Since the introduction of biomolecular testing for the identification of high-risk human papillomavirus DNA (hrHPV-DNA) in cervical cancer preventive strategies, many interesting aspects have emerged in this field; firstly, HPV-DNA testing has been demonstrated to have better sensitivity than conventional cytology in several settings: screening, triage of ASC-US and in follow-up after treatment. Despite this, some limitations of these new technologies have also been underlined: the major issue is the low specificity of the tests, which cannot discriminate between regressive and progressive infections. Thus, recent research has moved the attention towards novel markers of progression that could more precisely detect cases at real risk of cancer development. In view of the fact that progression to cancer is dependable of the E6/E7 proteins integration and transforming action, the overexpression of E6/E7 transcripts has been seen as a valuable marker of this risk. This review aims to summarise the literature data on this topic and to provide a clear view of the emerging perspectives. However, cervical cytology demonstrated a less than optimal sensitivity, and advances in the knowledge of the natural history of the disease have more recently suggested alternative approaches. Persistent infection with high-risk genotypes of the human papillomavirus (hrHPV) has been recognised as the necessary cause of cervical cancer . This leCurrently, three commercial tests exist for detecting hrHPV E6/E7 messenger RNA (mRNA). The PreTect HPV-Proofer  and the NucliSENS Easy Q HPV (bioMérieux) are based on the same technology, but are produced by different companies, with small differences in mRNA extraction protocol and data analysis . These tIn 2009, a group of researchers from Catholic University, Rome, published their findings on 180 colposcopically and histologically evaluated women, studied for the presence of HPV-DNA (HC II) and mRNA (NucliSENSE) . As expeHPV-DNA tests have low specificity and a high positivity rate in LSILs, making HPV-DNA test not particularly useful in triage of LSIL. The 14 genotype APTIMA test and especially the five genotype HPV E6/E7 mRNA tests have higher specificity and a low positivity rate in LSIL. A low positivity rate translates into a low referral rate for colposcopy, which is very appealing for triage situations –16. WomeWomen conservatively treated for CIN2–3 lesions are considered at high risk of developing invasive carcinoma for many years, and therefore, they require continued surveillance. In particular, between 5% and 20% of women treated for CIN2+ will develop recurrent disease within 3 years . For thiIn general, HPV E6/E7 mRNA testing has been demonstrated in several published experiences to have the characteristic of an accurate diagnostic tool in the field of cervical cancer prevention . For thiIn conclusion, since the beginning of the molecular era in the prevention of cervical cancer, many steps forward have already been made to overcome the limitations of cervical cytology alone; mRNA testing actually represents a new challenge, with the promising possibility of being integrated in the pool of valuable molecular tools that will hopefully lead to the elimination of invasive cervical cancer in women in the near future.


Objective: Human papillomavirus (HPV) and the HPV vaccine have been examined through multiple lenses over the past several years, though there is little work examining the role of perceived behavioral control (PBC) and its impact on potential recipients retrieving, understanding, and using online information with regard to the vaccine. Method: This study used survey data to examine the role of PBC as a moderator between attitudes and intention, and subjective norms (SN) and intention to get the HPV vaccine; and PBC as a moderator when seeking out Facebook, YouTube, and Twitter as information sources about HPV. Support was found for each prediction. Results: The interaction term of SN × PBC in particular had a strong influence on intention to get the vaccine. Discussion: Planned behavior variables explain intention to get the HPV vaccine, but data also suggest a need to root this research within intervention-based strategies. A wide body of research in the past several years has examined the human papillomavirus (HPV) vaccine. The sorts of advertising and educational messages which appeal to the target demographic – high school- and college-aged women – have been analyzed, indicating that there can be a sexually transmitted disease-related stigma attached to obtaining the HPV vaccine   with intention to getting the HPV vaccine. Additionally, we look at the role of information-seeking behaviors relating to HPV, particularly through social media. Specifically, we look at the role of PBC as a moderator between attitudes and intention, and subjective norms (SN) and intention when seeking out Facebook, YouTube, and Twitter as information sources about HPV.The TPB has been used previously to study patients' and parents' intentions to vaccinate and attitudes toward the vaccination. There is, however, a gap in the literature when addressing if and how patients utilize online resources in their search for more information on the vaccination. TPB was developed by psychologist Ajzen . AccordiIn recent years, a large effort has been made to promote uptake of HPV vaccine, which can cause cervical cancer and genital warts Bryan, . Two vacIn particular, much research has been devoted to examining factors associated with female intention to receive the vaccine . Current research finds that TPB variables account for as much as 60% of the variance accounted for in intention to get the HPV vaccine, even when testing TPB against other models, including the Health Belief Model  with intention to getting the HPV vaccine. Furthermore, we propose that the construct of PBC is a moderator between attitudes and intention, and subjective norms (SN) and intention, when seeking out Facebook, YouTube, and Twitter as information sources about HPV and the vaccine. Social media is a unique means by which individuals can learn more about the HPV vaccine. Facebook, Twitter, and YouTube are some of the most important social media forms that individuals use when they want to learn about these vaccines. The term itself, “social media”, has yet to have a concurrent definition used in research, but Merriam-Webster's .Subjective norm (SN) is a central social influence factor a person's perception that most people important to them think they should or should not perform a behavior in question  influence behavior through motivation to comply with referents' normative beliefs and expectations. Additionally, norms have a direct effect on behavioral intent through compliance or coercive social pressure.PBC is essentially the same idea as SE; the measure of a person's perception of his or her ability to complete a task. What differentiates PBC from SE, however, is that PBC incorporates two specific aspects: perceived capacity (PC) and perceived autonomy (PA) Yzer, . (PA) isUltimately, PBC is concerned with the resources and opportunities that either encourage or hinder behavioral performance. As such, the present study looks at PBC in the context of confidence and certainty of being able to complete a given task Yzer, .According to traditional research on reasoned action, attitudes, perceived norms, and PBC affect behavioral intent in a direct method, but even if attitudes and perceived norms toward a behavior are positive, if people lack the SE to do so, then they will not engage in that behavior  and intention to get the HPV vaccine. As such:H1: For sexually active adults, PBC moderates the relationship between attitudes and intention to get the HPV vaccine.H2: For sexually active adults, PBC moderates the relationship between subjective norms (SN) and intention to get the HPV vaccine.Given the relationship between ability to maintain sexual health and information-seeking behavior about HPV, we next look at actual information-seeking behaviors using social media – namely, Facebook, YouTube, and Twitter, which are identified as key resources that people use today to learn and communicate about information relating to HPV  research on perceived barriers to being vaccinated against HPV, a predictor was found in self-report frequency of media exposure. Similar research continues to advocate for the role of PBC as a moderator regarding intention to engage in positive, healthy behaviors  to learn about HPV.M = 22.5, SD = 5.14), and the majority of participants were undergraduate students . Participants predominantly reported Caucasian/White as their ethnicity (86.5%), with some Asian/Pacific Islander (4.1%), African American (5.4%), Hispanic/Latino (1.4%), Undisclosed (2.6%), and 5 missing values.Upon Institutional Review Board approval, data were collected in 2012 in a suburban community in the Midwestern USA. An online survey was distributed via an e-mailed link to a university population, including both faculty, staff, undergraduate, and graduate students. The survey was created to assess students' use of the Internet to address health concerns or issues. The survey asked participants questions about their sexual health, their use of the Internet to address health issues, and their perceptions and intention to get or complete the HPV vaccine. One hundred and seventy-four participants took the survey, ranging in ages 18–54 , but some did . After this, they answered four questions relating to how they maintain their sexual health, including whether or not they have had unprotected sex (76.8% said yes), and whether or not they feel they are good at maintaining their sexual health . Next, participants responded to questions that asked them about whether or not they had received the HPV vaccine – no participants in the entire sample had received the vaccine. Finally, participants responded to their perceptions of information where they could learn about the HPV vaccine. Upon completion of those questions, participants had completed the survey and were thanked for their time.M = 4.24, SD = 1.98). The scale showed high internal consistency .Intent to get/complete the HPV vaccination was measured by the average of three items  on a seven-point scale  in response to the base question, “Getting/completing the HPV vaccination over the