Human papilloma virus (HPV) in patients with esophageal carcinoma has previously been studied with an average detection rate of 15%, but the role of HPV in relation to survival is less clear. In cervical cancer, lung cancer and tonsil cancer HPV viral load is a predictive factor for survival and outcome of treatment. The primary aim was to study the spectrum of high-risk HPV types in esophageal tumors. Secondary, as a pilot study we investigated the association between HPV status and the survival rates.We compared both the presence and the viral load of high-risk HPV types 16, 18, 31, 33, 39, 45, 52, 58, and 67 in relation to clinical data from patients with esophageal carcinoma. Survival data and tumor samples were retrieved from 100 patients receiving treatment at the Department of Oncology, Uppsala Hospital, Uppsala, Sweden. The tumor samples were investigated for HPV viral load using real-time PCR.HPV 16 was detected in 16% of the patients; no other HPV type was detected. HPV 16 infection had no significant effect on survival (p = 0.72). Also, HPV 16 did not improve survival after treatment (radiotherapy or chemotherapy).Only HPV 16 was detected among the patients. HPV 16 in esophageal carcinoma patients did not influence survival or improve therapy response. However, given the size of the study there is a need to examine a larger cohort in order to understand in more detail the effect of high risk HPV types in esophageal carcinoma. Accordiin vitro studies the chemosensitivity as well as radiation sensitivity is decreased in HPV-infected cells [In patients with tonsil cancer, the presence of HPV in the tumors correlates with better survival . In a sted cells ,9. The ied cells . The meced cells .In the present study, viral load in a series of high-risk HPV types  were determined in esophageal carcinoma tumors. Secondary, as a pilot study we investigated the association between HPV status and survival in patients with esophageal carcinoma.The study was reviewed and approved by the research ethics committee, Uppsala University, Uppsala, Sweden.Patients with esophageal carcinoma, admitted to the Department of Oncology, University Hospital, Uppsala, Sweden, during 1990–2000 were identified. These patients formed a consecutive series. A total of 126 patients fulfilled the inclusion criteria but 26 patients were lost due to inadequate (n = 9) or absence of histological material (n = 17). The present study is based on a retrospective examination of esophageal carcinoma diagnostic biopsy samples from clinical cases, all retrieved tumor samples were re-evaluated before analysis.The following parameters were studied: age, gender, weight loss, performance status according to the Eastern Cooperative Oncology Group (ECOG)  at firstTreatment strategy was recorded as:2 and 5-FU 750 mg/m2, three cycles with an interval of three weeks of which two were given concomitantly).1. Preoperative radiation treatment, total dose of 40 Gy in 2 Gy fractions. This irradiation was given concomitant with chemotherapy , A. Lörincz (Digene Corporation) or G. Orth  or prepared by cloning from PCR products of clinical samples. The plasmids were used both as positive controls and to estimate the sensitivity of the assay.The biopsies were fixated by treatment in buffered formalin followed by paraffin embedding. Paraffin blocks from the primary tumor were cut in 10-μm sections and 4 sections/patient were collected in the same microcentrifuge tube. Samples were de-waxed in 1 ml xylene for 5 min. in room temperature and centrifuged at 14,000 rpm for 5 min. The supernatant was removed. This step was then repeated 5 times. Samples were gently vortexed between each step. 1 ml 95% ethanol was then added for 5 min. in room temperature and this was repeated with 70% ethanol. The samples were centrifuged 14.000 rpm for 5 min. between the ethanol changes. The samples were then dried in a 37°C heated block with open lids for 20 min. to remove residual ethanol.200–400 μl of dilution buffer was added to each tube . The volume of the dilution buffer was dependent of the amount of tissue available. Samples were subsequently incubated at 50°C overnight and thereafter heated to 94°C for 10 min. to inactivate the proteinase K.50 μl of saturated NaCl solution (approximately 6 M) was added to each tube and the samples gently vortexed for 5 min. The tubes were then centrifuged at 14.000 rpm at room temperature for 5 min. After centrifugation, white pellets were visible in the bottom of the tubes and supernatants were transferred to a new tube.DNA was precipitated with 2.5 volumes of 95% ethanol in -20°C for 1 hour and then pelleted by centrifugation at 14.000 rpm in room temperature for 30 min. The pellet was then washed with 70% ethanol followed by centrifugation for 5 min. DNA pellets were air dried and finally re-suspended in 100 μl TE buffer .The detection of the HPV was performed using a real-time PCR based method previously described . Briefly2 to 107 HPV copies per assay and is applicable to both fresh clinical samples and DNA extracted from archival samples. Reconstitution experiments, made to mimic infections with several HPV types, shows that individual HPV types can be detected in a mixture as long as they represent 1–10 percent of the main type. The system has been evaluated with respect to technical specificity and sensitivity, reproducibility, reagents stability, sample preparation protocol and applied to the analysis of clinical samples. This homogeneous assay provides a fast and sensitive way for estimating the viral load of a series of the most frequent oncogenic HPV types in biopsies.The system has a dynamic range from 102, 200 nM each of dATP, dCTP, dGTP and 400 nM dUTP , 0.625 U AmpliTaq Gold , 3 μg BSA  and 200 nM of each primer and probe, and 3 μl DNA extract. Amplification and detection was performed using a 7700 Sequence Detection System . The amplification ramp included an initial hold step of 10 min. at 95°C followed by a two-step cycle consisting of 15 sec. at 95°C and 1 min. at 57°C, repeated 40 times. Each real-time PCR run included reactions with no template controls containing all PCR components but without template DNA to ensure that the reagents mix were free of contaminants.The PCR amplification was performed in a 25 μl volume containing 1× PCR buffer gold , 300 μM 6-carboxy-X-rodamine , 3.5 mM MgClThe survival rates were estimated with the Kaplan-Meier product limit method, whereas univariate analysis was performed with log-rank test. Cox regression analysis was performed to investigate if certain continuous factors had a significant effect on survival. Spearman's rank order correlation was utilized for tests of associations between factors. A 5% significance level was used throughout the study.A total of 100 patients with esophageal carcinoma were investigated for the presence of the following types of human papilloma virus 16, 18, 31, 33, 39, 45, 52, 58, and 67. The patients were followed until 2003 with a median follow up time of 297 days (5–3675 days) and 11 (11%) patients were alive after follow-up. Patient's characteristic, median survival and median viral load for each investigated parameter are listed in Table Prior to the analysis of clinical samples, standard curves for the different HPV types were generated based on dilution series of the HPV plasmids, as described . Each ruHPV is an important risk factor for development of cervical cancer as well as head/neck and anal cancer -17. In tViral load has previously been investigated in esophageal carcinoma tumors with PCR technology . Si et aThe prognostic value of HPV status has previously been investigated in patients with esophageal carcinoma ,21. FuriLindel et al report HPV status as a prognostic parameter for radiotherapy response in cervical carcinoma patients . FurtherIn vitro studies report that cisplatin sensitivity is increased in HPV 16 transfected ovarian cancer cells [We investigated the HPV positive patients in relation to treatment. HPV positive patients receiving radiation treatment indicated a trend towards better survival, although this was not statistically significant (p = 0.16). Integration of HPV result in higher expression of the oncoproteins E6/E7, thereby abrogating the p53 and Rb protein functions, promoting genomic rearrangements  and deveer cells , in accoIn conclusion, we employed a sensitive real-time PCR assay for analysis of paraffin-embedded tissue from patients with esophageal carcinoma. Among the 100 patients investigated, HPV 16 was present in 16% of the patients. Given the limited sample size, the results of this pilot study should be interpreted with caution. However, the results indicate a positive association of HPV 16 viral load with survival and motivate further studies of the role of HPV 16 viral load in patients with esophageal carcinoma.Only HPV 16 was detected among the patients. HPV 16 in esophageal carcinoma patients did not influence survival or improve therapy response. However, given the size of the study there is a need to examine a larger cohort in order to understand in more detail the effect of high risk HPV types in esophageal carcinoma.The author(s) declare that they have no competing interests.MD and MB contributed equally as principal investigators and UG was the principal supervisor. SB, DB, GW assisted in the design of the study and obtaining funding. PH was responsible for the statistical analyses. AW, MM and IG contributed with evaluation of the material and did the laboratory analyses. All these investigators contributed to data interpretation and preparation of the paper.The pre-publication history for this paper can be accessed here:


