Although among women a decreasing prevalence of human papillomavirus (HPV) infection with increasing age has been consistently observed in high-resource countries, different age profiles have been reported elsewhere.We compared the age profile of high-risk (HR)-HPV prevalence in nine different areas of Northern and Central Italy by studying the women recruited in the intervention arm of the New Technologies in Cervical Cancer study and tested by Hybrid Capture 2. Differences in the age-distribution of HPV infection were investigated in each centre by the joinpoint approach in a logistic model. 46,900 women aged 25 to 60 years were included in the analysis.The HR-HPV age-standardised  prevalence ranged from 5.7% (Trento) to 10.3% (Ravenna). HR-HPV prevalence decreased as a logistic function of increasing age in 6 of 9 centres . The effect of age on HR-HPV prevalence slopes did not differ significantly among these 6 centres, whereas significant heterogeneity in intercepts (p < 0.001) was found, reflecting different overall HR-HPV prevalence between centres. One significant joinpoint was observed in 2 centres (Padua and Ravenna), indicating that the decrease in HR-HPV prevalence by age was better described using a function composed with two logistic segments. In Padua HR-HPV prevalence decreased only slightly up to 39 years but showed a steep downturn thereafter. In Ravenna HR-HPV prevalence decreased steeply down to 45 years of age and then showed a plateau. Finally, in Turin two significant joinpoints were observed: prevalence decreased only after age 29 and showed a plateau after age 39.per se.Our results showed substantial differences in overall and age-specific HR-HPV prevalence across Italian areas. These findings may be related to different timing of changes in sexual behaviours across regions. Age-specific HR-HPV prevalence in Italy does not support an influence of age  The prevalence of cervical human papillomavirus (HPV) infection varies across populations and according to a woman’s age. Studies from Europe-4 and NoThe very steep increase in the cumulative incidence of HPV infection observed among women who had recently become sexually active suggested that a majority of women acquire the infection in the first few years after sexual debut,20. HowePrevious studies were, however, based on samples of a few hundreds or few thousands women overall, limiting the possibility of studying age effect in detail. Therefore, we aimed at assessing HR-HPV prevalence and possible variations in the age-distribution of HPV prevalence in 46,900 women from a large multicentre randomised controlled trial conducted across nine different areas in Italy.versus HPV testing) for which the main endpoint was histologic detection of cervical intraepithelial neoplasia of grade 2 or more. Our report is based only on the HPV testing arm of NTCC. NTCC was conducted within organised cervical cancer screening programmes in nine centres in Northern and Central Italy  and was considered in determining HPV prevalence. Figure The New Technologies in Cervical Cancer (NTCC) study is a randomized trial of screening methods  or in the standard transport medium (Qiagen Incorporated) (NTCC phase 2). The Hybrid Capture 2 (HC2) hybridization assay  targeting HR-HPV types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59 and 68, was used to determine HR-HPV presence with a cut point of 1 relative light unit (RLU) for HPV positivity, as recommended by the manufacturer. High reproducibility of HPV testing between laboratories was documented.HR-HPV status from the first valid HC2 test was considered. For each centre, HR-HPV prevalence was standardized to the 2004 Italian female population in the same age groups for year 2004 aged 25–60 years. The hetThe age-distribution of HR-HPV prevalence in each recruitment centre was assessed performing a logistic joinpoint regression analysis. This method allows characterizing the age-specific prevalence using joint linear segments with different slopes, where the joinpoints represent the points of change in slope. If no significant joinpoints were identified, we characterized the age-specific HR-HPV prevalence profiles using a standard logistic regression with studied differences between centres and logistic effect of age as suggested by the intercepts and the slopes. For the centres without any significant joinpoint we tested the significance (significance level < 0.05) of differences between centres in intercepts, reflecting different overall HR-HPV prevalence, and age slopes, reflecting different declines of HR-HPV prevalence as a function of age. To test for significant differences in intercepts between centres we performed a log-likelihood ratio test comparing two logistic regression models: one accounting only for age as independent variable, the other for both age and centres. Similarly, to test for different declines of HR-HPV prevalence as a function of age among centres, we tested the statistical significance of the interaction between centres and age performing a log-likelihood ratio test.j joinpoint(s) versus the alternative of j + 1 joinpoint(s). The p-value is determined by a Monte Carlo method[jmax = 3) and set as significance level < 0.05). All the other statistical analyses were performed using STATA software .To test for the presence of statistically significant (significance level < 0.05) joinpoints and to estimate their value, we used the package “ljr” from the CRAN repository. In parto method. We alloA total of 47,369 women were randomly assigned to the HPV testing arm. After the exclusion of 469 women who did not have any valid HPV test, 46,900 women could be included in the present analysis.Table No significant joinpoints were observed in six of the nine centres . HR-HPV prevalence in these centres decreased as a logistic function of increasing age. Significant heterogeneity in intercepts (p < 0.001), as assessed performing a log-likelihood ratio test, was found between centres, reflecting different overall HR-HPV prevalence Figure . While HFigure We observed geographical variation in age-standardized and age-specific prevalence of HR- HPV infection in the Italian centres participating in the NTCC study; with the highest age-standardized prevalence in Ravenna (close to a touristic sea resort area) almost twice that of Trento , the lowest prevalence. Given that relevant differences in biological features of HR-HPV infections across Italian regions are implausible, the observed geographical variations are likely to reflect differences in sexual behaviour across Italian areas.In addition, although in all study centres HR-HPV prevalence followed the general pattern of decrease with increasing age typical of industrialised countries, qualitative differences were found  in the shape of age specific prevalence. In the majority of NTCC centres HR-HPV prevalence decreased as a logistic function of increasing age, i.e., a logistic function described HR-HPV prevalence reduction within the considered 25-to-60-year-old age range. In Turin and Padua, however, women showed higher HR-HPV infection prevalence up to about age 30 and 40 years, respectively. The same age-distribution of HR-HPV prevalence in Turin had been found in a previous smaller study. In turnOf notice, a steeper decrease in HR-HPV prevalence with age than that found in the NTCC study was observed in a study conducted in Central and Southern Italy. This fiDifferences in sexual habits and birth cohort effects may herald different future changes in the incidence of precancerous and cancerous lesions of the cervix in different parts of Italy. Increases in both incidence of and mThe variation in the shape of age-specific HR-HPV prevalence observed between centres in the NTCC study could also derive from different population mixing. On account of important migratory waves, for instance, less than half of the population living in Turin in 2011 was born in the city. As for many other large towns across industrialized countries, Turin is constantly subject to rural-to-urban migrations. Main reasons for immigration from both other Italian areas and abroad are studying and working purposes. We speculate that the constant inflow of relatively young immigrants may have an impact on sexual promiscuity and transmission chain of HPV infections. The consequences of immigration on older birth-cohorts are of less straightforward interpretation. Demographically relevant migrations to Turin, initially from Southern and North-eastern Italy, started in the 1960s. Almost half the women migrated to Turin from Southern Italy arrived during such period and would have not fallen in the age range eligible for the NTCC study.Our study has strengths and weaknesses. Study population is large and can be considered well representative of women aged between 25 and 60 years who participate in screening in the study areas. In a previous study of the determinants of screening attendance in Turin, we founper se in HR-HPV prevalence.In conclusion, we observed substantial differences in overall and age-specific HPV prevalence across Italian areas. These findings may be related to differences in sexual behaviour of women in different age groups and birth cohorts and in population mixing across study areas. Awareness of the existence of age or cohort effects may be useful in predicting trends in precancerous and cancerous lesions of the cervix and modelling the future impact of screening or HR-HPV vaccination in different Italian areas. In any case, the heterogeneity we observed does not support an influence of age CI: Confidence interval; CIN: Cervical intraepithelial neoplasia; HR: High-risk; HPV: Human papillomavirus; HC2: Hybrid capture 2; NTCC: New technologies in cervical cancer; RLU: Relative light unit.The authors declare that they have no competing interests.SF, GR, IB conceived the study. GR, SF, PGR and NS were involved in the study design. AGT, FC, MC, PDP, MDL, ADM, LDM and CN collected data. PP, PS, NS, MZ and PGR were responsible for quality control of data and algorithms. IB, GR performed statistical analysis and data analysis and interpretation with SF. IB, GR and SF drafted the manuscript and NS, FC and PGR edited it. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2334/13/238/prepubSupplementary information.Click here for file


