Here are the top 5 posts this month.

New use of old drug: Sildenafil Citrate (Viagra) improves amniotic fluid index in oligohydramnios.

Sildenafil Citrate (Viagra) improves amniotic fluid index in pregnancies complicated by oligohydramnios according to a new study published ahead of print on March 6,2017 in Journal of Obstetrics and Gynecology. [1]

https://obgynupdated.blogspot.com/2017/03/new-use-of-old-drug-sildenafil-citrate.html

ACOG releases recommendations for management of acute onset, severe hypertension in pregnancy and postpartum period.

It is estimated that ten million women develop preeclampsia each year around the world, with 76,000 deaths due preeclampsia and related hypertensive disorders.  It is also responsible for 50,000 stillbirths and early neonatal deaths in developing nations.

ACOG committee opinion was published online ahead of print in Journal of Obstetrics and Gynecology.

https://obgynupdated.blogspot.com/2017/03/acog-releases-recommendations-for.html

New Single Handed IUD Inserter for LILETTA released easing IUD insertion.

Allergan a leading global pharmaceutical company, and Medicines360, a nonprofit global women's health pharmaceutical company, recently launched the new LILETTA® (levonorgestrel-releasing intrauterine system) 52 mg IUD single-handed inserter (intrauterine device), for use by women to prevent pregnancy for up to three years. The system needs to be replaced after 3 years if continuous protection is desired. 

https://obgynupdated.blogspot.com/2017/03/new-single-handed-iud-inserter-for.html

Ethicon ENSEAL® X1 Large Jaw Tissue Sealer gets FDA approval: Excellent for performing abdominal and vaginal hysterectomies.

Ethicon, today announced the release of its new ENSEAL X1 Large Jaw Tissue Sealer. Designed for use in open surgeries it is an advanced bipolar device that provides less blood loss, less thermal spread, and improved ergonomics compared to as compared to Medtronic’s LigaSure Impact™.

https://obgynupdated.blogspot.com/2017/03/ethicon-enseal-x1-large-jaw-tissue.html

ASCO issues first global resource stratified guidelines for HPV vaccination for the prevention of cervical cancer.

ASCO today issued first guidelines on primary prevention of cervical cancer that can be used by physicians around the globe as it is tailored according to region, social and economic settings and healthcare resources available. The guidelines were published online in Journal of Global Oncology. [1]

The guidelines offer four levels of recommendations: basic, limited, enhanced and maximal based on the country’s healthcare circumstances and were developed by experts from multiple disciplines representing various countries across the globe.

https://obgynupdated.blogspot.com/2017/03/asco-issues-first-global-resource.html

Endocrine Society issues guidelines to treat Functional Hypothalamic Amenorrhea (FHA).

Functional Hypothalamic Amenorrhea is a term used to describe amenorrhea that results from stress, imbalance between the energy intake and energy consumed by the body. These commonly occurs in athletes, ballet dancers, figure skaters, runners and women who have eating disorders, who burn more calories than what they eat.

In response, the hypothalamus gradually slows down or shuts off completely leading to decrease in pulsatile GnRH release, absent LH surge, absence of follicular development, low serum estrogen and anovulation.

The guidelines were published online on March 22,2017 in Journal of Clinical Endocrinology & Metabolism. The other societies which supports the guidelines are The American Society for Reproductive Medicine, the European Society of Endocrinology, and the Pediatric Endocrine Society.

The guidelines were developed by a task force of 8 medical experts, a medical writer and a methodologist. They looked at 2 systematic reviews and other evidence based guidelines in literature to formulate the current guidelines.

Untreated FHA of long standing can lead to infertility, delayed puberty, osteoporosis and stress fractures.

A diagnosis of HA is suspected in adolescent and women who have persistently 45 days between periods or who have amenorrhea of more than 3 months.

The summary of recommendations are as follows:

FHA is a diagnosis of exclusion. It should only be diagnosed after all the anatomic, organic or endocrine causes of amenorrhea are ruled out. 

The physician should perform a complete physical examination to rule out pregnancy as a cause of amenorrhea. A complete psychological evaluation including the drive to achieve perfectionism and need for social approval, ambitions and expectations for self is also necessary to address the psychosocial aspect of FHA.

A detailed diet history, exercise patterns and athletic training along with menstrual history should be elicited.