CB is best known as the interception strategy employed by baseball outfielders to catch ballistic fly balls. CB is a time-optimal solution to catch targets moving along a straight line, or in a predictable fashion—such as a ballistic baseball, or a piece of food sinking in water. Many animals, however, have to capture prey that may make evasive and unpredictable maneuvers. Is CB an optimum solution to pursuing erratically moving targets? Do animals faced with such erratic prey also use CB? In this paper, we address these questions by studying prey capture in an insectivorous echolocating bat. Echolocating bats rely on sonar to pursue and capture flying insects. The bat's prey may emerge from foliage for a brief time, fly in erratic three-dimensional paths before returning to cover. Bats typically take less than one second to detect, localize and capture such insects. We used high speed stereo infra-red videography to study the three dimensional flight paths of the big brown bat,Eptesicus fuscus, as it chased erratically moving insects in a dark laboratory flight room. We quantified the bat's complex pursuit trajectories using a simple delay differential equation. Our analysis of the pursuit trajectories suggests that bats use aconstant absolute target direction strategy during pursuit. We show mathematically that, unlike CB, this approach minimizes the time it takes for a pursuer to intercept an unpredictably moving target. Interestingly, the bat's behavior is similar to the interception strategy implemented in some guided missiles. We suggest that the time-optimal strategy adopted by the bat is in response to the evolutionary pressures of having to capture erratic and fast moving insects.Acquisition of food in many animal species depends on the pursuit and capture of moving prey. Among modern humans, the pursuit and interception of moving targets plays a central role in a variety of sports, such as tennis, football, Frisbee, and baseball. Studies of target pursuit in animals, ranging from dragonflies to fish and dogs to humans, have suggested that they all use a Analysis of the three dimensional flight paths of the big brown bat reveals a similar strategy to intercept targets as used by some guided missiles. We argue in this paper that this strategy minimizes time-to-capture of an unpredictably moving insect.Echolocating bats forage on the wing in darkness. Their primary sensory system for hunting in the dark is echolocation ,2. TheyPrevious studies of fish , dragonfThe CB strategy has been successful in explaining pursuit behavior when the target moves at constant velocity and the pursuer moves at constant speed. Under the condition of constant target velocity a pursuer following a CB strategy intercepts the target by moving along a straight line while holding a fixed target bearing seeA given bp < vTv sin β), it cannot intercept the target, and there is no solution top > vTv sin β, then there are two solutions toIf a pursuer is too slow (X′Z to intercept the target in timeT (X′PY (not necessarily a straight line) that would allow the pursuer to intercept the target in shorter timeT′, at positionY. In that caseUnder the condition of constant target velocity, when a pursuer follows a CB strategy, it intercepts the target in minimum time. We offer a proof of this by contradiction: when holding a CB, the pursuer follows a straight path timeT A. SupposX′Z is the shortest interception path available to the pursuer. This demonstrates thatφ, defined byoptφ in what follows.a contradiction, implyingoptφ will vary from segment to segment. If the linear segments are long enough then the animal could still use the CB strategy to converge to the optimum bearing  remains constant. If the pursuer follows a constant absolute target direction (CATD) strategy where it maneuvers to minimize changes in the absolute direction to the target, the pursuer can maintain the optimum bearing for each instant of the pursuit. The pursuer can follow this strategy by adjusting both its direction of motion and its speed, ensuringp > vTv sin β as mentioned previously.In the case of an erratically moving target, a pursuer can maintain an optimum bearing using a different strategy. The velocities of the target and pursuer may be decomposed into two components, one parallel to the line joining them  or whether the bat uses a CATD strategy to meet its behavioral requirements. Our results indicate thatE. fuscus follows a CATD strategy.In this study we investigated whether the pursuit of erratically moving insects byE. fuscus emits echolocation cries through the open mouth, so the axis of the sonar beam is aligned with the axis of the head. These measurements, therefore, allowed us to compute the horizontal direction of the bat's head as it chased its prey  and accounts for 81% of the variance. In the horizontal plane, therefore, the bat keeps1) of the scatter ofdθ/dt) at the expense of  larger changes in bearing angle (dφ/dt) and absolute target direction. One reason for this difference in the bat pursuit strategy along the vertical dimension may be that the bat tends to pounce on the target from above (seeAs the bat maneuvers to reducebove seeB and4B.α), rather than the target bearing (φ), a constant. Thus the bat, unlike a variety of other animal species, does not use a CB strategy while following its prey. We propose that bats follow a CATD strategy. The bat adjusts its direction of flight and its speed of pursuit so as to maintain theabsolute direction to the target a constant during pursuit.These results show that the bat maneuvers to approach the instantaneous optimal bearing even when the target is moving erratically. In the horizontal plane the bat prefers to keep the absolute direction to the target (When the bat converges to (and maintains) the optimal bearing, the absolute direction to the target does not change. The CATD strategy produces a trajectory which, from the viewpoint of the target, makes the pursuer “appear” stationary against a distant background, and vice-versa. Such trajectories have been observed in the flights of male dragonflies engaged in territorial interactions and have been interpreted as camouflaging behavior on the part of the pursuing male . Becausedirection as sensed by its vestibular system. Because the bat can obtain an accurate estimate of target range through its echolocation system [We propose a simple mechanism that does not require the bat to explicitly compute the quantities in system , it woul system ,26, whe system . Our expeφ, the deviation from the optimum direction. We model the experimentally observed data using a delay-differential equation  and found that a delay ofτ = 120 ms produced the best fit (seeechoτ (the time delay between the emission and reception of the echo),auditoryτ  andmotorτ . Of these delay componentsechoτ is the easiest to estimate: the maximum prey distance is about 2 m, leading toechoτ ≤ 12 ms under room conditions. It is harder to obtain estimates for the other delays. Neural response latencies to echo stimuli in the bat midbrain can be less than 4 ms and greater than 20 ms [auditory =τ 20 ms, therefore, still leaves a major portion of the delay (about 90 ms or 75%) to be taken up bymotorτ. In this context, bat head movements with a latency of 100 ms are obtained from microstimulation of the bat superior colliculus [From the experiments, we observe that the bat maneuvers to reducequation . In cons fit see. We hypon 20 ms ,29. A cliculus  (a midbrliculus ). Intereliculus .Since the bat could perform the computations for the CATD strategy by maneuvering to null rotational movements of the head, the bat could link its vestibular system to appropriate flight musculature via a “vestibulo-pursuit reflex,” much like the vestibulocollic reflex. Whereas the traditional vestibulocollic reflex serves to stabilize the head direction when the body posture changes , the proThe bat's strategy is equivalent to following an intercept course to the target at every instant of time, assuming the target will continue moving at its current velocity. The CATD strategy has the important near-optimality property that under a piecewise linear approximation B it mini(E. fuscus) to study sonar guided flight. The sonar pulses produced by these bats are 2–20 ms long, and consist of multiple harmonics with the fundamental sweeping from approximately 60 kHz down to 22 kHz [We used big brown bats 22 kHz . The bat 22 kHz . When se 22 kHz ) where t 22 kHz . Images  22 kHz .. The mantis was released by hand as the bat was flying around in the room. The mantises had their ears plugged with Vaseline to suppress ultrasound-triggered diving behavior. The mantises made erratic flight maneuvers after release into the room. The tethered insects were inch-long mealworms tethered by a length of monofilament fiber. The tethered insects were concealed in a trapdoor mechanism that was placed at random positions on the ceiling. The bat was allowed to fly in the room for a period of time (10–30 s) after which the prey was released from the trapdoor. The tethered insect was moved in sections of an arc after release by activating a motorized boom attached to the trapdoor assembly. Each bat was tested individually as it chased a single prey presented in the room. A trial consisted of the release of the insect and the first attempt by the bat to capture it.The bats were trained to catch both free flying and tethered insects. Each bat was tested individually as it chased a single prey presented in the room. The free flying insects were a species of praying mantisVideo S1The video has been slowed down by a factor of 10. The bat's position at each frame is depicted by a blue circle and its trajectory is drawn as a blue line. The insect's position is depicted by a black cross and its trajectory is drawn as a black line. The sonar beam patterns depicted in the animations use grayscale to represent sonar beam intensity. Black is the direction of the most intense part of the beam. Shades of gray are linearly scaled to the sound intensity. The computed beam direction for each vocalization is shown as a short black line.(487 KB WMV)Click here for additional data file.Video S2The video has been slowed down by a factor of 10. The bat's position at each frame is depicted by a blue circle and its trajectory is drawn as a blue line. The insect's position is depicted by a black cross and its trajectory is drawn as a black line. The sonar beam patterns depicted in the animations use grayscale to represent sonar beam intensity. Black is the direction of the most intense part of the beam. Shades of gray are linearly scaled to the sound intensity. Bearing lines from the bat to the insect are drawn at 100-ms intervals.(502 KB WMV)Click here for additional data file.Video S3The video has been slowed down by a factor of 10. The bat's position at each frame is depicted by a blue circle and its trajectory is drawn as a blue line. The insect's position is depicted by a black cross and its trajectory is drawn as a black line. The sonar beam patterns depicted in the animations use grayscale to represent sonar beam intensity. Black is the direction of the most intense part of the beam. Shades of gray are linearly scaled to the sound intensity. The computed beam direction for each vocalization is shown as a short black line.(565 KB WMV)Click here for additional data file.Video S4The video has been slowed down by a factor of 10. The bat's position at each frame is depicted by a blue circle and its trajectory is drawn as a blue line. The insect's position is depicted by a black cross and its trajectory is drawn as a black line. The sonar beam patterns depicted in the animations use grayscale to represent sonar beam intensity. Black is the direction of the most intense part of the beam. Shades of gray are linearly scaled to the sound intensity. Bearing lines from the bat to the insect are drawn at 100-ms intervals.(573 KB WMV)Click here for additional data file.