Pap screening combined with loop electrosurgical excision procedures (LEEP) is almost 100% effective in preventing cervical cancer mortality yet many countries with these procedures have now implemented broad HPV vaccination programs. HPV vaccines have not been demonstrated to be more effective or safer than Pap screening in the prevention of cervical cancer and Pap screening will still be required even in vaccinated women. The HPV vaccine costs Au$450 per person and it does not protect against ~30% of cancer. This investigation analyses the cost-effectiveness of using the HPV vaccine in countries where Pap screening and surgical procedures have already reduced cervical cancer mortality to very low rates. Cost-effectiveness of vaccination programs is being determined by mathematical models which are founded on many assumptions. It is necessary to examine the rigor of these assumptions to be certain of the health benefits that are predicted. In 2002 scientists concluded that HPV 16 and 18 were the central and independent cause of most cervical cancer. This conclusion was based on molecular technology. If HPV 16 and 18 infections are the central and independent cause of most cervical cancer then the incidence of HPV 16 and 18 should vary with the incidence and mortality of cervical cancer worldwide. This correlation does not exist. It is also observed that the majority of HPV 16/18 infections do not lead to cervical cancer. This indicates that other etiological or ‘risk’ factors are necessary for persistent HPV infection to progress to cancer. The benefits of HPV vaccines have been determined by using pre-cancerous lesions in young women as a surrogate for cervical cancer. This surrogate is found to be inadequate as an end-point for cervical cancer. Clinical trials have only provided speculative benefits for the efficacy of HPV vaccines against cancer and the long-term risks of the vaccine have not been established. Pap screening will still be required in vaccinated women hence HPV vaccination programs are not cost-effective, and may do more harm than good, in countries where regular Pap screening and surgery has already reduced the burden of this disease. Knowledge of the etiology of cervical cancer has been developed over the last century and during this time many lifestyle and environmental factors have been implicated in the etiology of this disease ,2. In 20In 1995, Bosch et al. set out to characterise the global distribution of HPV genotypes because they knew this was ‘essential to the development of vaccination strategies to curb the burden of cervical cancer’  p.797. IWhilst PCR methods are more sensitive and specific than liquid hybridization techniques and enable the identification of different genotypes, the specificity of this technique depends upon the type of primer used: type-specific or broad-spectrum . The BosBy 2002 scientists were proposing that human papillomavirus (HPV) Type 16 and 18 was the ‘first ever identified necessary cause of human cancer’ . This suSeveral risk factors have been identified including infection with other sexually transmitted infections (STI’s), high parity, smoking and hormonal contraceptives . The strClinical trials to test the hypothesis that the quadrivalent HPV vaccine would be effective against cervical cancer, and not just the prevention of HPV 16/18 infection, were started in phase 3 trials in 2003 ,11. ThesThis paper examines the epidemiology of HPV infection and its progression to cervical cancer in different countries. It analyses the assumptions that have been made to claim that a vaccine against cervical cancer is cost-effective (CE) in countries with already established Pap screening programs. The cost-effectiveness of HPV vaccines has been determined using mathematical models that are limited by the assumptions they are based on . An indeInfection with HPV 16 and 18 has been stated to be the central and independent cause of cervical cancer. This infers that no other factors are required for pathogenesis to occur. However, epidemiologists observe that an infectious agent is an insufficient cause of disease [In 1995 it was observed that the distribution of HPV genotypes 16 and 18 was similar among all countries: developing and developed . HPV 16 less prevalent in the countries with the highest rates of cervical cancer [In the 60’s and 70’s many developed nations had the same high rates of cervical cancer as the developing nations today but mortality was reduced due to changes in environmental and lifestyle factors and the introduction of Pap screening programs . China al cancer . This lel cancer .Bosch et al. state ‘HPV 16 has been found to be the most prevalent HPV type in cytologically normal women as well as women with cervical intraepithelial neoplasia (CIN) and women with cervical cancer’  p797. ItDespite the lack of correlation between HPV 16 and 18 with the burden of cervical cancer globally, it was claimed that infection with high-risk HPV is the central etiological factor in cervical cancer worldwide and independent of other risk factors  p796. FuIf HPV 16 and 18 are the central independent cause of most cervical cancer then the incidence of these subtypes should be higher in the developing nations where the incidence and mortality of cervical cancer is the highest. This general correlation would exist even if there were local variations in the dominant genotypes. However, the incidence of HPV 16 and 18 is similar in all countries; indeed, HPV 16 is slightly higher in the developed nations where cervical cancer is the lowest [e lowest . The gloIn 1995 it was known that HPV infection on its own was not sufficient to cause cervical cancer . FactorsProstitutes have an increased risk of developing cervical cancer which can be reduced by the use of condoms and microbicides ,23. ThisHPV DNA is associated with the development of squamous cell cervical cancer (SCC) and cervical adenocarcinoma (CAC) . In 2003how much cervical cancer can be prevented by an HPV vaccine.HPV natural history shows that only 5% of HPV infections progress to CIN 2 or 3 within 3 years . Of thisThe decision to use this end-point was based on four key features ,25,27:1. They are obligate precursors of cervical cancer.2. They are closely associated in temporal sequence to the development of invasive cervical cancer.3. They are associated with a high risk of development of invasive cervical cancer  p.1.4. Reductions in incidence or treatment are shown to result in a reduction in risk of invasive cervical cancer.The first feature needs qualification. Whilst it is true that pre-cancerous lesions are obligate precursors of cancer, the majority of lesions do not progress to cancer ,20. MostSimilarly, features two and three are only true when the environmental and lifestyle risk factors (listed above) are also present . This isScreening for high-risk HPV infection would identify a very large number of women but only a few of them would be at risk of cervical cancer  p 9. Thiindependent cause of the disease. There is ‘overwhelming evidence that infection with HPV is necessary, though not sufficient, for development of cancer of the cervix’[In 2006 when HPV vaccine was licensed and approved for use in the population there was no standard serological assay for detecting HPV antibodies and it was not known what level of antibody titre would be protective against HPV infection ,30. An aThe expression of disease from an HPV infection depends upon environmental co-factors and most HPV infections are harmless if these co-factors are not also present ,13,20. Cdid not provide sufficient identifying information to allow medical review of the individual cases. As a result, the US Centers for Disease Control and Prevention (CDC) vaccine adverse events and reporting system (VAERS) cannot be used to infer causal associations between vaccines and adverse events [During the two and a half years following the licensure of this vaccine many adverse events to HPV vaccines were reported . Althouge events .This is also because the system is a ‘passive’ system based on voluntary reporting and not an ‘active’ follow up of the health outcomes of all vaccinated individuals . PassiveRare adverse events following immunization (AEFI) were observed more often in the post licensure data than the pre-licensure data . This isI. The longer time period over which the data was collected andII. The larger number of people that were included in the trial.In the pre-licensure trials adverse events were only actively monitored for 15 days after vaccination . HoweverI. It is a passive system so events are underreported.II. Not all reported events are systematically validated.III. Inconsistency in the quality and completeness of reported data.IV. Reporting biases.active follow up of vaccinated individuals.An accurate comparison of adverse events in the clinical trials could not be determined with the unvaccinated group because the placebo was not inert . The manIn the clinical trials 0.1% of women discontinued due to adverse events and 3.6% of pregnant women in both the placebo and vaccinated groups experienced a serious adverse event  p. 17. TThe WHO states that background information about the health status of adolescents including acute, chronic and autoimmune diseases should be collected before broad HPV vaccination programs are established  p.6. ThiGovernment policy-makers in many countries are using epidemiological and economic models to determine the cost-effectiveness of HPV vaccines . There aThe HPV vaccine is being utilised in many countries even though it is known that there are many uncertainties in the health outcomes predicted by the models because of the use of simplified assumptions ,15. MathAlmost all HPV models assume that infection, clearance, progression and regression for each HPV type are independent of infection from other types . Althougif the duration of vaccine protection is greater than 30 years or if booster doses are given when the duration of efficacy is short-term [at least HPV 16 to be cost-effective [In 2008, Brisson et al. stated that the HPV vaccine trials were showing ‘promising’ results  The CE mort-term . Other sffective . Yet theffective .Mathematical models present cost-effectiveness as a ratio (CER) defined as the incremental cost of obtaining a unit of health effect from an intervention when compared to an alternative . Models The assumptions that have been used in the CER models for HPV vaccines include:1. HPV DNA on its own is a cause of cervical cancer.2. HPV 16 and 18 infections are a high risk for developing cervical cancer.3. High-grade pre-cancerous lesions (CIN 2/3) in 15–26 year old women are a surrogate for cervical cancer.4. The other 13 + strains of HPV will not infect and progress to cervical cancer.5. The duration of the vaccine is longer than 10 years.6. There are few serious side-effects produced by the vaccine.HPV vaccine is not proven safer or more effective than Pap screening combined with loop electrosurgical excision procedure ,28 thereThe introduction of the HPV vaccine was based on a number of questionable assumptions that are addressed here.When scientists trialed this vaccine against pre-cancerous lesions in 2003 it was known that HPV 16 and 18 could persist for a lifetime without causing cervical cancer. Many co-factors had been identified in causality and there were significant gaps in the scientific knowledge regarding the interaction of co-factors with many oncogenic HPV genotypes in pathogenesis. An HPV 16 or 18 infection does not lead to cancer without co-factors being present. The majority of HPV 16/18 infections (90%) are harmless, self-limiting and asymptomatic