Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Italian Journal of Gynaecology & Obstetrics March 2017 - Vol. 29 - N. 1 - Supplement - ISSN 2385 - 0868 The Official Journal of the Società Italiana di Ginecologia e Ostetricia (SIGO) Supplement Idipharma Award “Four best original works relating to the development of knowledges on the reepithelization action of TIAGIN®” Partner-Graf 1 Italian Journal of Gynaecology & Obstetrics The Official Journal of the Società Italiana di Ginecologia e Ostetricia (SIGO) Supplement Idipharma Award “Four best original works relating to the development of knowledges on the reepithelization action of TIAGIN®” Partner-Graf Editor in Chief Scollo Paolo, Catania Editors Valensise Herbert, Roma Vizza Enrico, Roma Editorial Board Cervigni Mauro, Roma Chiantera Vito, Palermo Costa Mauro, Genova De Stefano Cristofaro, Avellino De Vita Davide, Salerno Ercoli Alfredo, Novara La Sala Giovanni Battista, Reggio Emilia Locci Maria Vittoria, Napoli Marci Roberto, Roma Monni Giovanni, Cagliari Ragusa Antonio Franco, Milano Sirimarco Fabio, Napoli Trojano Vito, Bari Viora Elsa, Torino Editorial Staff Zerbinati Roberto Zerbinati Serena Management, Administrative office Partner-Graf Srl - Via F. Ferrucci, 73 - 59100 Prato Tel 0574 527949 - Fax 0574 636250 E-mail: [email protected] The Italian Journal of Gynaecology & Obstetrics is a digital magazine. You can download it freely from www.italianjournalofgynaecologyandobstetrics.com or www.italianjog.com It. J. Gynaecol. Obstet. 2017, 29: N. 1 - Supplement Table of contents 5 Effects of micro-crystals of titanium dioxide with covalently bound silver ions and extracts of Aloe Barbadensis (TIAGIN®) on Vaginal Health Index Score (VHIS) and Female Sexual Function Index (FSFI) in patients affected by vaginal disepithelization: a prospective, single-center cohort analysis 7 Role of vaginal TIAGIN® in cervical reepithelialization and high-risk HPV clearance in patients with low-grade cervical lesions 13 Efficacy of TIAGIN® on post-operative reepithelialization in women subjected to cervical surgery (LEEP or laser cone biopsies): case-control study 17 Colposcopy and cytology after treatment with TIAB® system and hyaluronic acid-based vaginal capsules in patients who have undergone cervical surgery due to an HPV-related disease 25 Antonio Simone Laganà, Benito Chiofalo, Roberta Granese, Vittorio Palmara, Onofrio Triolo Caterina Ricci Anna Daniela Iacobone, Eleonora Petra Preti, Ailyn Mariela Vidal Urbinati, Eugenia Tomás Roldán Giada Lavitola, Nicoletta De Rosa, Ilaria Morra, Carmine Nappi, Giuseppe Bifulco 5 Italian Journal of Gynaecology & Obstetrics March 2017 - Vol. 29 - N. 1 - Quarterly - ISSN 2385 - 0868 Effects of titanium dioxide microcrystals with covalently bonded silver ions and Aloe Vera extract (TIAGIN®) on the Vaginal Health Index Score (VHIS) and Female Sexual Function Index (FSFI) in patients with vaginal de-epithelialization: a prospective, single-center cohort analysis Antonio Simone Laganà1, Benito Chiofalo1, Roberta Granese1, Vittorio Palmara1, Onofrio Triolo1 Gynecology and Obstetrics Unit, Department of Human Pathology in Adulthood and Childhood “G. Barresi”, University of Messina, Messina, Italy 1 ABSTRACT Objective: to evaluate the effects of titanium dioxide microcrystals with covalently bonded silver ions and Aloe Vera extract (TIAGIN®) on the Vaginal Health Index Score (VHIS) and Female Sexual Function Index (FSFI) in patients with vaginal de-epithelialization. Materials and methods: we enrolled 45 postmenopausal women with vaginal de-epithelialization, who underwent VHIS evaluation and completed an FSFI test. We recorded their age, age at onset of menopause, parity and Body Mass Index. After this baseline evaluation, patients underwent 30 days of vaginal treatment with one capsule per day of TIAGIN®. After treatment, all patients were evaluated again using the same methods as the pre-treatment phase. Results: after treatment there was significant improvement in all VHIS parameters (elasticity, fluid secretion type and consistency, pH, epithelialization of vaginal mucosa, and moisture) and in the total score (p=0.006). Similarly, after treatment there was also a significant improvement in 4 FSFI areas (lubrication, orgasm, satisfaction, and pain) and in the total score (p=0.005). None of the patients reported any local or systemic side effects during treatment. Conclusions: we observed a significant improvement in both the VHIS and FSFI, which can be considered direct and indirect signs of increased vaginal epithelialization following vaginal treatment with TIAGIN®. SOMMARIO Obiettivo: valutare gli effetti di microcristalli di biossido di titanio con ioni d’argento covalentemente legati ed estratti di Aloe Barbadensis (TIAGIN®) sul Vaginal Health Index Score (VHIS) e Female Sexual Function Index (FSFI) in pazienti affette da disepitelizzazione vaginale. Materiali e metodi: abbiamo arruolato 45 donne in post-menopausa affette da disepitelizzazione vaginale, valutate mediante VHIS e FSFI. Abbiamo registrato età, età di insorgenza della menopausa, parità e Body Mass Index. Dopo la valutazione iniziale, le pazienti sono state trattate con una capsula vaginale al giorno di TIAGIN®, per 30 giorni. Dopo il trattamento, tutte le pazienti sono state rivalutate usando la stessa metodologia applicata durante la valutazione iniziale pre-trattamento. Risultati: dopo il trattamento abbiamo osservato un miglioramento significativo di tutti i parametri del VHIS (elasticità, tipo e consistenza della secrezione, pH, epitelizzazione e umidificazione della mucosa vaginale) e dello score totale (p=0.006). Parallelamente, abbiamo osservato anche un miglioramento di 4 domini del FSFI (lubrificazione, orgasmo, soddisfazione, dolore) e dello score totale (p=0.005). Nessuna delle pazienti ha riportato effetti indesiderati locali o sistemici durante il trattamento. Conclusioni: i nostri dati dimostrano significativi miglioramenti sia del VHIS che del FSFI, che possono essere considerati segni indiretti dell’aumentata epitelizzazione vaginale dopo trattamento con TIAGIN®. Keywords: Aloe Vera, silver ions, Vaginal Health Index Score, Female Sexual Function Index (FSFI), vaginal de-epithelialization. Corresponding to: [email protected] Copyright 2017, Partner-Graf srl, Prato DOI: 10.14660/2385-0868-61 7 It. J. Gynaecol. Obstet. 2017, 29: N. 1 - Supplement INTRODUCTION 8 There is mounting evidence to suggest that sexual health plays a pivotal role throughout women’s lives, from puberty to the postmenopausal period(1,2). According to the World Health Organization, sexual health requires a positive approach to human sexuality and an understanding of the complex factors that shape human sexual behavior(3). Despite the need for more epidemiological research into female sexual dysfunction (FSD), it is widely acknowledged that it increases as women age and affects about 40-45% of adult women(4). To this regard, common risk factor categories associated with FSD include individual general state of health, diabetes mellitus, cardiovascular disease, other genitourinary diseases, psychiatric/psychological disorders, other chronic diseases, and sociodemographic conditions (5-8). Nevertheless, the multidimensional nature of human sexuality may also play a detrimental part in objectifying the real contributing factors to possible dysfunctions(9,10). On the basis of these elements, several approaches and methods have already been proposed in order to recognize and measure sexual health, FSD rate, and severity. As has been widely reviewed by Rosen(11), on one hand objective measures, such as vaginal photoplethysmography or Duplex ultrasound, have been used in some studies but lack standardization and are unsuitable for use in large-scale clinical trials, while on the other hand, self-reported event logs or questionnaires are best suited for research or clinical assessment of female sexual function. Among these questionnaires, one of most used and validated is the Female Sexual Function Index (FSFI)(12), which consists of 19 items designed to asses 6 important areas of female sexuality: desire, arousal, lubrication, orgasm, satisfaction, and pain. In addition to these important determining factors, numerous studies have reported that adequate vaginal epithelialization is strictly related to satisfactory quantity and quality of sexual activity(13), even after autologous in vitro cultured vaginal tissue transplantation in patients with Meyer-von-Rokitansky-KüsterHauser syndrome(14,15). Like the FSFI, the need for an objective and measurable evaluation of vaginal mucosa led to the development of the Vaginal Health Index Score (VHIS)(16), which analyzes overall elasticity, fluid secretion type and consistency, pH, epithelialization of vaginal mucosa, and moisture. Several pharmacological treatments have already been developed to improve vaginal TIAGIN®’s effect on vaginal de-epithelialization epithelialization and, consequently, sexual health in the female population (17,18). Nevertheless, current data is still not sufficient to draw any firm conclusions regarding the gold standard treatment. Recent evidence reported that Aloe Vera extracts have significant antioxidant (19), antibacterial(20), anti-inflammatory, and woundhealing properties (21). Furthermore, similar beneficial properties were reported for silver ions(22-24). Considering these elements and the lack of robust available data in literature, the aim of the current study is to evaluate the effects of titanium dioxide microcrystals with covalently bonded silver ions and Aloe Vera extract (TIAGIN ®) on the VHIS and FSFI in patients with vaginal de-epithelialization. MATERIALS AND METHODS We performed a prospective, single-center cohort analysis between March and May 2016 at the Gynecology and Obstetrics Unit, Department of Human Pathology in Adulthood and Childhood “G. Barresi”, University of Messina (Messina, Italy). We enrolled post-menopausal women with vaginal de-epithelialization, excluding patients with significant comorbidities (chronic cardiovascular, immune, endocrine, and metabolic disorders, and cancers) and patients who had used any other kind of pharmacological treatment (including the substances tested in this study) during the previous 3 months. The study design complies with the Declaration of Helsinki, conforms to the Committee on Publication Ethics (COPE) guidelines (http://publicationethics.org), and was approved by the Institutional Review Board (IRB) of the hospital where it was performed. Each patient who participated in this study was fully informed of the procedures involved and signed a consent form for data collection for research purposes. All the design, analysis, data interpretation, drafting, and revision processes complied with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: guidelines for reporting observational studies(25), available through the EQUATOR (Enhancing the QUAlity and Transparency Of health Research) network (http://www.equator-network.org). For all the enrolled patients, we recorded age, age at onset of menopause, parity, and Body Mass Index (BMI). All the patients underwent VHIS Antonio Simone Laganà et al.. TIAGIN®’s