Human papillomavirus (HPV), a sexually transmitted infection andthe etiologic cause of genital warts and cervical cancer, ishighly prevalent in sexually active men and women. Althoughcervical screening procedures have significantly reduced thedisease burden associated with HPV infection, they are expensiveand abnormal results cause significant emotional distress.Therefore, prevention may be an effective strategy for reducingthe economic, psychosocial, and disease burden of HPV infection.Multivalent vaccines are now in clinical development. A bivalentvaccine that protects against HPV 16 and 18, and a quadrivalentvaccine which protects against HPV types 6, 11, 16, and 18, havebeen shown to significantly reduce the occurrence of incident andpersistent HPV infections in phase 2 clinical trials; phase 3trials are currently underway. HPV vaccines will be most effectivewhen administered prior to initiation of sexual activity, andvaccination campaigns should aggressively target preadolescent andadolescent populations. Human papillomavirus (HPV) is the most common newly acquiredsexually transmitted infection (STI) in the United States, with anestimated 20 million people infected . FurtherMore than 100 different types of HPV have been identified, 5 Tabl. Low-risIn contrast to infection with HPV types 6 and 11, infection withhigh-risk HPV types 16 and 18 can lead to anogenital cancers. HPVtypes 16 and 18 cause 70% of all cases of cervical cancer, withhalf of all cervical cancers caused by type 16 alone . PersistThe transmission typically occurs through the skin-to-skinanogenital contact. Increased risk for acquiring HPV hasbeen associated with multiple sexual partners, younger age ofsexual debut, failure to use condoms, and sex with uncircumcisedmales. HoweverAnnual cervical cancer screening is expensive. In a study of women enrolled in a USAhealth care plan, it was estimated that an average of $26,415 per1000 women was spent on annual cervical screening and treatmentfor HPV-related diseases . When thHPV infection is most prevalent in adolescents and young adults,and this group also incurs the majority of HPV-associated healthcare costs. When it comes to HPV-related health care, women in the20–29 year age group incurred an annual cost of $51,863 per 1000women. The estAssembly of infectious virus, a necessary step in the HPV lifecycle, involves the formation of the capsid, or outer layer, ofthe virion. The capsid is composed of two proteins, L1 and L2,which are expressed later in infection. The major capsid proteinL1 comprises the outermost layer of the capsid and is necessaryfor virus structure. HPV vacEarly studies with a monovalent vaccine against HPV 16 have shownthat VLP vaccines induce a strong immune response against L1 inanimal models, 22 and Immune responses to HPV infection are type-specific; therefore,vaccine efficacy can be greatly improved by combining VLPs fromseveral types of HPV into one multivalent vaccine. Multivalentvaccines that offer protection against the most commondisease-causing HPV types are in late stages of clinicaldevelopment. Currently, a bivalent vaccine that protects against 2high-risk HPV types, and a quadrivalent vaccine that protectsagainst 2 high-risk and 2 low-risk HPV types are being tested.To determine the efficacy, immunogenicity, and safety of abivalent vaccine containing HPV types 16 and 18, a double-blind,placebo-controlled phase 2 trial was conducted on 1113 women(15–25 years old) with no prior history of HPV infection andnormal cervical cytology. In thisIncluding additional HPV types in vaccines would be expected tocumulatively reduce HPV-associated disease burden by preventingadditional HPV infections. A quadrivalent vaccine has beendeveloped to protect against HPV types 6, 11, 16, and 18. Adouble-blind, placebo-controlled phase 2 safety and efficacy trialwas conducted on more than 500 women aged 16–23 years. Women whowere enrolled in the trial received either the quadrivalentvaccine  or placebo  on day 1, month 2, and month 6, and then were followed for36 months. ResultsRecently, data from the phase 3 Females United to UniversallyReduce Endo-ectocervical disease (FUTURE II) clinical trial werepresented. The quadrivalent HPV vaccine was 100% effective atpreventing CIN 2/3, AIS, and cervical cancer associated with HPV16 or 18 infection during two years of follow-up. The vaccine waswell-tolerated and there were no vaccine-related serious adverseevents.Vaccines that provide protection against the most commondisease-causing HPV types would be expected to significantlyreduce the incidence of HPV-associated diseases. ReducingHPV-associated disease burden may also reduce the health carecosts associated with these diseases.Although HPV vaccines are not currently available to the public,their potential public health benefits have been reported inseveral mathematical modeling studies –35. SandGenital warts and abnormal Pap tests can also produce anxiety andemotional distress. In fact, diagnosis with genital warts is oftenthe most anxiety-provoking outcome of HPV infection.BecauseA number of obstacles will need to be overcome to maximize thepublic health benefits of HPV vaccination. Vaccination programsmust identify appropriate candidates for vaccination, establishbooster requirements, and overcome potential individual, parental,and social barriers to HPV vaccine acceptance. For example,individuals may view acceptance of HPV vaccines as admitting torisky sexual behavior. Furthermore, research has shown thatknowledge about HPV, an infection that many people know littleabout, is directly correlated to vaccine acceptance–39. PareAdministering HPV vaccines to populations prior to initiatingsexual activity will yield the greatest health benefit.Because preadolescent and adolescent children are generallysexually naïve and develop robust immune responses tovaccines, vaccinating young adolescents is predicted tosignificantly reduce the incidence of HPV infection andHPV-associated diseases. In order to foster broadacceptance of HPV vaccine, public health initiatives will need toeducate parents/caregivers as well as health care professionalsabout the risks associated with HPV infection and the benefits ofvaccination.Vaccination has been widely accepted as an effective means bywhich infectious diseases can be prevented or eliminated. VLPvaccines that protect against infection with the most commondisease-causing HPV types are currently in clinical developmentand early reports have suggested that HPV vaccines are highlyefficacious in preventing HPV infection and HPV-associateddisease. HPV vaccines will be most effective when administeredprior to initiation of sexual activity and vaccination initiativeswill most likely target preadolescent and adolescent populations.


Cervical cancer remains one of the greatest killers of women worldwide. It is difficult to foresee a dramatic increase in cure rate even with the most optimal combination of cytotoxic drugs, surgery, and radiation; therefore, testing of molecular targeted therapies against this malignancy is highly desirable. A number of epigenetic alterations occur during all stages of cervical carcinogenesis in both human papillomavirus and host cellular genomes, which include global DNA hypomethylation, hypermetylation of key tumor suppressor genes, and histone modifications. The reversible nature of epigenetic changes constitutes a target for transcriptional therapies, namely DNA methylation and histone deacetylase inhibitors. To date, studies in patients with cervical cancer have demonstrated the feasibility of reactivating the expression of hypermethylated and silenced tumor suppressor genes as well as the hyperacetylating and inhibitory effect upon histone deacetylase activity in tumor tissues after treatment with demethylating and histone deacetylase inhibitors. In addition, detection of epigenetic changes in cytological smears, serum DNA, and peripheral blood are of potential interest for development of novel biomolecular markers for early detection, prediction of response, and prognosis. Cervical cancer remains one of the greatest killers of women worldwide. According to Globocan 2000, it is estimated that in 2000 the numbers of patients diagnosed with and those who died from this disease were 470,606 and 233,372, respectively . It is rCervical cancer is currently staged clinically according the International Federation of Gynecology and Obststrics (FIGO) guidelines. In terms of treatment, invasive disease can be divided into three main groups: 1) early stage going from microinvasive disease IA1, IA2 to macroscopic disease confined to cervix and measuring <4 cm, IB1; 2) locally advanced FIGO stages IB2-IVA, and 3) IVB and recurrent disease  and zebularine [272] as well as HDAC inhibitors including SAHA, M344, depsipeptide [273], and valproic acid [274] are radiosensitizers. In addition, it is very noteworthy that HDAC inhibitors such as phenylbutyrate, trichostatin A, and valproic acid are able to reduce cutaneous radiation toxicity following radiotherapy [275]. Therefore, radiation or chemoradiation in combination with DNA demethylating agents and/or HDAC inhibitors is a research avenue to be explored. Based on these data, a phase II study of transcriptional therapy with the demethylating hydralazine plus the histone deacetylase inhibitor magnesium valproate added to chemoradiation with cisplatin is ongoing in FIGO stage IIIB cervical carcinoma.Epigenetic alterations are at least if not more important than genetic defects for the development and progression of malignant diseases. In cervical cancer, a number of epigenetic alterations occurring during all stages of cervical carcinogenesis in both human papillomavirus and host cellular genomes have been identified. These include global DNA hypomethylation, hypermetylation of key tumor suppressor genes, and histone modifications. From the diagnostic point of view, because epigenetic abnormalities occur very early in the carcinogenic process they can potentially be exploited as molecular markers for early detection. In this sense, identification of a set of genes hypermetylated in cytologic smears could offer novel means for screenning. Assessment of hypermethylated genes in primary tumor or in serum DNA may serve as a prognostic factor or as a means of predicting response to radiation, chemotherapy, and transcriptional agents.In the therapeutic field, transcriptional therapy is a very promising form of cancer treatment that is being extensively evaluated. It is too early to evaluate usefulness. However, it has now been demonstrated that inhibitors of DNA methylation and histone deacetylases can reactivate expression of tumor suppressor genes and induce hystone hyperacetylation in the tumors of patients with cervical cancer after treatment with these agents.AD-G conceived and wrote the manuscript; ML contributed with the HPV section; MC, LC, CA and EC participated in the discussion, analysis of the content.