next year would be … ” These items showed strong reliability .Following typical recommendations for TPB research Ajzen,  attitudeM = 2.80, SD = 2.04). The scale showed good internal consistency .Perceptions of normative influences over getting the HPV vaccination were measured through the average of four times (e.g. “Most people who are important to me think that I should get the HPV vaccination” and “Many women like me plan on getting/completing the HPV vaccination.”) on seven-point scales . Items included, “If I wanted to, I could get/complete the HPV vaccination in the next year,” and “It is mostly up to me if get/complete the HPV vaccination in the next year.” The items showed good reliability .The average of five items was used to assess PBC using seven-point scales . The items showed decent reliability . Attitudes toward social media have been assessed in similar ways with similar reliability  were measured by the mean of an eight-item semantic differential  on a seven-point scale .The dependent variable was intention to get the HPV vaccine with the item “I intend to get/complete the HPV vaccine within the next 12 months.” Participants who had already completed the HPV vaccine were excluded from the analysis. Responses were coded on a 1 to 7 Likert scale ranging from Multiple regression analysis was used to test each hypothesis. Variables were mean-centered and product terms were created to represent all two-way interactions. The means, standard deviations, and zero-order correlations of all variables are displayed in Dillard and Spear  argued tTo investigate a moderating effect of PBC, we computed regressions on attitudes toward intention to get the HPV vaccine, intention to get/complete the HPV vaccine, norms relating to intention to get/complete the HPV vaccine, and PBC and intention to get/complete the HPV vaccine as predictors.F  = .250, p < .493, R2 = .043. Step 2 included attitudes toward getting the HPV vaccine. In step 3, PBC toward getting the HPV vaccine was included. Finally, in step 4, the interaction term of ATT × PBC was added. Prior to regression analysis, all independent variables were centered to reduce multicollinearity errors. B = .286, SEB = .074, β = .222, p < .05, ^R2 = .009, which includes attitudes, PBC, and the interaction term. However, we consider the baseline of p < .05 and the sample size. When the Attitudes × PBC term was added to the model, there was a significant relationship to the model, although it was small, B = .142, SE B = .166, β = .031, p < .05, ^R2 = .001. However, there is support for H1.H1 stated “For sexually active adults, PBC moderates the relationship between attitudes and intention to get the HPV vaccine.” Hierarchical multiple regression was performed. The control variables (gender and age) were initially entered into step 1 and were not significantly associated with intention to get/complete the HPV vaccine, B = .628, SEB = .341, β = .032, p < .001, ^R2 = .001. Furthermore, a stronger relationship for SN × PBC was found than ATT × PBC, which may suggest that peer influence has a stronger relationship to PBC and subsequent intention, B = .146, SEB = .322, β = .144, p < .014, ∧R2 = .001.H2 stated “For sexually active adults, PBC moderates the relationship between subjective norms (SN) and intention to get the HPV vaccine.” Hierarchical multiple regression was again performed; step 2 included subjective norms (SN) toward getting the HPV vaccine. In step 3, PBC toward getting the HPV vaccine was included. Finally, in step 4, the interaction term of SN × PBC was added. B = .307, SEB = .043, β = .040, p < .009, ^R2 = .031.Finally, H3 stated “For sexually active adults, PBC moderates the relationship between attitudes and intention to use social media web sites  to learn about HPV.” Hierarchical multiple regression was again performed; step 2 included attitudes toward using social media web sites  to learn about the HPV vaccine. In step 3, PBC toward getting the HPV vaccine was included. Finally, in step 4, the interaction term of PBC × Social Media was added. In this study, we elaborated on research done on the HPV vaccine using a planned behavior framework Ajzen, . We founH1 and H2 suggested that when added to the model as an interaction term, PBC would moderate the relationship between attitudes and intention to get the HPV vaccine and subjective norms (SN) and intention to get the HPV vaccine. Support was found for both hypotheses, although we found a greater relationship for the impact of subjective norms (SN). Despite this contribution, its limitations should be noted. The results of this study are survey based, which, while useful, are somewhat limiting for H3, which looked at the role of social media content related to the HPV vaccine. We included this hypothesis because numerous studies have recommended exploring online content about vaccine information-seeking behaviors Roark, , and givAn intervention design for HPV vaccination intention can be done in a way that is firmly rooted in a planned behavior approach focusing on the strength of control beliefs  in HPV vaccination behavior. Moreover, Dillard and Spear  paved thIndeed, numerous possibilities exist for examining perceived control, but it is clear that a strong intervention should be a next step in the research. As a key predictor of behavior, intention is important to study, but the gap between intention and behavior may be better understood through PBC, which can contribute to the prediction of behavior and help to inform intervention design.The current study used an online survey based on convenience sampling. This was a useful first step in gathering data necessary to begin to explore the behavior–intent relationship surrounding the HPV vaccine, but it is a notable limitation. For instance, studying populations both younger and older would provide very valuable data and an additional insight. Furthermore, a limitation of the current study is that with social media still being measured in many ways, we chose to measure it in a way similar to Ajzen's  recommenResearch on planned behavior has long suggested that perceived control can moderate the relationship between attitudes and intention, but the support of these data suggests that there may be a deeper need to continue to examine PBC in further HPV research, and for research beyond health issues. If PBC is a persistent factor in deciding to get the HPV vaccine, then perhaps it should be more aptly targeted in intervention-based research. Furthermore, HPV has been a widely addressed issue in recent years, with a range of studies focusing anywhere from young adult to older adults, female and male intention to get the vaccine, and so forth. HPV in particular is an interesting issue to address using an integrated planned behavior model because the outcome of behavioral intention is very direct. The results from this study can also have an impact on public health policy and intervention; knowing how individuals use social media and its potential effect on their attitudes and intentions toward getting a vaccine can help public health policy-makers in designing campaigns to reach particular populations.Our results also showed that PBC moderated the relationship between attitudes and intention to use social media web sites to learn about HPV. In this context, perceived control refers to one's perceived ability to seek out and make use of materials about HPV found through social media web sites. Perceived control again emerged as a significant factor, which speaks to the power of social media, and that we can further utilize it as a platform to target in HPV research.


Anal cancer has become one of the most common non-AIDS-defined tumors among Human Immunodeficiency Virus-positive (HIV+) individuals, and a rise in its incidence among HIV+ Men who have Sex with Men (MSM) has been shown, despite the introduction of Highly Active Anti-Retroviral Therapy (HAART). Human Papillomavirus (HPV) infections are highly prevalent among HIV+ MSM and recent studies have shown high rates of HPV-associated anal intraepithelial neoplasia (AIN) and anal cancer among this population.In the present study we determined the prevalence and nature of HPV co-infections in the anal canal of 324 HIV+ MSM attending a high specialty medical center in Mexico City, DNA extraction and amplification with generic primers for HPV was performed, followed by detection of specific types and co-infections with INNO-Lipa, and identification of variants by amplification and sequencing of the E6 and LCR region of HPV 16.We found a very high prevalence of HPV infections among this cohort (86%), with more than one fourth of them (28%) positive for type 16. Among HPV16-positive patients, European variants were the most prevalent, followed by Asian-American ones. Among these individuals (HPV-16+), we identified co-infections with other 21 HPV types namely; 11, 51, 52, 6, 66, 68, 74, 18, 45, 35, 26, 44, 70, 53, 54, 82, 31, 33, 56, 58, 59.HIV+ MSM show a very high rate of HPV infections in the anal canal and those with type 16 exhibited a multiplicity of associated types. This study emphasizes the need for an early detection of HPV infections among HIV+ MSM in order to establish its utility to prevent anal neoplasia and cancer.The online version of this article (doi:10.1186/s12879-014-0671-4) contains supplementary material, which is available to authorized users. HPV are well known for their association with cervical cancer , and havInfections with HPV represent the most common sexually transmitted disease worldwide. HPV is a double-stranded DNA virus, and 160 different types of HPV officially described have been found at mucosal or cutaneous sites, each with a specific tissue tropism. At least 30 of them have been identified with high predilection for the ano-genital tract. Specific types, such as 6 and 11, are classified as low-risk (LR) types because they have been found to be associated only with benign lesions. In contrast, high-risk (HR) types, including most notably 16 and 18, have been found to be associated with both low- and high-grade anal squamous intraepithelial lesions (ASIL) as well as the majority of cervical and anal cancers ,15]..15].Risk factors for the presence of anal HPV include the presence of anal warts and a history of receptive anal intercourse, HIV infection, and a low CD4 cell