effect on vaginal de-epithelialization evaluation (as described by Bachmann et al.) (16) , always performed by the same gynecologist in order to avoid inter-observer variability, and completed the FSFI test. After this baseline evaluation, all the enrolled patients underwent 30 days of vaginal treatment with one capsule per day of titanium dioxide microcrystals with covalently bonded silver ions and Aloe Vera extract (TIAGIN®). Any patient taking less than 80% of the allocated dose of study drug was regarded as noncompliant and excluded from the study. The study drug was supplied free of charge and none of the enrolled patients were paid to join or continue the study. After treatment, all the patients were evaluated again using the same methods as the pre-treatment phase (VHIS evaluation by the same gynecologist who performed it during the pre-treatment phase and self-reported FSFI). All the side effects were recorded and an independent data safety and monitoring committee evaluated the study results. Statistical analyses were performed by using the SPSS ver. 12.0 (SPSS Inc., Chicago, IL, USA) software package. The assumption of normal distribution for continuous variables was tested with the Kolmogorov–Smirnov test for goodness of fit. Continuous variables were compared between pre- and post-treatment phases using the Student t-test. A p-value of <0.05 was considered statistically significant. RESULTS We enrolled 45 patients who met the inclusion/ exclusion criteria and signed an informed consent form. Age, age at onset of menopause, parity, and BMI are reported in Table 1. All the patients declared that they took at least 90% of the allocated dose of study drug (good compliance). Table 1. Characteristics of enrolled patients Mean ± Standard Deviation Age Age of menopause onset Parity Body Mass Index 56.9 ± 10.0 48.8 ± 2.9 2.3 ± 0.8 23.8 ± 3.2 Pre- and post-treatment VHIS results are reported in Table 2, whereas results for FSFI are reported in Table 3. In particular, after treatment there was a significant improvement in all VHIS parameters (elasticity, fluid secretion type and consistency, pH, epithelialization of vaginal mucosa, and moisture) and in the total score (p=0.006). Similarly, after the treatment there was also a significant improvement in 4 FSFI areas (lubrication, orgasm, satisfaction, and pain) and in the total score (p=0.005), whereas the improvement for the remaining 2 areas (desire, arousal) was not significant (p=0.126 and p=0.082, respectively). None of the patients reported any local or systemic side effects during treatment. Table 2. Comparison of Vaginal Health Index Score between pre-treatment and post-treatment phases. Vaginal Health Index parameters Pre-treatment (Mean ± Standard Deviation) Post-treatment (Mean ± Standard Deviation) p Elasticity 2.4 ± 0.8 2.7 ± 0.5 0.036 Fluid Secretion type and consistency 2.0 ± 0.8 2.3 ± 0.5 0.036 pH 2.3 ± 0.8 2.6 ± 0.6 0.047 Epithelial mucosa 2.3 ± 0.8 2.6 ± 0.5 0.036 Moisture 2.6 ± 0.7 2.9 ± 0.7 0.045 Vaginal Health Index Score 11.6 ± 3.0 13.1 ± 1.9 0.006 Pre-treatment (Mean ± Standard Deviation) Post-treatment (Mean ± Standard Deviation) p Desire 3.7 ± 1.1 4.0 ± 0.7 0.126 Arousal 3.2 ± 0.7 3.4 ± 0.3 0.082 Lubrication 2.8 ± 0.7 3.1 ± 0.4 0.014 Orgasm 3.3 ± 1.0 3.7 ± 0.7 0.031 Satisfaction 3.8 ± 0.8 4.1 ± 0.4 0.027 Pain 2.8 ± 1.3 3.3 ± 0.7 0.024 Female Sexual Function Index score 19.5 ± 3.9 21.4 ± 2.0 0.005 Table 3. Comparison of Female Sexual Function Index between pre-treatment and post-treatment phases. Female Sexual Function Index parameters 9 It. J. Gynaecol. Obstet. 2017, 29: N. 1 - Supplement DISCUSSION 10 TIAGIN®’s effect on vaginal de-epithelialization Sexual wellbeing has attracted growing attention and increased in importance over recent decades, both for men and women. Since the first pioneering studies in 1960, researchers have taken many steps forward in understanding the complex mechanisms behind female sexuality(26,27). In addition to the important psychological aspects that may affect it(28), there is mounting evidence to suggest that the vaginal microenvironment plays a pivotal role in modulating moisture and pain perception during intercourse (29-31). Although vaginal cytokine levels are not linked to postmenopausal vulvovaginal symptoms(32), it is possible that hormonal modifications (especially in post-menopause) may alter the vaginal microbiome and leukocyte polarization(33,34), two key elements responsible for pain modulation(35). Several treatments have already been developed to improve vaginal epithelialization and ameliorate related symptoms and signs(36-38), although the available studies differ significantly in terms of the methods used and thus in the results obtained, making it difficult to identify the best approach. Very few studies have investigated the effects of Aloe and silver ions on the vaginal microenvironment, although this data could be misinterpreted since in most studies the researchers mixed these two compounds with others(39), or data analysis was based on animal models(40). To the best of our knowledge, this is the first report on the effects of silver ions and extracts of Aloe Vera in patients with vaginal de-epithelialization. Our analysis demonstrated a significant improvement in both the VHIS (p=0.006) and FSFI (p=0.005), which can be considered direct (VHIS) and indirect (FSFI) signs of increased vaginal epithelialization. On the one hand, all the most important vaginal health parameters increased, whereas on the other hand the latter indirectly ameliorated female sexual functions. Indeed, all the FSFI parameters increased significantly, with the exception of desire and arousal, which may be more dependent on the patient’s psychological state(41). Despite our significant results, the study was affected by several limitations. Firstly, we did not use a control group, although we opted for this study design since it would have been unethical not to provide any therapy to patients with vaginal de-epithelialization or to administer them a placebo. Moreover, our study was not blind, so patients and researchers were all aware of the purpose of the investigation and the drugs being used. What is more, our analysis was limited to the post-menopausal period and the study population was quite small. Considering these latter elements, we would like to take this opportunity to encourage future studies with greater statistical power, which may confirm our results within larger cohorts. Furthermore, future research should explore whether treatment with silver ions and Aloe Vera extract could increase vaginal fluid levels of platelet-derived growth factor (PDGF), vascular endothelial growth factor (VEGF) and fibroblast growth factor (FGF), which are the most important mediators responsible for re-epithelialization. REFERENCES 1) Slater C, Robinson AJ. Sexual health in adolescents. Clin Dermatol 2014;32:189–95. 2) Schwenkhagen A. Hormonal changes in menopause and implications on sexual health. J Sex Med 2007;4 Suppl 3:220–6. 3) World Health Organization. Defining Sexual Health. World Heal Organ 2006:0–30. 4) Derogatis LR, Burnett AL. The epidemiology of sexual dysfunctions. J Sex Med 2008;5:289–300. 5) Lewis RW, Fugl-Meyer KS, Bosch R, Fugl-Meyer AR, Laumann EO, Lizza E, et al. Epidemiology/risk factors of sexual dysfunction. J Sex Med 2004;1:35–9. 6) Laganà AS, Burgio MA, Ciancimino L, Sicilia A, Pizzo A, Magno C, et al. Evaluation of recovery and quality of sexual activity in women during postpartum in relation to the different mode of delivery: a retrospective analysis. Minerva Ginecol 2015;67:315–20. 7) Laganà AS, Burgio MA, Retto G, Pizzo A, Granese R, Sturlese E, et al. Management of the second phase of labour: perineum protection techniques. Minerva Ginecol 2015;67:289–96. 8) Laganà AS, Terzic M, Dotlic J, Sturlese E, Palmara V, Retto G, et al. The role of episiotomy in prevention of genital lacerations during vaginal deliveries - results from two european centers. Ginekol Pol 2015;86:168-75. DECLARATION OF INTEREST This study did not receive any grants or funding. The authors have no proprietary, financial, professional, or other personal interest of any nature in any product, service, or company. TIAGIN®’s effect on vaginal de-epithelialization 9) Barbara G, Pifarotti P, Facchin F, Vercellini P. The “Kaleidoscopic” Nature of Female Sexuality: The Importance of a Comprehensive Approach to Sexual Functioning. J Sex Med 2016;13:1143–4. 10) Laganà AS, Platania A, Butticè S, Vitale SG. Comment on “Impact of Mode of Delivery on Female Postpartum Sexual Functioning: Spontaneous Vaginal Delivery and Operative Vaginal Delivery vs Cesarean Section”. J Sex Med 2016;13:1142–3. 11) Rosen RC. Assessment of female sexual dysfunction: review of validated methods. Fertil Steril 2002;77 Suppl 4:S89–93. 12) Rosen R, Brown C, Heiman J, Leiblum S, Meston C, Shabsigh R, et al. The Female Sexual Function Index (FSFI): a multidimensional self-report instrument for the assessment of female sexual function. J Sex Marital Ther 2000;26:191–208. 13) Engeland CG, Sabzehei B, Marucha PT. Sex hormones and mucosal wound healing. Brain Behav Immun 2009;23:629–35. 14) Nodale C, Vescarelli E, D’Amici S, Maffucci D, Ceccarelli S, Monti M, et al. Characterization of human vaginal mucosa cells for Autologous in vitro cultured vaginal tissue transplantation in patients with MRKH syndrome. Biomed Res Int 2014;2014:201518. 15) Panici PB, Bellati F, Boni T, Francescangeli F, Frati L, Marchese C. Vaginoplasty using autologous in vitro cultured vaginal tissue in a patient with Mayer-vonRokitansky-Kuster-Hauser syndrome. Hum Reprod 2007;22:2025–8. 16) Bachmann GA, Notelovitz M, Kelly SJ, Owens A, Thompson C. Long-term nonhormonal treatment of vaginal dryness. Clin Pr Sex 1992;8:8. 17) Simon J, Nachtigall L, Gut R, Lang E, Archer DF, Utian W. Effective treatment of vaginal atrophy with an ultra-low-dose estradiol vaginal tablet. Obstet Gynecol 2008;112:1053–60. 18) Lima SM, Yamada SS, Reis BF, Postigo S, Galvão da Silva MA, Aoki T. Effective treatment of vaginal atrophy with isoflavone vaginal gel. Maturitas 2013;74:252–8. 19) Hu Y, Xu J, Hu Q. Evaluation of Antioxidant Potential of Aloe vera (Aloe barbadensis Miller) Extracts. J Agric Food Chem 2003;51:7788–91. 20) Ferro VA, Bradbury F, Cameron P, Shakir E, Rahman SR, Stimson WH. In vitro susceptibilities of Shigella flexneri and Streptococcus pyogenes to inner gel of Aloe barbadensis Miller. Antimicrob Agents Chemother 2003;47:1137–9. 21) Farzadinia P, Jofreh N, Khatamsaz S, Movahed A, Akbarzadeh S, Mohammadi M, et al. Anti-inflammatory and Wound Healing Activities of Aloe vera, Honey and Milk Ointment on Second-Degree Burns in Rats. Int J Low Extrem Wounds 2016;15:241–7. 22) Tian J, Wong KKY, Ho CM, Lok CN, Yu WY, Che CM, et al. Topical delivery of silver nanoparticles promotes wound healing. ChemMedChem 2007;2:129–36. 23) Atiyeh BS, Costagliola M, Hayek SN, Dibo SA. Effect of silver on burn wound infection control and healing: Review of the literature. Burns 2007;33:139–48. 24) Babu R, Zhang J, Beckman EJ, Virji M, Pasculle WA, Wells A. Antimicrobial activities of silver used as a polymerization catalyst for a wound-healing matrix. Biomaterials 2006;27:4304–14. Antonio Simone Laganà et al.. 25) von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol 2008;61:344–9. 