Medicine is a scientific art: once science is not clear, choices are made according to individual and collective beliefs that should be better understood. This is particularly true in a field like adolescent idiopathic scoliosis, where currently does not exist definitive scientific evidence on the efficacy either of conservative or of surgical treatments.To verify the philosophical choices on the final outcome of a group of people believing and engaged in a conservative treatment of idiopathic scoliosis.We performed a multifaceted study that included a bibliometric analysis, a questionnaire, and a careful Consensus reaching procedure between experts in the conservative treatment of scoliosis (SOSORT members).The Consensus reaching procedure has shown to be useful: answers changed in a statistically significant way, and 9 new outcome criteria were included. The most important final outcomes were considered Aesthetics (100%), Quality of life and Disability (more than 90%), while more than 80% of preferences went to Back Pain, Psychological well-being, Progression in adulthood, Breathing function, Scoliosis Cobb degrees , Needs of further treatments in adulthood.In the literature prevail outcome criteria driven by the contingent treatment needs or the possibility to have measurement systems . SOSORT members give importance to a wide range of outcome criteria, in which clinical and radiographic issues have the lowest importance.We treat our patients for what they need for their future , and their present too . Technical matters, such as rib hump or radiographic lateral alignment and rotation, but not lateral flexion, are secondary outcomes and only instrumental to previously reported primary outcomes. We advocate a multidimensional, comprehensive evaluation of scoliosis patients, to gather all necessary data for a complete therapeutic approach, that goes beyond x-rays to reach the person and the family. Medicine is art: a scientific art, but always art ,2. MedicThis is particularly true in a field like adolescent idiopathic scoliosis, where currently the lack of RCTs does not allow to have any definitive evidence demonstrating the efficacy either of conservative or of surgical treatments -12. In aLooking at the thoughts of physicians facing scoliosis, we can see that as far as four centuries B.C. Hyppocrates aimed at restoring the correct anatomy through methods that should act in accordance to nature ; it was Psychological well-being (PWB) and Quality of Life (QoL), including actual and future Disability (Dis), were already clear in the mind of some pioneers such as Stagnara, who stated that we have to treat human beings with a deformity, not X-rays. Blount Cobb also considered other outcomes in addition to avoiding the increase (or decrease) of the curve per se: they included improving muscle tone, vital capacity, Aesthetic (Aes) appearance, posture and health, and these were all reasons to prescribe exercises .The cornerstone studies  on the In this situation, in which many aims have been proposed it seems that the world of treatment, focused on X-rays and scoliosis Cobb degrees (SCD), is not so strictly conscious of the long term results of which SCD are only a part, and presumably not the most important one;with our paper we aimed to verify the philosophical choices, the final outcome of a group of people believing and engaged in conservative treatment of idiopathic scoliosis.The work has been performed in four distinct parts:• A systematic literature search on the topic and a bibliometric analysis.• A questionnaire preparatory to the Consensus Meeting.• A Consensus reaching procedure, including distribution to participants of results of previous steps (first part of this paper: preliminary document) and a M• A final Consensus questionnaire.First, we aimed at identifying all papers that could have faced the philosophical topic of our paper. We searched the Medline database, using free text, from the date of inception to November 2004, without applying any language restriction. We used the words idiopathic scoliosis and set the limits editorial, guideline, meta-analysis and randomized controlled trial. Moreover, we made a hand-search in the Library of an Italian Study Group  fully dedicated to the rehabilitation of spinal diseases in general and to scoliosis in particular; itcontain more the 300 books on these topics, published from 1978 (creation date of the Study Group) to 2004. According to the abstract, we selected the final papers that were read to search relevant information on the topic to be introduced in the document sent to participants to the Consensus Meeting.Secondly, we performed a bibliometric analysis: we wanted to verify how many papers that dealt with outcomes in the treatment of adolescent idiopathic scoliosis considered the possibly relevant outcomes. During the preparation of the study, the possibly relevant outcomes of scoliosis treatment have been proposed by the first author and submitted to a preliminary Consensus between the authors of this study: a final list was provided according to Table The questionnaire has been prepared through a Consensus between the authors of the study. We made a first version, that was discussed by e-mail in order to produce a second edition that was submitted to a pre-test by e-mail, to obtain the final form. The title of the questionnaire was 'Why do we treat? What we want to obtain and avoid for our patients'and the following questions were proposed:outcomes? • When you start a treatment for adolescent idiopathic scoliosis, what do you want to obtain/avoid in adult age for your patient? What are your final priority: 1 high – 2 medium – 3 low)?• Which outcomes are more important • Define the st International Meeting on Conservative Management of Spinal Deformities held in January 2004 in Barcelona; the Questionnaires have been sent also to all other people interested in the conservative treatment of adolescent idiopathic scoliosis that it was possible to retrieve according to indexed literature. To gather the highest number of opinions, it was required to fill in the questionnaire independently by the participation to the Consensus Meeting, and to reply by e-mail 1.5 months before the Meeting. We received 19 compiled questionnaires.The possibly relevant outcomes of scoliosis treatment identified by the authors were listed and the questionnaire was set according to Table A summary document, prepareAccording to the results of the Consensus Meeting, a final questionnaire was prepared and proposed to the participants to the Consensus Meeting. The first part was similar to that distributed before the meeting and reported in Table All data were managed using Microsoft Excel 2000. Pre and post-Meeting answers were compared using the chi-square test.For the purposes of this article we considered 135 papers, while the bibliometric analysis considered a base of 2372 papers published in Medline. We verified that the highest frequency of citation of the considered outcome criteria for adolescent idiopathic scoliosis relate to SCD, while BP, radiographic rotation (Perdriolle degrees – PD) and PiA receive less, but still significant importance. The other identified outcomes are much more less considered: the low importance given to Dis and QoL is particularly noticeable.th, the other usual clinical and radiographic measurement were considered of low importance; Dis had the lowest score. BP, Aes, Needs of further Treatments in Adulthood (NTA) and Rib Hump (RH) have been chosen because they are considered important for General belief, while in the other cases for Literature Evidence , to analyse an unusual topic in the literature, such as the motivation for treatment, that is in any case undoubtedly strictly related to everyday clinical behaviours. Looking in general to the results, it seems that in the literature data on radiographic, but also clinical outcome criteria, prevail, while they were considered of the lowest importance in the answers to the questionnaire, and even lower after the Consensus Meeting.SOSORT members considered Aes as very relevant and of primary importance, and this increased after the Consensus; only almost 3.5% of the studies in the literature on idiopathic scoliosis relate to this issue. These results presumably reflect the actual absence of means to measure this outcome, (that was encountered by some authors who anyway produced very interesting studies), and the fact of being compelled to rely only on simple observation and individual judgement: there hToday, the SRS-22 questionnaire,51-53, tQoL is considered of primary and high importance by SOSORT members, with an increase of rank after Consensus, while in the literature this outcome is almost neglected (1.48% of papers). Data on QoL in the literature appear strictly related (sometimes even confused) with data on Dis, but this is not true only for scoliosis; in fact this outcome is almost new in the field of spine research  and shouSOSORT members at first considered Dis as the less relevant outcome, in a way reflecting the literature (only 1% of the studies), while after discussion in the Consensus Meeting its importance increased greatly, up to rank 3, as well as the importance. Dis is considered so important by the general community that since 1980 the World Health Organisation, with the aim of better understanding health conditions, proposed a companion classification of the International Classification of Diseases (ICD), named International Classification of Impairment, Disability and Handicap (ICIDH),79; it bBefore the Meeting, BP was considered a relevant, but secondary, outcome criterion for SOSORT members, but its priority increased with Consensus and importance became primary. In the literature BP is an important issue associated with idiopathic scoliosis . Papers are mostly split in two between adulthood (46.8%) and growing age (44%), and relate to almost all possible topics in idiopathic scoliosis treatment. In adults, BP has been reported as follows: life prevalence 61% in high degree curvatures, one yeaIn summary, BP is a good reason to treat our patients on a literature basis looking at adulthood, while, as far as we know today, it is not immediately necessary in adolescents. Presumably, exercises are the best treatment of actual BP, while bracing can have a detrimental effect; conservative treatments seem to have better results on the future than surgery.PWB was not included in the first questionnaire, while after Consensus its importance was considered as primary and the priority ranked significantly fifth according to SOSORT members. In the literature it is not so much represented , while it is usually considered in QoL and Dis studies,76,77,98PiA is a rather important primary outcome criterion and is present in as far as 4.6% of papers on idiopathic scoliosis. Its importance has been highly stressed by SOSORT members before the Meeting, while it decreased after Consensus. In the past there was the general belief that after the end of growth there was no progression of scoliosis. Many stSOSORT members considered this a quite important primary issue, without big changes after Consensus. We were not able to create a valid Medline search strategy for this outcome criterion, so we lack the data on the literature; anyway, in this respect we could consider those coming from issues that could need