count . In a SpIn a recent study in immunocompetent heterosexual men, the incidence of overall ano-genital HPV infections was 24.8% .condyloma to squamous intraepithelial lesions (SILs) and cancer.The anal and cervical epithelia possess similar embryonic origins. Histologically, columnar epithelium with a transition zone (with increased metaplastic activity) and a more differentiated squamous epithelium are observed. The anal and cervical epithelia are infected by the same types of HPV, producing similar manifestations that range from The fact that multiple concurrent infections with HPV constitute an associated morbidity among patients infected with HIV has only recently been recognized .In Mexico, there have been few reports describing the prevalence of anal HPV among HIV+ MSM. In 2002, we studied a group of 31 HIV+ MSM from Mexico City and detected HPV in the anal canal of 74.2% of the cases; 67.7% were positive for HR HPV types (hcII test B: 16/18/31/33/35/39/45/51/52/56/58/59/68), and 64.5% were positive for LR HPV types (hcII test A: 6/11/42/43/44) .In this study, we determined the prevalence of HPV types infecting the anal canal of HIV+ MSM and characterized the type 16 variants. In addition, we characterized the HPV types associated with HPV type 16 in the anal canals of these patients.We analyzed 324 anal exudates from HIV+ MSM patients attending the HIV Clinic at the Instituto Nacional de Ciencias Médicas y Nutrición “Salvador Zubirán” (INCMNSZ) in Mexico City. Patients over 18 years old, who presented to care between August and December 2008, were invited to participate. Samples were obtained with a cytobrush and inserted into a tube collector containing PreservCyt. The study was approved by the Ethics Committees of INCMNSZ SSA, and the Instituto Nacional de Cancerología, SSA. Written informed consent was obtained from all of the participants.Socio-demographic, clinical and sexual behavior information was collected using a self-applied written questionnaire, with assistance of one of the researchers (NR-M) who aid participants if needed. Clinical information was verified and completed with information available in the clinic records.Extraction and purification of DNA was performed with the Genomics Wizard kit (PROMEGA). Polymerase chain reaction (PCR) was performed using the MY09/11 primers, which detect a fragment from the L1 gene. Positive samples were evaluated in a second PCR with specific primers to detect the E6 gene of HPV type 16 or a fragment form the LCR of HPV type 18. Negative samples underwent a second PCR using the GP5+/6+ primers, which detect a shorter fragment from the L1 gene and those positive underwent PCR reactions to detect type 16 E6 gene or an LCR fragment form type 18. Finally, all negative samples were subjected to a final PCR to identify a fragment from the β-globin gene to rule out problems of DNA quality or integrity. HPV type 16+ samples were subjected to a PCR to identify variants within E6 and the long control region (LCR) with specific primers. The PCR products were sequenced using the Big Dye terminator kit and an AB Applied Biosystems Prism 3100. For the identification of the other viral types present in the samples, we used the INNO-LiPA HPV Genotyping Extra kit (INNOGENETICS), which detects 28 different HR types of HPV  as well as a number of low-risk HPV genotypes  and the additional types 69, 71, and 74.The statistical analyzes were performed by using the Kruskall-wallis test for continuous variables and chi-square test and Fisher-exact test were done to compare proportions of categorical variables.A total of 324 MSM patients attending the HIV/AIDS Clinic at the INCMNSZ between August and December 2008 were invited and agreed to participate in this study. The majority was young adults  years old, educated and economically active .The mean duration of HIV infection since diagnosis was 83 (SD = 66.4) months. Approximately 58.4% of the participants had received a diagnosis of AIDS at some point during the course of their HIV disease. Three hundred two (92.4%) of 324 patients were being treated with HAART; 85.1% of the patients exhibited a T lymphocyte CD4 count above 200 cells/μl (mean = 442 cells/ ml), and 75% exhibited <400 copies/ml of HIV-1 RNA. A significant association was found between presence of HPV and age. HPV- patients were older than those that were HPV+ . Of the HPV+ samples, 27.5% were positive for type 16 (77/279), 8.6% for type 18 (24/279), 36% for both types (101/279) and 64% for other HPV types (178/279). Finally, only 45 samples were found to be HPV- (13.6%)  were the European variants (E), followed by Asian American (AA) variants 22.5%) and African (Af) variants (2.5%). Within the European variants, we identified 7 different subclasses: E-P in 11 samples, E-m in 2 samples, E-G131G in 2 samples, E-A176T in one sample, E-A176G in 6 samples, E-A178T in 3 samples, and E-C188G in 5 samples. Concerning the Asian American variants, we identified 2 subclasses: AAa in 6 samples and AAc in 3 samples. Finally, an Af variant was identified in one sample. All of these results are summarized in Figure .5% and AIn addition, we analyzed which other types of HPV were present in this sub-population of 39 samples of HPV type 16+ individuals. The most frequent co-infecting HPV genotypes were 6, 11, 44 and 70 among the low-risk types; 16, 18, 52, 26, 31, 33, 35, 39, 45, 51, 52, 53, 56, 58, and 59 among the high-risk types; and 66 (probable high risk), 69/71 and 74, which are currently considered indeterminate risk (see Figure The distribution of the number of different HPV types in this sub-population is shown in Figure We performed a statistical analysis to compare clinical variables among HPV type 16/18+ and HPV- patients and found that age, viral suppression and time since diagnosis were significantly different among them. HPV- patients were older, have more HIV viral suppression and more time since diagnosis than HPV16/18+ patients (see Table Further studies comparing the prevalence of HPV in the oral cavity among these patients will be performed with a follow-up that could address the prevalence of HPV and anal lesions among this cohort of HIV+ MSM.HPV has been extensively studied for its role in cervical cancer development, but its association with anal cancer is less well defined. This study was conducted among HIV+ MSM attending a specialty medical center in Mexico City. We observed a high prevalence of HPV infections in the anal region, confirming previous reports ,18]. HR. HR18]. The high prevalence of anal HPV, particularly type 16 could considerably increase the possibility of developing anal cancer among this population. Our results suggest that the early detection and treatment of lesions in the anal epithelium of these individuals may prevent anal cancer, one of the few non–AIDS-defining malignancies. Priority should be given to the identification and treatment of anal lesions in MSM with HIV/AIDS .In Mexico, few data on this type of cancer, and even fewer with respect to the HIV+ population, have been obtained. Here, we describe the prevalence of different HPV types co-infecting individuals with HPV type 16, and we identify the type 16 variants in the anal canal of a population of HIV+ MSM.


Despite the fact that the implication of human papillomavirus (HPV) in the carcinogenesis and prognosis of cervical cancer is well established, the impact of a co-infection with high risk HPV (HR-HPV) and Epstein-Barr virus (EBV) is still not fully understood.Fifty eight randomly selected cases of squamous cell carcinomas (SCC) of the uterine cervix, 14 normal cervices specimens, 21 CIN-2/3 and 16 CIN-1 cases were examined for EBV and HPV infections. Detection of HR-HPV specific sequences was carried out by PCR amplification using consensus primers of Manos and by Digene Hybrid Capture. The presence of EBV was revealed by amplifying a 660 bp specific EBV sequence of BALF1. mRNA expression of LMP-1 in one hand and protein levels of BARF-1, LMP-1 and EBNA-1 in the other hand were assessed by RT-PCR and immunoblotting and/or immunohischemistry respectively.HR-HPV infection was found in patients with SCC (88%), low-grade (75%) and high grade (95%) lesions compared to only 14% of normal cervix cases. However, 69%, 12.5%, 38.1%, and 14% of SCC, CIN-1, CIN-2/3 and normal cervix tissues, respectively, were EBV infected. The highest co-infection (HR-HPV and EBV) was found in squamous cell carcinoma cases (67%). The latter cases showed 27% and 29% expression of EBV BARF-1 and LMP-1 oncogenes respectively.The high rate of HR-HPV and EBV co-infection in SCC suggests that EBV infection is incriminated in cervical cancer progression. This could be taken into account as bad prognosis in this type of cancer. However, the mode of action in dual infection in cervical oncogenesis needs further investigation. Cervical cancer is the second most prevalent cancer among the Algerian women. The association between human papilomavirus (HPV) and cervical neoplasia is well documented . High riThe long period of time (years) it takes for the development of cervical cancer after HPV infection suggests the involvement of other etiologies (such as viruses or cell compounds) in malignancy process. The synergistic effect of carcinogenic factors such as two or more viruses interacting at different stages of tumor development has been reported -4. EpsteBARF1 is one of the EBV-encoded proteins secreted in the serum of NPC patients  and exprTseng et al.  reportedAs it is well known EBV can transform cells bearing the EBV/C3d receptor making them receptive to other oncogenic stimuli . These rWe looked, in this study, for the presence of both EBV and HPV DNA sequences in Algerian patients with SCC and cervical lesions. We examined the presence of EBV infection and the EBV-HPV co-infection. The presence of EBV in cervical cancer tissues suggests its possible involvement in the cervical cancer progression. Initially, PCR amplification was used to identify the co-infection. This was followed by an investigation on EBV oncogenes  expression using immunoblotting and immunohistochemistry. This expression would reflect the transformation mechanism of cervical cells.Since EBV could play an important role in Nasopharyngeal carcinoma and Burkitt’s lymphoma highly frequent in Algeria, Our hypothesis was a possible co-infection by HPV and EBV in Algerian SCC and cervical lesions.Fifty eight biopsies of SCC from Algerian women were analyzed to assess the presence of low and high-risk HPV strains. PCR and Hybrid Capture 2 (HC2) tests revealed that out the 58 studied samples 51 (88%) were positive to HR-HPV strains and 7 (12%) were HPV infection free. Among these HPV cases, 40 biopsies were exclusively infected by high-risk HPV strains and 11 were co-infected with high- and low-risk HPV  was confirmed by Southern blot hybridization using the random primer kit with Using PCR and HC2, 21 CIN-2/3 and 16 CIN-1 lesions and 14 normal tissue samples were investigated for HPV genome. The two methods showed a good correlation. 