and are not a high risk of cervical cancer or warts. Environmental and lifestyle factors are known to influence the global incidence and mortality of cervical cancer and this is demonstrated by the lack of correlation between HPV 16 and 18 and the mortality to cervical cancer. HPV 16 and 18 infections are a necessary causal factor in approximately 70% of cases but they are not a sufficient cause.HPV infection is not an independent cause of cervical cancer and the universal vaccination of all women in developed countries results in the large majority of these women being exposed to the risks of the drug without being at risk of cervical cancer.how much cervical cancer can be prevented with a quadrivalent HPV vaccine.The natural history of HPV 16/18 infection in the 15 – 26 year demographic does not support the conclusion that HPV precancerous lesions are a precursor for cervical cancer: the opposite is true. The majority of pre-cancerous lesions in this demographic regress naturally and do not lead to cancer later in life. This indicates that a measure of efficacy against pre-cancerous lesions (CIN 2 and 3) in young women is an inadequate surrogate for determining some cervical cancer but there is no empirical evidence to indicate how much cancer it can prevent in developed countries where cervical cancer is already a low risk due to Pap screening programs.It is believed that this vaccine will protect against ~70% of cervical cancer. The assumption is that vaccinated women will not be infected with the 13 other HPV subtypes that are associated with carcinogenesis. Approximately 30% of cervical cancer is linked to HPV genotypes that are not covered in the vaccine. Therefore it is recommended that all vaccinated women should still have regular Pap screening to ensure they are protected. Preventing infection from HPV 16 and 18 assumes that it will prevent The duration of this vaccine was unknown when it was approved by the FDA in 2006 and it is still unknown in 2013. Duration of the vaccine is believed to be at least 5 years as predicted by mathematical modeling performed by the manufacturer. In addition, duration of the vaccine is not an indication of the protection against cervical cancer – only against infection from HPV 16/18. Protection against cervical cancer requires knowledge of the interaction of HPV 16/18 infection with co-factors in pathogenesis as well as the chances of re-exposure to HPV 16/18. In addition, 30% of cervical cancer is not associated with HPV 16 and 18 infections therefore vaccine duration is an incomplete measure of protection from cervical cancer.active surveillance system to monitor adverse events. This allows scientists to claim there is no indication that the adverse events reported after HPV vaccination are caused by the vaccine. It is being claimed that these events are a ‘coincidence’ and government regulators are stating the vaccine is ‘safe and effective’ based on a lack of evidence: not evidence-based science.Safety was not adequately investigated in the clinical trials for this vaccine. The trials for this vaccine did not use an inert placebo in the unvaccinated group and they did not study the latent effects of the vaccine components for a year or more after exposure. In addition, there is a lack of knowledge about the harm this vaccine will cause in the population because there is no HPV vaccination programs have been founded on mathematical models that are using uncertain assumptions. HPV vaccines have not been proven to be effective against cervical cancer because inadequate surrogates and end-points have been used to test this hypothesis and cervical cancer takes 10–30 years to develop. Approximately 90% of HPV infections clear spontaneously and are asymptomatic and harmless: only a fraction lead to cervical cancer over 2–3 decades. This is a significant factor in the broad use of an HPV vaccine in adolescents. Vaccination programs are targeting 11–12 year olds in which the risk of cancer death is zero. In comparison, the risk of vaccine injury or death is very real. This risk may be small or large but it is necessary to have an accurate estimate before broad vaccination programs are implemented. Governments that implement HPV vaccination programs are shifting the risk and not eliminating the risk of adverse health outcomes.In addition, vaccination programs are very expensive compared to the cost of screening programs. Pap screening is almost 100% effective in preventing cervical cancer and virtually risk free. In contrast, the HPV vaccine is very expensive and it cannot prevent 30% of cervical cancer: Pap screening will still be required. HPV vaccines will not be cost-effective against screening programs until they can prevent 100% of cervical cancer without significant adverse events.Currently the benefit of the vaccine against the burden of cervical cancer in developed countries is unknown and there are risks of injury and death that have not been accurately determined. HPV vaccines are not demonstrated to be safer or more effective than Pap screening combined with surgical procedures. Hence it follows that implementing broad HPV vaccination programs is not cost-effective in countries where regular Pap screening programs are available and will still be required. HPV vaccines in vaccination programs in these countries are offering uncertain benefits in reducing the burden of cervical cancer and may cause more harm than good due to the lack of investigation of their long-term safety.in situ; HSIL: High-grade squamous intraepithelial lesions; WHO: World Health Organisation; IARC: International Agency for Research on Cancer; PCR: Polymerase chain reaction; US: United States; CDC: Centre for disease control and prevention; VAERS: Vaccine adverse event reporting system; CE: Cost-effectiveness; CER: Cost-effectiveness ratio.HPV: Human papillomavirus; SCC: Squamous cell cervical cancer; CAC: Cervical adenocarcinoma; AIS: Adenocarcinoma The authors declare that she has no competing interest.


Amniotic fluid embolism (AFE) is one of the leading causes of maternal mortality and morbidity in developed countries. Current thinking about pathophysiology has shifted away from embolism toward a maternal immune response to the fetus. Two immunologic mechanisms have been studied to date. Anaphylaxis appears to be doubtful while the available evidence supports a role for complement activation. With the mechanism remaining to be elucidated, AFE remains a clinical diagnosis. It is diagnosed based on one or more of four key signs/symptoms: cardiovascular collapse, respiratory distress, coagulopathy, and/or coma/seizures. The only laboratory test that reliably supports the diagnosis is the finding of fetal material in the maternal pulmonary circulation at autopsy. Perhaps the most compelling mystery surrounding AFE is not why one in 20,000 parturients are afflicted, but rather how the vast majority of women can tolerate the foreign antigenic presence of their fetus both within their uterus and circulation? When first described in the first half of the 20th century, amniotic fluid embolism was presumed to be the result of the physical obstruction of the maternal pulmonary circulation by fetal material contained within amniotic fluid , 2. In tWhile “embolism” is contained with the disease name both in its original Spanish and English descriptions, there are a number of confounding clinical observations about AFE that cast doubt on this mechanism of disease , 2. FirsThe first specific suggestion of anaphylaxis as a mechanism of AFE was made by Attwood in 1956 . Benson In considering the role of mast cell degranulation in the mechanism of amniotic fluid embolism, the serological evidence should be considered separately from the histological data since, in both cases, the evidence is somewhat mixed. Serum tryptase testing in AFE points against a role for AFE while tryptase staining in pulmonary histology at autopsy provides a more nuanced picture.In 2001, a study of nine women with amniotic fluid embolism was published in which specific evidence of anaphylaxis was sought . Seven oSince this study, elevated serum tryptase levels have been reported in fatal cases of amniotic fluid embolism. In three such reports, serum tryptase levels have been only slightly elevated, raising serious questions about the premise that anaphylaxis reflects the underlying mechanism –20. In tWith 100% of 6 AFE patients testing negative for tryptase in the largest series to date, the best that can be said about serum tryptase in AFE is that it has very poor sensitivity . HoweverThe evidence from maternal pulmonary histology is more complex concerning the role of anaphylaxis in AFE. Two studies by Italian pathologists did find evidence of mast cell degranulation in the maternal pulmonary vasculature. The first study performed mast cell counts per fixed area by using an immunohistochemical stain for tryptase . The invIn summary, the available evidence suggests that mast cell degranulation does take place in the lungs in fatal AFE cases and does not do so in other mortal pregnancy conditions. This is hard to reconcile with the general lack of significant circulating tryptase elevations in AFE. These observations together suggest that pulmonary mast cell involvement in fatal cases may be a secondary process and not necessarily the primary mechanism of AFE. This possibility is all the more intriguing because mast cell degranulation can occur as a result of complement activation . In consFinally before leaving the subject of anaphylaxis and amniotic fluid embolism, the suggestion that the disease be renamed “Anaphylactoid Syndrome of Pregnancy” should be considered , 27. WhiThe frequency of adult respiratory distress syndrome as a sequela of AFE suggested to Jacob and Hammershmidt in 1982 , and HamWith both serologic and histologic evidence, the complement pathway appears more promising than anaphylaxis as a possible mechanism of disease. However, as a diagnostic tool, both sensitivity and specificity are poorly characterized. As with tryptase, complement levels in AFE remain an investigational tool and should not be used to either confirm or refute a clinical diagnosis.During the investigations into complement activation in AFE, an interesting footnote should be mentioned. It appears that some degree of complement activation during normal labor is physiologic and peaks at the moment of birth. Two separate studies in which serial complement levels were obtained in normal laboring parturients have been performed. The first was done as part of the 2001 study looking at complement and tryptase levels in AFE . A healtThere is a reasonably broad consensus in the published literature on the clinical diagnosis of AFE without the reliance on laboratory markers. In general, the definitions of the disease point to one or more of the following clinical signs first characterized by Courtney in 1974: cardiovascular instability, respiratory distress, coagulopathy, or coma/seizures