26) Baumeister RF, Twenge JM. Cultural suppression of female sexuality. Rev Gen Psychol 2002;6:166–203. 27) Padgug RA. Sexual Matters: On Conceptualizing Sexuality n History. Radic Hist Rev 1979:3–23. 28) Jayne C, Gago BA. Diagnosis and treatment of female sexual arousal disorder. Clin Obstet Gynecol 2009;52:675–81. 29) Castelo-Branco C, Biglia N, Nappi RE, Schwenkhagen A, Palacios S. Characteristics of post-menopausal women with genitourinary syndrome of menopause: Implications for vulvovaginal atrophy diagnosis and treatment selection. Maturitas 2015;81:462–9. 30) Nappi RE, Palacios S. Impact of vulvovaginal atrophy on sexual health and quality of life at postmenopause. Climacteric 2014;17:3–9. 31) Levine KB, Williams RE, Hartmann KE. Vulvovaginal atrophy is strongly associated with female sexual dysfunction among sexually active postmenopausal women. Menopause 2008;15:661–6. 32) Stute P, Kollmann Z, Bersinger N, von Wolff M, Thurman AR, Archer DF. Vaginal cytokines do not differ between postmenopausal women with and without symptoms of vulvovaginal irritation. Menopause 2014;21:840–5. 33) Hummelen R, Macklaim JM, Bisanz JE, Hammond JA, McMillan A, Vongsa R, et al. Vaginal microbiome and epithelial gene array in post-menopausal women with moderate to severe dryness. PLoS One 2011;6:e26602. 34) Archer DF. Vaginal atrophy and disease susceptibility: the role of leukocytes. Menopause 2015;22:804–5. 35) Thomson JC. Chronic inflammation of the peritoneum and vagina: review of its significance, immunologic pathogenesis, investigation and rationale for treatment. J Reprod Med 2005;50:507–12. 36) Castelo-Branco C, Cancelo MJ, Villero J, Nohales F, Juliá MD. Management of post-menopausal vaginal atrophy and atrophic vaginitis. Maturitas 52 Suppl 1:S46-52. 37) Domoney C. Treatment of vaginal atrophy. Womens Health (Lond Engl) 2014;10:191–200. 38) Pickar JH. Emerging therapies for postmenopausal vaginal atrophy. Maturitas 2013;75:3–6. 39) Talwar GP, Dar SA, Rai MK, Reddy KV, Mitra D, Kulkarni SV, et al. A novel polyherbal microbicide with inhibitory effect on bacterial, fungal and viral genital pathogens. Int J Antimicrob Agents 2008;32:180–5. 40) Telefo PB, Moundipa PF, Tchana AN, Tchouanguep Dzickotze C, Mbiapo FT. Effects of an aqueous extract of Aloe buettneri, Justicia insularis, Hibiscus macranthus, Dicliptera verticillata on some physiological and biochemical parameters of reproduction in immature female rats. J Ethnopharmacol 1998;63:193–200. 41) Giraldi A, Rellini AH, Pfaus J, Laan E. Female sexual arousal disorders. J Sex Med 2013;10:58–73. 11 Italian Journal of Gynaecology & Obstetrics March 2017 - Vol. 29 - N. 1 - Quarterly - ISSN 2385 - 0868 Role of TIAGIN® vaginal formulation in cervical reepithelialization and high-risk HPV clearance in patients with low-grade cervical lesions Caterina Ricci1 1 Polo Salute della Donna e del Bambino, Fondazione Policlinico Universitario A. Gemelli - U.C.S.C.- Rome Director: Prof. Giovanni Scambia ABSTRACT Background: high-risk HPV infection, particularly when associated with a low-grade cervical lesion, is a very common problem, especially in young women. It is often associated with the presence of cervical ectropion/ ectopy, which causes bleeding and consequent anxiety and discomfort for the patient. The use of a molecule able to trigger the reparatory processes of the cervical epithelium, while also providing antibacterial action and boosting the local physiological immune response, could be a valid aid for the clinical management of such cases. Objective: to evaluate the reepithelialising action and efficacy of TIAGIN® vaginal formulation in a group of patients with low-grade cervical lesions (ASC-US /L-SIL) positive for high-risk HPV with cervical ectropion/ ectopy, treated with TIAGIN® vaginal formulation, by analysing the cytological clearance percentage, the HPV clearance percentage, any regression of the lesions visible during colposcopy and the degree of ectropion/ ectopy reepithelialisation at 6 months. Results: data was collected from 19 patients, with a mean age of 31. Almost all the patients managed to complete the prescribed treatment. Only 1 of the 19 patients stopped treatment after the first cycle due to intolerance to the product and was therefore excluded from the analysis, conducted on 18 patients. The cytology check-up at 6 months after treatment with TIAGIN® vaginal formulation was negative in 12 out of 18 patients (66.7%), while the microbiological clearance rate at 6 months after treatment was 50% with 9 negative HPV tests out of 18. At 6 months, 9 out of 18 patients (50%) had negative colposcopy results following complete regression of the AT1. In the remaining 50%, the colposcopy results were unchanged or improved, without any progression or the need for a biopsy. Bleeding had stopped in all patients at the 6-month check-up. In 5 patients (27.8%), the ectropion/ectopy was unchanged compared to T0. In 3 patients (16.6%), it was at least 25% smaller. In 10 patients (55.6%) it was resolved and completely reepithelialised. Corresponding to: [email protected] Copyright 2017, Partner-Graf srl, Prato DOI: 10.14660/2385-0868-62 Conclusions: in clinical practice, vaginal TIAGIN® vaginal formulation has shown itself to be a promising therapeutic aid in the management of low-grade cervical lesions caused by high-risk HPV, and is a valid option for the conservative management of bleeding ectropion/ectopy. Although this data is very interesting and promising, further evaluation and validation is required from prospective studies involving a larger number of subjects. Keywords: Aloe Barbadensis, silver ions, Vaginal Health Index Score, Female Sexual Function Index (FSFI), vaginal disepithelization.hormone. SOMMARIO Introduzione: l’infezione da HPV ad alto rischio, in particolare associata a una lesione cervicale di basso grado è una problematica attualmente molto diffusa, specie nelle giovani donne. Ad essa spesso si associa la presenza di un ectropion/ectopia, causa di sanguinamento e conseguente ansia e sconforto per la paziente. L’utilizzo di una molecola che riesca ad innescare i processi riparativi dell’epitelio cervicale, svolgendo anche un’azione antibatterica, e a coadiuvare la risposta immunitaria fisiologica locale, potrebbe rappresentare un valido aiuto nella gestione clinica. Obiettivi: valutare l’azione riepitelizzante e l’efficacia di TIAGIN® formulazione vaginale in un gruppo di pazienti con lesioni di basso grado della cervice uterina (ASC-US /L-SIL) positive ad HPV ad alto rischio con ectropion/ectopia cervicale, trattate con TIAGIN® per applicazione vaginale, analizzando la percentuale di negativizzazione della citologia, la percentuale di negativizzazione dell’HPV test, l’eventuale regressione delle lesioni colposcopicamente visibili e il grado di riepitelizzazione dell’ectropion/ectopia a 6 mesi, Risultati: sono stati raccolti i dati relativi a 19 pazienti con età media di 31 anni. La quasi totalità delle pazienti è riuscita a portare a termine la terapia prescritta; solo 1 paziente su 19 ha sospeso il trattamento dal primo ciclo per intolleranza al prodotto ed è stata quindi esclusa dall’analisi, condotta su 18 pazienti. La citologia di controllo a 6 mesi dopo terapia con 13 It. J. Gynaecol. Obstet. 2017, 29: N. 1 - Supplement Role of TIAGIN® in the management of patients affected by low-grade lesions of the uterine cervix TIAGIN® formulazione vaginale è risultata negativa in 12 pazienti su 18 (66,7%). Il tasso di negativizzazione microbiologica a 6 mesi dopo terapia è risultato del 50% con 9 negativizzazioni dell’HPV test su 18. Al tempo 6 mesi 9 pazienti su 18 (50%) mostravano una negativizzazione del quadro colposcopico in termini di regressione completa della TA1. Nel restante 50% il quadro colposcopico è risultato invariato o ridotto in estensione, senza alcuna progressione o necessità insorta di prelievo bioptico. Tutte le pazienti hanno mostrato al controllo a 6 mesi una risoluzione del sanguinamento. In 5 pazienti (27,8%) l’ectropion/ectopia risultava invariato rispetto al T0. In 3 pazienti (16,6%) risultava ridotto in dimensioni di almeno il 25%. In 10 pazienti (55,6%) risultava risolto e completamente riepitelizzato. Conclusioni: TIAGIN® formulazione vaginale si è mostrato nella pratica clinica un promettente supporto terapeutico nella gestione delle lesioni di basso grado della cervice uterina causate da HPV ad alto rischio, e una valida opzione nella gestione conservativa dell’ectropion/ectopia sanguinante. Tali dati, seppur interessanti e promettenti, necessitano di valutazioni e ulteriori validazioni in studi prospettici su più ampio campione. Parole chiave: Ectropion, HPV Riepitelizzazione, ASC-US/L-SIL, BACKGROUND 14 High-risk HPV infection, particularly when associated with a low-grade cervical lesion, is a very common problem, especially in young women. These lesions are known to present a significant possibility of spontaneous regression, meaning that conservative and observational management is often an option.(1) The presence of cervical ectropion/ectopy, which causes bleeding and consequent anxiety and discomfort for the patient, is also very widespread and often occurs alongside the lesions. Gynaecologists and colposcopists are routinely required to manage these problems on an outpatient basis. The role played by the local vaginal immune system in determining the regression/ progression of HPV-related lesions having been amply demonstrated in literature(2-3), the use of a molecule able to trigger the reparatory processes of the cervical epithelium while also providing antibacterial action and boosting the local physiological immune response, could be a valid aid for the clinical management of such cases. The TIAB® complex (titanium dioxide with covalently linked monovalent silver ions) is a nanotechnology product contained in TIAGIN® for vaginal application and foam for vulvar application. It kills the microorganisms in question, particularly fungi, bacteria and viruses, through a twofold mechanism: by blocking the enzymatic respiratory system through interaction with the ribosome; by damaging the cell wall and making it permeable. This complex has been shown to act on 650 microorganisms in the vagina and possesses considerable reepithelialising potential(4-5). In vitro studies have particularly highlighted the antiviral potential of silver nanoparticles thanks to their interaction with membrane viral glycoproteins. In fact, by bonding to them and changing their three-dimensional structure by altering the S-S bonds, they reduce the opportunity for the virus to enter the host cell(6). In greater detail, a study conducted in 2011 demonstrated the antiviral activity of silver nanoparticles on a cervical cell culture model with regard to the HIV-1 virus by means of various mechanisms: TNF-alpha reduction, stimulation of lymphocyte production and immune cell activation(7). However, there are no studies in literature designed to establish the possible efficacy of this complex on cervical lesions caused by high-risk HPV. OBJECTIVE