a treatment if they appear, such as reduced BF or BP or PiA; the same could be done looking at the data from natural history and longThe answers to the questionnaire by SOSORT members gave the highest and primary importance at BF before the Meeting, while Consesus reduced it a lot. In the literature almost 5% of the studies on idiopathic scoliosis considers this issue, that relies on well established, extensively tested and used ways of measurement in respiratory medicine. The outcome "Exercise efficiency", added after Consensus, refers to the same bibliographic references. BF has been used as a means to evaluate patients before and after surgery,110, andth both for priority and importance (primary); further lowered these results after Consensus, ranking SCD 8th for priority and considering it of secondary importance. Also KLD (more than 8%) and PD (6.58%) have highest ranks for the presence in the literature on idiopathic scoliosis, while they had some of the lowest scores and were of secondary importance for SOSORT members, both before and after the Meeting. On the contrary, a clinical sign as RH has a scant consideration in the literature on idiopathic scoliosis ; its priority is quite high for SOSORT members and, contrarily to radiographic data, it has been considered a primary outcome both before and after the Meeting. Looking at the literature, it is not possible to go in great details, because papers with these outcomes relate to almost all possible topics in idiopathic scoliosis. Natural history at 40 years tells us that curves under 30° remain stable after the end of growth, while they progress on average of 19° when they are over this value, in particular if they overcome 50°, but also on bracing  as well Why do we treat? What do we want for our patients? In the literature, outcome criteria driven by the contingent treatment needs or the possibility to have measurement systems  prevail: these results could be biased by the method used, that did not include a complete analysis of each single paper, even if the authors' knowledge of the literature and the international Meetings on the topic confirm the idea that we are used to thinking much more to how to do then to why we do. Experts


The authors have designed this book to be a practical reference guide for working cytopathology professionals. It is meant to bridge the gap between cytomorphology as practiced for the last half century with the new molecular biology and molecular technologies.Since Drs. Meisels and Fortin published their pivotal paper on "Condylomatous Lesions of the Cervix and Vagina I: cytologic patterns". Acta Cytologica. 20: 505-9, 1976 the field of gynecologic cytopathology has grown exponentially. This discovery that HPV has premalignant and malignant potential is the most important event in Cytopathology since the introduction of Cytology as a diagnostic tool by Dr. George N. Papanicolaou. It has spawned an enormous amount of new research on the morphogenesis and carcinogenesis of cervical cancer in women.st century. This chapter is a scholarly, detailed account of the early investigators and their works including: Dr. George N. Papanicolaou, Dr. Aurel Babes, Dr. Herbert Traut, Dr. J. Ernest Ayre; just to name a few. Dr. Naylor notes the contributions of Dr. Alexander Meisels and his colleagues with their description of the Human Papillomavirus infection in the koilocyte and its link to cervical cancer. Dr. Naylor's discussion continues with screening programs for cervical cancer, the pap Smear Exposé of 1987 and all of its consequences, the beginnings of The Bethesda system (TBS) Reporting System for Gynecologic specimens, the advent of the new Liquid-Based preparations for Cervical Cytology Screening and the development of Automated Screening Technologies.Chapter One,"Cytopathology of the Uterus: Historical Perspectives" by Dr. Bernard Naylor, traces the earliest publications of cellular biologists in the 1800's, through the major cytological writings of the 20th and the 21From chapters 2 through 7 Cytopathology of Squamous lesions, Glandular Lesions, Rare Lesions of the Uterus are discussed as well as infections and benign lesions and Hormonal Cytology. These topics are all discussed concisely and flawlessly.Chapters 8 through 18 cover Epidemiology, Human Papillomavirus, and cervical Carcinogenesis, Biomarkers in Cervical Cancer, Quality Assurance, Molecular and Serologic Diagnosis of HPV Infections;There are extensive technical tips and procedural notes given as well as listings of the Guidelines for the Management of Women with Cytological Abnormalities.Chapter 16, "A Brief history of Cytology Automation" is a very balanced, unbiased account of events leading up to the present climate of liquid-based Pap smears being the norm rather than the exception. Author Dr. Dorothy Rosenthal discusses all aspects of this subject including the ramifications of "placing automated instruments on the witness stand" in a legal case.This textbook, written by Dr. Alexander Meisels and his co-author Dr. Carol Morin, is a complete, all inclusive, comprehensive reference manual of relevant issues, diagnostic entities, methodologies and technologies in uterine cytopathology. This book contains contributions from eleven other Cytopathology experts from North America and Europe. Concise information coupled with copious relevant references and exemplary photomicrographs when appropriate. The aesthetic qualities of this book begin with the front cover logo of the three koilocytes surrounded by the symbols representing the organizational structure of the papillomavirus genome for HPV – 16. This cutting edge desktop reference manual containing outstanding photomicrographs should be included in personal and professional libraries.All of the figures and tables are beautifully designed. All illustrations and photomicrographs are aligned with the explanatory text. The photographic image numbers are highlighted in various colors, and also in the corresponding text, giving them prominence in the text, thus facilitating reading. The graphics of the tables are color coded which highlights the corresponding text."Modern Uterine Cytopathology: Moving to the Molecular Smear" bridges the gap from the early years of cervical cytopathology through the present transitional period of molecular biology and new cytopathology and molecular technologies. The book is unparalleled in its scope and theme.Dr. Alexander Meisels is an internationally known pioneer in Cytopathology; an extraordinary researcher, tireless educator and superb diagnostician who has lead us down an exciting path in the last thirty years since his discovery that Human Papillomavirus is the etiologic agent in cervical cancer.It is only fitting then, that he and his colleagues have written this quintessential reference textbook that will lead the Cytopathology community through our present transitional period into the exciting future of uterine cytopathology."Modern Uterine Cytopathology : Moving to the Molecular Smear" is destined to become a perennial classic in Cytopahology reference publications.I highly recommend this book.Barbara Mahoney M.Sc., CT, (ASCP), ( IAC), (CSMLS).Medical Laboratories of Windsor, Windsor, Ontario, Canada.


Cost-effectiveness analyses (CEAs) can provide useful information to policymakers concerned with the broad allocation of resources as well as to local decision makers choosing between different options for reducing the burden from a single disease. For the latter, it is important to use country-specific data when possible and to represent cost differences between countries that might make one strategy more or less attractive than another strategy locally. As part of a CEA of cervical cancer screening in five developing countries, we supplemented limited primary cost data by developing other estimation techniques for direct medical and non-medical costs associated with alternative screening approaches using one of three initial screening tests: simple visual screening, HPV DNA testing, and cervical cytology. Here, we report estimation methods and results for three cost areas in which data were lacking.To supplement direct medical costs, including staff, supplies, and equipment depreciation using country-specific data, we used alternative techniques to quantify cervical cytology and HPV DNA laboratory sample processing costs. We used a detailed quantity and price approach whose face validity was compared to an adaptation of a US laboratory estimation methodology. This methodology was also used to project annual sample processing capacities for each laboratory type. The cost of sample transport from the clinic to the laboratory was estimated using spatial models. A plausible range of the cost of patient time spent seeking and receiving screening was estimated using only formal sector employment and wages as well as using both formal and informal sector participation and country-specific minimum wages. Data sources included primary data from country-specific studies, international databases, international prices, and expert opinion. Costs were standardized to year 2000 international dollars using inflation adjustment and purchasing power parity.Cervical cytology laboratory processing costs were I$1.57–3.37 using the quantity and price method compared to I$1.58–3.02 from the face validation method. HPV DNA processing costs were I$6.07–6.59. Rural laboratory transport costs for cytology were I$0.12–0.64 and I$0.14–0.74 for HPV DNA laboratories. Under assumptions of lower resource efficiency, these estimates increased to I$0.42–0.83 and I$0.54–1.06. Estimates of the value of an hour of patient time using only formal sector participation were I$0.07–4.16, increasing to I$0.30–4.80 when informal and unpaid labor was also included. The value of patient time for traveling, waiting, and attending a screening visit was I$0.68–17.74. With the total cost of screening for cytology and HPV DNA testing ranging from I$4.85–40.54 and I$11.30–48.77 respectively, the cost of the laboratory transport, processing, and patient time accounted for 26–66% and 33–65% of the total costs. From a payer perspective, laboratory transport and processing accounted for 18–48% and 25–60% of total direct medical costs of I$4.11–19.96 and I$10.57–28.18 respectively.Cost estimates of laboratory processing, sample transport, and patient time account for a significant proportion of total cervical cancer screening costs in five developing countries and provide important inputs for CEAs of alternative screening modalities. Cervical cancer disproportionately affects women in developing countries . Unlike Several factors have led to an expansion of the options for cervical cancer control. First, the availability of reliable HPV DNA assays has led to numerous studies documenting its higher sensitivity for detecting precancerous lesions compared with a single cytology test. Second, recent studies suggest that alternate screening strategies that use HPV DNA testing or simple visual screening methods may be more practical in some areas of the world -19. ThirScreening alternatives rely on different levels and types of resources such as laboratory infrastructure, staff mix, and clinical visits. These differences have important implications for the magnitude of the actual, total screening cost for each woman. Most importantly, they are not