in the absence of other explanations . Benson The UK Obstetric Surveillance System criteria for AFE are a bit more nuanced although still clearly similar to the Japanese and the American clinical definitions . The BriThere are several nuances to the clinical diagnosis of AFE. All definitions assign the diagnosis with the proviso that alternative diagnoses have been excluded although this does not preclude other comorbidities such as abruption. Yet several other clinical findings are associated with AFE even if they are not always considered diagnostic in their own right. For instance, uterine atony has been closely associated with AFE in several reports , 40. BeyAn examination of the current state of laboratory diagnosis of AFE is fraught with conflicting and paradoxical evidence. To be sure, AFE as a clinical entity emerged from the autopsy room with eight maternal deaths at the University of Chicago defining the first series of the disease. These first cases had large amounts of apparent fetal material in the maternal pulmonary vasculature. It is, therefore, no surprise that finding any fetal material in the maternal circulation has been presumed to confirm a diagnosis of AFE. However, this is clearly not the case as there have been any number of both individual case reports and case series in which fetal material is present in the maternal circulation in women not experiencing AFE. To add confusion to the issue, the limited autopsy studies available draw quite a different picture from studies in living patients.There are a growing number of reports in the literature in which fetal material is found in the maternal circulation of living parturients who do not have amniotic fluid embolism. Perhaps the earliest reports are those of two separate cases in which fetal material was found in the maternal circulation of the uterus at the time of peripartum hysterectomy in women who did not have AFE , 50. In In contrast, two case reports relied on the observation of intravascular fetal material in the uterus to confirm a diagnosis of amniotic fluid embolism. In the first, the authors assume that they “prevented AFE” by ligating the uterine vessels with the fetal material in it . They saTo make matters more confusing, the limited data from autopsy studies suggest that intravascular fetal material is both sensitive and specific for AFE. In 1998, Japanese investigators used a immunohistochemical stain for a fetal antigen, STN, to make a diagnosis of AFE at autopsy . All fouThe difference in the presence of fetal material in the maternal vasculature between those dying and surviving is seen in another study of 135 women with AFE in Japan . In thisAs with tryptase and complement, the presence or the absence of fetal material in the maternal circulation of living women cannot either confirm or refute the diagnosis of AFE. However, the limited available evidence suggests a somewhat different conclusion at autopsy, where the presence of intravascular fetal material does seem to be specific for AFE. It is unclear why there should be a difference in the sensitivity and specificity of intravascular fetal material between the living and the dead. An obvious explanation is that a greater amount of fetal material may be more mortal and thus more detectable at autopsy. Yet this does not seem entirely satisfactory on further examination since the amount of fetal material in fatal AFE cases was not necessarily massive and indeed present only in microscopic amounts.Much has been published about amniotic fluid embolism that, in light of current evidence, needs to be revised. The evidence does not support renaming the disease “Anaphylactoid Syndrome of Pregnancy.” The only laboratory test that is diagnostic at this time is the finding of fetal material in the maternal pulmonary circulation at autopsy. Serum tryptase levels should not be used to affirm or refute a diagnosis of AFE. Similarly, while there is better evidence concerning complement, it too remains an investigational tool and is not yet a reliable diagnostic marker. There is enough of a worldwide consensus on diagnostic criteria to permit reasonably consistent clinical diagnoses in the absence of confirmatory laboratory testing at the present. Generally, the diagnosis relies on one or more of four signs or symptoms occurring during pregnancy or shortly thereafter: cardiovascular collapse, respiratory distress, coagulopathy, and coma or seizures. Finally, intravascular fetal material in living women clearly does not necessarily result in AFE although it may not be either benign or physiologic. Perhaps the best way forward is the continued use of a difficult but achievable methodology—looking at immune markers in sera obtained from healthy controls and acutely ill pregnant women, both with and without AFE. The study of AFE is important both because it causes significant morbidity and mortality among mothers and their babies and also because a better understanding of this disease may lead to a more insight into immune tolerance in general. The overarching importance of the question underlying the mechanism of AFE is not so much why does a specific patient get the disease but rather how can women tolerate the presence of so much foreign antigen within both their uterus and their circulation?


The role of human papillomavirus (HPV) in malignant and non-malignant genital diseases in women is well known and the corresponding epidemiological burden has been widely described. However, less is known about the role of HPV in anal, penile and head and neck cancer, and the burden of malignant and non-malignant HPV-related diseases in men. The objective of this review is to estimate the epidemiological burden of HPV-related cancers and non-malignant diseases in men in Europe.The annual number of new HPV-related cancers in men in Europe was estimated using Eurostat population data and applying cancer incidence rates published by the International Agency for Research on Cancer. The number of cancer cases attributable to HPV, and specifically to HPV16/18, was calculated based on the most relevant prevalence estimates. The annual number of new cases of genital warts was calculated from the most robust European studies; and latest HPV6/11 prevalence estimates were then applied. A literature review was also performed to retrieve exhaustive data on HPV infection at all anatomical sites under study, as well as incidence and prevalence of external genital warts, recurrent respiratory papillomatosis and HPV-related cancer trends in men in Europe.A total of 72, 694 new cancer cases at HPV-related anatomical sites were estimated to occur each year in men in Europe. 17,403 of these cancer cases could be attributable to HPV, with 15,497 of them specifically attributable to HPV16/18. In addition, between 286,682 and 325,722 new cases of genital warts attributable to HPV6/11were estimated to occur annually in men in Europe.The overall estimated epidemiological burden of HPV-related cancers and non-malignant diseases is high in men in Europe. Approximately 30% of all new cancer cases attributable to HPV16/18 that occur yearly in Europe were estimated to occur in men. As in women, the vast majority of HPV-positive cancer in men is related to HPV16/18, while almost all HPV-related non-malignant diseases are due to HPV6/11. A substantial number of these malignant and non-malignant diseases may potentially be prevented by quadrivalent HPV vaccination. Human papillomavirus (HPV) has been established as a necessary cause of cervical cancer. Around 50% of women become infected with HPV by age 20-30 years  and persAs early as 1983, it was suggested that a subset of cancers of the oral cavity and larynx may be caused by HPV . The juxIn 2007 the International Agency for Research on Cancer (IARC) concluded that there was "sufficient" evidence to support the carcinogenicity of HPV in the penis, anus, oral cavity, oropharynx and tonsils, and "limited" evidence to support the carcinogenicity of HPV in the larynx . This stIn addition to cancer, HPV is responsible for some non-malignant diseases. Indeed, the great majority of genital warts, recurrent respiratory papillomatosis and oral papillomas are attributable to HPV, mostly HPV6/11 -12.All HPV-induced cancers and non-malignant diseases are necessarily preceded by HPV infection. However, little is known about the prevalence of HPV infection and related diseases in men at different anatomical sites. Therefore the purpose of this review is to estimate the epidemiological burden of HPV-related cancers and non-malignant diseases, as well as the prevalence of HPV infection, in men in Europe.A literature review was performed to retrieve exhaustive European data on trends of HPV-related cancers, incidence and prevalence of genital warts, recurrent respiratory papillomatosis and HPV infection. Searches were conducted on MEDLINE and included articles published from January 1990 through November 2010.Articles containing data on the trends of HPV-related cancers were obtained by combining the search terms "HPV", "human papillomavirus", "cancers" and "trends". Those with data on the prevalence and incidence of genital warts and recurrent respiratory papillomatosis were obtained by using different combinations of the following search terms "genital warts", "anogenital warts", "external warts", "condyloma/condylomata acuminata", "incidence" and "prevalence"; and "papillomatosis", "incidence" and "prevalence", respectively. Finally, articles containing data on the incidence and prevalence of HPV infections were obtained by combining the search terms "HPV", "human papillomavirus", "infection", "oral cavity", "oropharynx", "larynx", "anus", "penis", "men" and "males".Only articles referring to the populations of the 26 European countries included in this review were considered. Articles identified from the reference lists of retrieved publications were also included.th Revision (ICD-10) codes C01-C02, C03-C06, C09, C10, C12, C13, C14 and C32,  database, were applied to the respective Eurostat country male population estimates . The age*age- and sex-specific annual incidence rate**age- and sex-specific populationThe expected numbers of new cancer cases of all selected countries were then summed up to estimate the overall European Burden.The number of cancer cases that may have been attributable to HPV and specifically to HPV16/18 was then evaluated by applying cancer-specific HPV prevalence and HPV16/18 prevalence estimates, respectively, extracted from the most relevant published data. When available, European data were used. When European data were not available, worldwide data were used.For comparison purposes, the same methods were also used to estimate the epidemiological burden of HPV-related cancers in women in Europe. HPV-related cancer sites in women are the cervix uteri (ICD-10 code C53), vagina (C52), vulva (C51), anus (C21) and a subset of head and neck cancers .The CI5 database, available on the IARC website , containOnly cancer registries that meet the IARC's quality criteria, i.e., that have reliable national or regional cancer registry data, are included in the CI5 database. We selected all European Union countries. Four of them  were not included in the CI5 database as they did not have reliable registry data. Three European countries  that do not belong to the European Union were also selected as they are located in the same geographical area and share similarities in terms of way of life. Hence a total of 26 European countries were included in this analysis.Information in the CI5 database originated from national cancer registries for Austria, Bulgaria, Cyprus, the Czech Republic, Denmark, Estonia, Finland, Iceland, Ireland, Latvia, Lithuania, Malta, the Netherlands, Norway, Slovenia, Slovakia and Sweden. Regional cancer registry data were available for Belgium, France, Germany, Italy, Poland, Portugal, Spain, Switzerland and the United Kingdom.To ensure that national populations were adequately represented in countries where only regional cancer registries exist, the geographical coverage and distribution of these registries was assessed.To estimate the annual number of incident cases of genital warts, two European publications which provided, based on their design, the most robust incidence data for Europe, were selected ,17: bothFor comparison purposes the same method was used to estimate the epidemiological burden of HPV-related genital warts in women in Europe.Head and neck cancers generally first occur between 30 and 35 years of age among men in Europe. The incidence then steadily increases with a peak in the sixth decade of life for oropharyngeal cancer and cancer of the oral cavity, and in the seventh decade of life for laryngeal cancer Figure .The overall age-standardised incidence rates of the subset of head and neck cancers included in this review, irrespective of HPV status, ranged from 5.6 (in Cyprus) to 33.0 (in France) per 100,000 man-years in Europe (CI5 Volume IX) Figure . They weAmong the included subset of head and neck cancers, laryngeal cancer had the highest incidence in Europe , higher than that of cancer of the oral cavity  and oropharynx .Moreover, the incidence of cancer at different head and neck sites did vary by geographical region. For example, cancer of the oral cavity was predominant in the Nordic countries, while oropharyngeal cancer was most common in Western and Central European countries . In the remaining European countries, laryngeal cancer was the most common, with incidence rates representing up to 50% of head and neck cancers in several countries  Figure .Within the included subset of head and neck cancers, a total of 67,354  new cases were estimated to occur in men in Europe every year . Assuming an HPV prevalence of 16.0% for cancer of the oral cavity, 28.2% for oropharyngeal cancer  and 21.3% for laryngeal cancer , a totalHPV16/18 are the predominant types in HPV-positive head and neck cancers. They are thought to be present in 68.2% and 34.1%, respectively, of HPV-positive cancers of the oral cavity, 86.7% and 2.8% of HPV-positive oropharyngeal cancers and 69.2% and 17.0% of HPV-positive laryngeal cancers [Three European studies reported an increasing incidence trend in the included subset of head and neck cancers in men. In the United Kingdom, the incidence of squamous cell carcinoma of the oral cavity and oropharynx in men rose by 51% between 1989 and 2006 . In SwedAnal cancer generally first occurs between 30 and 35 years of age among men in Europe. The incidence then steadily increases with age in all European countries (data not shown). Age-standardised rates of anal cancer ranged from 0.2  to 0.7 per 100,000 man-years (in the United Kingdom) (CI5 Volume IX) Figure .A total of 2,162  new anal cancer cases were estimated to occur each year in men in Europe, irrespective of HPV status. Given the overall HPV prevalence of 84.2% (95%CI: 81.5%-86.9%)  in anal Several studies have reported an increasing trend in the incidence of anal cancer in men in Europe over time. In Southeast England the age-standardised incidence rates in men increased from 0.79 per 100,000 man-years in 1960-1964 to 1.06 in 2000-2004. The Scottish Cancer Registry recorded an increase in the age-standardised incidence rates of anal squamous cell carcinoma in men, from 0.14 per 100,000 man-years in the late 1970s to 0.37 in the late 1990s, with a peak of 0.44 in 1993-1997 . SimilarIn Europe, penile cancer tends to be diagnosed at age 30-35 years onwards, with an incidence peak in the seventh decade of life (data not shown). Age-standardised rates of penile cancer in men in Europe, irrespective of HPV status, ranged between 0.5 (in Finland) and 1.1 per 100,000 man-years  (CI5 Vol. IX) with substantial geographical variations  new penile cancer cases were estimated to occur annually in Europe. Assuming an overall HPV prevalence of 46.7% (95%CI: 42.0%-51.3%) and a specific HPV16/18 prevalence of 60.2% and 13.4% respectively among HPV-positive cancers , 1,484  clinic attendees and heterosexual men with multiple sexual partners. The overall prevalence of anal HPV infection in these high-risk groups ranged between 15.3% in a sample of 85 male STD clinic attendees  and 94.1Twenty-three European studies provided information on the prevalence of penile HPV infections in more than 4,300 men. The majority of the study subjects belonged to high-risk groups . The overall HPV prevalence ranged from 2.2% (95%CI: 0-6.4) in the semen of 46 husbands of women with HPV-related genital lesions , to 72.9One study , includiUsing different data sources and extrapolation methods, this review showed that the overall estimated epidemiological burden of HPV-related cancers and non-malignant diseases is high among men in Europe. In addition to malignant diseases, which include a subset of head and neck cancers and anal and penile cancers, non-malignant diseases such as genital warts and recurrent respiratory papillomatosis are also associated with HPV. Moreover, the majority of HPV-positive cancers in men are attributable to oncogenic HPV16/18, while the great majority of genital warts and virtually all cases of recurrent respiratory papillomatosis are caused by HPV6/11.In this report, a total of 72,694 new HPV-related cancer cases were estimated to occur each year in men in Europe. Moreover, we estimated that 17,403 of these cancers could be attributable to HPV, of which 15,497 were estimated to be specifically attributable to HPV16/18.In addition, between 335,301 and 380,961 new cases of genital warts were estimated to occur annually in men in Europe, with 286,682-325,722 of them attributable to HPV6/11.Recurrent respiratory papillomatosis is a very rare disease and incidence data in Europe are scarce. It was not possible to estimate the number of new annual cases in men in Europe. Nevertheless, the association with HPV is particularly strong for this disease, and virtually all cases are attributable to HPV6/11 .There was high variability in the incidence of head and neck cancers, irrespective of HPV status, with age-standardised incidence rates in Europe ranging from 5.6 to 33.0 per 100,000 man-years. The distribution of the subset of head and neck cancers included herein also varied throughout Europe. This may be partially due to regional differences in HPV prevalence, which are in turn related to differences in the distribution of risk factors for HPV infection, such as sexual behaviour. It may also be due to differences in the distribution of non-HPV-related risk factors like alcohol consumption and tobacco use, which explain some 80% of these cancers.Large cohort studies from Sweden show increasing evidence of a steady rise in the incidence of a subset of cancers of the oral cavity   and oropAn overall number of 2,162 annual cases were estimated to occur in men in Europe, irrespective of HPV status and the association of anal cancer with HPV is extremely strong (84.2% HPV-related) .An increasing trend in the incidence of anal cancer has been reported for a number of countries, including Denmark , Sweden Three thousand one hundred seventy-eight new penile cancer cases, irrespective of HPV status, were estimated to occur yearly in Europe with almost half of these cases  attributable to HPV.In addition to regional differences in penile HPV prevalence, differences in the incidence of penile cancer may be due to differences in the regional distribution of risk factors that are not related to HPV infection, such as smoking, phimosis and absence of circumcision ,80.The burden of genital warts in men in Europe is substantial. Extrapolated from the most robust European incidence data collected in Germany and in the United Kingdom, new cases were estimated to range between 335,301 and 380,961 in men in Europe every year. The vast majority are estimated to be attributable to HPV6/11. As for HPV-related malignant diseases, the incidence of genital warts varies highly by geographical region. This may be due partially due to differences in the distribution of risk factors for HPV infection. Furthermore, there is some evidence of a steady rise of genital warts in men in the United Kingdom .Genital warts are not life-threatening, but they are associated with high morbidity: psychosocial stigma, psychosexual dysfunction, depression and lower quality of life ,83. TreaIn Europe, only two studies provided data on the incidence of recurrent respiratory papillomatosis in both sexes: 0.35-0.38 per 100,000 person-years. There was no specific information about incidence in men but the sex ratio for juvenile onset recurrent respiratory papillomatosis was reported to be 1:1, while there was a pronounced male preponderance in onset in adulthood .Virtually 100% of cases are caused by HPV, the most common types being HPV6/11 ,70. AlthOverall HPV prevalence in the head and neck ranged from 0 to 18% among men in Europe, and specific prevalence of all high-risk HPV types from 0 to 14.5%. Due to the small number of European studies and the relatively small sample sizes, these results must be considered with caution. More robust data are available when worldwide studies are considered. Indeed, a systematic review of all published studies worldwide (n = 18) that detected HPV DNA in the oral cavity of 4,070 cancer-free subjects found a pooled HPV prevalence (any type) of 4.5% (95%CI: 3.9%-5.1%); the prevalence of high-risk types was 3.5% (95%CI: 3.0%-4.1%) . In a reThe prevalence of anal HPV infection in men in European studies ranged between 15.3%  and 94.1The prevalence of penile HPV infection in men in Europe ranged from 2.2% (95%CI: 0.0%-6.4%)  to 72.9%Most of the studies that evaluated the prevalence of HPV infection in anogenital sites included high-risk populations. Nevertheless, data from the United States have shown a very high prevalence of anogenital HPV infection (65%) in population-based studies ,88. The In addition, a recent global review of the age-specific prevalence of HPV infection