The study objective was to evaluate the reepithelialising action and efficacy of TIAGIN® vaginal formulation as an adjuvant in the resolution of HPV-related low-grade cervical lesions in a group of patients with low-grade cervical lesions (ASC-US /L-SIL) positive for high-risk HPV with cervical ectropion/ectopy. We particularly analysed the cytological clearance percentage, the HPV clearance percentage, the regression of lesions visible during colposcopy and the degree of reepithelialisation of the ectropion/ ectopy at 6 months. SETTING Colposcopy Clinic, University Hospital. Role of TIAGIN® in the management of patients affected by low-grade lesions of the uterine cervix MATHERIALS AND METHODS Data was gathered on 19 patients with a mean age of 31 (20-62 years old), who attended the Colposcopy Clinic between December 2015 and August 2016, all of whom were suffering from low-grade cervical lesions (ASC-US /L-SIL) positive for high-risk HPV with cervical ectropion/ectopy, treated with TIAGIN® vaginal formulation. The patients, assessed during an initial visit (Time 0), all met the following criteria: Pap test indicative of low-grade lesions (ASC-US /L-SIL), colposcopy with evidence of bleeding ectropion/ectopy, HPV test positive for high-risk genotypes. The exclusion criteria were: pregnancy, use of other immune system adjuvant therapies, previous cervical treatments. The patients underwent a colposcopy at T0 and T6 months, performed by the same SICPCV-accredited colposcopists. At T0, all 18 patients showed an AT1 (abnormal transformation zone suggestive of a low-grade lesion in accordance with the SICPCV classification)(8) on the type 1 transformation zone (fully visible ectocervical squamocolumnar junction as per the IFCPC 2011 classification)(9) associated with bleeding ectropion/ectopy. The patients were treated on the basis of the following dosage regimen: TIAGIN® vaginal formulation 1/day for 10 days a month for 4 months. They were then reassessed after 6 months (Time 6m), when the Pap test, colposcopy and HPV test were repeated. Traditional cytology and Multiplex HPV PCR tests were used in the study, in keeping with routine clinical practice at the facility. The patients were permitted to replace TIAGIN® capsules with TIAGIN® vaginal softgel capsules when the product was launched on the market and replaced. Caterina Ricci due to intolerance to the product in the form of localised itching and was therefore excluded from the analysis, conducted on 18 patients. All the patients demonstrated a preference for the TIAGIN® softgel formulation and found it easier to use than the TIAGIN® capsules used during the first treatment cycles. At T0 the cytology results showed 13 patients with L-SIL and 5 patients with ASC-US. The follow-up cytology assessment at 6 months after treatment with TIAGIN® vaginal formulation was negative in 12 out of 18 patients (66.7%), with all the ASC-US cytology tests and 7 of the L-SIL cytology tests coming back negative. All the study patients had an HPV test at T0 that was positive for high-risk genotypes (the 18 patients were found to have 9 different genotypes, with 2 cases of multiple infection). The microbiological clearance rate at 6 months after treatment was 50%, with 9 cases of clearance out of 18. The colposcopy examinations found all 18 patients to have an AT1 associated with bleeding ectropion/ectopy at T0. At 6 months, 9 of the 18 patients (50%) were found to be negative during the colposcopy due to complete regression of the AT1. In the remaining 50%, the colposcopy results were unchanged or improved, without any progression or the need for a biopsy. Bleeding had stopped in all patients at the 6-month check-up. In 5 patients (27.8%), the ectropion/ectopy was unchanged compared to T0. In 3 patients (16.6%), it was at least 25% smaller. In 10 patients (55.6%) it was resolved and completely reepithelialised. These results are summed up in Table 1 and Fig. 1. Table 1. Cytological, colposcopic and microbiological response in 18 patients OUTCOMES The outcomes we evaluated were the cytological clearance percentage, the HPV clearance percentage, any regression of lesions visible during colposcopy and the degree of reepithelialisation of the ectropion/ectopy at 6 months. This outcome was evaluated as: complete resolution, partial regression or unchanged appearance compared to T0. RESULTS Almost all the patients managed to complete the prescribed treatment. Only 1 of the 19 patients stopped treatment after the first cycle Figure 1 Degree of ectropion/ectopy reepithelialization 15 It. J. Gynaecol. Obstet. 2017, 29: N. 1 - Supplement Role of TIAGIN® in the management of patients affected by low-grade lesions of the uterine cervix DISCUSSION The findings in our study seem promising given the high rate of cytological, microbiological and also colposcopic regression of the HPV-related low-grade cervical lesions in the group analysed after treatment with TIAGIN® vaginal formulation. These results are more or less comparable with the spontaneous regression data present in literature and superior as regards the rate of spontaneous cytological and microbiological regression(10-12). The findings regarding the rate of ectropion/ ectopy reepithelialisation are also significant for clinical management purposes, with bleeding being resolved in all cases and complete reepithelialisation of the ectropion/ectopy being achieved in 55.6%. These results also appear promising in consideration of the lack of studies reported in literature regarding a conservative, therapeutic approach to the medical management of ectropion/ectopy. This study is certainly limited by its small population and relatively short time scale, considering the natural history of HPV 16 REFERENCES 1) Natural history and epidemiology of HPV infection and cervical cancer. Castellsaguè X. Gynecol Oncol 2008; 110(3 Suppl 2):S4-7. 2) Role of Innate Immunity against Human Papillomavirus (HPV) Infections and Effect of Adjuvants in Promoting Specific Immune Response. Alfredo Amador-Molina, et al. Viruses. 2013 Nov; 5(11): 2624-2642. 3) Immune responses to human papilloma viruses. Stanley MA. Indian J Med Res 2009;130:266-76. 4) Evaluation of the efficacy of titanium dioxide with monovalent silver ions covalently linked (TIAB®) as an adjunct to scaling and root planning in the management of chronic periodontitis using pcr analysis: a microbiological study. Lauritano D, et al. J boil regul homeost agents. 2015 jul-sep;29(3 suppl 1): 127-30. 5) TIAGIN® Capsule vaginali foglietto illustrativo 6) Silver nanoparticles as Potential Antiviral Agents. Galdiero S. et al. Molecules 2011, 16 8894-8918. infection that underlies low-grade cervical lesions. On the other hand, it offers an interesting starting point for studies involving a larger population and tangible support for the clinical use of TIAGIN® in the analysed setting. CONCLUSIONS In its vaginal formulations TIAGIN® has shown itself to be a promising therapeutic aid in the clinical management of low-grade cervical lesions caused by high-risk HPV, thanks also to its good tolerability and ease of use, especially in the softgel formulation. It has also been shown to be a valid option for the conservative management of bleeding ectropion/ectopy. Although this data is very interesting and promising, further evaluation and validation is required from prospective studies involving a larger number of subjects. 7) Silver nanoparticles are broad-spectrum bactericidal and virucidal compounds. Lara HH et al. Journal of Nanobiotechnology 2011, 9:30. 8) SICPCV: gestione della paziente con pap-test anormale. Linee Guida Edizione 2006. Anno XXI; N. 1 Dicembre 2006. 9) 2011 colposcopic terminology of the International Federation for cervical Pathology and Colposcopy. Bornstein J et al. Obstet Gynecol. 2012 Jul; 120(1):166-72. 10) Human Papillomavirus Infection and Time to Progression and Regression of Cervical Intraepithelial Neoplasia. Nicolas F. Schlecht, et al. Jnl of Natl Cancer Inst. Volume 95, Issue 17 pp. 1336-1343. 11) Natural history of dysplasia of the uterine cervix. Holowaty P, et al. Jnl Natl Cancer Inst. 1999 Feb 3; 91(3):252-8. 12) A long-term study of women with normal colposcopy after referral with low-grade cytological abnormalities. Smith M.C. et al: BJOG. 2006; 113(11): 1321-8. Italian Journal of Gynaecology & Obstetrics March 2017 - Vol. 29 - N. 1 - Quarterly - ISSN 2385 - 0868 Efficacy of TIAGIN® on post-operative reepithelialization in women subjected to cervical surgery (LEEP or laser cone biopsies): case-control study Anna Daniela Iacobone1, Eleonora Petra Preti1, Ailyn Mariela Vidal Urbinati1, Eugenia Tomás Roldán2 1 2 Preventive Gynaecology Unit, European Institute of Oncology, Milan CERISMAS Research Centre, Catholic University of Milan ABSTRACT Objective: to evaluate the efficacy of post-operative treatment with TIAGIN® vaginal softgel in the reepithelialisation of the cervix and the prevention of the most common post-operative complications. Methods: a prospective and randomised case-control study in women who had undergone cervical surgery: TIAGIN® users for 15 days and non-users. All patients underwent a clinical examination at baseline and at 30 days. The post-treatment reepithelialisation process was evaluated by 2 colposcopists. A visual analogue questionnaire was completed in the second and fourth week after surgery to assess vaginal bleeding, leucorrhoea, abdominal pain and impact of pain on quality of life. Results: 30 patients were enrolled: 12 as controls and 18 as cases. 5 LEEP (41.77%) and 7 laser cone biopsies (58.33%) were carried out among controls and 9 LEEP (50.00%) and 9 laser cone biopsies (50.00%) among cases. CIN2-3 was detected in more than 70% of patients. No statistically significant differences were observed in post-operative complications, with the exception of the rate of atypical leucorrhoea (66.67% in controls vs 16.67% in cases) (p=0.011). Complete reepithelialisation was seen in 66.6% of cases and in 8.33% of controls, respectively (p=0.002). Conclusion: the post-operative use of TIAGIN® vaginal softgel leads to rapid cerval reepithelialisation. SOMMARIO Obiettivo: efficacia del trattamento post-operatorio di TIAGIN® softgel vaginali nella riepitelizzazione della cervice uterina e nella riduzione delle complicanze postoperatorie. Metodi: studio prospettico randomizzato in pazienti sottoposti a LEEP/laserconizzazione: pazienti trattate con TIAGIN® softgel vaginali per 15 giorni e controlli non trattate. Le pazienti hanno eseguito visita ginecologica e colposcopia al tempo zero e a 30 giorni. Il grado di riepitelizzazione cervicale é stato valutato da 2 colposcopisti esperti. Un questionario visuo-analogico è stato somministrato dopo 2 e 4 settimane dall’intervento chirurgico per valutare entità del sanguinamento, leucorrea, intensità del dolore addominale ed impatto del dolore sulla qualitá di vita. Risultati: 30 pazienti arruolate di cui 12 nel gruppo controllo e 18 nei casi. Sono state eseguite: 5 LEEP (41.77%) e 7 laserconizzazioni (58.33%) nei controlli; 9 LEEP (50.00%) e 9 laserconizzazioni (50.00%) nei casi. 70% delle pazienti ha avuto un istologico CIN2/3. Nel gruppo dei controlli si è avuta una maggior leucorrea rispetto ai casi (66.67% vs 16.67%) (p=0.011), mentre la riepitelizzazione completa si è verificata nel 66.6% del gruppo dei casi rispetto all’8.33% dei controlli (p=0.002). Non sono state trovate altre differenze statisticamente significative nel tasso di complicanze post-operatorie. Conclusioni: TIAGIN® softgel vaginali nel postoperatorio velocizza la riepitelizzazione della cervice. Keywords: TIAGIN® vaginal softgel, cervical surgery, post-operative complications, reepithelialisation Corresponding to: [email protected] Copyright 2017, Partner-Graf srl, Prato DOI: 10.14660/2385-0868-63 17 It. J. Gynaecol. Obstet. 