Initial Screening Laboratory tests should include serum beta HCG, CBC, electrolytes, liver function test, renal function tests and ESR.

Once the diagnosis is made the patients should be administered full endocrine evaluation including serum thyroid-stimulating hormone, free thyroxine, prolactin, luteinizing hormone, follicle-stimulating hormone, estradiol, and anti-Mullerian hormone.

A progesterone challenge test should be done to rule out structural abnormalities of genital tract.

A consultation with nutritionist is a very important form of treatment as regular cycles can be restored with more calories and proper diet.

A Brain MRI is often advised if patient complaints of persistent headache and visual problems to rule out pituitary adenoma.

Those adolescents or women with more than 6 months of amenorrhea should be tested for BMD with dual-energy X-ray absorptiometry.

These patients need an inpatient treatment if they have electrolyte imbalance, bradycardia or hypotension.

Patients who have had a fair trial with nutritional guidance, psychological treatment and exercise limitation should receive short-term transdermal E2 therapy with cyclic oral progestin.

Bisphosphonates, denosumab, testosterone, and leptin to improve bone mineral density is not advised in patients with FHA.

FHA patients wishing to conceive should undergo a complete fertility evaluation and treatment based on the results. Often cognitive behavioral therapy is very successful and restores ovulation and fertility without any medication.

Catherine M. Gordon of Cincinnati Children’s Hospital Medical Center in Cincinnati, Ohio, and the chair of the task force that authored the guideline said in a press release “This energy imbalance needs to be addressed to effectively treat hypothalamic amenorrhea and typically requires behavioral modifications. Referring patients to a nutritionist for specialized dietary instructions is an extremely important part of their care. Menstrual cycles can often be restored with increased calorie consumption, improved nutrition or decreased exercise activity.”

Exploited or Empowered? Cambodia bans the export of breast milk.

Courtesy: Getty images

Cambodia banned the export of breast milk on Tuesday, putting a stop to the business of a U.S.-based company that had been selling the milk in the United States.

Dozens of Cambodian women have been selling their excess milk to a US based company Ambrosia, which in turn marketed the milk to US consumers who had lactational failure.

Cambodian Cabinet ordered the health minister to put a stop to the practice immediately. The order, issued by Ngor Hong Ly wrote, “Although Cambodia is poor and [life is] difficult, it is not at the level that it will sell breast milk from mothers.”

Several countries around the world run breast milk bank, breast milk is also sold via websites and private networks. This case is controversial because UNICEF made a statement about the practice "exploiting vulnerable and poor women for profit and commercial purposes", and said breast milk should not be commercialized.

UNICEF further reported a fall in number of children breast fed by 10% in recent years.

Ryan Newell, co-owner of Ambrosia said in defense “mothers were allowed to sell their milk only twice a day and were required to wait until their children were at least 6 months old, the age at which the World Health Organization recommends that parents begin adding supplementary food to baby diets.”

"We're not taking away from those children," Newell said from the company's offices in Orem, Utah, south of Salt Lake City. "We're just taking the extra that those mothers would be losing at that point if they start weening their children."

"We've been able to offer these women work where they are earning two to three times what they would be making elsewhere," Newell said. "They're able to stay home with their kids more because they are not working the insane hours."

The women who gave the breast milk were regretful about the ban. Speaking to media, the women said selling their milk gave them a much-needed stable source of income while enabling them to stay at home and take care of their children. They could earn up to $12 a day - a considerable sum.

Some researchers argue that "If the buyer and seller are happy with the process then we have to respect that that is their decision."

The question remains unanswered whether the Cambodian women are exploited because of economic incentive to sell milk and cutting down the supply to their own children or they are empowered by money they earn to support the family?  

The experts do agree that selling human milk across international borders is complex issue which requires extreme scrutiny.  

Sources:

BBC News

Reuters Health

FDA Approves PARP inhibitor Zejula for treatment of recurrent ovarian cancer.

courtesy:www.multivu.com

The U.S.Food and Drug Administration today approved Zejula (niraparib) for the maintenance treatment of epithelial ovarian, fallopian tube or primary peritoneal cancer in adult patients who have already responded well to platinum-based chemotherapy.