captured in the simple "assay cost" of each alternative – the staff time, supplies and equipment needed to collect a cervical sample. Furthermore, such differences can be magnified by country-specific characteristics such as population density, availability of staff and facilities, and topography. Therefore, cost-effectiveness results in one country may differ from those in another country.We conducted a cost-effectiveness analysis of screening strategies in India, Kenya, Peru, South Africa, and Thailand . For thiWe identified three areas for which cost data were unavailable, and for which country-specific characteristics seemed particularly important to reflect. These included the cost of laboratory processing of cervical samples; the cost of transporting cervical samples from clinical sites to the laboratory; and the value of patient time traveling, waiting, and receiving care. We supplemented limited primary cost data in these three areas by developing alternative estimation methods. These estimation methods were then used in a CEA of alternative cervical cancer screening approaches based on three different initial screening tests: simple visualization methods, HPV DNA testing, and cervical cytology.To estimate the costs associated with screening, we adhered to the general guidelines recommended for performing cost-effectiveness analyses -28. A soCost estimates for three cervical cancer screening technologies – cervical cytology; HPV DNA testing with Hybrid Capture 2; and simple visual screening – were required Table . HoweverFirst, all activities associated with each screening technology were identified. Then, for each activity, we identified all resources used. Resources were categorized as either direct medical or direct non-medical. Direct medical resource inputs included staff time, disposable supplies, equipment and facilities depreciation used both for the collection of cervical samples as well as for the transport and laboratory processing of these samples. Direct non-medical resource inputs included patient transportation from home to the site where cervical samples were collected as well as patient time spent traveling, waiting, and interacting with medical staff.Unit cost data for each resource type were compiled. Because these unit costs were derived from more than one year, country-specific deflators were used to adjust all costs to constant year 2000 terms . InflatiThe quantity of each resource was multiplied by its associated unit cost. These results were then summed to estimate the total cost of screening as well as the cost of each component.Demonstration projects from five countries provided primary data on screening activities, resource categories, resource quantities, and unit costs. For staff costs, country-specific data from hospital and national salary scales for categories of health personnel were used.An expert panel was provided with the primary cost and resource data from all countries and consulted to produce a standardized list of resource types and quantities that reflected the expected usage patterns for national screening programs . ExpertsWe identified three areas for which primary data collected from in-country demonstration projects were more difficult to generalize. These included: (1) costs associated with laboratory processing of samples for either cervical cytology or HPV DNA testing using Hybrid Capture 2; (2) costs associated with transporting laboratory samples from the site of collection to the laboratory for processing; (3) costs of women's time traveling to and from the site of service delivery, waiting for service delivery, and receiving the service. For each of these areas, alternate estimation methods were employed.To estimate the cost of laboratory sample processing, we took a detailed quantity-and-price approach for cervical cytology and HPV DNA laboratory sample processing. Simple visual screening did not require samples from the initial screening visit to be processed in a laboratory, and thus no estimate of this type of laboratory processing costs was made for simple visual screening.Staff requirements, productivity levels, and equipment depreciation were estimated by an expert panel who had significant experience with implementing cervical cancer screening and in developing country healthcare provided input on laboratory processing . Staff cBecause laboratory sample processing is relatively complex and certain elements such as facilities costs are difficult to estimate without detailed information from established laboratories in each country, we compared the detailed quantity-and-price approach to a previously published analysis of US-based cervical cytology laboratory costs. We modified the method used in the previously published analysis to provide comparative, country-specific estimates based on productivity levels for cytotechnicians and cytopathologists, simplified facilities costs, and a lump sum disposable supply cost for the five countries of interest . To estiBecause cytology laboratories rely more heavily on human productivity than on automated processing equipment and HPV DNA laboratories rely more heavily on automated processing equipment than human productivity, we performed a sensitivity analysis on our estimates in which we varied the staff productivity assumptions from 33–200% for cytology laboratories and the equipment costs between 33–200% for HPV DNA laboratories.We used the laboratory sample processing capacity estimates for each type of laboratory as an input for estimating the cost of laboratory sample transport, with the exception of simple visual screening which does not routinely require laboratory processing of samples collected at the initial screening visit.We used a spatial model to estimate transport costs. Based on a country's land area, population size, population structure, and percent rural population, we estimated the density of screen-eligible women. In this case, we wished to estimate the average, rural density of 35 year-old women because this was the target screening group for each year Figure  32,33].,33.32,33For a laboratory functioning at a particular capacity level, we then determined the size of the area serviced by the lab:Each laboratory is assumed to serve all eligible individuals within a laboratory area. All laboratory areas taken together form a Voronoi diagram of a country's land area with each laboratory at the center of a specific Voronoi cell . Within The time spent driving this route was estimated by using percentage paved and unpaved roads in each country as well as the average speed driven on paved and unpaved roads ,36.Four costs were calculated for laboratory transport. Two were derived from the estimates.Additionally, vehicle maintenance was based on WHO-CHOICE data, and straight line depreciation of the initial vehicle purchase price was performed over the useful life of the vehicle . The proThe cost estimate produced by this method reflects rural laboratory sample transport costs. To calculate national average laboratory sample transport cost, an urban sample transport cost was estimated by multiplying the rural transport cost an efficiency factor associated with much higher urban population density. Then, a weighted average of these two costs was taken to produce a national average transport cost estimate.A plausible range for sample transport cost was based on estimating transport costs using two alternative efficiency assumptions. First, we generated a lower bound by assuming complete efficiency – only the portion of vehicle use; depreciation; driver time; and gasoline consumption that were attributable to sample transport were included in the estimate. Second, we generated an upper bound by assuming that each driver and vehicle would sit idle when not being used for sample transport, attributing the total cost of driver and vehicle to sample transport.Because the location and number of sites from which laboratory samples would be collected on the driving route was uncertain, we re-estimated our plausible range estimates based on efficiently using all resources but using a driving length that was 4 times the original length estimated.It is difficult to estimate the value of women's time in developing countries using conventional approaches  becauseMethod 1:proportionformal * wagerateformalMethod 2:proportionformal * wagerateformal + proportioninformal * wagerateminWe used the two methods to form reasonable bounds for sensitivity analyses. The first method was used to form the lower bound because it does not value productive time not spent in the formal sector. The second method was used to form the upper bound because it assumes that all potentially productive time not used in the formal sector is used for informal or unpaid labor and further assumes that the value of these activities is equivalent to a minimum wage.A summary of the component costs making up the total cost of cervical cancer screening and their percentage contribution to the total is shown in Figure Table Table Estimates of patient time value using only formal sector wages and participation levels as well as those using weighted averages of formal sector wages and minimum wages are shown in Table The cost of laboratory processing, laboratory sample transport, and patient time accounted for 51%, 42%, 26%, 53%, and 66% of the total direct medical and non-medical costs of cervical cytology for India, Kenya, Peru, South Africa, and Thailand. For HPV DNA testing using Hybrid Capture 2, these percentages were 62%, 48%, 33%, 51%, and 65%. From a public health system payer perspective, with no patient time or patient transport costs included, laboratory processing and sample transport were 43%, 44%, 45%, 18%, and 48% of total direct medical costs for cervical cytology and 60%, 55%, 52%, 25%, and 58% of total direct medical costs for HPV DNA testing using Hybrid Capture 2 respectively.The estimates presented in this paper differ slightly from those used in our previous paper primarily because we have updated and expanded the estimation methods and sensitivity analyses used to consider cervical cancer screening costs .Cost-effectiveness analyses (CEAs) are increasingly used to assess the value provided by health care interventions for a given level of spending. Yet, it is difficult to evaluate the cost-effectiveness of delivering services that have not been previously implemented within a country, in part because real-world cost data on program implementation is lacking. Using only selected direct medical costs for which data is available – the "assay cost" – may lead to invalid cost estimates that exclude potentially important components. From a societal perspective, we believe that the three additional costs components estimated in this analysis account for between 26% and 66% of the per-patient cost of cervical cancer screening visits in India, Kenya, Peru, South Africa and Thailand. By varying assumptions in the estimation techniques it was possible to generate plausible ranges of costs useful for sensitivity analyses.The quantity and price approach for estimating the cost of cervical cytology laboratory sample processing was generally consistent with estimates from our face validity exercise. The methods differed in two important ways. First, the quantity and price approach did not have sufficient data to estimate actual facilities costs associated