in men  identifiLittle is known about the natural history of HPV infection in men. Few studies have prospectively assessed HPV infection, and therefore few data are available on the incidence, acquisition and persistence of HPV infection in men. A recent review on HPV prevalence in men concluded that, in contrast to results for women, age-specific prevalence curves remained relatively flat with age, or declined only slightly with post-peak prevalence. Thus, men may potentially have more long-term persistent HPV infections, or a higher rate of re-infection .For comparison purposes, the methods described above were also used to estimate the epidemiological burden of HPV-related cancers and genital warts in women in Europe. Using our methods of estimation, a total of 32,562 cancer cases specifically due to HPV16/18 were expected to occur in women in Europe every year. The new annual number of cases of genital warts attributable to HPV6/11 in women in Europe was estimated to range between 288,959 and 388,873.A total of 48,059 HPV16/18-positive cancer cases were estimated to occur annually in Europe in both sexes, of which more than 30% occur in men  than women . In addition, new cases of genital warts attributable to HPV6/11 in both genders were estimated to range between 614,681 and 675,555 yearly in Europe, half of them affecting men.The preliminary effects of HPV vaccination on genital warts and precancerous lesions have been reported from Australia, where a vaccination programme using the quadrivalent HPV vaccine was implemented. The data showed that in addition to a significant decline in the number of cases of genital warts and in the incidence of high-grade cervical abnormalities among young women in Australia, the number of cases of genital warts among heterosexual men also declined markedly .Our report has several limitations. A short-term prediction method was used to estimate the expected number of incident cancer cases in 2008 from the most recent data collected from 1998 to 2002. Therefore these predictions were accurate only if the disease rates remained stable over time. In the case of an increasing trend, they would slightly underestimate the expected number of cases, and the opposite would be true in the case of a decreasing trend.As mentioned above, the CI5 database contains national cancer incidence rates for 17 European countries. For the remaining nine countries included in this report only regional incidence rates were available in the CI5 database. Although we assessed the geographical coverage and distribution of these regional registries, other non-controllable factors, like differences in alcohol and tobacco consumption, could vary and influence regional incidence rates. The results should thus be interpreted with particular caution.The presence of HPV DNA is used to calculate the prevalence of HPV in a given population. However the mere presence of HPV is insufficient to prove causation, as the infection may be transient and not related to the carcinogenic process. Therefore our application of previously published HPV prevalence to an estimated number of new cancer cases may have yielded an overestimation of cases attributable to HPV infection. Finally, the prevalence of HPV16/18 co-infections has not been evaluated, thus summarising HPV16/18 prevalence may have led to an overestimation of the cancer burden attributable to these types.Another limitation is the absence of sex-specific HPV prevalence data in anal and head and neck cancers. Consequently, our report assumed that HPV prevalence is the same in both sexes. Currently, we have no reliable data that would confirm this hypothesis, and it seems to be inconsistent with the worldwide data from the meta-analysis by De Vuyst et al. , which sWe applied the same HPV prevalence to all European countries in this report. However, regional differences in HPV prevalence could exist, notably due to the fact that in some countries other non-HPV-related risk factors, i.e., tobacco or alcohol consumption may predominate. Furthermore, when type-specific HPV data for Europe was lacking, we used worldwide data, thus assuming that there is no difference in the HPV16/18 distribution between Europe and other parts of the world.The method used to estimate the expected annual number of new genital wart cases attributable to HPV6/11 has also some limitations. We based our estimations on incidence data extracted from only two studies and only one of them was population-based . In addiA total of 15,497 new cancer cases attributable to HPV16/18, and between 286,682 and 325,722 new cases of genital warts attributable to HPV6/11, were estimated to occur yearly in men in Europe.The burden of HPV-related cancer in men is higher than generally perceived and is primarily driven by head and neck cancers. There is currently no routine screening for HPV-related cancers in men, and head and neck cancers in particular are associated with very high morbidity. In addition, there is some evidence of a steady rise of the incidence of HPV-related cancers and genital warts.The high proportion of HPV-positive cancers attributable to HPV16/18, and of non-malignant diseases attributable to HPV6/11, underscores the potential to prevent the majority of HPV-related diseases among men through prophylactic vaccination with the quadrivalent HPV vaccine. Further research is needed to evaluate the efficacy of prophylactic HPV vaccines at non-cervical sites in men and women.CI: Confidence interval; CI5: Cancer Incidence in Five Continents; CIN: Cervical intraepithelial neoplasia; GUM: Genitourinary medicine clinics; HPV: Human papillomavirus; IARC: International Agency for Research on Cancer; MSM: Men who have sex with men; STD: Sexually transmitted disease.SH and GDF are employed by Sanofi Pasteur MSD. SS has consulted Sanofi Pasteur MSD with regard to HPV in human diseases. MB has received occasional transport to attend scientific meetings from Glaxo Smith Kline. XC has received travel and speaker honoraria and investigator grants through ICO from Merck & Co. Inc., Glaxo Smith Kline and Sanofi Pasteur MSD.SH contributed to the study design, literature research, data-analysis, interpretation of findings and drafting of the manuscript. SS contributed to the study design, interpretation of findings and critical editing of the manuscript. GDF contributed to the study design, interpretation of findings and critical editing of the manuscript. MB contributed to the data-analysis, interpretation of findings and critical editing of the manuscript. XC contributed to the study design, data-analysis, interpretation of findings and critical editing of the manuscript. All authors critically reviewed the manuscript and approved the final version.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2407/12/30/prepub


Overweight and obesity are public health issues in the United States, and veterans have a higher rate of overweight and obesity than the general population. Our objective was to examine whether copayment elimination increased use of a weight loss clinic by veterans.We examined clinic use by 44,411 new patients seen in a Veterans Affairs (VA) MOVE! weight management clinic before the copayment elimination and clinic use by 64,398 new patients seen in the year after copayment elimination. We examined clinic use via mixed-effects models for patients who were already exempt from copayment and patients who were newly exempt from copayment. We used 2 outcomes before and after copayment elimination: 1) the ratio of number of clinic visits by new users with the mean number of MOVE! clinic visits by all users, and 2) the number of clinic visits by each new user in the 6 months after their first visit. All models were adjusted for patient and clinic factors.Among newly exempt patients, the clinic-standardized rate of new use increased by 2.2% after the copayment was eliminated but increased 12% among already exempt veterans. This finding was confirmed in adjusted analyses. Analysis of number of clinic visits adjusted for patient and clinic factors also found that exempt and nonexempt veterans had similar numbers of repeat clinic visits.We saw an unexpected larger increase in demand among veterans who receive all VA care for free. These results suggest that VA should not assume that copayment reductions for selective preventive services will motivate patient change and achieve intended system-level outcomes. Obesity is a major health and health care problem; more than one-third of Americans are currently obese and another approximately one-third are overweight . ObesityDespite widespread dissemination of evidence-based weight management recommendations, only 20% of people trying to lose weight adhere to guidelines on dietary intake and physical activity . Patienthttp://www.move.va.gov/move23.asp) to develop tailored, behaviorally based dietary changes and physical activity self-management support that are delivered through individual or group face-to-face counseling and that are supported with interventions that use weight loss medications, intensive outpatient programs, and bariatric surgery. More than 40% of veterans who participated in at least 2 MOVE! treatment sessions lost at least 5% of their body weight in the short term; only 12.5% of nonparticipants matched for age, sex, comorbidities, and body mass index lost this amount  developed the MOVE! Weight Management Program for veterans in 2006. The program provides a systematic, evidence-based approach to weight management for the nearly 6 million veterans served by approximately 153 hospitals and 956 outpatient clinics . On June 15, 2008, VHA policy makers eliminated the copayment because patients and clinic staff expressed concern that the copayment was a barrier to initial and ongoing participation. The copayment change was communicated to VA staff at local sites but not to veterans through a coordinated national communications strategy. The policy to eliminate copayments is consistent with value-based insurance design principles that link cost sharing directly to clinical value so that cost-effective or cost-saving products and services have lower copayments than less cost-effective products and services . Value-bThe objective of this study was to evaluate the effect of the MOVE! copayment elimination on use of the MOVE! clinic by patients who had not previously received MOVE! clinic services. We examined whether the ratio of first-time MOVE! clinic visits to mean overall clinic use  increased after the copayment was eliminated. We also examined whether new users increased the number of visits they made to the MOVE! clinic in the 6 months after their first visit.The Durham VAMC Human Subjects Protection committee reviewed and approved this study. We employed a cross-sectional pre–post study design with a nonequivalent control group. We had 2 distinct and nonoverlapping cross-sectional cohorts: 1) a preperiod  cohort of veterans who were new MOVE! clinic users in the year before the