Richard Pazdur, M.D., acting director of the Office of Hematology and Oncology Products in the FDA’s Center for Drug Evaluation and Research and director of the FDA’s Oncology Center of Excellence said “Maintenance therapy is an important part of a cancer treatment regimen for patients who have responded positively to a primary treatment. Zejula offers patients a new treatment option that may help delay the future growth of these cancers, regardless of whether they have a specific genetic mutation.”

According to an estimate by the National Cancer Institute more than 22,000 women will be diagnosed with these cancers in 2017 and more than 14,000 will die of these diseases.

Zejula is the first poly ADP-ribose polymerase (PARP) inhibitor to receive FDA approval to use without testing for BRCA mutation. It acts by preventing DNA repair by blocking an enzyme in the repair pathway.

The drug is niraparib and will be sold under the brand name Zejula by the manufacturer Tesaro (Waltham, Mass.).

FDA approved Zejula following results of a Phase III ENGOT-OV16/NOVA randomized trial of 553 patients who have already responded well to platinum-based chemotherapy. In addition, the patients were also tested for BRCA mutation although it does not require BRCA mutation or other biomarker testing. 

The study looked at the time for which the patients remained free from tumor recurrence irrespective of their BRCA status. Patients with BRCA mutation on Zejula did not have any recurrence for 21 months vs. 5.5 months for the same patient population taking a placebo. Patients who do not have BRCA mutation (n=350) on Zejula had 9.3 months of disease free survival compared to 3.9 months for patients on placebo.

Thus, the drug is more effective in patients who have the BRCA mutation but it can be given to patients who does not have the germline defect.

Partial trial results were published online December 1,2016 in the New England Journal of Medicine(NEJM).

Zejula have the usual side effects of chemotherapy drugs. Low blood counts, low platelets along with insomnia and high blood pressure are the most distressing side effects leading to discontinuation of drug in 15% of patients. It is contraindicated in pregnant and lactating mothers.

Zejula also received the ‘orphan drug status ‘by FDA because of its use in treatment of primary peritoneal cancer, a rare malignancy that is generally considered as ovarian-like. The orphan drug status is granted when a drug is used to treat rare disease.

The other two PARP inhibitors approved by FDA are olaparib (Lynparza, AstraZeneca) and rucaparib(brand name, Rubraca; Clovis Oncology, Boulder, Colo.) both are only used in patients with BRCA mutation and require testing for BRCA mutation.

ACOG releases recommendations for management of acute onset, severe hypertension in pregnancy and postpartum period.

It is estimated that ten million women develop preeclampsia each year around the world, with 76,000 deaths due preeclampsia and related hypertensive disorders.  It is also responsible for 50,000 stillbirths and early neonatal deaths in developing nations.

A woman in developing country is seven times more likely to develop preeclampsia than a woman in a developed country, contributing to 10-25% of all Maternal mortality.

In the United States, preeclampsia complicates approximately 3-5% of pregnancies, accounting for 10-15% of maternal deaths and 3% of perinatal deaths.

ACOG says “Introducing standardized, evidence-based clinical guidelines for the management of patients with preeclampsia and eclampsia has been demonstrated to reduce the incidence of adverse maternal outcomes.”

ACOG committee opinion was published online ahead of print in Journal of Obstetrics and Gynecology.

Women who are pregnant or postpartum presenting with acute onset severe systolic (greater than or equal to 160 mm Hg) as well as severe diastolic hypertension (greater than or equal to 110 mm Hg) require urgent antihypertensive therapy.

Hospitals, doctor’s office and other institutions handling emergencies should initiate treatment with first line drugs within 30-60 minutes of confirming the diagnosis to prevent maternal stroke.

Intravenous labetalol and hydralazine have long been used as the first line drugs in managing hypertensive emergencies in antenatal and postnatal women.

Recent available evidence suggests that immediate release oral nifedipine may also be considered an alternative first line therapy, especially in circumstances when an IV line is not secured. Some studies in recent time have shown that it brings down BP faster than labetalol and hydralazine. Concurrent use of Nifedipine and Magnesium Sulfate requires tertiary care setup and close monitoring of mother’s vital signs.

Use of all these three drugs does not requires cardiac monitoring.

In rare cases all the three drugs, labetalol, hydralazine and nifedipine may fail to relieve acute hypertensive emergency. In such circumstances, expert opinion of maternal-fetal medicine specialist, anesthesiologist and critical care subspecialist is sought. The second line alternative to be considered are nicardipine or esmolol by infusion pump.

