocervical curette (ECC), without a decrease in the quality of sampling.Two hundred patients with cervical dysplasia were randomized at the colposcopy clinic of the University Hospital of Geneva into two groups according to technique. Patients and physicians' preference regarding the technique as well as the quality of samples were assessed. ECB samples were analyzed using both cytological (cell block) and histologic analysis, while ECC samples were analyzed using standard histologic analysis.Of the 200 patients, 89 were randomized to ECC, 101 to ECB and 10 were excluded due to incomplete information or cervical stenosis. Physicians preferred ECB against ECC, classifying it more frequently as an easy technique (94.1% vs.61.4%, p

Background: Human Papillomavirus is a common sexually transmitted infection, representing the main cause of genital warts and cervical cancer. The objective of this study was to evaluate basic knowledge and beliefs regarding HPV infection and HPV vaccine among undergraduate healthcare men and women students, as well as their attitudes towards HPV vaccine. Methods: Undergraduate women and men (nursing and midwifery curses) attending three Schools of Health Sciences located in Switzerland. A total of 427 women and 223 men have completed the web questionnaire, which included questions on their socio-demographic background and about basic knowledge and attitudes toward the HPV infection and vaccination. Results: Women undergraduate students have a better knowledge of HPV infection than their men counterparts, although there was a significant gap in knowledge of the disease’s mode of transmission and prevention. Among women, 72.6% of respondents reported having received at least one dose of HPV vaccines versus 31.4% for men respondents. Conclusion: The results of this study revealed a poor understanding among undergraduate healthcare men and women students about the HPV infection, its mode of transmission and its prevention. Our findings highlight the need to improve education on HPV for undergraduate healthcare students in order to increase the awareness of the disease.

Combined oestrogen-progestin oral contraceptives cause venous thromboembolism in women of reproductive age. Healthcare providers typically rely on women’s characteristics, medical history and family history to select the most appropriate contraceptives, in an effort to reduce risks of venous thromboembolism. This position paper discusses the use of a new prediction tool (Pill Protect®), available in Switzerland, which adds genetic profiling to clinical characteristics with the aim of predicting individual contraceptive-related thrombotic risks and individualising contraceptive prescription. After reviewing the available data regarding this tool, we believe that its development and validation process may be incomplete and that it is uncertain whether the use of Pill Protect® would lead to better health outcomes. Until we understand the necessarily rigorous scientific validation of this tool, we urge caution to physicians and women who may want to use it.

Visual inspection of the cervix after application of 5% acetic acid (VIA) is a screening technique for cervical cancer used widely in low and middle-income countries (LMIC). To improve VIA screening performance, digital images after acid acetic application (D-VIA) are taken. The aim of this study was to evaluate the use of a smartphone for on- and off-site D-VIA diagnosis.Women aged 30-65 years, living in the city of Ambanja, Madagascar, were recruited through a cervical cancer screening campaign. Each performed a human papillomavirus (HPV) self-sample as a primary screen. Women testing positive for HPV were referred for VIA followed by D-VIA, cervical biopsy and endocervical curettage according to routine protocol. In addition, the same day, the D-VIA was emailed to a tertiary care center for immediate assessment. Results were scored as either D-VIA normal or D-VIA abnormal, requiring immediate therapy or referral to a tertiary center. Each of the three off-site physicians were blinded to the result reported by the one on-site physician and each gave their individual assessment followed by a consensus diagnosis. Statistical analyses were conducted using STATA software.Of the 332 women recruited, 137 (41.2%) were HPV-positive and recalled for VIA triage; compliance with this invitation was 69.3% (n = 95). Cervical intraepithelial neoplasia was detected in 17.7% and 21.7% of digital images by on-site and off-site physicians, respectively. The on-site physician had a sensitivity of 66.7% (95%CI: 30.0-90.3) and a specificity of 85.7% (95%CI: 76.7-91.6); the off-site physician consensus sensitivity was 66.7% (95%CI: 30.0-90.3) with a specificity of 82.3% (95%CI: 72.4-89.1).This pilot study supports the use of telemedicine for off-site diagnosis of cervical intraepithelial neoplasia, with diagnostic performance similar to those achieved on-site. Further studies need to determine if smartphones can improve cervical cancer screening efficiency in LMIC.

Human papillomavirus (HPV) self-sampling (self-HPV) is valuable in cervical cancer screening. HPV testing is usually performed on physician-collected cervical smears stored in liquid-based medium. Dry filters and swabs are an alternative. We evaluated the adequacy of self-HPV using two dry storage and transport devices, the FTA cartridge and swab.A total of 130 women performed two consecutive self-HPV samples. Randomization determined which of the two tests was performed first: self-HPV using dry swabs (s-DRY) or vaginal specimen collection using a cytobrush applied to an FTA cartridge (s-FTA). After self-HPV, a physician collected a cervical sample using liquid-based medium (Dr-WET). HPV types were identified by real-time PCR. Agreement between collection methods was measured using the kappa statistic.HPV prevalence for high-risk types was 62.3% (95%CI: 53.7-70.2) detected by s-DRY, 56.2% (95%CI: 47.6-64.4) by Dr-WET, and 54.6% (95%CI: 46.1-62.9) by s-FTA. There was overall agreement of 70.8% between s-FTA and s-DRY samples (kappa = 0.34), and of 82.3% between self-HPV and Dr-WET samples (kappa = 0.56). Detection sensitivities for low-grade squamous intraepithelial lesion or worse (LSIL+) were: 64.0% (95%CI: 44.5-79.8) for s-FTA, 84.6% (95%CI: 66.5-93.9) for s-DRY, and 76.9% (95%CI: 58.0-89.0) for Dr-WET. The preferred self-collection method among patients was s-DRY (40.8% vs. 15.4%). Regarding costs, FTA card was five times more expensive than the swab (~5 US dollars (USD)/per card vs. ~1 USD/per swab).Self-HPV using dry swabs is sensitive for detecting LSIL+ and less expensive than s-FTA.International Standard Randomized Controlled Trial Number (ISRCTN): 43310942.