with laboratory activity, whereas the method used for the validation exercise uses the average facilities cost within a given country as a proxy. Second, the productivity assumptions in the quantity and price approach are more modest than in the latter. In this case, while facility cost inclusion tends to make estimates obtained with the quantity and price approach lower, the difference in productivity assumptions has the opposite effect. Hence, the overall quantity and price estimates are similar to those obtained from the validation exercise.Limitations of the laboratory sample processing estimates include their reliance on expert opinion as opposed to directly observed data in each country of interest. Second, the estimates depend on a particular set of technologies being used. For example, automation of slide reading for cervical cytology would introduce larger equipment and supply costs but would also reduce staff costs and change the capacity of the laboratory. Such a change would require a revised assessment of sample processing costs. Finally, costs of certain inputs were assumed to be equal to international market prices. Were these inputs to be produced locally, their value, as measured by their opportunity cost, could be different.In areas where population density was lowest and paved road networks were scarcest, our estimates of laboratory sample transport costs were highest. Because the laboratory units we considered for processing cervical cytology samples were larger than those used to process HPV DNA samples, the per-sample cost of transport was lower for cervical cytology laboratories. Since major resource inputs such as gasoline and vehicle depreciation were internationally traded goods, their relative costs in different countries had less impact on cost estimates than did the density of road networks and the rural population. Plausible bounds on laboratory sample transport costs were constructed by assuming resources were arbitrarily divisible – that their remainders could be used efficiently for other purposes – or that resources had to be consumed in whole quantities – that their remainders could not be used efficiently for other purposes.Limitations of the laboratory sample transport estimates include a reliance on national averages for road network density and rural population density. Additionally, changes in elevation and natural obstacles such as the Peruvian Andes affect the estimates of transport distance and time in important ways. While refinement of estimates through the use of provincial data and geographic information system (GIS) data may be desirable, a trade-off exists between the accuracy of estimates and the ability to form comparable estimates for multiple developing countries without additional costly data gathering efforts. Because of this lack of data, the method's predictions have yet to be validated against real-world costs incurred by the operation of a laboratory transport system in a developing country setting.While the method assumes each laboratory unit is serviced by one transport unit, existing infrastructure or administrative considerations may make laboratory aggregation into larger centers more appealing. While this may lead to economies of scale for laboratory processing costs, laboratory sample transport costs would require new estimates. Similarly, while our estimation method applies to transport of laboratory samples from fixed health clinics to a centralized laboratory, some have proposed the use of mobile screening clinics ,45. BecaWhen informal and unpaid labor was included in the cost of patient time, the estimate increased substantially. Because cervical cancer screening modalities other than single visit "see and treat" options require multiple trips to clinical sites and potentially district hospitals, the value of patient time traveling, waiting, and receiving care can be substantial. This is the case because even though the per-hour time cost is relatively low, sparse health and transportation infrastructures require travel over long distances and substantial waiting times at health facilities before receiving care.Limitations of our approach also include a reliance on minimum wage scales to value unpaid and informal labor. Minimum wages can be sector-specific and can overstate the market value of the labor they compensate. Additionally, we used the minimum wage for all types of unpaid and informal labor and did not differentiate high value from low value activities. Finally, the proportion of time spent in the formal and informal economic sectors was not age-specific. Thus, if the target screening population – women from 35–40 – had a different pattern of employment our estimate would not capture the difference.There is little prior literature on cost estimates for laboratory sample processing in developing country settings. A study of the cost-effectiveness of cervical cancer screening in South Africa used information on laboratory costs from the existing cervical cytology services in the country and included additional test kit costs for HPV DNA testing derived from the manufacturer . A similNo prior studies were found that directly estimated the cost of laboratory sample transport in developing countries. The method we have employed makes a number of simplifying assumption about population distribution, clinic distribution, and topography. With more complete data, our method could be extended to accommodate these details. Depending on the nature of the additional data, Operations Research techniques for locating new facilities given a set of constraints including maximizing coverage and minimizing cost or distance that have been developed for a variety of other applications could be applied . Other wThe topic of valuing productive labor, especially of women, in the informal and unpaid sector of the economy is particularly important, especially in countries where less than half of female productive labor takes place in the formal sector. Formalized methods do exist for estimating the value of these activities -53. Thestechnical efficiency of different cervical cancer screening strategies for reducing mortality from one disease. Our purpose is to provide information to country-based decision makers choosing amongst a range of options for cervical cancer screening. For this goal, it is important to use country-specific data to the extent possible and to explicitly represent cost differences between countries that might make one strategy versus another a more or less attractive locally . Accordingly, we developed methods to deal with imperfect data availability, generating country-specific cost estimates that included important patient time and infrastructure costs that went beyond simple assay cost estimates.Large-scale efforts to use cost-effectiveness analysis to assess multiple interventions for many different disease areas have been published relatively recently ,54,55. TWhen several viable interventions exist for addressing a serious public health problem, CEA can provide one useful type of information for decision makers. When primary cost data are lacking because a specific type of program has yet to be implemented in a given country, it is possible to use other techniques whose simplifying assumptions allow their data requirements to be satisfied with publicly available data. Because of the uncertainty introduced by the simplifying assumptions, the techniques can also be used to generate plausible ranges of estimates for sensitivity analyses. In the context of cervical cancer screening and prevention, use of these techniques helped to quantify important component costs that influenced the overall results of our cost-effectiveness analysis in five developing countries.CEA – Cost-effectiveness analysisDNA – Deoxyribonucleic acidGDP – Gross Domestic ProductGIS – Geographic information systemHPV – Human papillomavirusI$ – International DollarPPP – Purchasing Power ParityUK – United KingdomsUS – United StatesWHO – World Health OrganizationWHO-CHOICE – World Health Organization – Choosing Interventions That Are Cost-EffectiveThe author(s) declare that they have no competing interests.JDG participated in the conception and design, acquisition of data, and development of methods for the paper as well as drafting the initial manuscript. SJG participated in the conception and design, development of methods, and in the critical revision of the manuscript for important intellectual content. Both authors read and approved the final manuscript.


Objective: To determine whether hypothermia during Cesarean delivery is a risk factor for postoperativeinfection.Methods: An historical cohort investigation was conducted on all women delivered by Cesarean at our centerduring 2001. Initial recovery-room temperature, taken via the oral or axillary route, was used as a surrogatefor intraoperative temperature. Adding 0.5°C to axillary temperatures generated oral temperature equivalents.Women with chorioamnionitis were excluded, as were those with an initial recovery-room temperature thatexceeded 37.9°C or was recorded more than 20 minutes after the end of surgery. Prophylactic antibiotics were given during Cesarean delivery.Results: A total of 42 women (7.6%) were diagnosed with postoperative infections. Infections includedendometritis (n= 25), wound abscess (n = 7), wound cellulitis (n = 7) and urinary tract infection (UTI) (n = 4).No cases of septic pelvic thrombophlebitis or pelvic abscess occurred. One woman had both endometritis and aUTI. Mean temperatures were higher, rather than lower, for women who subsequently had postoperativeinfections compared with those who did not . Mean temperaturesfor the various postoperative infections were as follows: endometritis, 36.5 ± 0.8°C (p  < 0.001 vs. uninfectedgroup); wound abscess 36.0 ± 0.8°C (p = 0.63); wound cellulitis, 36.3 ± 0.6°C (p = 0.14); UTI, 36.7 ± 0.9°C(p = 0.04).Conclusions:  Women who develop post-Cesarean infections have higher initial recovery-room temperaturesthan those who do not develop such infections. This suggests the presence of subclinical infection at the timeof Cesarean. Evaluating whether intraoperative warming has any role during Cesarean delivery requires arandomized clinical trial.


All cases of cutaneous malignant melanoma, CMM, diagnosed in Northern Ireland between 1974-1978 were reviewed, classified and followed up until the end of 1984. The overall 5 year survival is 54%, among the worst reported in recent literature. Multivariate analysis of these cases confirms some previous findings from other studies, but also reveals features not apparent in univariate analysis. Prognosis worsens with increasing thickness and the presence of ulceration. Likewise histopathological type has an independent effect on survival, ALM having the worst prognosis. Tumour profile emerges as a significant feature affecting prognosis, flat lesions having the poorest outlook, given their thickness. Survival is worse with increasing age. Anatomical site is less important than suggested by previous univariate analysis. Sex has little influence on prognosis when adjusted for the other variables. Cell type and pigmentation are of no prognostic value. Several features including diagnostic delay contribute to the poor overall survival for CMM in Northern Ireland. Educational intervention is essential if this trend is to be reversed.