95% (20/21) CIN-2/3 cases were infected by HR-HPV compared to 40% (8/21) were co-infected with EBV. Among the 16 CIN-1 cases, HR-HPV was present in 75% (12/16) with 12.5% (2/16) of co-infections. The remaining twenty three EBV free cases (CIN-1 and CIN-2/3) were infected with either high or/and low risk HPV strains. Among the fourteen normal cervix samples, only two were HR-HPV positive and only one was co-infected  and protein (BARF-1) expression of EBV oncogenes was assessed in only 23 out of 58 samples. However, all the three proteins  were immunohistochemically assessed in 45 out 58 of SCC biopsies  of cervical carcinoma among the Algerian women involved in this study. The presence of EBV was found in 69% of cervical cancer biopsies, suggesting its possible association with the development of cervical cancer. This is in agreement with previous reports ,23,24. HUsing immunohistochemistry technique, to our knowledge, we are the first to detect EBV antigens in the cervix tissue. The difference in our results between the PCR method and protein detection has three possible explanations; (i) DNA amplification using PCR is a more sensitive technique than the detection of antigens using Immunohistochemistry or immunoblotting, (ii) EBV genome is present but its genes are not abundantly expressed in EBV-infected cells and (iii) a contamination by EBV-positive B lymphocytes infiltrating the connective tissue or EBV-positive normal cervical epithelium adjacent to the lesions. PCR results on their own merely indicate the presence of EBV in the cervix tissue but not necessarily in the epithelial cells.Our data suggest that co-infection with EBV and HR-HPV may be of cervical significance in the ethiopathogenesis of uterine cervical cancer. However, few cells in cervical tissue were infected by EBV and harbor EBV LMP-1 protein Figure . The expEBV DNA has been shown in the exfoliating cells . The virIn this study, EBV latent genes were expressed in some squamous epithelia. The cervix might be a site for chronic EBV shedding in a similar manner to the nasopharynx. It is widely accepted that EBV infects B lymphocytes through CD-21 (EBV/C3d) receptor  which arPreliminary presented results of EBV and HR-HPV co-infection in Irish, North American, Thailand and Japanese SCC cases were recently reported ,3. In ouOne hundred and nine cervix specimens taken from female patients attending a gynecological department in Algiers (Algeria) were randomly selected and enrolled for EBV and HPV-DNA detection and genotyping Figure . We obtaTissues were cut using sterile blades in a lysis buffer  and treated with RNase A (10 mg/ml) for two hours at 37°C. DNA was obtained after proteinase K digestion, by phenol-chloroform extraction, ethanol precipitation and solubilized in 20 μl TE buffer . DNA quantities and purity were assessed by spectroscopy.The HC2, a standardized US FDA-approved test has been employed to detect one or more of 13 carcinogenic HPV types . This enzyme-linked immunosorbent assay is based on a sandwich hybridization followed by a non-radioactive alkaline phosphatase reaction following the manufacturer’s instructions.Specimens were subjected to PCR with general HPV primers using conventional L1 consensus primers, MY11 (GCMCAGGGWCATAAYAATGG) and MY09 (CGTCCMARRGGAWACTGATC). The assays were conducted according to the manufacturer’s protocol .32P-labeled-BamH1-A probe prepared with a random primer DNA-labeling kit (Stratagene) [6 cpm/ml of the labeled BALF1 probe.As previously published by our group , EBV PCRatagene) . The hybatagene)  with 106RNA was extracted from control and specimens with Trizol reagent (Invitrogen) according to the manufacturer’s instruction. Total RNA was treated with DNase . Reverse transcriptase PCR (RT-PCR) was carried out as previously described . LMP-1 wBiopsy tissues were cut using sterile blades in lysis buffer, RIPA , and treated with antiprotease . The lysCervix tissues were formalin fixed, dehydrated in alcohol and embedded in paraffin. Immunostaining was performed according to the streptavidin-biotin peroxidase complex method, using monoclonal antibodies against HPV, LMP-1 and EBNA-1. Briefly, sections were cut to a thickness of 4 μm, mounted on silane-treated slides (Superfrost), and dried 1 hour at 60°C. All sections were then deparaffinized in xylene, rehydrated through alcohol, and washed in phosphate-buffered saline. This buffer was used for all subsequent washes. Sections for LMP-1, EBNA-1 and HPV detection were heated in a microwave oven twice for 5 min in citrate buffer (pH 6.0). Mouse monoclonal antibodies (at a dilution of 1:500) anti-LMP-1 , and anti-EBNA-1  were used respectively as the primary antibody and incubated overnight at room temperature followed by a conventional streptavidin peroxidase method . Signals were developed with 3, 30-diaminobenzidine for 5 minutes and counter-stained with hematoxylin. The results were scored for the positive signals in tissue cells. The same samples were sectioned at 4 μm thickness and routine hematoxylin- and eosine-stained for histologic examination.HPV: Human papillomavirus; EBV: Epstein-Barr virus; SCC: Squamous-cell carcinoma; CIN: Cervical intraepithelial neoplasia.The authors declare that they have no competing interests.AK for HPV classification and HPV detection, RT-PCR, PCR, Immunohistochemistry, Southern blotting, immunoblotting, analysis of results and redaction. NS for HPV classification and HPV detection. AB for preparation of cell scrapings and biopsies of the cervix. KH for analysis of results. AG for preparation of cell scrapings and biopsies of the cervix. TO for analysis of results and for redaction. AB for analysis of results and for redaction. All authors read and approved the final manuscript.


The most common human papillomavirus (HPV) genotypes isolated from cervical cancer in select African countries are HPV-16, HPV-18, HPV-35, and HPV-45, but the most common genotypes in Zambia are unknown. The overall objective of this study was to assess the potential impact of current HPV vaccines in preventing cervical cancer in Zambia, by determining the combined prevalence of HPV-16 and/or HPV-18 in invasive cervical cancer (ICC) and high-grade pre-cancer [cervical intraepithelial neoplasia 2 or 3 (CIN2/3)] cases.We compared DNA extraction techniques to determine which assay performs well in the Zambian context, where unbuffered formalin is used to fix specimens. We then tested specimens with the Abbott RealTime High-Risk HPV test to estimate the prevalence of HPV-16/18 in formalin-fixed, paraffin-embedded ICC and CIN2/3 specimens. DNA extraction using heat (without xylene) was more successful than xylene-based extraction. Over 80% of specimens tested using heat extraction and the Abbott RealTime HPV test were positive for HPV. HPV-16 and/or HPV-18 were identified in 65/93 (69.9%) ICC specimens positive for HPV and in 38/65 (58.5%) CIN2/3 specimens positive for HPV.To our knowledge this is the first report to identify HPV genotypes in cervical cancers in Zambia. A combined HPV-16/18 prevalence of 69.9% in ICC specimens suggests that current vaccines will be highly protective against cervical cancer in Zambia. Cervical cancer is the second most common cancer in women worldwide  and is tStudies of pre-cancer specimens in South Africa and Zambia reported a wide diversity of HPV genotypes ,10, geneTo assess the impact that current vaccines can have in preventing cervical cancer in Zambia, we first compared DNA extraction techniques to determine which performed better in the Zambian context. We then estimated the combined prevalence of HPV-16 and/or HPV-18 in formalin-fixed, paraffin-embedded (FFPE) ICC and cervical intraepithelial neoplasia 2 or 3 (CIN 2/3) specimens from UTH. Our main outcomes were the percentages of specimens positive for HPV-16 and/or HPV-18.UTH and the adjacent Cancer Diseases Hospital in Lusaka are the primary centers for cancer diagnosis and treatment in Zambia. FFPE cervical specimens obtained during routine clinical care from 2007–2012 and stored at the UTH Pathology Department were used for this study. Unbuffered formalin is used for routine specimens at UTH, which likely leads to more degraded DNA than if buffered formalin were used . SpecimeWe compared two extraction techniques: heat-dependent and xylene-dependent. The heat extraction technique was adapted from Steinau et al. . To eachThe xylene extraction technique was adapted from Kocjan et al. . To eachNucleic acid concentrations were determined using a Nanodrop ND-1000 spectrophotometer , and DNA extracts were frozen at −80°C until further analysis.β-globin gene, to monitor DNA extraction and amplification. A cycle threshold (Ct) value of <35 was considered positive for each of the RealTime channels.Extracted DNA was tested using the Abbott RealTime High Risk HPV assay , which uses real-time PCR to amplify and detect 14 high-risk genotypes [www.openepi.com). p < 0.05 was considered significant.Data were entered into Microsoft Excel™ , cleaned with SAS™ version 9.2 , and analyzed using SAS™ and Open Epi  were extracted using the two techniques. The mean nucleic acid concentration (standard deviation) following heat extraction was 117.4 ng/μl (85.4 ng/μl), while that following xylene extraction was 38.2 ng/μl (35.9 ng/μl) .The 27 FFPE specimens were tested with the RealTime assay. RealTime successfully identified HPV in the vast majority of specimens: one or more HPV was identified in 23/27 with heat extraction and 21/27 with xylene extraction  and 75 CIN 2/3. Of 114 ICC specimens tested, 88% were valid results  was lower than that in ICC specimens, but the difference was not significant . This is consistent with previous studies in Zambia and South Africa that reported a wide diversity of HPV types in pre-cancer samples ,10. The Strengths of this study include the successful development of assays to identify HPV from FFPE specimens in the Zambian context and the ability to estimate the impact of HPV vaccines on both pre-cancer and cancer. Weaknesses include the relatively small number of specimens sampled from a single referral center. However, because UTH is the primary center for cancer diagnosis and treatment in Zambia, we believe that our estimate of the prevalence of HPV-16/18 in cervical cancers is the best available for the country to date.With an estimated 69.9% of ICC specimens at UTH containing HPV-16 and/or HPV-18, current HPV vaccines can have a substantial preventive impact on cervical cancer in Zambia. These data provide a rationale to advocate for delivery of HPV vaccines throughout Zambia. In addition, the methods described here can be used to examine the role of HPV in other cancers in Zambia, such as head and neck cancers , and the