2017, 29: N. 1 - Supplement INTRODUCTION 18 Wound healing is a multifaceted process comprising three phases: inflammation, proliferation and remodelling with the growth of the epithelium and connective tissue.(1) The production of cytokines deriving from the inflammatory processes influences the healing process, while certain immunological mediators and bacterial colonisation can delay this process(2). The early inflammation that occurs as a physiological response to the tissue damage can prevent an incipient infection, but prolonged inflammation can cause cell damage. In fact, the presence of pathogens produces toxins and enzymes that protract the inflammatory response and delay healing, with an increased risk of complications.(2-3) The rapid repair of the wound bed is essential in order to avoid secondary bacterial infection and thus prevent complications, particularly after surgery. Silver-based products have historically been recommended in wound management because of their bactericidal properties. However, the frequent and long-term application of these topical products produced inflammation and cosmetic defects. What is more, the advent of antibiotic therapy considerably reduced the use of these medications. The arrival of nanotechnology has allowed to create silver nanoparticles, with improved solubility and surface properties and, consequently, fewer side effects.(4) The innovative patented TIAB® formula creates a protective film on the vaginal mucosa that releases nanoparticles of ionic Ag (Ag+) stabilised with TiO2 (TIAB® System). The silver nanoparticles have a larger surface area and this increases the release rate of the individual metal charges, which are the most soluble and biologically active part.(5) They also possess multiple antibacterial mechanisms: they are oxidized and release a silver charge that damages the cellular membrane of the pathogenic microorganisms. The ions penetrate the cytoplasm, prevent the replication of the DNA, deactivate the respiratory enzymes and block cellular division until cell lysis occurs. They also generate free radicals, which have significant bactericidal properties.(6-8) TIAGIN ® contains a blend of TIAB® and hyaluronic acid. During the inflammatory phase, lowmolecular-weight hyaluronic acid accumulates in the wound bed, where its main function is to modulate the action of the inflammatory cells and the activity of fibroblasts, such as cell migration, TIAGIN® and reepithelialisation after cervical surgery cytokine synthesis and microbe phagocytosis. High-molecular-weight hyaluronic acid, on the other hand, keeps the wound moist by absorbing water. During the second phase of tissue damage, hyaluronic acid acts on the fibrocyte differentiation mechanisms and the expression of macrophage metalloelastase. In brief, all the mechanisms involved in the tissue repair phase involve lowmolecular-weight hyaluronic acid as the principal player, as it aids the rapid reconstruction of the healthy tissue.(9-10) Various clinical studies have been carried out to evaluate the use of low-molecular-weight hyaluronic acid in the various fields of medicine, including gynaecology.(11-12) A cone biopsy is a surgical procedure used for the diagnosis and treatment of pre-cancerous lesions affecting the uterine cervix. Surgical techniques vary depending on the hospital and the experience of surgeons. A cold knife cone biopsy used to be the most common surgical procedure, but the most widespread technique today is LEEP (Loop Electrosurgical Excision Procedure), while specialist sites carry out laser cone biopsies.(13-14) All these techniques remove part of the uterine cervix for histopathological analysis. They are relatively simple procedures and are usually performed under local anaesthetic. In literature, there are very few studies about the immediate and/or subsequent complications associated with the various techniques described above. A recent meta-analysis, which compares LEEP/laser cone biopsy with cold knife cone biopsy estimates that adverse events affect around 1.1% of women, subdivided into: bleeding (RR 0.226-0.859), infection (RR 0.128-0.089), PID (RR 0.139-0.138) and minor bleeding (RR 0.363-2.450).(15) On the contrary, a more considerable number of studies evaluated obstetric outcomes in women subjected to surgical treatment of the cervix. Cold knife cone biopsy would seem to be associated with a higher number of preterm births and/or PPROM, as laser cone biopsy, compared to LEEP procedures. The reason of these results is probably related to the quantity of tissue removed, that leads to an increased risk of bacterial infections, PPROM and preterm birth, rather than the technique itself.(16) At present, there are no clinical studies evaluating the efficacy of capsules containing silver nanoparticles associated with hyaluronic acid (TIAGIN® vaginal capsules) in women who have just undergone cervical surgery. Hyaluronic acid has a positive effect on fibroblast proliferation. Anna Daniela Iacobone et al. TIAGIN® and reepithelialisation after cervical surgery Thanks to its negative charge, it is localised in the extracellular region, where a hydrophilic network develops and can carry nutrients and metabolites to the different cell types by means of a percolation mechanism. Moreover, the addition of Ag+ NPs fosters collagen formation and controls its spatial orientation. Therefore, it is possible to hypotizise that the scarring and antibacterial action of this combination (Ag + hyaluronic acid) can reduce post-surgical repair times and post-operative complications. OBJECTIVE The primary objective of our study was to evaluate the efficacy of post-operative treatment with TIAGIN® vaginal capsules in the reepithelialisation of the cervix and the prevention of the most common post-operative complications (abdominal pain, bleeding and atypical vaginal discharge). MATERIALS AND METHODS We carried out a prospective and randomised case-control study in women who had undergone cervical surgery in order to compare the reparatory phenomena and post-operative complications at 2 and 4 weeks after the operation between TIAGIN® vaginal capsule users and non-users. All the women who underwent LEEP (Loop Electrosurgical Excision Procedure) or a laser cone biopsy at our institute from 11 April 2016 to 31 July 2016 were given the opportunity to take part in the study. The exclusion criteria were: pregnancy, congenital or acquired immune deficiency syndrome, immunosuppressant use, previous hysterectomy, and/or the use of other vaginal medications during the week prior to surgery. The study was approved by our Institute Review Board and all the participating subjects signed an informed consent form. The study protocol included two enrolment arms: a group of patients subjected to postoperative treatment with vaginal capsules containing TIAGIN® for 15 days and a group of patients who did not take any post-operative vaginal treatment. The randomisation procedure was carried out by personnel not involved in the clinical study, who also assigned the progressive participation numbers. All patients underwent a clinical examination, including a gynaecological visit and a speculum examination at baseline (at the time of surgery) and at 30 days. The clinical evaluations were carried out by gynaecological experts in cervical disease, certified by the Italian Society of Colposcopy and Cervicovaginal Pathology, who assigned a score between 1 and 3 to the posttreatment reepithelialisation process (1: ectocervix completely reepithelialised, 2: ectocervix covered in a thin epithelium with areas of immature metaplasia, 3: ectocervix with persistent areas of erosion, prone to bleeding), based on a subjective assessment. All the enrolled women completed a baseline questionnaire regarding their socio-demographic characteristics and obstetric/gynaecological history and a questionnaire regarding the main post-operative complications in the second and fourth week after surgery. The complications questionnaire used a visual analogue scale as follows: √ extent of vaginal bleeding (slight-moderate-abundant) √ extent of leucorrhoea (0-10) √ intensity of abdominal pain (0-10) √ impact of pain on quality of life (1-5) STATISTICAL ANALYSIS Patients’ main characteristics were expressed as absolute and percentage frequencies. Post-operative complications and the clinical evaluation of the reepithelialisation process of cases and controls were grouped together as categorical variables and compared with Fisher’s exact test. P values ≤ 0.05 were considered statistically significant. Alla data were analysed using SAS software (version 9.3). RESULTS From April to July 2016, more than 150 cervical surgery procedures were carried out at our institute, all on an outpatient and day surgery basis. A total of 30 patients were enrolled: 12 in the control group and 18 in the case-study group. The low percentage of subjects signing up to the study can be attributed almost entirely to the need to attend a check-up visit 30 days after the operation, as many of our patients live over 100 km away from our hospital. The main socio-demographic and clinical 19 It. J. Gynaecol. Obstet. 