Once the blood pressure is stabilized, detail evaluation of maternal and fetal well-being is carried out to make plans for long term drug therapy and timing of delivery.

The American College of Obstetricians and Gynecologists has identified additional resources on topics related to this document that may be helpful for ob-gyns, other health care providers, and patients. It may be viewed at www.acog.org/More-Info/Hypertension In Pregnancy.

The full text of the ACOG recommendations and suggestions can be accessed here. 

Channel Medsystems completes pivotal study of Cerene® Cryotherapy Device for successful office based Endometrial ablation.

Cerene® Cryotherapy Device screenshot 

Channel Medsystems, a company based at Emeryville, CA announced the successful completion of the treatment phase in its CLARITY Pivotal Study. The pivotal study evaluated the safety and efficacy of Cerene® Cryotherapy Device in 242 women with heavy menstrual bleeding who have already completed the family.

Clarity study was a multisite study involving 8 locations in US along with few international locations. The study recruited its first participant in October 2016 and completed the study in just 5 months in early March 2017. The trial examined  parameters of comfort, recovery time and uterine healing for women undergoing  procedure.

The study participants were very enthusiastic about the treatment plan because the Cerene device, is designed to address women’s need for an effective, comfortable, office-based treatment with minimal to no downtime after the procedure.

Cerene® Cryotherapy Device screenshot

Cerene® Cryotherapy Device screenshot

“The Cerene cryoablation is a convenient, simple, and well-tolerated office procedure,” said Dr. Ted Anderson, Director of the Division of Gynecology at Vanderbilt University Medical Center and Investigator in the CLARITY study. “A patient can have this treatment the same way she has an IUD placed – in her gynecologist’s office with minimal pain management and very little discomfort. This has the potential to be a real game-changer for ablation.”

All women in the study were awake and responsive during the procedure, in contrast to heat ablation, allowing the investigators to collect data on pain scores throughout the therapy.

The Cerene Cryotherapy Device uses extreme cold to destroy tissue thereby reducing scarring and intrauterine adhesions that are often associated with heat-based treatments. Scarring and adhesions often lead to failure of procedure and reoperation. The cryothermic  delivery system was incorporated into disposable, ergonomic device that can be held by hands thereby eliminating bulky equipments.

The initial studies were presented  at 42nd American Association of Gynecologic Laparoscopists (AAGL)  Global Congress in Washington, D.C. in 2013. The subjects of initial studies were women who were scheduled for hysterectomy. The studies show that Channel Medsystems’ cryothermic therapy had an acceptable safety profile, can be performed in a clinically appropriate timeframe and was well-tolerated by the subject without the need for general anesthesia or conscious sedation.

The histopathogy specimen of the removed uteri showed selective   depth of ablation for  uterine cavity , cornua and lower uterine segment without compromising the function of uterine tissue. The results were parallel to currently-available hyperthermic therapies.

“Cerene is different from other endometrial ablation technologies I routinely use. Unlike current heat-based ablation devices, my patients actually relaxed once the two-and-a-half-minute treatment was initiated. This was a completely different treatment experience for me, my patients, and my staff,” lead investigator Dr. Jose Leal of Monterrey, Mexico’s Universidad Autónoma de Nuevo León said in a prepared statement.

This device is limited to investigational use in the US, Canada, and Mexico.

For more information visit the website www.channel medsystems.com.

        Channel Medsystems endometrial cryoablation procedure animation video

source: http://www.channel medsystems.com

Toshiba Medical releases Aplio i-series of three advanced ultrasounds.

The Aplio i-series

Toshiba Medical released 3new advanced ultrasound machines for crystal clear viewing that is necessary for fast, reliable and precise musculoskeletal (MSK) diagnoses.

The Aplio i-series is highly advanced scalable systems made up of the Aplio i700, Aplio i800 and Aplio i900. The series uses a new beam-forming technology, iBeam that increases penetration for viewing deep muscles and joints without losing on spatial and contrast resolution.

The innovative iSense design provides efficient ergonomics to boost productivity in the workforce environment in routine and complicated cases. With its image  guided user interface and touch control screens and real-time Quick Scan, the physician is able to  seamlessly navigate the system without pushing a button.