The identification of suited early detection tests is one among the multiple requirements to reduce cervical cancer incidence in developing countries.INK4a/Ki-67 dual-stain cytology in a screening population in Thika district, Kenya and compared it to high-risk human papillomavirus (HR-HPV) DNA testing and visual inspection by acetic acid (VIA) and Lugol’s iodine (VILI).We evaluated p16INK4a/Ki-67 cytology. Of 22 women that showed up for colposcopy and biopsy, 6 women were diagnosed with CIN3 and two with CIN2. All women with CIN2/3 were negative in VIA/VILI screening and positive by HR-HPV DNA testing. But HPV was also positive in 91.7 % (11/12) of women with normal histology. p16INK4a/Ki-67 cytology was positive in all 6 women with CIN3, in one of the two CIN2 and in only 8.3 % (1/12) of women with normal histology.Valid results for all tests could be obtained in 477 women. 20.9 % (100/477) were tested positive for HR-HPV DNA, 3.1 % (15/477) had positive VIA/VILI and 8.2 % (39/477) positive p16INK4a/Ki-67 cytology is an interesting test for further studies in developing countries, since our findings point to a lower fraction of false positive test results using p16INK4a/Ki-67 cytology compared to HPV DNA testing in a Kenyan screening population. VIA/VILI missed all histology-proven CIN2/3.p16 Cancer of the uterine cervix is the third most common cancer in women around the world and still the leading cancer in women in Sub Sahara Africa . Of the Implementation of nationwide screening for cervical cancer has been successful in reducing the incidence and mortality rates of cervical cancer in many countries . A furthCervical cancer is caused by long lasting infections of the cervical squamous cell epithelium with human papillomaviruses (HPV). The infection is usually acquired during adolescence when women become sexually active and infection prevalence my reach over 50 % [Currently the primary screening tests for cervical cancer in most countries with implemented screening programs is Pap cytology, where a smear is taken from the cervix, stained with a dye cocktail and assessed under a light microscope for neoplastic alterations. Pap screening requires advanced infrastructures and experience as it is characterized by multiple visits for diagnosis and treatment, because it has a low single-test sensitivity of between 55 to 80 % , 7 and gDifferent programs investigate and assess alternative approaches, particularly the use of visual screening methods, such as visual inspection with acetic acid (VIA), for pre-cancer and cancer detection and the use of cryotherapy as a pre-cancer treatment method. This is optimally achieved in a single visit and can be carried out also by competent non-physicians, including nurses and midwives. Because the diagnostic accuracy of VIA is largely heterogeneous, in some setting only reaching a sensitivity of ~40 %  and therDetecting the viral DNA is a highly sensitive test for cervical cancer early detection, detecting more premalignant alterations than Pap cytology, used in addition to Pap cytology in certain settings and currently introduced as an alternative for primary screening in many industrialized countries . HoweverINK4a, which becomes overexpressed in response to viral oncogene E7 expression [INK4a as a specific biomarker for cells with transforming HPV infections [INK4a but retain the capacity to proliferate and are thus double-positive for p16INK4a and the proliferation marker Ki-67, while senescent cells express p16INK4a but are Ki-67 negative [INK4a and the proliferation marker Ki-67  is designed for application on cytologic smears taken from the uterine cervix with a brush, spread on a glass slide, stained for expression of the two markers and assessed under a light microscope. The test demonstrated high sensitivity comparable to HPV DNA testing but superior specificity compared to HPV DNA testing in a European screening population [There are different biomarkers that have been identified and suggested to improve diagnosis of cervical cancer and its precancerous lesions. One promising marker is the cyclin dependent kinase inhibitor p16pression . A numbefections . HPV-trapulation , 17.INK4a/Ki-67 cytology in a screening population of Kenyan women and compare it to VIA/VILI and HPV DNA testing. Additionally the study was designed to evaluate the diagnostic performance of the tests to detect high grade CIN.The objective of the present study was to study overall positivity rates of p16INK4a/Ki-67 cytology (low cell number) and/or HPV DNA (no cell pellet), 477 samples remained for evaluation. Mean age of these 477 study participants was 35.6 years, ranging between 18 and 74 years (standard deviation 9.9 years). A detailed socio-demographic characterization of the study population is given in reference [A total of 498 women met the eligibility criteria. After exclusion of women with incomplete personal information (no age documented), no VIA/VILI and/or invalid laboratory results in either Pap cytology (low cell number), p16INK4a/Ki-67 cytology was positive in 8.2 % (39/477) of the women, with highest rate of positivity in women of age 36 to 40 years  and no positives in women younger than 21 years  were tested positive for HR-HPV. Highest HPV prevalence was found with 35.7 % (5/14) among women younger than 21 years (18–20 years) and prevalence decreased with older age groups with the lowest prevalence  in those older than 55 years  of the women with the highest prevalence in the age group 46 to 50 years  and no positives in women younger than 21 or older than 55 years , 2.9 % 14/477) had LSIL, 0.2 % (1/477) AGUS, 5.5 % (26/477) ASCUS and 2.1 % (10/477) had HSIL diagnosed in Pap cytology  and 0.030 (p16INK4a/Ki-67), respectively; overall positive and negative agreement 77.1 % (HPV) and 89.5 % (p16INK4a/Ki-67)). Of the 15 VIA/VILI positive women, only 3 were tested positive for HPV DNA and 2 positive for p16INK4a/Ki-67.Agreements between VIA/VILI, HPV results and p16INK4a/Ki-67 cytology are shown in Table INK4a/Ki-67 results  with total positive and negative agreement of 85.5 %. The majority of samples positive for p16INK4a/Ki-67 were also positive for HPV DNA (35/39), however more than half of HPV DNA positive samples were p16INK4a/Ki-67 negative (65/100).A moderate agreement was observed between HPV and p16INK4a/Ki-67 was positive. Women with only negative test results were considered as disease negative. Of the 22 women which appeared for colposcopy, 4 had no visible lesion and were thus not biopsied, 8 had normal histology in the punch biopsies, 2 women had CIN1, 2 had CIN2 and 6 women were diagnosed with CIN3. All biopsies were evaluated independently from H&E evaluation for p16INK4a expression and all CIN2 and CIN3 lesions showed positive diffuse p16INK4a expression, while normal and CIN1 cases were p16INK4a-negative, thus supporting the diagnosis of high-grade dysplasia in 8 women .The histopathology of a biopsy is considered as the gold-standard for the diagnosis of cervical dysplasia. Women were invited to colposcopy and biopsy if at least one of the tests VIA/VILI, Pap cytology, HPV DNA, and/or p16INK4a/Ki-67 cytology was positive in all 6 CIN3 lesions, in one of the two CIN2 lesions and in only 8.3 % (1/12) of women with normal histology in the punch biopsy  of women with normal histology. p16INK4a/Ki-67 results in relation to Pap cytology were assessed. VIA/VILI was positive in only 30 % (3/10) of women with HSIL cytology. HPV DNA testing was positive in 80 % (8/10) of women with HSIL cytology, but also positive in 17.8 % (76/426) of women with negative Pap cytology. p16INK4a/Ki-67 dual stain cytology was positive in 70 % (7/10) women with HSIL cytology and only 4.2 % (18/426) women with normal cytology  is used in some setting with variable sensitivity and specificity . HPV DNA disease , 20.INK4a/Ki-67 cytology yielded a lower overall rate of positive results  and most importantly no positives in women younger than 21 years. This indicates that the test does not pick up the many transient and non-transforming HPV infections in this age group that most likely do not need to be treated. Furthermore p16INK4a/Ki-67 cytology was positive in all 6 women with CIN3 lesions, in one of the two CIN2 lesions and in only 8.3 % (1/12) of women with normal histology in the punch biopsy.HPV DNA testing yielded the highest rate of overall positive results  in our study with highest HPV prevalence in women younger than 21 years. Among women with available colposcopy and biopsy HPV DNA testing detected all women with histologically confirmed high grade lesions (n = 8), but was also positive in 91.7 % (11/12) of women with normal histology. p16INK4a/Ki-67 cytology staining was performed in an experienced laboratory in Heidelberg, Germany. However, the availability as ready-to-use reagents and little technical equipment which is required might give the opportunity to implement it in an environment with less advanced infrastructure. We used the PreservCyt ThinPrep system for cytology preparations in the study as this allowed to use one cervical swab for all tests. However, p16INK4a/Ki-67 cytology staining can also be performed on conventional cytology smears. There is no published data on direct comparison of