2017, 29: N. 1 - Supplement TIAGIN® and reepithelialisation after cervical surgery characteristics of the study population are summarized in Table 1 and are comparable in the two groups. The enrolled patients had a mean age of 39.26 ± 13.44 and were predominantly multiparous (56.67%). As regards to methods of contraception, the use of birth control pills was prevalent in the control group (16.67%), while barrier contraception was predominant in the case group (44.44%). Table 1. Main socio-demographic and clinical characteristics of the enrolled population. TOTAL (N=30) CONTROLS (N=12) CASES (N=18) Mean (SD) Mean (SD) Mean (SD) 39.26 (13.44) 41.25 (3.54) 39.94 (14.14) n (%) n (%) n (%) Nulliparous 13 (43.33) 6 (50.00) 7 (38.89) Smoker 13 (43.33) 5 (41.66) 8 (44.44) Oral contraceptives 3 (10.00) 2 (16.67) 1 (5.56) Condom use 9 (30.00) 1 (8.33) 8 (44.44) Vaginal infections in the last year 9 (30.00) 3 (25.00) 6 (33.33) Cystitis in the last years 7 (23.00) 3 (25.00) 4 (22.22) LEEP 14 (46.67) 5 (41.77) 9 (50.00) 16 (53.33) 7 (58.33) 9 (50.00) Negative 3 (10.00) 1 (8.33) 2 (11.11) CIN1 4 (13.00) 2 (16.67) 2 (11.11) 22 (73.33) 9 (75.00) 13 (72.22) 1 (3.33) 0 (0.00) 1 (5.56) Age (years) Operation type Laser cone biopsy Histology test CIN 2-3 VAIN3 20 The surgical procedures carried out were as follows: 5 LEEP (41.77%) and 7 laser cone biopsies (58.33%) among controls and 9 LEEP (50.00%) and 9 laser cone biopsies (50.00%) among cases. The histopathological analysis revealed the presence of CIN2-3 in more than 70% of patients of both groups. The clinical evaluation of the post-surgery cervical reepithelialisation process at 30 days revealed a statistically significant difference between the two groups (Figure 1). Fig. 1 Cervical reepithelialization score TIAGIN® and reepithelialisation after cervical surgery Anna Daniela Iacobone et al. In fact, in 66.6% (12/18) of the women who used vaginal capsules containing TIAGIN®, the examining gynaecologists assigned a score of 1, indicating complete reepithelialisation, which was only awarded in 8.33% (1/12) of the women who did not use any local post-surgery treatment. In addition, 50% (6/12) of the control group showed areas of erosion prone to bleeding during the postoperative visit (p=0.002). (Figures 2.1 and 2.2). Fig. 2.1 Two control patients immediately after the operation and at the 30-day check-up Fig. 2.2 Two cases patients immediately after the operation and at the 30-day check-up As shown in Figure 3 no statistically significant differences were observed in post-operative complications between cases and controls, both at 2 and 4 weeks, with the exception of the rate of atypical leucorrhoea at 2 weeks, which was higher in the control group (66.67%) compared to the case group (16.67%) (p=0.011). Lastly, none of the patients reported severe abdominal pain or maximum impact of pain on quality of life. Fig. 3 Post-operative complications 21 It. J. Gynaecol. Obstet. 2017, 29: N. 1 - Supplement CONCLUSIONS In the light of recent literature, there are no studies about the use of silver nanoparticles in combination with hyaluronic acid to reduce the risk of complications after cervical surgery. Many methods have been evaluated for the prevention of severe bleeding after cone biopsies. Doyle reports the application of a Monsel solution post-treatment,(17) Kim K. describes a retrospective study for the use of a fibrin sealant on the wound bed post-LEEP [18] and Kim JJ. describes the preventive use of Tachosil®.(19) All these authors showed that these agents do not lead to a statistically significant difference in the prevention of bleeding, except Kim K., which demonstrates a significant reduction of severe bleeding (p=0.033, OR - 0.328, 95% CI 0.117-0.917), despite a consistant impact on costs.(18) Indeed, the most recent guidelines do not advise any specific therapeutic agent for the prevention of severe bleeding. Our study reflects the results of previous studies regarding the risk of slight or severe bleeding, with no statistically significant difference between TIAGIN® vaginal capsule users and non-users. However, the number of patients was limited and there were no episodes of severe bleeding that required hospitalisation and/or cervical haemostasis, even in the cases of cone biopsies with a cone length of > 2 cm. For what concerns compliance of patients, none of the case-subjects stopped treatment due to problems associated with the use of the capsules 22 TIAGIN® and reepithelialisation after cervical surgery (increased bleeding, blood loss, discomfort or other), so confirming the good tolerability of the capsules and their easy application. The most statistically significant finding is related to the clinical evaluation, which demonstrates good and rapid reepithelialisation in the group of women treated with TIAGIN® capsules. This result could have a considerable impact on the risk of infection and chronic inflammation. We should not forget that, by reducing the length of the uterine cervix, cervical surgery can increase the risk of infection and preterm birth. Previous literature already showed that the higher risk of preterm birth is a consequence of modifications of the local vaginal flora in association with other co-factors. The rapid repair process in TIAGIN® vaginal capsule users means that the uterine cervix is shortly exposed to chronic inflammation and associated cytotoxic factors. Thereafter, the bactericidal effect of silver acts as an adjuvant in this process, restricting bacterial colonisation. Although not statistically significant in terms of the immediate complications associated with cervical surgery, all these factors entail an improved healing of the uterine cervix and a possible benefit for subsequent obstetric outcomes. A long-term follow-up and more clinical studies evaluating obstetric outcomes are certainly mandatory to verify whether this kind of support treatment during the post-surgery phase can lead to a long-term improvement of quality of life. TIAGIN® and reepithelialisation after cervical surgery REFERENCES 1) Effect of silver on burn wound infection control and healing: review of the literature. Atiyeh, B.S., Costagliola, M., Hayek, S.N., Dibo, S.A. Burns 2007;33:2:139:148. 2) Topical delivery of silver nanoparticles promotes wound healing. Tian, J., Wong, K.K., Ho, C.M. et al. ChemMedChem 2007;2:129-136. 3) Thw comparative efficacy of two antimicrobial barrier dressings: in vitro examination of two controlled release of silver dressings. Wright, J.B., Hansen, D.L.Burrel, R.E., Wounds 1998;10(6):179-188. 4) Probing the wound healing potential of biogenic silver nanoparticles. Dhapte V., Kadam S., Moghe A., Pokharkar V. Journal of wound care 2014; 33(9):431-441. 5) Silver nanoparticles as a new generation of antimicrobials. Rai, M., Yadav, A., Gade, A. Biotechnol adv 2009;27:76-83. 6) Silver nanoparticles-the real “silver bullet” in clinical medicine? Wong, K., Liu, X. Med Chem Commun 2010;1:125-131. 7) Chitosan-hyaluronic acid/nano silver composite sponges for drug resistant bacteria infected diabetic wounds. Anisha, B.S., Biswas, R., Chennazhi, K., Jayakumar, R. Int J Biol Macromol 2013; 62:310-320. 8) The potent antimicrobial properties of cell penetrating peptide conjugated silver nanoparticles with excellent selectivity for Gram-positive bacteria over erythrocytes. Liu, L., Yang, J., Xie, J. et al. Nanoscale 2013;5:3834-3840. 9) High and low molecular weight hyaluronic acid differentially regulate human fibrocyte differentiation. Maharjan AS., Pilling D., Gomer RH., PLoS One 2011;6(10):e26078. 10) Hyaluronan as an immune regulator in human disease. Jiang D., Liang J., Noble PW. Physiol Rev 2011 Jan; 91(1):221-64. 11) Diagnosis and treatment of atrophic vaginitis. Bachmann GA., Nevadunsky NS. Am Fam Physician Anna Daniela Iacobone et al. 2000 May 15;61(10):3090-6. 12) Effectiveness and safety of vaginal suppositories for the treatment of the vaginal atrophy in postmenopausal women: an open, non-controlled clinical trial. Costantino D., Guaraldi C. Eur Rev Med Pharmacol Sci 2008Nov-Dec;12(6):411-6. 13) Surgery for cervical intraepithelial neoplasia. Martin-Hirsch PP, Paraskevaidis E, Bryant A, Dickinson HO. Cochrane database Syst Rev 2013;12:CD001318. 14) Treatment of cervical intraepithelial neoplasia using the loop electrosurgical excision procedure. Wright Jr TC., Cagnon S., Ricart RM., Ferenczy A. Obstet Gynecol 1992; 79:173-8. 15) Systematic reviews and meta-analyses of benefits and harms of cryotherapy, LEEP, and cold knife conization to treat cervical intraepithelial neoplasia. Santesso N., Mustafa RA., Wiercioch W., Kehar R., Gandhi S., Chen Y., Cheung A., Hopkins J., et al., International Journal of Gynecology and Obstetrics 2016;132:266-271. 16) The risk of pretermbirth following treatment for precancerous changes in the cervix: a systematic review and meta-analysis. Bruinsma FJ, Quinn MA. BJGO 2011; 118(9);1031-41. 17) Does application of Monsel’s solution after loop diathermy excision of the transformation zone reduce post operative discharge? Results of a prospective randomized controlled trial. Duyle M., Warwick A., Redman C., Hiller C., Chenoy R., O’Brien S. Br J Obstet Gynaecol 1992;99:1023-4. 18) Efficacy of fibrin sealant in reducing hemorrhage after a loop electrosurgical excision procedure. Kim K., Park SI., Kim MH., Choi SC., Ryu SY., Lee ED. Gynecol Obstet Invest 2012;74(1):1-5. 19) Efficacy of TachoSil® in preventing hemorrhage after loop electrosurgical excision procedure. Kim WY., Lee DH., Kang JH., Song T., Lee KW., Kim KH. Eur J Obstet Gynecol Reprod Biol 2015 Nov;194:245-8. 23 Italian Journal of Gynaecology & Obstetrics March 2017 - Vol. 29 - N. 1 - Quarterly - ISSN 2385 - 0868 Colposcopy and cytology after treatment with TIAB® system and hyaluronic acid-based vaginal capsules in patients who have undergone cervical surgery due to an HPV-related disease Giada Lavitola1, Nicoletta De Rosa1, Ilaria Morra1, Carmine Nappi1, Giuseppe Bifulco1 1 Department of Obstetrics, Gynaecology and Urology, Federico II University Hospital Trust, Naples) ABSTRACT Introduction: LEEP (Loop Electrosurgical Excision Procedure) is the preferred technique for the treatment of high-grade precancerous cervical lesions (CIN2+). The post-operative follow-up provides for a colposcopy and cytology check-up 6 months after treatment. These examinations are designed to detect the presence of any residual disease. The surgical wound must have healed completely at the follow-up in order to obtain conclusive diagnostic results. This study aims to evaluate the efficacy of a topical TIAB® system and hyaluronic acid-based therapy in inducing complete tissue repair. Materials and methods: 327 patients diagnosed with CIN2+ who had undergone LEEP were randomised into two groups. Group 1 (No. 152) received post-operative treatment with TIAB® system and hyaluronic acid-based vaginal capsules. Group 2 (No. 175) was the control group and did not receive any treatment. The patients underwent a colposcopy and cytology check-up at 1 and 4 months after treatment. Results: at 1 month after treatment, the cytology assessment showed group 1 to have a higher percentage of satisfactory cytological specimens, a lower percentage of altered microbial flora and a higher incidence of complete maturation (p<.001). At the 4-month follow-up, it was found to have a lower percentage of altered microbial flora and a higher incidence of complete maturation (p<.001). The colposcopy carried out at 1 month shows a significantly higher percentage of inadequate results in group 2 than in group 1. At 4 months, 74.3% of colposcopies in group 2 showed the presence of immature metaplasia, which was significantly higher than in group 1 (3.3%; p<.001). Conclusions: topical treatment with TIAB® system and hyaluronic acid-based vaginal capsules permits rapid restoration of the ectocervix following LEEP treatment. Complete tissue scarring allowed the satisfactory and adequate execution of the cytology and colposcopy examinations in 80.3% and 89.5% of cases respectively, at 1 month after follow-up, and a trophic squamous epithelium at 4 months after treatment. Keywords: LEEP; colposcopy; cervical intraepithelial neoplasia; hyaluronic acid; TIAB® system. Corresponding to: [email protected] Copyright 2017, Partner-Graf srl, Prato DOI: 10.14660/2385-0868-64 SOMMARIO Introduzione: la LEEP (Loop Eletrosurgical Excision Procedure) è la tecnica di elezione per il trattamento delle lesioni preneoplastiche del collo uterino di alto grado (CIN2+). Il follow up post-operatorio prevede un controllo colposcopico