Dan Skyba, director, Ultrasound Business Unit, Toshiba America Medical Systems, Inc. said “With the Aplio i-series, our customers have access to the high-quality imaging they rely on for confident diagnoses without sacrificing clinical efficiency or patient safety. By combining excellent image quality with brand new controls and ergonomic features in a real-time workflow, the Aplio i-series systems make ultrasound the go-to solution for musculoskeletal imaging, as well as for a wider array of imaging needs.”

The i800 comes with an ultra-high frequency (24 MHz) transducers to image shallow targets without losing resolution. The i900 is more useful in cardiovascular applications.

The Aplio i-series was showcased at this year’s Society of Skeletal Radiology (SSR) 2017 annual meeting in Santa Barbara, Calif., March 19–22, 2017.

Link to the full product information.

 

Oral contraceptive pill use protects against colorectal, endometrial and ovarian cancer.

 courtesy: Getty images

Women who have ever used the ‘pill’ have a decreased chance of having colorectal cancer, endometrial cancer or ovarian cancer than women who had never used the pill according to a new research from The University of Aberdeen, UK

The study was published in February issue of American Journal of Obstetrics and Gynecology.[1]

The study answers three important questions about safety of the use of OC. (1) What is the duration of benefits for endometrial, ovarian, and colorectal cancer. (2) Does combined oral contraceptive use during the reproductive years led to new cancer risks as we age? (3) What is the risk benefit ratio for cancer among past users as they age and enter old age when the general population risk of cancer increases?[2]

This is the longest running study of its kind  that looked at data from 46,022 women who were recruited by the UK Royal College of General Practitioners' Oral Contraception Study in 1968 -1969 and were followed for up to 44 years. The study looked at risk of specific and general cancer risk for women who have ‘ever’ used the pill against the women who have ‘never’ used the pill.

The pill was first approved for contraceptive use in 1960 and was an instant hit with 2.3 million women using it by 1963. Controversies ranged from its inception and are still rife about the pill causing cancers, blood clots, heart attack and stroke.

Few studies have documented that women are protected against GI malignancies and are at increased risk of breast and cervical cancer while currently using pills or being a recent user.

The current study data showed that the protective effect of pill lasts for 30 years even after the pill is stopped and pill users have a 19% lower risk of GI malignancies, 26% lower chance of lymphatic, and hematopoietic cancer, 34% lower risk of endometrial cancer and a 33% lower risk of ovarian cancer.

The study showed a slight increased chance of breast and cervical cancer while using the pill but this was neutralized and plummeted to the general population risk in 5 years of stopping the pill.

The cohort did not show increased risk of any other malignancy as the women aged.

The authors concluded that “Most women who choose to use oral contraceptives do not expose themselves to long-term cancer harms; instead, with some cancers, many women benefit from important reductions of risk that persist for many years after stopping.”

Professor Helen Stokes-Lampard, Chair of the RCGP, said: “Millions of women worldwide who use the combined oral contraceptive pill should be reassured by this comprehensive research that they are not at increased risk of cancer as a result – and that taking the pill might actually decrease their risk of certain cancers.”[3]

“This is not to advocate that women should be given the pill as a preventative measure against cancer as we know that a minority of women do have adverse health effects as a result of taking the pill. Ultimately decisions to prescribe the pill need to be made on a patient by patient basis, but this research will be useful to inform the conversations we have with our patients when discussing various contraceptive options that are available.”

“Long-term and ongoing research into the health effects of any medication is important in shaping new clinical guidelines around the care we are able to provide to our patients – and it’s encouraging to hear that RCGP research that originated in in the 1960s is still having a positive impact and increasing our knowledge now.”

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[1] Iversen L, Sivasubramaniam S, Lee AJ, et al. Lifetime cancer risk and combined oral contraceptives: the Royal College of General Practitioners’ Oral Contraception Study. Am J Obstet Gynecol 2017

[2] http://www.sciencedirect.com/science/article/pii/S0002937817301795

[3] http://www.rcgp.org.uk/news/2017/march/pill-study-should-reassure-millions-of-women-workdwide-says-rcgp.aspx

Automated smartphone-based system for analyzing sperm count and motility at home.

courtesy:Harvard.edu

Nearly 12% of world’s male population suffer from infertility but, it is often not diagnosed because of various stigmas associated with it. Men in our society are often reluctant to get the needed pathological tests, especially the semen analysis.

Researchers at Brigham and Women’s Hospital and Massachusetts General Hospital(MGH) have developed a home based test that can be performed in privacy of your home, in remote or low resource areas using an inexpensive device that attaches to the smartphone.