copayment elimination and 2) a postperiod  cohort of veterans who were new MOVE! clinic users in the year after the copayment elimination. No patients in the preperiod cohort were represented in the postperiod cohort. Patients were identified as new users if they had no MOVE! clinic use in the 12 months before the index visit (their first MOVE! clinic visit) in the preperiod or postperiod. The cohort included incident, rather than prevalent, MOVE! users to enable us to identify immediate effects  of the cAlthough nonexempt veterans during the preperiod were required to pay a $15 copayment until the copayment was eliminated on June 15, 2008, for the purpose of this study we refer to veterans in the preperiod (and the postperiod) who did not meet requirements for exemption and for whom the MOVE! copayment was eliminated as the “newly exempt” cohort. We hypothesized that copayment elimination would most affect the behavior of new clinic users in the postperiod. We compared MOVE! clinic visits by newly exempt veterans to clinic visits by a subgroup of veterans in the preperiod and postperiod cohorts who were exempt from copayments for all outpatient clinic visits. Seventeen percent of the preperiod cohort were veterans who were required to pay copayments, and 16% of the postperiod cohort were newly exempt veterans who became newly exempt in the year after copayment elimination.The sample included 126 VAMCs with high-volume MOVE! clinics, defined as having 30 or more MOVE! participants during the preperiod. This threshold was chosen to identify VAMCs that had moved beyond the start-up phase of MOVE! implementation. For the clinic-standardized rate of new MOVE! use, we aggregated data to the clinic level by month for new users in the preperiod and the postperiod. The number of MOVE! visits by new users in the 6 months after their index visit was defined for 21,193 preperiod and 26,520 postperiod new users. We excluded 23,218 preperiod new users from the analysis of attendance precopayment and postcopayment removal because their first MOVE! clinic visit occurred within 6 months of the copayment elimination , so they had less than 6 months of preperiod time to make a repeat visit. We excluded 37,878 postperiod new users whose first visit occurred between December 16, 2008, and June 14, 2009, for parallel cohort construction. The final sample included 44,411 preperiod and 64,398 postperiod new users.To construct the 2 MOVE! clinic use outcomes and most patient characteristics , we used 2006–2009 VHA Outpatient Care File data, which contains information on every VHA outpatient visit. The first clinic use outcome was measured monthly at the clinic level separately for exempt and newly exempt users  during the preperiod. This outcome was a ratio in which the numerator was the number of MOVE! first-time visits within each clinic by patients who were new users, and the clinic-specific denominator was the overall mean monthly number of MOVE! visits to that clinic. This ratio, which we refer to as the clinic-standardized rate of new MOVE! use, represents the ratio of first-time MOVE! clinic visits to mean overall clinic use by all users (prior users and new users). The denominator was constant during the 24 months and the 2 copay groups, ranging from 0.0 to 4.3, so the ratio varied only according to the monthly change in the number of veterans who were using the MOVE! clinic for the first time. The denominator reflected the overall mean number of MOVE! clinic visits, so it was possible for the number of MOVE! clinic visits by new users in a given month to be larger than the overall monthly mean preperiod use . The second use outcome was a count variable that measured at the patient level in both the preperiod and postperiod , and consisted of the number of MOVE! visits by new users in the 6 months after their first clinic visit.To control for comorbidity, we obtained Diagnostic Cost Group (DCG) risk-adjustment scores for each patient in the preperiod and postperiod cohorts. DCG scores have been as predictive of veterans’ 1-year expenditures and mortality as other comorbidity scores ,15. PatiThe analysis for the first outcome was a linear mixed-effects model based on the framework of a split-plot design . In thisWe used a negative binomial mixed-effects model to estimate differences in the number of MOVE! clinic visits. The fixed effects in the model included the main factors of interest: an indicator for copayment eligibility, an indicator for the preperiod or postperiod cohort, and an interaction of the copay eligibility and pre–post indicators. This interaction term indicates whether use of the MOVE! clinic changed significantly in exempt vs nonexempt veterans between the preperiod and postperiod. Additional fixed effects included veterans’ age, DCG score, sex, race, and marital status. A clinic-level random effect was included in the model to account for the intraclass correlation of patients from the same clinic. All analyses were conducted using SAS version 9.2  and Stata version 10 .During the year before the copayment elimination, the mean clinic-standardized rate of new MOVE! clinic use was higher for new users who were copayment exempt (18.0%) than for those required to pay copayments (3.6%), which suggests that for every 2 nonexempt veterans newly using MOVE! in the preperiod, 10 exempt veterans newly used MOVE! The mean clinic-standardized rate by veterans exempt from copayments and new to the MOVE! program increased from 18% to 30% of all clinic visits, while the mean clinic-standardized rate by veterans formerly required to pay copayments and new to the MOVE! program increased from 3.6% to 5.8%. Compared with nonexempt new users, the relative increase in the clinic-standardized rate new MOVE! clinic visits by exempt veterans was 12% in the year before the copayment elimination and 2.2% after. In the adjusted analysis , we founP < .001, In the preperiod and postperiod, compared with nonexempt patients, exempt patients were younger , more likely to be female (12% vs 7%), less likely to be white (50% vs 54%), and less likely to be married (52% vs 70%) and had higher mean DCG scores (0.75 vs 0.61)  may have increased demand for MOVE! services by both patients and VHA clinicians. The increase in MOVE! use by exempt veterans after copayment elimination suggests that VHA does not need to be concerned about “a run on services” following copayment elimination. Exempt veterans may have used MOVE! at a higher rate than newly exempt veterans because they have greater VA use in general. To increase MOVE! use among newly exempt veterans, VA may want to consider direct financial incentives to veterans instead of a copayment reduction. A copayment reduction may be less motivating to individuals compared with a deposit contract approach , direct This study has several limitations. First, these results may not generalize to MOVE! clinics that had low volume in the year before the copayment elimination or to more recent years . Second, we do not have baseline obesity and overweight status for the exempt and nonexempt groups. Higher-income, nonexempt veterans may have had fewer candidates for participation in the MOVE! program, which could account for the lower enrollment increase in that population. Third, we did not have data on the number of veterans who wanted to participate in the MOVE! program but were unable to participate. If a disproportionate share of veterans required to pay copayments were placed on waiting lists to enroll in MOVE!, these results would underestimate the response to the copayment elimination by these veterans because they only reflect actual MOVE! clinic visits. Fourth, there may have been changes in MOVE! clinics themselves over time that created maturation biases that potentially confounded the effect of the copayment elimination. Fifth, the examination of the MOVE! clinic copayment using a cross-sectional time-series study design of new MOVE! clinic users, some of whom were newly exempt veterans and some of whom were nonequivalent “always exempt” veterans, may have limited the internal validity of this evaluation. However, examination of MOVE! clinic demand by new users and inclusion of a control group  controlled for regression-to-the-mean bias and other threats to internal validity.Eliminating the copayment reduced a financial barrier to access the MOVE! clinic, yet we did not observe increased use by veterans newly exempt from these copayments compared with veterans who were already exempt from copayments. Unexpectedly, we saw a larger increase in demand among veterans who receive all VA care for free, which may have been driven by clinic staff perception of greater potential benefit of MOVE! clinic use in this segment of the population or by a greater perceived value of this exemption. Copayment elimination may be less important for health behavior change services that require ongoing commitment from patients. These results suggest that VA should not assume that copayment reductions for selective preventive services will motivate patient change and achieve intended system-level outcomes.


Spirituality plays an important role for many people. In particular, its crucial role among people at the end-of-life (EoL) has been recognized. Currently one out of 4 deaths in the US is a veteran. The study of spirituality among veterans who are at the EoL is therefore urgently needed. The objectives of this study are to understand the spiritual needs and spiritual care provided to veterans at the EoL in the Veteran Administration (VA) Healthcare System. We particularly focused on how military experience impacts spirituality and the spiritual care for veterans who, at the EoL, are still suffering from these experiences.We conducted a qualitative study that interviewed VA chaplains, veterans who are at the EoL and their families. The interviews were recorded, transcribed, and then analyzed based on Grounded Theory.Veterans and their families expressed a range of spiritual needs including religious activities, divine intervention , reconnection to their religion, time with family, compassion/love, respect, and conversations about spiritual concerns. One unique need of veterans is to process negative impacts  from events that occurred during their combat experience. Chaplains reported various approaches for addressing this special need. Some veterans indicated the desires for more frequent and longer visits from chaplains. Veterans however reported that spiritual care can be provided by professionals  other than chaplains.The results of our study highlight the importance of addressing spiritual needs of veterans in healthcare. The study finding that some veterans, who at the EoL, are still struggling with spiritual issues related to events that occurred during combat many decades earlier indicates early interventions for addressing these issues might prevent the long-term suffering of more recent veterans, such as the recently returned troops from Iraq.