e citologico a distanza di 6 mesi dal trattamento. Tali indagini hanno come obiettivo di identificare la presenza di patologia residua. Una completa guarigione della ferita chirurgica al follow up è necessaria per ottenere esami diagnostici conclusivi. Obiettivo di questo studio è di valutare l’efficacia di una terapia topica a base di TIAB® system e acido Ialuronico nell’induzione di una completa restituzio ad integrum dei tessuti. Materiali e metodi: 327 pazienti con diagnosi di CIN2+ e sottoposte a LEEP sono state randomizzate in due gruppi. Il gruppo 1 (N= 152) ha eseguito nel post-operatorio una terapia con capsule vaginali a base di TIAB® system e acido ialuronico; il gruppo 2 ( N=175) è stato considerato gruppo di controllo e non ha eseguito alcuna terapia. Le pazienti hanno quindi eseguito follow up citologico e colposcopico a 1 e a 4 mesi dal trattamento. Risultati: a distanza di 1 mese dal trattamento il gruppo 1 ha dimostrato al referto citologico una percentuale maggiore di preparati citologici soddisfacenti, una più bassa percentuale di flora microbica alterata ed una più alta incidenza di maturazione completa (p< .001); al follow up eseguito al mese 4 viene dimostrata una più bassa percentuale di flora microbica alterata ed una più alta incidenza di maturazione completa (p< .001). La colposcopia eseguita al mese 1 dimostra una percentuale di referti inadeguati significativamente maggiore nel gruppo 2 che nel gruppo 1. Al mese 4, nel gruppo 2 la percentuale di colposcopie che rivelano la presenza di metaplasia immatura è del 74.3 %, significativamente maggiore rispetto al gruppo 1 (3.3%; p<.001). Conclusioni: la terapia topica con capsule vaginali a base di TIAB® system e acido ialuronico consente una rapida restitutio ad integrum della portio a seguito di trattamento LEEP. La cicatrizzazione tissutale completa consente l’esecuzione di citologia e colposcopia soddisfacenti e adeguate nell’80.3% e nell’89.5% dei casi, rispettivamente, già ad 1 mese di follow up, ed un epitelio squamoso trofico a 4 mesi dal trattamento. 25 It. J. Gynaecol. Obstet. 2017, 29: N. 1 - Supplement INTRODUCTION Cervical intraepithelial neoplasia (CIN) are precursors to cervical cancer. As recommended by the US ASCCP(1) and Italian SICPCV(2) guidelines, the preferred treatment for CIN2+ lesions is excision. LEEP is the most widespread technique used to treat these lesions. Women who have undergone treatment for CIN face a 2-to-5-times higher risk of developing cervical cancer during their life time compared to the general population.(3) Because of this, they must undergo the first cytology check-up with colposcopy at 6 months after treatment.(4-5) Surgery aims to remove the abnormal tissue. Its extent depends on the extent of the lesion identified during the colposcopy and may vary between 7 and 25 mm in depth.(5) The cervix has a high capacity for tissue regeneration. The data that demonstrates this derives from studies that have evaluated the post-partum tissue regeneration capacity of this region. It is the result of a series of biological processes that involve proinflammatory factors, metalloproteinases and proteins involved in the synthesis of the extracellular matrix.(6-8) It has been shown that cervical tissue regenerates itself within 6 months of excisional surgery. Tissue regeneration is related to the quantity of tissue excised and exceeds 75% when the excised tissue accounts for less than 14% of the length of the cervix.(9) Silver nanoparticles (AgNPs) have demonstrated bactericidal, virucidal and fungicidal activity. The patented TIAB® system contains titanium dioxide microcrystals with covalently linked silver ions. (10-11) The TIAB® system has also shown reepithelialising properties, inasmuch as it regulates collagen production.(12) Hyaluronic acid (HA) is one of the main components in the extracellular matrix and plays an important role in regulating tissue repair. During the reepithelialisation process, high localised concentrations of HA stimulate the migration and proliferation of fibroblasts and the formation of granulation tissue, encouraging the deposit of collagen fibres and stimulating neoangiogenesis.(13) This study aims to evaluate whether combined therapy with the TIAB® system and HA can accelerate the physiological tissue repair process in order to permit an early follow-up in patients who have undergone LEEP. 26 Effect of TIAB® system for tissue healing after LEEP MATERIALS AND METHODS From September 2013 to May 2015, all patients diagnosed with CIN2+ who needed excisional surgery at the Colposcopy and Cervical Pathology clinic were enrolled in a randomised prospective study. The inclusion criteria for enrolment were: 1. A positive histological diagnosis of CIN2+ following punch biopsy, in accordance with WHO criteria.(14) 2. Aged between 30 and 40 years old. 3. No medical history of systemic disorders such as: diabetes mellitus, thyroid disorder, blood clotting disorders. Patients diagnosed with microinfiltrating or invasive carcinoma or pregnant patients with cervical disease were excluded from the study. After having read and discussed the patient information sheet and agreed to participate in the study, all the eligible patients who met the inclusion criteria were enrolled and underwent a colposcopy and loop electrosurgical excision procedure (LEEP) with an RF diathermy loop. The colposcopy was carried out using the standard technique: application of a vaginal speculum, cleaning of the ectocervix with sterile physiological solution, application of 5% acetic acid, observation through the colposcope with a 10x and 40x magnifying lens, subsequent application of Lugol’s iodine, followed by further observation. The colposcopic images were attached to the reports. The reports were written on the basis of the colposcopy criteria identified by the IFCPC in 2011.(15) The surgery involved 4 phases: 1. Colposcopy 2. Radial infiltration with local anaesthetic (ropivacaine hydrochloride monohydrate 7.5) of the four quadrants of the ectocervix. 3. Tissue excision in one or two steps depending on the shape of the ectocervix and the extent of the lesion. 4. Vaporisation of the wound bed with ball electrode at a power of 70 Watts, with careful haemostasis control. The surgical specimen went sent away on a support and fixed in formaldehyde 4% (DIAPATH). The sample was then sent to the Pathological Anatomy laboratory, where it was washed, included in paraffin and sectioned. Multiple 4 μm sections for each biopsy sample were stained with hematoxylin/eosin. The examined samples were classified in accordance with WHO criteria as negative, CIN1, CIN2, CIN3/Carcinoma in situ or microinvasive.(14) Giada Lavitola et al. Effect of TIAB® system for tissue healing after LEEP The patients were then randomised into two groups: group 1 underwent treatment with TIAB® and hyaluronic acid-based vaginal capsules for 10 days a month for 4 months from the day after the operation. Group 2 did not receive any pharmacological treatment. Patients in both groups then underwent a colposcopy and cytological sampling at 1 and 4 months after the operation. The cytological sample was taken using the standard technique: application of a vaginal speculum, cleansing of the ectocervix with physiological solution, ectocervical sampling with an Ayre’s spatula and endocervical sampling with a Cytobrush. The samples were rubbed on a slide, fixed with isopropyl alcohol - polyethylene glycols (GIMAFIX) and sent to the Pathological Anatomy laboratory. The samples then underwent standard staining according to the Papanicolaou method, before being examined. For the purpose of evaluating ectocervical reepithelialisation, the cytology reports were categorised as follows: 1. satisfactory or unsatisfactory for reading (due to severe phlogosis, presence of red blood cells that obscured the specimen). If the sample was inadequate for whatever reason (e.g. insufficient fixation, air drying artefacts or the presence of contaminants), the case was excluded from the study. 2. Presence or absence of altered lactobacillary microbial flora. 3. The degree of cellular maturation was then assessed: a. Grade 1: reparatory metaplasia b. Grade 2: complete maturation The presence or absence of epithelial cellular anomalies was not considered as a classification criterion. The colposcopy reports were also graded on the basis of tissue maturation: 1. Inadequate colposcopy, incomplete scarring makes diagnosis impossible. 2. Colposcopic picture of acidophilia, suggestive of immature metaplasia. 3. Normal colposcopic picture of a completely mature trophic squamous epithelium. Patients with abnormal changes were excluded from this study. STATISTICAL ANALYSIS SPSS 20.0 (SPSS Inc. Chicago, IL) software was used for the statistical analysis. The data distribution was evaluated using the Shapiro Wilks test. The Wilcoxon test and Student’s t-test were used to compare the nonparametric and parametric continuous data between the groups. The Chi-squared test was used to compare the categorical data between the groups. The level of significance for all the tests was set at p<0.05. RESULTS Three hundred and fifty-two patients met the inclusion criteria and were enrolled and randomised in the study. Of these, 327 patients completed the first and second colposcopy and cytology follow-up and were therefore included in the statistical analysis. 152 patients (group-1) received post-operative treatment with TIAB® system and hyaluronic-based vaginal capsules, while 175 patients did not receive any treatment (group 2, control). Twenty-five patients were excluded from the study: 14 patients were lost during follow-up, 4 patients did not take the prescribed treatment, 7 patients had positive colposcopy results at 1 month after treatment. The patients’ demographic data is summed up in Table 1. Table 1 Demographic variables of the two study groups Group 1 (No.=152) Group 2 (No.=175) p value Age (years) 33.7 ± 2.5 33.6 ± 2.4 NS Parity (no.) 0.4 [0.3-0.5] 0.3 [0.2-0.4] NS Group 1: patients receiving post-operative therapy with the TIAB® system Group 2: control group Mean ± sd; mean [CI, 95%] 27 It. J. Gynaecol. Obstet. 