The team has shown that the device can analyze an unwashed, unprocessed liquefied semen sample in <5-s mean processing time with ~98% accuracy based on the World Health Organization (WHO) guidelines. The study was published online in today’s Science Translational Medicine.

Current semen analyzing methods are lab based, require sophisticated instruments and are labor intensive requiring highly trained technicians to produce reliable results. These can be computer-assisted semen analysis (CASA) or Manual microscope-based testing.

courtesy:harvard.edu

The smartphone based platform consists of a hardware component and a software component.The hardware part of the analyzer consists of an optical attachment with a disposable microchip and polydimethylsiloxane (PDMS) bulb used to load the sample by capillary action.  The microchip uses only <35 μl of liquefied semen for the test.

The software application consists of user friendly interface that guide the user through each step of the testing. The app analyzes, image and report the results at an average time of 4.48 s. It uses the smartphone camera for imaging. The results are stored in the app, so that the parameters can be compared over time.

The device was tested by the team by analyzing 350 clinical semen specimens at the MGH Fertility Center. The test could detect sperm concentration (<15 million sperm/ml) and motility (<40%) among samples according to WHO guidelines with 97.71% accuracy.

The developers also tested the use of the platform by trained vs. untrained people and it performed well in both the cases.

Apart from its use as at-home male fertility testing, it could be used by males who have undergone vasectomy to ensure the absence of sperm from the semen sample. It could also be used in veterinary medicine for animal breeding.

The total cost to fabricate the smartphone accessory and the disposable microfluidic device was only $4.45 as compared to thousands of dollars for a typical CASA-based platform.

The device is currently in a prototyping stage. The team plans to perform additional tests and will file for FDA approval. The platform demonstrates that how software can be integrated with hardware and microfluidics to develop a point of care device as a very useful tool in male infertility.

A very similar YO sperm test system recently received FDA clearance and is already in market for sale and use by consumers.

The full text of the article in Science Translational Medicine can be accessed here.

                                              

                                   

                               A smartphone-based test for male fertility

ASCO issues first global resource stratified guidelines for HPV vaccination for the prevention of cervical cancer.

ASCO today issued first guidelines on primary prevention of cervical cancer that can be used by physicians around the globe as it is tailored according to region, social and economic settings and healthcare resources available. The guidelines were published online in Journal of Global Oncology. [1]

HPV Vaccine 

The guidelines offer four levels of recommendations: basic, limited, enhanced and maximal based on the country’s healthcare circumstances and were developed by experts from multiple disciplines representing various countries across the globe.

The final recommendations were based on modified guidelines from WHO, CDC, and Canadian guidelines. 

Virtually all cervical cancers are caused by HPV infections and coverage with HPV vaccines in the female population could reduce up to 90% of cervical cancer incidence worldwide based on current vaccine availability and HPV worldwide distribution.

According to WHO “A large majority (around 85%) of the global burden occurs in the less developed regions, where it accounts for almost 12% of all female cancers.”  It further states that “Two HPV vaccines are now being marketed in many countries throughout the world - a bivalent and a quadrivalent vaccine. Both vaccines are highly efficacious in preventing infection with virus types 16 and 18, which are together responsible for approximately 70% of cervical cancer cases globally.”

Courtesy:elbiruniblogspotcom.blogspot.com

Currently, there are three prophylactic HPV vaccines approved and recommended in the United States, Europe, and many regions and countries: the bivalent (2vHPV; against HPV 16 and 18), quadrivalent (4vHPV; against HPV 6, 11, 16, and 18), and nine valent (9vHPV; against HPV 6, 11, 16, 18, 31, 33, 45, 52 and 58).

Although these guidelines specifically mention cervical cancer, vaccination also protects against other HPV-related cancers, such as other anogenital and potentially oropharyngeal cancers.

Vaccination strategy for girls.

So, in all resource settings two doses of HPV vaccines are recommended for girls age 9 to 14 years, with an interval of at least 6 months and possibly up to 12 to 15 months.

In maximal and enhanced settings, if the girls have reached age 15 or more and received the first dose before the age of 15 they may complete the series before age 26. If they did not receive any dose before 15 years than they should receive 3 doses and the series can be complete till 26 years of age.