p16INK4a/Ki-67 cytology using both cytologic methods  for the same woman; there was however no significant difference in p16INK4a/Ki-67 cytology performance between women screened with conventional smears compared to women screened with liquid-based cytology demonstrated in a large European primary screening study [In our study p16ng study .INK4a/Ki67, particularly in combination with the ThinPrep system cannot be regarded as affordable for low-resource settings. On the long run however cost-effectiveness will largely depend on incentives of ministries, industry and finally the performance of the used tests. In this regard the present study may add an important data set for upcoming initiatives and cost analyses.In the present study we solely evaluated the diagnostic performance of the tests; we however would like to point out that there is an urgent need now to complement diagnostic studies by well-designed cost-effectiveness analyses. Presently p16VIA/VILI, which is currently used in some regions in developing countries, detected none of the women with histologically proven CIN2+, thus women would have been missed by the test. VIA/VILI has the advantage that it is cheap, requires no advanced equipment and can be used as a point-of-care test allowing for screening and cryotherapy if necessary on the same day. However its diagnostic performance can be poor, as indicated by our result.INK4a/Ki-67 testing yielded a similar detection rate of CIN2+ and a substantially lower rate of positive tests in women with negative histology compared to HPV DNA. Moreover, the overall lower test positivity rate particularly in young women of p16INK4a/Ki-67 compared to HPV DNA testing suggests that only little transient infections are picked up and warrants further evaluation of the test in countries with high HPV prevalence. p16INK4a/Ki-67 cytology can be performed within 5 hours manually and does not necessarily require technical equipment except a heating bath and a microscope, thus potentially being performed at a health facility within one day under standardized and controlled conditions. Assessing the slides does not require morphological interpretation, positive are considered all slides with one or more cells expressing both markers, p16INK4a and Ki-67. This can be learned in a brief training session even by people without prior cytologic or pathologic training [Although the sample size is limited by the low number of women which followed the invitation to colposcopy and biopsy, it is a promising finding that p16training . For furtraining .INK4a/Ki-67 dual-stain cytology was evaluated in a cross-sectional study in women living in Thika district, Kenya. Liquid-based cytology (LBC) samples were taken and sent to Heidelberg, Germany, where HR-HPV DNA testing and p16INK4a/Ki-67 immunostaining was performed. Additionally, Pap staining was performed from the LBC sample in Heidelberg. According to the study protocol, women with a positive VIA/VILI and/or HR-HPV and/or p16INK4a/Ki-67 test, and/or Pap cytology result were invited for colposcopy/biopsy to obtain a histopathologic diagnosis followed by treatment in cases were indicated. With the limitation that a sole positive HR-HPV DNA test only resulted in immediate colposcopy in women older than 30 years.The rate of positive test results and diagnostic performance of VIA/VILI, HR-HPV DNA detection and p16Ethical approval was obtained from the National Ethical Review Committee at the Kenya Medical Research Institute and women who agreed to participate signed an informed consent form.Women were recruited for the study in Thika District, Kenya in February 2010. The population is both rural and urban. Women who live in this region were invited to participate in the study through posters placed at markets places, churches, and health centers. Women were eligible for the study if they were (a) self-identified as residing in the region, (b) were ages 18 and above, (c) had an intact uterus, (d) did not report the use of vaginal medication for the previous two days, (e) did not report treatment for cervical disease for the previous 6 months, and (f) were not pregnant at the time of the study.INK4a/Ki-67 cytology, and HR-HPV DNA detection were performed from the same vial at the Department of Applied Tumor Biology, Heidelberg, Germany. VIA/VILI was performed by the nurses after the cytology sample was taken and documented in a standard form.Cervical cells were collected by female nurses using the liquid-based cytology ThinPrep® Pap test Kit  according to manufacturer’s instruction and stored in the PreservCyt solution vial  at ambient temperature. All tests, Pap cytology, p16ThinPrep® slides were stained according to routine Pap staining laboratory protocols. All Pap cytology slides were read blinded to all other results at the Institute of Pathology, A2, Mannheim, Germany by an experienced cytotechnologist and gyneco-pathologist. The result was reported according to the Bethesda system.INK4a and Ki-67, respectively using the CINtec PLUS kit  according to the manufacturer’s instructions. The cervical cancer cell line C4-1 was used as positive control. The dual-staining results in brown visualization of p16INK4a protein and red visualization of Ki-67 protein. Samples were considered as p16INK4a/Ki-67 dual-stain positive when at least one cell was visible on the slide under a light microscope expressing both proteins, thus if at least one cell was found with a red nucleus (Ki-67) surrounded by brown cytoplasm (p16INK4a).A second ThinPrep® slide was prepared from all samples and stained manually with a mix of two monoclonal antibodies against p16After processing for cytology, four mls of residual PreservCyt® solution was used for HR-HPV detection. The HR-HPV detection was carried out using the Hybrid capture 2® (hc2) test  according to the manufacturer’s instructions. A positive hc2 result was defined as RLU/Co ≥ 1.INK4a  and slides with a diffuse p16INK4a expression beginning in the basal and parabasal cell layers were considered as p16INK4a histology positive.Colposcopy was performed at Thika District Hospital by an experienced gynecologist. Four to five punch biopsies were taken from the cervix of women with visible lesions. The tissue was placed in formalin and embedded in paraffin for hematoxylin & eosin staining. The slides were assessed by an experienced pathologist at Institute of Pathology, A2, Mannheim, Germany. A second section from all biopsies was stained immunohistochemically for p16Results were computed as number of positive and negative test results in the entire study cohort, in different age groups and separated for cyologic and histologic diagnosis. Inter-assay agreements were assessed using Cohen's kappa statistics.INK4a/Ki-67 and Pap cytology test were considered as disease negative. Women with a positive VIA/VILI and/or HR-HPV and/or p16INK4a/Ki-67 test, and/or Pap cytology result were invited for colposcopy/biopsy to obtain a histopathologic diagnosis . Women who showed up for colposcopy but had a normal appearing cervix were not biopsied and were considered as disease negative. Since most women with positive screening test results did not show up for colposcopy as per protocol, a gold standard disease endpoint for the evaluation of the diagnostic performance of the tests was only available for a subset of study participants. Prevalence of positive test results and agreements of the different tests was assessed in the entire study population.Women with negative VIA/VILI, HPV DNA, p16


Cervical cytology has continually evolved. Nowadays, the category of atypical glandular cells (AGC) is less frequent than atypical squamous cells (ASC), associating poorly-reproducible inter-observer interpretation. Cellular characters sometimes surpass benign reparatory processes or associate high-grade squamous precursor lesions, glandular neoplasia, including cervical adenocarcinoma, endometrial neoplasm and even extrauterine adenocarcinomas. Therefore, AGC needs special attention and aggressive diagnostic procedures.Nevertheless, the most common viral infection of the reproductive tract, the human-papillomavirus (HPV) infection, shouldn’t be underestimated, as about 30% of AGC cases are HPV-positive. The presence of HPV in AGC patients identifies a group at higher-risk for developing cervical neoplasia. Studies show that 70% of AGC-HPV-negative patients have no evidence of cervical cancer, and 76% of AGC-HPV-positive results may present glandular or squamous neoplasia.This is a retrospective study to determine the value of the AGC Pap test category in detecting endocervical and endometrial pathology and the potential pitfalls of false positive diagnosis. It was performed in the University Emergency Hospital of Bucharest during March/2009 – December/2013. The total number of presentations for cervical pathology was 14,219. The diagnosis of AGC was found in 58 cases (0.41%).The age range was 24 to 59y (median age 41).In 46 cases (79%) AGC was the only cytologic anomaly found. In 12 cases the AGC cytology was associated with squamous lesion: ASC-US (6 cases), LSIL (1 case), ASC-H (1 case) and HSIL (4 cases).Most colposcopies (58%) were negative for lesions, some were non-satisfactory (12%), 5 (8.6%) revealed polyps, 12 (20%) had squamous lesions; there was no colposcopic diagnosis of adenocarcinoma.Among the 58 cases of AGC 17 (29.3%) were HPV-positive.Follow-up histology in 42 cases revealed: cervical or endometrial hyperplasia, metaplasia or polyps, endocervical or endometrial adenocarcinoma, cervical squamous carcinoma, CIN 1/2/3, endocervical leiomyoma, herpetic infection, inflammation, endometrial atrophy, endometriosic ovarian cyst. There were 12 cases with negative pathology findings and 16 cases without biopsy.There is a large panel of pathology, other than glandular, or no pathology at all, responsible for AGC cytology.AGC encompasses endometrial glandular neoplasia in addition to cervical glandular neoplasia and squamous neoplasia and, less commonly, metastatic disease from more distant sites.There is an association between HPV infection and the gravity of endocervical lesions; patients who test positive should be carefully followed.There is an association between age and diagnosis. Young patients are likely to have squamous lesions while older ones are likely to have glandular neoplasia.