2017, 29: N. 1 - Supplement Effect of TIAB® system for tissue healing after LEEP Table 2 shows the cytology reports for the two study groups at 1 month and 4 months after surgery. A statistically significant difference was observed between the two study groups as regards the adequacy of the cytological specimen at the 1 month follow-up. The specimen was unsatisfactory in 40.6% of the untreated cases (group-2) and in 19.7% of the treated cases (group-1) (p <.001). A statistically significant difference was also demonstrated between the groups in the percentage of altered microbial flora and the maturation index at both month 1 and month 4 (table 2), with a lower microbial alteration percentage and a higher complete maturation percentage in group 1. As regards the data concerning the colposcopy (table 2), a statistically significant difference was observed in the colposcopic picture between the groups at 1 month and 4 months from surgery. The percentage of inadequate colposcopic pictures at the first month of follow-up was 41.7% in the control group, while it was just 10.5% in the treated group (Table 3). Table 2 Cytology reports for the two study groups at 1 month and 4 months after surgery Cytology Time 1 Time 1 Group 1 Group 2 p Group 1 Group 2 p (No. = 152) (No. = 175) value (No. = 152) (No. = 175) value Satisfaction 122 (80.3) 104 (59.4) <.001 144 (94.7) 159 (90.9) <.001 Unsatisfaction 30 (19.7) 71 (40.6) 8 (5.3) 16 (9.1) Normal 141 (92.8) 128 (73.1) 145 (95.4) 145 (82.9) Altered 11 (7.2) 47 (26.9) 7 (4.6) 30 (17.1) Complete 51 (33.6) 11 (6.3) 150 (98.7) 110 (62.9) Incomplete 101 (66.4) 164 (93.7) 2 (1.3) 65 (37.1) Adequacy Microbial flora <.001 <.001 Maturation Index <.001 <.001 Group 1: patients receiving post-operative therapy with the TIAB® system Group 2: control group no (%) Table 3 Colposcopy reports for the two study groups at 1 month and 4 months after surgery Coldoscopy 28 Time 2 Time 1 Group 1 (No. = 152) Group 2 (No. = 175) p value Group 1 (No. = 152) Group 2 (No. = 175) p value Inadeguate 16 (10.5) 73 (41.7) <.001 0 (0) 5 (2.9) <.001 Immature metaplasia 121 (79.6) 99 (56.6) 5 (3.3) 130 (74.3) Trophic original epithelium 15 (9.9) 3 (1.7) 147 (96.7) 40 (22.9) Group 1: patients receiving post-operative therapy with the TIAB® system Group 2: control group no (%) Effect of TIAB® system for tissue healing after LEEP DISCUSSION Our findings demonstrate that combined topical treatment with TIAB® system and HA accelerates the cervical healing process in patients who have undergone LEEP due to CIN2+. A significant increase was demonstrated in the percentage of cytology specimens adequate for examination after just one month of treatment and the percentage of adequate colposcopies was also significantly higher in the treated group. In fact, at 1 month from treatment, just 10.5% of cases in group 1 presented an inadequate colposcopy and only 19.7% of cases an inadequate cytological specimen. At 4 months, group 1 recorded 100% adequate colposcopies and just 5.3% cytological samples unsatisfactory for examination. Spontaneous bleeding, partial cervical deepithelialisation and excessive inflammatory infiltrate are the conditions that have the most effect on misdiagnosis during colposcopy and cytology. Treatment with TIAB® system and HA also reduces the number of cases with altered microbial flora at both 1 month and 4 months from surgery and this probably contributes to tissue maturation, with a positive effect on the cytological specimen. The cervical squamous epithelium is the first and most important form of innate immune response in the genital environment, acting as a mechanical barrier that protects against attacks by opportunist pathogens.(16) In the absence of this barrier and in the presence of favourable factors such as cervical bleeding as a result of surgery, which alters the vaginal pH, various pathogens can reproduce more easily and alter the normal resident microbiota. The onset of infection in a region undergoing active cervical reepithelialisation can delay the scarring process, interfering with normal cellular maturation processes. The antimicrobial and antibacterial power of the TIAB® system would probably tend to restore balance to the local microbial flora, preventing contamination with other microbial forms. The diagnostic and therapeutic procedure for CIN lesions does not involve cervical swabs being taken. The presence of infection is therefore not a decisive factor when choosing the most opportune time for treatment. Post-operative therapy with a drug that has antibacterial and antimycotic properties can reduce the risk of developing infections during the post-operative period and definitively delaying prompt and proper healing. Giada Lavitola et al. Wound healing is a complex process, characterised by angiogenesis, granulation tissue formation, collagen depositing, epithelialisation and wound contraction.(17) AgNPs have been shown to promote cutaneous wound healing by means of anti-inflammatory activity.(18) What is more, it has been demonstrated in animals and in the presence of an excisional wound, that AgNPs contribute positively to the reepithelialisation process, boosting fibroblast activation.(19) Hyaluronic acid also possesses specific reepithelialising properties, leading to fibroblast proliferation and constituting a hydrophilic network at the level of the extracellular matrix that facilitates the transport of nutrients and metabolites that encourage faster tissue regeneration.(13) Our findings show that topical therapy with the TIAB® system and HA encourages faster reepithelialisation and squamous cervical tissue maturation. At the 4-month follow-up, the group of treated patients showed a trophic squamous epithelium in 97% of cases, unlike the untreated subjects, who presented immature metaplastic tissue in 74% of cases and completely mature tissue in just 23% of cases. In terms of clinical impact, this data suggests that in patients who require an earlier follow-up so as to rule out the persistence of the disease, treatment with the TIAB® system and HA could provide certain benefits with a lower risk of uncertain or inadequate cytology and colposcopy results. It could therefore be of particular benefit to immunodeficient patients or those receiving therapy with immunosuppressants, so that they can resume therapy that is generally suspended in the presence of HPV-related disease as soon as possible, and to patients trying to conceive, so that they do not have to delay for excessive periods of time. In fact, while CIN is a condition that can develop at any age, in the natural history of the infection and carcinogenesis the peak incidence of CIN2-3 occurs in women aged between 25 and 35, a period that coincides with the childbearing age in western countries.(20) 29 It. J. Gynaecol. Obstet. 2017, 29: N. 1 - Supplement 30 Effect of TIAB® system for tissue healing after LEEP Fig. 1 Colposcopic picture (a) and cytological picture (b) at 1 month from excisional surgery in a control group patient (group 2). a) A large area of deepithelialisation can be observed, with spontaneous bleeding. b) The red blood cells obscure the view. Specimen inadequate for examination. Fig. 2 Colposcopic picture (a) and cytological picture (b) at 4 month from excisional surgery in a control group patient (group 2). a) Treatment outcomes can be observed with a periorificial metaplastic epithelium. b) Reactive cellular changes caused by phlogosis. Enlarged nuclei and perinuclear halos with cytoplasmic vacuolations can be observed. Fig. 3 Colposcopic picture (a) and cytological picture (b) at 1 month from excisional surgery in a group 1 patient a) Cervical reepithelialisation can be observed with metaplastic squamous epithelium. b) Squamous epithelium with typical repair, associated with mild phlogosis. Enlarged nuclei can be observed with evident nucleolus. Basophilic cytoplasm. Fig. 4 Colposcopic picture (a) and cytological picture (b) at 4 months from excisional surgery in a group 1 patient. a) Complete reepithelialisation can be observed with a trophic and mature squamous epithelium. b) Mature squamous metaplasia Effect of TIAB® system for tissue healing after LEEP REFERENCES 1) Massad LS, Einstein MH, Huh WK, et al. 2012 ASCCP Consensus Guidelines Conference 2012 updated consensus guidelines for the management of abnormal cervical cancer screening tests and cancer precursor. J Low Genit Tract Dis. 2013 Apr;17(5 Suppl 1):S1-S27. 2) Gestione della paziente con Pap Test anormale. Linee Guida Edizione 2006. Società italiana di Colposcopia e Patologia Cervico Vaginale. 3) Strander B, Andersson-Ellström A, Milsom I et al. Long term risk of invasive cancer after treatment for cervical intraepithelial neoplasia grade 3: population based cohort study cervical intraepithelial neoplasia grade 3. BMJ, 2007, 335(7629): 1077. 4) Arbyn M. Et al. “EDS. European Guidelines for quality assurance cervical cancer screening.” Cap.6: management of abnormal cervical-cytology. 2Ed. Bruxelles. European Community. 5) NHS Cervical Screening Programme. Colposcopy and Programme Management. NHSCSP Publication number 20 Third Edition March 2016. 6) Timmons BC, Mahendroo M. Process regulating cervical ripening differ from cervical dilation and postpartum repair: insights from gene expression studied. Reprod Sci. 2007; 14:53-62. 7) Mahendroo M. Cervical remodelling in term and preterm birth: insights from an animal model. Reproduction. 2012; 143:429-438. 8) Stanley R, Ohashi T, Mowa C. Postpartum cervical repair in mice: a morphological characterization and potential role for angiogenic factors. Cell Tissue Re. 2015 Oct;362(1):253-63. 9) Papoutsis D, Rodolakis A, Mesogitis S, Sotiropoulou M, Antsaklis A. Regeneration of uterine cervix at 6 months after large loop excision of the transformation zone for cervical intraepithelial neoplasia. BJOG. 2012 May;119(6):678-84. 10) Lara HH, Romero-Urbina DG, Pierce C, Lopez-Ribot JL, Arellano-Jiménez MJ, Jose-Yacaman M. Effect of silver nanoparticles on candida albicans biofilms: an ultrastructural study. J Nanobiotechnology. 2015 Dec 15;13-91. 11) Orlowski P, Tomaszewska E, Gniadek M, Baska P, Giada Lavitola et al. Nowakowska J, Sokolowska J, Nowak Z, Donten M, Celichowski G, Grobelny J, Krzyzowska M. Tannic acid modified silver nanoparticles show antiviral activity in herpes simplex virus type 2 infection. PLoS One. 2014 Aug 12;9(8):e104113. 12) Kwan KHl, Liu X, To MK, Yeung KW, Ho CM, Wong KK. Modulation of collagen alignment by silver nanoparticles results in better mechanical properties in wound healing. Nanomedicine. 2011 Aug;7(4):497-504. 13) Liang J, Jang D, Noble PW. Hyaluronan as a therapeutic target in human disease. Adv Drug Deliv Rev. 2016 Feb 1;97:186-203. Doi:10.1016/j. addr.2015.10.017. Epub 2015 Nov 2. 14) Wells M. Epithelial tumors. In: Tavassoli FA, Devilee P. editors. World Health Organization classification of tumors: pathology and genetics of tumors of the breast and female genital organs. Lyons, France: IARC Press; 2003. P. 269-70. 15) 2011 Colposcopic Terminology of the International Federation for Cervical Pathology and Colposcopy. Bornstein J et al. Obstet Gynecol 2012. Jul;12081):166-72. 16) Hickey DK, Patel MV, Fahey JV and Wira CR. Innate and adaptive immunity at Mucosal Surfaces of the Female Reproductive Tract: Stratification and Integration of Immune Protection against the Transmission of Sexually Transmitted Infections. J Reprod Immunol. 2011 March;88(2):185-94. 17) Midwood KS, Williams JE, Schwarzbauer JE. Tissue repair and the dynamics of the extracellular matrix. Int J Biochem Cell Biol, 36 (2004), pp. 1031-1037. 18) Tian J, Wong KK, Ho CM, Lok CN, Yu WY, Che CM et al. Topical delivery of silver nanoparticles promotes wound healing. ChemMedChem, 2 (2007), pp. 129-136. 19) Liu X, Lee PY, Ho CM, Lui VC, Chen Y, Che CM et al. Silver nanoparticles mediate differential responses in keratinocytes and fibroblasts during skin wound healing. ChemMedChem, 5(2010), pp. 468-475. 20) Kyrgiou M, Koliopoulos G, Martin-Hirsch P, Arbyn M, Pren-diville W, Paraskevaidis E. Obstetric outcomes after conservative treatment for intraepithelial or early invasive cervical lesions: systematic review and metaanalysis. Lancet 2006;367: 489-98. 31