In basic and limited resource setting, girls who received single dose can received additional dose between 15 to26 years if enough resources still exist for two dose vaccination among girls between 9-14years of age.

Vaccination strategy for boys.

In Basic settings boy’s vaccination is not recommended, while in limited, enhanced and maximal settings boys can receive vaccination if more than 50% of target female population are immunized, resources and infrastructure exist for boy's vaccination.. The same age related strategy should be applied as girls. This prevents the noncervical human papillomavirus–related cancers and diseases.

Vaccination strategies in special populations: These recommendations are uniform in all resource settings.

Women who are immunocompromised or HIV positive should be immunized according to the age group, but they should receive 3 doses.

Vaccines is not recommended in pregnant women nor women receiving treatment of cervical cancer precursor lesions (cervical intraepithelial neoplasia grade ≥ 2; eg, conization, loop electrosurgical excision process, or cryotherapy; all resource settings).

The latest vaccine coverage data by CDC shows that Six out of 10 teen girls (63 percent) and five out of 10 teen boys (50 percent) in the United States have started the HPV vaccination series (i.e., received at least one dose of HPV vaccine), according to data from the 2015 National Immunization Survey-Teen (NIS-Teen).[2]

The full text of the ASCO recent guidelines can be accessed here.

American Society of Clinical Oncology (ASCO) have released new resource stratified, evidence based global screening guidelines for secondary prevention of cervical cancer which can be accessed here.

The American Society of Clinical Oncology (ASCO) has issued recommendation on managing invasive cervical cancer which can be accessed here.

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[1] http://ascopubs.org/doi/full/10.1200/JGO.2016.008151

[2] https://www.cdc.gov/hpv/hcp/vacc-coverage.html

Innovative Breast Ultrasound system for cancer screening in women with dense breast.

Courtesy: GE systems

Mammography is the gold standard for early detection and cancer screening for breast cancer, however it may miss the cancer in about one third of patients with dense breast tissue. According to a study about 40% of women in US have dense breast.

Dense breast also increases the likelihood of developing cancer by 5 to 6 times as compared to women with normal breast density.  Often the cancers are detected very late in women with dense tissue because of imaging difficulty.

GE Introduced a new version of its automated breast ultrasound system ‘the Invenia Automated Breast Ultrasound System(ABUS)’.

Courtesy: GE systems

GE says, “Invenia ABUS is a comfortable, non-ionizing alternative to other supplemental screening options for women with dense breast tissue. When used in addition to mammography, Invenia ABUS can improve breast cancer detection by 35.7 percent over mammography alone.” It is not a substitute for mammography but a non-ionizing adjunct to the procedure and can detect early stage, node negative, invasive cancers.

The Invenia ABUS system is designed for screening and it shifts the diagnostic approach from hardware based system to software based system. The system creates a reproducible, fully automated scan that takes 15 minutes to complete. It captures whole breast three dimensional images that are displayed at the workstation as 2mm coronal view slices.

It also adjusts the signals levels in the nipple area so that it looks like surrounding tissue enhancing visualization. Other distinct features helping in better image quality and increasing visualization are Breast Border Detection and Chest Wall Detection.

The reverse curve transducer is designed to enhance the breast coverage and patient’s comfort during examination. Patients also report to be more comfortable because of absence of the pressing and pain sensation so common to mammography.

The system received FDA approval in 2014 and currently 180 hospitals are using it. 

The European Asymptomatic Screening Study screened 1,668 women between the ages of 40-74 with ABUS in a 15-minute exam after they had already undergone digital mammography screening. The results showed a 57 percent relative increase in cancer detection.

The findings were equivalent to 6.6 cancers detected per 1,000 women, compared with 4.2 percent of those who received mammography alone.

In a recent interview with medgadget[1] at the National Consortium of Breast Centers Conference,[2]Dr. Georgia Giakoumis Spear of NorthShore University Health System affirmed that ABUS is complementary to mammography and it is not meant for replacing it.  The NorthShore hospital is using the system for 15 months and is extremely satisfied with the results. They found about 25 cases of occult breast cancer not detected by mammography. 

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[1] http://www.medgadget.com/2017/03/breast-cancer-detection-using-ultrasound-interview-dr-georgia-giakoumis-spear-northshore-university-health-system.html

[2] https://www2.breastcare.org/welcome-to-the-annual-national-interdisciplinary-breast-center-conference/