The purpose of this study was to assess the consequences of a national immunization program with HPV vaccine for both boys and girls in Denmark, including the prophylactic effects on all potentially vaccine preventable HPV-associated diseases in male and female.The study focussed on the quadrivalent vaccine which protects against HPV type 6, 11, 16 and 18, and the vaccine’s protection against genital warts, cervical intraepithelial neoplasia, cervical cancer, anogenital cancer  and head and neck cancer  were included in the analyses. In general, the analysis was performed in two phases. First, an agent-based transmission model that described the HPV transmission without and with HPV vaccination was applied. Second, an analysis of the incremental costs and effects was performed. The model did not include naturally-acquired immunity to HPV in the simulations.In the base case result  an ICER of 3583 €/QALY (3-dose regime) is estimated when all HPV-related diseases are taken into account. Vaccination of girls & boys vs. vaccination of girls only an ICER of 28,031 €/QALY (2-dose regime) and 41,636 €/QALY (3-dose regime) is estimated.Extension of the current HPV programme in Denmark to include boys and girls is a cost effective preventive intervention that would lead to a faster prevention of cancers, cancer precursors and genital warts in men and women. Persistent human papillomavirus (HPV) infections with HPV genotype 16 and genotype 18 are responsible for about 70% of all cervical cancer . HPV cauTwo vaccines are currently available on the market: a quadrivalent  and a bivalent vaccine (including genotypes 16 and 18). Both vaccines effectively protect against precancerous lesions in the cervix, vulva or vagina and cervical cancer; in addition, the quadrivalent prevents precancerous anal lesions, anal cancer and anogenital warts.Currently, HPV vaccination of adolescent girls is part of the national immunization programme in a number of countries -16. In tSince 2009, the national immunization programme in Denmark offers free quadrivalent human papillomavirus vaccine to all girls aged 12 years. Furthermore, in 2012 and 2013 a catch up program was implemented for all women up to 27 years old.The purpose of this study was to assess by modelling the economic consequences of a national immunization program with publicly financed quadrivalent HPV vaccine for both boys and girls aged 12 years or a for only girls aged 12 years in Denmark compared with screening program alone, including the prophylactic effects on all HPV-associated diseases.the cost-effectiveness of vaccinating 12-year-old girls in Denmark compared to no HPV vaccinationThe following scenarios were analysed in the study:the cost-effectiveness of vaccinating 12-year-old girls and boys in Denmark compared to vaccinating girls alone.andThe study focussed on the quadrivalent vaccine which protects against HPV type 6, 11, 16 and 18, and the vaccine’s protection against genital warts, cervical intraepithelial neoplasia, cervical cancer, anogenital cancer  and head and neck cancer  were included in the analyses. Protection against recurrent respiratory papillomatosis was not included in the analysis among others because no Danish study reports the costs of recurrent respiratory papillomatosis.A previously developed and published model was used ,27. Thishttp://ccl.northwestern.edu/netlogo), an agent based transmission model was developed that describes the HPV transmission dynamics before and after introduction of HPV vaccination. Second, an analysis of the incremental costs and effects was performed using Microsoft® Excel. A more comprehensive description can be found in [The analysis was performed in two phases. First, using the software NetLogo (version 4.0.2)  and cervical cancer were also simulated. No natural immunity following infection was assumed, suggesting that an individual infected by one type of HPV has the same risk of being re-infected by the same type.The acquisition of HPV infection and natural course of HPV related cancers at non-cervical sites are poorly understood. Hence, it is difficult to construct a model of HPV infection and disease in these sites that accurately captures the underlying biological processes . As a siThe model operates with several variables, some of which relate to the entire population  and some of which are agent-specific , see Table It was assumed that the current Danish cervical screening program remained unchanged implying that women aged 23-64 years are offered screening every 3-5 years. Therefore, cervical cancer screening was not modelled. A 62-year time horizon was applied implying that the first year group of 12-year-olds are followed until the age of 74 years in order to include all costs and benefits of the vaccination programme (i.e. the second year group of 12-year-olds are followed 61 years etc.).http://www.ema.europa.eu/ema). In some studies cross protection are included (e.g. [The vaccine’s possible protection against non-vaccine HPV types (i.e. cross protection) was not included in the analyses even though slight evidence suggests that some cross protection might exist . Thus, Compared to the previous publication , the modFor each scenario the incremental cost (vaccination cost minus future costs averted by vaccination) per life year gained (LYG) and the incremental cost per quality adjusted life year (QALY) gained by the HPV-vaccination was estimated. Given the age distribution for cancer deaths and that for the general population, it was possible to estimate the life-years gained (LYG) due to a lower incidence of cervical cancer, anogenital cancer and head and neck cancer. Similarly, given the modelled decrease in the specific diseases and given the QALY-weights for the general population and the specific diseases Table , the gaiA health care sector perspective was applied and included direct costs of vaccination and future averted health care sector costs of HPV-associated diseases. The applied health care costs appear from Table Future costs and effects were discounted at a rate of 3% in the base case.One-way sensitivity analyses varying one parameter, while holding other parameters at their base case value, were performed. The parameters varied appear from Table Based on a recently published study, Danish authorities have changed the quadrivalent vaccine regime from 3 doses to 2 doses . TherefoIt should be noted that this multi-way sensitivity analysis did not address all sources of uncertainty as some parameters were not included . However, these parameters were varied in the NetLogo simulations as distribution for these parameters were assumed  fairly precise, indicating that the model was well calibrated (cf. ). When vIn the base case result with a 85% vaccination rate the cost per QALY gained by female vaccination (compared to no vaccination) was € 3,581 when including all HPV-related diseases in the analysis Table . A 85% vFrom Table Inclusion of the vaccine’s protection against anogenital cancer and head and neck cancer, , in the analysis may better address the relevance of routine vaccination of boys. ICERs of vaccination of girls and boys compared to vaccinaition of girls only appear from Table In Denmark, routine vaccination of girls has been conducted since 2008. Currently some countries have expanded the HPV immunization programme to include routine vaccination of boys . TherefoThe uncertainty in the results of the cost-effectiveness analysis is summarized in the cost-effectiveness acceptability curves Figure . In DenmThis study was based on a Danish agent based model on HPV transmission and vaccination. The model was initially developed for the Danish National Board of Health . This stIn the base case result  an ICER of 3,581 €/QALY is estimated when all HPV-related diseases are taken into account. Compared to some studies these are relative low ICERs. However, the results vary with the assumptions and the results are sensitive to the choice of discount rate, the choice of time horizon, vaccine price and vaccination rate. Seen in that perspective, the range of results should be considered. However, these Danish results estimating relative low ICERs is to some extent due to the high Danish incidence and mortality of HPV related cancers . The inComparison with results from others studies analysing HPV-vaccination in other countries is not straightforward because of differences in modelling approach  and other parameters, including vaccination scenario (2 or 3 doses) and other country specific conditions. However, the results for female vaccination only lie within the same range/level as the study from Elbasha et al.  – with tOn the other hand, Kim et al. , also inNaturally, this analysis has a number of limitations. Firstly, only heterosexual transmission of HPV was simulated ignoring transmission between homosexual and heterosexual persons. Men who have sex with men (MSM) have a higher HPV disease burden  and the current HPV programme will not protect this high-risk ground.Secondly, unlike most other studies this model did not include naturally-acquired immunity to HPV in the simulations.Thirdly, the model simulates a closed society with no continuous influx of unvaccinated persons. Increased globalisation increases the risk of HPV transmission across national borders thereby lowering the impact of potential the herd protection of men.Fourth, 100% vaccine efficacy and lifelong protection was assumed. Assuming a reduced vaccine efficacy (99.8% or 93.5%) only change the results on the margin as shown in the 2010-publication . On the Fifth, it was assumed that the current Danish cervical screening program remained unchanged. Presently, the cervical screening program is being reviewed and it may in the long run be modified due to a decrease in the incidence of cervical cancer. Inclusion of a future modification of the screening program, leading to a possible reduction in the screening cost, in principle should be taken into account. However, it has not been taken into account leading to a marginal inaccurate estimation of future costs related to HPV-vaccination. Although sensitivity and scenario analyses are performed, health economic analyses using modelling is a simplified representation of real life involving several assumptions.Sixth, two different sources were used for the applied QALY weights for the general population and for the specific occurrences/illnesses Table . FurtherFinally, possible future variations in the incidence of HPV-related cancers are not incorporated in the model simulations. The overall incidence of HPV related cancers has increased over the last 30 years in Denmark and the incidence of head and neck cancers is expected to increase further in the future. An underestimation of the future incidence leads to an underestimation of the cost of head and neck cancer.Extension of the current HPV programme in Denmark to include boys and girls is a cost effective preventive intervention that would lead to a faster prevention of cancers, cancer precursors and genital warts in Denmark which is the country in the world with the highest risk of getting a cancer diagnosis .