Public health organizations in the United States emphasize the importance of providing routine screening for breast cancer, cervical cancer, and colorectal cancer, as well as vaccinations against influenza and pneumococcal disease among older adults. We report a composite measure of adults aged 50 years and older who receive recommended cancer screening services and vaccinations.We analyzed state data from the 2002 Behavioral Risk Factor Surveillance System, which included 105,860 respondents aged 50 and older. We created a composite measure that included colonoscopy or sigmoidoscopy within 10 years or a fecal occult blood test in the past year, an influenza vaccination in the past year, a Papanicolaou test within 3 years for women with an intact cervix, a mammogram, and for adults aged 65 and older, a pneumonia vaccination during their lifetime. We performed separate analyses for four age and sex groups: men aged 50 to 64, women aged 50 to 64, men aged 65 and older, and women aged 65 and older.The percentage of each age and sex group that was up-to-date according to our composite measure ranged from 21.1% of women aged 50 to 64 (four tests) to 39.6% of men aged 65 and older (three tests). For each group, results varied by income, education, race/ethnicity, insurance status, and whether the respondent had a personal physician.These results suggest the need to improve the delivery of cancer screenings and vaccinations among adults aged 50 and older. We propose continued efforts to measure use of clinical preventive services. Healthy People 2010 is a national initiative that has set specific health and health care objectives  and the National Health Interview Survey (NHIS). Although this approach is well suited for assessing progress toward There is currently no index that combines data on the use of all recommended clinical preventive services among adults. In this article, we present a composite measure of cancer screening services and vaccinations obtained by adults aged 50 years and older as a first step toward assessing overall clinical preventive service delivery. We chose to begin our assessment by combining these two sets of interventions because they are universally recommended and data on their use in all 50 states and the District of Columbia are available through the 2002 BRFSS. Composite indices have long been used for the surveillance of childhood vaccinations .Our approach aims to provide a more meaningful and practical measure of the state of clinical preventive service delivery. Such a comprehensive measure could also enhance the ability of health departments and community groups to assess disparities in delivering preventive services, to better gauge progress toward measurable objectives, and to identify best practices for achieving prevention goals.We used data from the 2002 BRFSS; the BRFSS is an ongoing state-based telephone survey of randomly selected adults and is coordinated by the Centers for Disease Control and Prevention (CDC). The survey collects data from noninstitutionalized adults aged 18 and older on health practices that are related to the leading causes of death and disability . We limiWe analyzed responses to the BRFSS core questions on the use of clinical preventive services recommended by the USPSTF for adults aged 50 and older: colorectal cancer screening, mammography, Papanicolaou (Pap) test, and influenza and pneumococcal vaccinations . These qup-to-date, was determined separately for four age and sex groups. For men aged 50 to 64, the up-to-date measure included men who met the recommendation for colon cancer screening and influenza vaccination (two services). For women aged 50 to 64, the up-to-date measure included women who met the recommendations for colon cancer screening, breast cancer screening, cervical cancer screening, and influenza vaccination (four services). The up-to-date measure includes women with a hysterectomy among those who met recommendations for cervical cancer screening. Because a Pap test is not normally recommended for these women, it would be incorrect to classify them as not being up-to-date on cervical cancer screening. For adults aged 65 and older, the up-to-date measure included the cancer screening tests for their sex, plus an influenza vaccination and a pneumococcal vaccination (three services for men and five services for women). The number of tests required for being up-to-date was two for men aged 50 to 64, three for men aged 65 and older, four for women aged 50 to 64, and five for women aged 65 and older .From the separate measures for cancer screenings and vaccinations, we created a variable to measure whether a person had received all of these clinical preventive services as recommended by the USPSTF. Because the recommendations vary by age and sex, this measure, which we call being From responses to several questions on race and ethnicity that permitted respondents to indicate more than one race, we created five groups: white (limited to non-Hispanic whites), black (limited to non-Hispanic blacks), Hispanic of any race, Asian or Pacific Islander, and American Indian or Alaska Native. Level of education was recoded from multiple responses into four categories: less than high school, high school graduate or general equivalency diploma (GED), some college, and college graduate. Health insurance status was determined by the response to a single question and coded yes or no. Data on household income were coded into four groups: less than $25,000, $25,000 to $49,999, $50,000 to $74,999, and $75,000 and above. Respondents were asked if they had a personal physician; those with one or more were coded as yes. Health status was dichotomized into 1) fair or poor or 2) good, very good, or excellent.Stata, Version 8.0 , was used in all statistical analyses to account for the complex sample design of the BRFSS. Most analyses were performed on subpopulations representing four age and sex groups: men aged 50 to 64, women aged 50 to 64, men aged 65 and older, and women aged 65 and older. Pearson's chi-square tests were used to compare the percentage of adults who were up-to-date on the recommended services for their age and sex group by demographic characteristics. For mapping purposes, we divided state results into quartiles and then combined the middle two quartiles.The median state response rate for the 2002 BRFSS was 58.3% (range 42.2%–82.6%) . ResultsWe combined data for 49 states and the District of Columbia to examine the percentage of adults who were up-to-date among demographic and risk-factor subgroups . Black, Among both men and women in all age groups, having more education was strongly related to being up-to-date. Respondents with less than a high school education were much less likely to be up-to-date (range 12.4%–29.5%) than those with a college degree (range 25.4%–43.8%). Similarly, higher income was associated with being up-to-date on cancer screening and vaccinations. Adults with health insurance were about twice as likely to almost three times as likely to be up-to-date as adults with no insurance. The same was true for adults with a personal physician compared with those without one. Overall, people who reported fair or poor health were more likely to be up-to-date than those who reported good, very good, or excellent health.State-specific prevalence estimates for each of the age and sex groups were divided into quartiles and mapped . States The percentage of each age and sex group that was up-to-date is presented by state in This analysis of state BRFSS data indicates that among the four age and sex groups, the state medians for adults who are up-to-date with recommended cancer screenings and vaccinations range from 22.1% (women aged 50 to 64) to 38.2% (men aged 65 and older). Although the delivery rates of individual clinical preventive services may be relatively high — cervical cancer screening, for example, is at a national median of 81.0% — overall levels of protection provided by cancer screenings and vaccinations are low.This study did not include data on cholesterol screening or tetanus–diphtheria vaccination, or data on clinical preventive services that are also recommended according to a specific schedule. Other excluded measures included screening for abnormalities of blood pressure, height, weight, obesity, vision, and hearing; chemoprevention for cardiovascular disease (aspirin); and counseling on calcium intake, folic acid, tobacco cessation, drug and alcohol use, sexually transmitted diseases, human immunodeficiency virus (HIV), nutrition, physical activity, sun exposure, oral health, injury prevention, and polypharmacy.In addition to low absolute levels, the data indicate important differences among states. For each of the four age and sex groups, Minnesota consistently had the highest up-to-date percentages. Several factors may explain why this state has done so well in preventive service delivery: a high proportion of the population is enrolled in managed care; the state has a low uninsurance rate; and state-sponsored outreach promotes colorectal cancer screening and adult vaccinations. Additional research is necessary to fully explore the reasons for success in Minnesota. Many of the lowest measurements were found in the southeastern and south-central United States; these states have low rates of health insurance among adults .Each of the four age and sex groups has its own set of recommended clinical preventive services. There were significant differences in being up-to-date among racial and ethnic categories. Based on consistency across age and sex groups, it appears that blacks, Hispanics, and Asians may be less likely than whites to be up-to-date for cancer screenings and adult vaccinations. There may be higher rates of screening among American Indians because many American Indians receive health care through the Indian Health Service, which emphasizes preventive health practices. Further investigation of these racial and ethnic disparities is warranted.Not only are reasons for racial and ethnic disparities not clear from the data but these disparities also are confounded by disparities in being up-to-date according to educational, socioeconomic, and insurance status. Respondents who have a college degree are 1.5 to 2 times more likely to be up-to-date than respondents who do not have a high school degree. Receipt of clinical preventive services is also consistently associated with higher income level for each of the four age and sex groups. Large differences exist between people who have medical insurance and people who do not. People with health insurance or personal physicians have approximately two to three times the rate of clinical preventive service delivery as people without either of them. According to the U.S. Census, 11.1% of whites, 19.6% of blacks, 18.8% of Asians, and 32.7% of Hispanics lacked insurance in 2003 . These fMore than 95% of adults aged 65 and older have health insurance through Medicare, which pays for cancer screening and vaccinations . NonetheOur results suggest that most respondents have received at least one cancer screening or vaccination. Therefore, most adults aged 50 and older have had some contact with the health care system within the past few years, but they do not receive the preventive services recommended for their age and sex group. At the same time, the analysis indicates that up-to-date rates are not low because adults lack only a single service.This work builds on the analysis of others . The BRFThis study has a number of limitations. First, the BRFSS relies on self-reported data. Depending on the measure, self-reports can result in overestimates or underestimates compared with other data sources, such as health care records. Unfamiliarity with medical terms and telescoping  recalli,25. A reThe results of this study suggest several potential next steps. From a surveillance perspective, we recommend that state-based surveys such as the BRFSS consider periodically collecting in the same year information about clinical preventive services with specific schedules . In this way, a more complete measure of delivered adult clinical preventive services recommended by age and sex can be calculated. One of the strengths of a composite measure of clinical preventive services is that it emphasizes the overall protection of individuals by combining measurements across disease categories. We also recommend that surveys such as the BRFSS examine the feasibility and implications of routinely reporting a composite measure such as the one suggested by this study. Healthy People 2010 objectives have not yet been updated to match USPSTF recommendations. The building blocks of composite measures will change as recommendations for individual interventions evolve. For example, colorectal cancer screening guidelines for The results of this study also suggest that the delivery of clinical preventive services in physicians' offices needs continued attention. Among respondents who indicated having a personal physician, the group with the highest proportion of up-to-date was men aged 65 and older at only 41.5%; the group with the lowest proportion was women aged 50 to 64 at 22.8%. Despite important initiatives designed to improve the provision of clinical preventive services in physicians' offices, such as the Agency for Healthcare Research and Quality's Put Prevention Into Practice (PPIP) , more woFrom a public health standpoint, new kinds of programs are needed to address the shortfall identified by this study. Access to each of the recommended clinical preventive services can be facilitated inside and outside of the clinical setting. New initiatives must focus on populations, not patient panels. A community-wide strategy has been developed by the Sickness Prevention Achieved through Regional Collaboration (SPARC) program in Connecticut, Massachusetts, and New York, and has achieved promising results ,32 by exAdditional analytic work is necessary. An examination of data from states that collect information on cholesterol screening and tetanus–diphtheria vaccinations will yield a more complete — and perhaps lower — composite measure of up-to-date use of recommended services. A multivariable regression analysis will provide a fuller understanding of factors that are most strongly and independently associated with failure to be up-to-date, and a longitudinal analysis of trends in the composite measure will yield useful information for targeting state preventive health efforts.This study reports low composite rates of adult clinical preventive service delivery based on 2002 BRFSS data for adults aged 50 and older and highlights significant disparities among groups. We must redouble our efforts to develop more effective approaches to delivering these basic adult clinical preventive services.