Cervical intraepithelial neoplasia grade 3 (CIN3), the immediate cervical cancer precursor, is a target of cervical cancer prevention. However, less than half of CIN3s will progress to cancer. Routine treatment of all CIN3s and the majority of CIN2s may lead to overtreatment of many lesions that would not progress. To improve our understanding of CIN3 natural history, we performed a detailed characterization of CIN3 heterogeneity in a large referral population in the US.We examined 309 CIN3 cases in the SUCCEED, a large population-based study of women with abnormal cervical cancer screening results. Histology information for 12 individual loop electrosurgical excision procedure (LEEP) segments was evaluated for each woman. We performed case-case comparisons of CIN3s to analyze determinants of heterogeneity and screening test performance.CIN3 cases varied substantially by size (1–10 LEEP segments) and by presentation with concomitant CIN2 and CIN1. All grades of CINs were equally distributed over the cervical surface. In half of the women, CIN3 lesions were found as multiple distinct lesions on the cervix. Women with large and solitary CIN3 lesions were more likely to be older, have longer sexual activity span, and have fewer multiple high risk HPV infections. Screening frequency, but not HPV16 positivity, was an important predictor of CIN3 size. Large CIN3 lesions were also characterized by high-grade clinical test results.We demonstrate substantial heterogeneity in clinical and pathological presentation of CIN3 in a US population. Time since sexual debut and participation in screening were predictors of CIN3 size. We did not observe a preferential site of CIN3 on the cervical surface that could serve as a target for cervical biopsy. Cervical cancer screening procedures were more likely to detect larger CIN3s, suggesting that CIN3s detected by multiple independent diagnostic tests may represent cases with increased risk of invasion. The natural history of human papillomavirus (HPV) leading to invasive cervical cancer is well established Reporting CIN3 as a single outcome based on the worst histological diagnosis on the cervix Detailed mapping of the LEEP segments that covers the surface of the entire cervix provides an opportunity to identify and characterize clinical subgroups of CIN3 cases. Thus, we performed a detailed characterization of LEEP specimens to understand predictors of CIN3 heterogeneity and to evaluate the relationship of CIN3 heterogeneity with screening test results in a large population-based study of women with abnormal cervical cancer screening results. Examining the heterogeneity CIN3 cases referred to a colposcopy clinic after abnormal cervical cancer screening may aid in elucidating the biological differences between CIN3 cases, and thereby inform future efforts to reduce unnecessary treatment of CIN3 that are not clinically important.We conducted the analysis in the Study to Understand Cervical Cancer Early Endpoints and Determinants (SUCCEED), a large population-based study composed of women referred to the University of Oklahoma Health Sciences Center (OUHSC) for abnormal cervical cancer screening test results. SUCCEED design and methodology, including the details on enrollment, questionnaire data, HPV DNA genotyping, histology, and cytology procedures, have been described in depth elsewhere Participants completed interviewer-administered, standardized questionnaires and provided liquid-based cytology specimens for ThinPrep Pap and HPV genotyping by Linear Array (Roche Diagnostics). OUHSC gynecologists performed colposcopic examination according to routine OUHSC practice. Women were treated by LEEP of the transformation zone, if indicated by ASCCP guidelines Every LEEP specimen was divided into 12 topographically designated sections or segments (a “clockface” depiction of the cervix) for detailed histopathological mapping. According to the SUCCEED study protocol, two segments from each LEEP representing the worst lesion and normal cervical tissue were snap-frozen for molecular studies. The remaining 10 segments were formalin-fixed, paraffin-embedded and analyzed to generate individual histology results for each segment. The study pathologists at OUHSC, masked to HPV genotyping data, determined the histology using CIN terminology. One or more of the following diagnoses were noted for each o'clock segment of the cervix per individual: other, negative/normal, atypical metaplasia, CIN1, CIN2, CIN3, adenocarcinoma in situ, squamous cell carcinoma, and adenocarcinoma. In addition, if the clinician determined that the entire transformation zone or extent of a lesion could not be visualized adequately, endocervical curettage (ECC) and/or a deeper, secondary LEEP (“top hat procedure”), which removes tissue from higher up in the endocervical canal, were performed. Per common practice, the cases were categorized according to the worst diagnosis for each woman based on the diagnosis of the most abnormal LEEP segment, ECC, and/or top hat.During the study period, 975 women were managed by LEEP Figure 1continuous adjacent LEEP segments with CIN3. In addition, we dichotomized the CIN3 lesion size as a “small” versus “large” CIN3 lesion, defined by a cut-off of <3 CIN3 segments versus 3+ CIN3 segments. Similar trends were observed with different cut-points .For our analysis, we defined the diagnosis of each o'clock segment of the cervix by the most severe diagnosis, if more than one diagnosis was noted for an individual LEEP segment. We focused our analysis on the following worst outcomes for each LEEP segment: normal, CIN1, CIN2, and CIN3. A priori, we defined subgroups of CIN3 cases by the presence or absence of CIN1 and CIN2 in conjunction with the presence of CIN3 in any of the LEEP segments. Accordingly, we categorized the CIN3 cases into four subgroups: solitary CIN3, CIN3+CIN2, CIN3+CIN2+CIN1, and CIN3+CIN1. As a sensitivity analysis, we further categorized solitary CIN3 as “true” solitary CIN3 cases by excluding cases with CIN1 and/or CIN2 diagnoses in any of CIN3 LEEP segments. We also a priori defined the size of CIN3 by the number of LEEP segments with CIN3 among all LEEP segments analyzed and the number of 2 test. In addition, we tested for trend across ordered groups using the nptrend command, a nonparametric test that is an extension of the Wilcoxon rank-sum test. We also calculated the percent detection of small versus large CIN3 lesions by the diagnostic tests. For all analyses, P-values of ≤0.05 were considered statistically significant. All tests of statistical significance were two-tailed. Analyses were performed using Stata 11.1 .First, we performed a case-case comparison of the four CIN3 subgroups for selected known risk factors of cervical cancer: age at LEEP, length span of sexual activity , parity, OC use, lifetime number of sexual partners, smoking, Pap test history (number in past five years), HPV genotypes  HPV type infections, and presence of HPV16 infections). We also performed a case-case comparison for diagnostic factors based on the following cervical cancer screening tests: cytology results prior to LEEP, biopsy results at LEEP visit, and colposcopic impression results at LEEP visit. In addition to the categorical variables of these screening test results, we dichotomized the screening test results to distinguish low grade from high grade diagnoses: biopsy histology of CIN3+ compared with CIN2 or less, cytology of high-grade squamous intraepithelial lesions (HSIL) or worse (HSIL+) compared with less than HSIL, colposcopic impression of CIN3+ compared with CIN2 or less. Second, we evaluated the differences between categories of CIN3 lesion size with the same factors. We tested for differences between categorical variables and CIN3 subgroups and lesion size using the Pearson χcontinuous CIN3 size (data not shown). In addition, we also observed a variable range in number of CIN2 (1–10 segments) and CIN1 (1–6 segments) present as concomitant lesions among the CIN3 cases (data not shown).Three hundred and nine women were identified as CIN3 cases according to the worst LEEP diagnosis Table 1.We summarized all 309 women included in the analysis in a single circular histogram Figure 3The majority of these women  had CIN lesions of lower grades in other LEEP segments in addition to the CIN3. About half of the heterogeneous lesions were CIN3 cases with CIN2 lesions (n = 116), followed by CIN3 without additional lesions (n = 79) and CIN3+CIN2+CIN1 (n = 79), as well as a small percentage of CIN3+CIN1 (n = 35) Table 2.The distributions of clinical and pathological characteristics examined and presented in CIN3 size was widely distributed in the study population and ranged from 87 women (28%) with one CIN3 segment involved to 55 (18%) women with CIN3 across five or more CIN3 segments Table 3.continuous CIN3 size (data not shown). Dichotomizing CIN3s by lesion size (<3 vs. 3+), the sensitivity of HSIL cytology at LEEP was 74% for small CIN3s and 86% for large CIN3s  presented with CIN3 lesions in conjunction with lower grades of CIN in different regions on the cervix. We observed a wide range of CIN3 sizes from small focal lesions to extensive CIN3 covering most of the cervix. To better characterize women within the CIN3 diagnostic group, we examined the distribution of risk factors as well as clinical and pathological information from cervical cancer screening tests by CIN3 subgroups and CIN3 lesion size.Some previous studies have suggested that CIN may be more common on the anterior and posterior lips of the cervix than at the lateral angles We also observed that compared to CIN3 cases with CIN2, solitary CIN3 and CIN3+CIN1 cases were more likely to have a larger sized CIN3 lesion. Our data corroborate the model that high-grade pre-cancer grows out from a small lesion possibly surrounded by low grade lesions, such that either CIN3 expands while the CIN1 regresses We sought to understand how clinical and pathological characteristics are related to CIN3 lesion size. The CIN3 lesions observed by McCredie and colleagues in their retrospective study of women with untreated CIN3 who progressed to cancer were large We did not observe associations between other risk factors previously reported to be associated with HPV infection and progression  and CIN3 size, suggesting that these factors are not paramount at the later stages of CIN3 natural history. However, we noted an insignificant trend of less OC use in women with larger CIN3s. We recently observed in the same population that contraceptive methods requiring doctor visits such as OCs are associated with more Pap tests in the previous five years, which could explain this observation (data not shown).In addition, we examined the effect of CIN3 size on cervical cancer screening results and found that larger CIN3 lesions were more likely to be diagnosed as HSIL+ at time of LEEP visit. Similarly, larger CIN3 size was more common among more severe colposcopic impression at time of LEEP visit and with a higher percentage of a CIN3+ biopsy result at the colposcopy visit, demonstrating that larger CIN3 cases are easier to detect by colposcopy. These finding highlight a current dilemma in cervical cancer screening: new screening tests such as HPV DNA detection are more sensitive than the current gold standard of following up cytology with colposcopy and biopsy The main strengths of our study are the large population-based sample of CIN3s and the detailed mapping of LEEP specimens, which allowed for a thorough evaluation of the heterogeneous manifestations of CIN3 cases. While examination of the 12 LEEP segments allowed us to study lesion size in unprecedented detail, a finer resolution would have provided more accuracy since multiple histologic diagnoses could be found even within a LEEP segment. Although the cross-sectional design of our study may be viewed as a limitation, it is not possible to follow CIN3 prospectively. Furthermore, this design permitted the accrual of large numbers of women into the study for studying CIN3 cases with detailed mapping of disease in LEEP specimens. In addition, our analysis was not based on panel adjudication of histology results, but on the community histology diagnosis by a single experienced pathologist.In summary, our data showed that women with CIN3 lesions without concomitant CIN2 or CIN1 lesions were more likely to be older, have longer sexual activity span, and have fewer high risk HPV infections and that larger CIN3 lesions were more common among women infrequently screened, with HSIL or worse cytology, and CIN3 or worse impression in colposcopy. Interestingly, we also observed that in our population, HPV16 positivity was not associated with larger CIN3 lesion size. Although our and others' data suggest that CIN3 lesion size is an important indicator of risk of invasion, lesion size can only be determined post-treatment. We show that HSIL cytology and CIN3 impression in colposcopy with CIN3 biopsy results point to larger CIN3s that most likely have a higher risk of invasion compared to small incipient lesions. While the findings from this study are important, they are not sufficient to establish which CIN3 should be treated. We are now conducting detailed molecular analyses of cervical lesions, using microdissection to permit the molecular evaluation of CIN3 heterogeneity to identify better risk markers for management of CIN3.