Supplemental Digital Content is available in the text Few studies have been conducted on the relationship between metabolic syndrome (MetS) and cervical human papillomavirus (HPV) incidence and persistent infection.We performed a prospective cohort study including 8598 female employees in Hunan, China. First, the subjects were stratified into HPV-negative (N = 7282) and HPV-positive (N = 1316) subgroups, according to the results of an HPV DNA test at baseline. Second, comparisons of the risks of HPV incident and persistent infection between MetS-positive (exposed) and MetS-negative (unexposed) groups were conducted among the HPV-negative and -positive subgroups, respectively.adj = 1.21, 95% CI: 1.05, 1.41) and high-risk type HPV persistence . No single metabolic component was associated with the risk of HPV persistence.There were 976 (11.39%) subjects diagnosed with MetS and 1316 subjects diagnosed with HPV infection at baseline. The 12-month cumulative incidence of any type of HPV and high-risk type HPV were 7.28% (530/7282) and 6.26% (456/7282), respectively. Obesity was a modifier of the association between MetS and HPV incident infection. As long as obesity presented, MetS and hypertriglyceridemia were significantly associated with an increased risk of HPV incident infection (any-type or high-risk type) (adjusted risk ratios (RR) were 2.88 : 1.16, 7.19) and 3.29 , respectively). Among those infected with HPV at baseline, the 12-month type-specific persistence rates were 51.67% and 53.38% for any-type and high-risk type HPV, respectively. No interaction was found between obesity and MetS with regard to the risk of HPV persistence. After adjustment for confounding factors, MetS was still associated with increased risk of any-type HPV persistence (RRThe prevalence of MetS was 11.39% among the Hunan female occupational population. MetS was associated with an increased risk of persistent cervical HPV infection and also with an increased risk of HPV incident infection when obesity presented as well. Growing epidemiological evidence indicates that the presence of MetS would not only increase the risk of cardiovascular disease8 but also increase the risk of several different cancer diseases, such as colorectal cancer, breast cancer, lung cancer, prostate cancer, and bladder cancer.9 The latest researches suggest that MetS or MetS components are also risk factors for cervical cancer.13 One or more of the following factors may contribute to the increased risk of cervical cancer among MetS patients: increased risk of HPV incident infection; decreased possibility of HPV clearance among the infected (increased risk of HPV persistence); and altered prognosis of those with persistent HPV infection. However, it is unclear how many of these factors contribute to the increased risk of cervical cancer and exactly how they may contribute. To answer those questions, the relationship between MetS and HPV infection should be studied. To the best of our knowledge, only 2 previous studies have discussed the associations and reached inconsistent conclusions. Liu et al14 claimed that obesity status was a modifier between HPV infection and MetS: decreased HPV prevalence was only found among obese women with MetS but not among nonobese women with MetS. In contrast, Kuo and Fujise15 found no association between MetS and HPV infection. Moreover, a lack of temporality was inherent in those cross-sectional studies, and thus the associations between MetS and HPV incident and persistent infection have not been addressed. Therefore, the above-mentioned questions cannot be answered based on the existing published data. Given the inconsistent relationship between MetS and HPV infection and the paucity of prospective studies on the associations between MetS and HPV incident and persistent infection, we performed a prospective cohort study in Hunan, China to estimate the associations between MetS and HPV incident and persistent infection, and to test whether those associations were modified by obesity status.Metabolic syndrome (MetS) is defined as having 3 or more of the following componentsThis cohort study was performed at the Third Xiangya Hospital of Central South University (TXYHCSU). All of the female employees (N = 8992) from 373 organizations were enrolled in our study when they attended the annual employee health exam at the TXYHCSU between January 2010 and June 2014. The selected organizations were administrative institutions or local government units, arranging health exams for employees (including the retired) every year. All of the participants were followed for 12 months following enrollment. The subjects (N = 173) who were maiden, pregnant, or planned to become pregnant in the next year; were taking immunosuppressants; or had undergone amputation of the cervix at baseline were excluded. Furthermore, women (N = 194) who may already have had persistent HPV infection at enrollment  were also excluded. Another 27 subjects were lost to follow-up and were excluded from analysis because of death or job change, resulting in a final sample size of 8598.All of the study procedures were approved by the human investigation committees at the TXYHCSU and Central South University. The eligible subjects were informed about the cohort study upon their arrival at the hospital for their annual health exam. After obtaining written consent, an in-person interview was conducted at baseline by trained interviewers using a standardized and structured questionnaire. The questionnaire covered information on demographics, reproductive history, lifestyle factors, medical history including a diagnosis of hypertension or diabetes, and prescription drug use for hypertension, diabetes, or lipid-lowering.16 Briefly, after the steps of DNA extraction from cervical cells, gene amplification (PCR), and diversion hybridization, 21 types of HPV could be detected, including 15 high oncogenic risk types  and 6 low oncogenic risk types .Cervical specimens were collected both at the time of enrollment and 12 months later by qualified gynecologists with cervical brushes. The brush heads with collected specimens were stored in a 4 °C fridge in capped bottles with preserving liquid and processed for HPV DNA genotyping within 1 week. HPV genotyping by HybriMax was performed with an HPV GenoArray Test Kit  according to the manufacturer's instructions.17 Briefly, the average of 3 seated blood pressure measurements after 15 minutes resting was recorded by skilled physicians. Blood samples were collected at 08:00 to 10:00 AM after a fasting period of 12 hours. Concentrations of fasting blood glucose and triglycerides were determined using an enzymatic colorimetric assay. The high-density lipoprotein cholesterol (HDL-c) concentration was measured by lipoprotein electrophoresis.Other physical examinations were conducted with the same methods described in our previous study.7 MetS was defined as having 3 or more of the following 5 components: central obesity – waist circumference ≥80 cm ; elevated blood pressure – systolic blood pressure (SBP) ≥130 mmHg, diastolic blood pressure (DBP) ≥85 mmHg, a previous diagnosis of hypertension, or the current use of anti-hypertension medications; hypertriglyceridemia – triglycerides ≥1.69 mmol/L or taking lipid-lowing medications; low HDL – HDL-c < 1.29 mmol/L ; and hyperglycemia – fasting glucose ≥5.6 mmol/L, previous diagnosis of diabetes, or the current use of antidiabetes medications. All of the study subjects were classified into MetS-positive (exposed) and MetS-negative (unexposed) groups according to their metabolic health status. The recommended body mass index (BMI) value for the Asian population was considered to classify obesity (BMI ≥ 27.5 kg/m2).HPV incident infection ) was defined as individuals without HPV infection at baseline but who were infected with any types of HPV 12 months later. HR-HPV incident infection ) was defined as individuals without any type of HPV infection at baseline but who were infected with high-risk types 12 months later. Type-specific HPV persistence ) was defined as positivity for the same HPV DNA type in cervical samples collected at baseline and 12 months later from the same woman. If a woman was found to be infected with HPV at baseline, but the second HPV test 12 months later showed a negative result or a different HPV type on 2 occasions, then she was considered to have cleared that HPV type ). Type-specific HR-HPV persistence ) was defined as persistent HPV infection with high-risk HPV types. According to the National Cholesterol Education Program Adult Treatment Panel III (NECP-ATP-III) criteria,18 If there was homogeneity between the different layers (P ≥ 0.05), then obesity status was considered as a confounding factor. Meanwhile, in cases in which there was heterogeneity (P < 0.05), the associations were separately described in the obese and nonobese layers. Multivariate log-binomial regression models were used to calculate the RR and 95% confidence intervals (CIs) for the associations between MetS, metabolic components, and the risk of any-type HPV incident infection, HR-HPV incident infection, type-specific persistent infection with any type of HPV, and type-specific persistent HR-HPV infection. Potential confounding variables included in the models were age at baseline , years of education , marital status , menarche age , age at first sexual intercourse , number of sexual partners in the past 6 months at baseline , and obesity status at baseline . When each of the metabolic components was treated as an exposure of interest, the other metabolic components except for the one of interest were additionally included in the models as adjustment variables. Statistical significance was assessed at the 5% level (2-tailed test). All of the analyses were performed using SAS software, version 9.2 .The flow chart of our analytical scheme is presented in Figure Of the 8598 study subjects, 976 11.35%) were diagnosed with MetS, 2418 (28.12%) with central obesity, 1766 (20.54%) with elevated blood pressure, 1306 (15.19%) with hypertriglyceridemia, 606 (7.05%) with low HDL-c, and 1572 (18.28%) with hyperglycemia. Compared to the unexposed group, women with MetS were more likely to be older   and type-specific HR-HPV persistence . No single metabolic component was significantly associated with type-specific any-type or high-risk type HPV persistence , 52 (60.23%), 18 (53.85%), 16 (52.05%), and 33 (50.00%) had the highest type-specific HR-HPV persistence rates. No multiplicative or additive interactions were found between obesity and MetS for the association between MetS and the risk of HPV persistence 20 and to female adults in Shanghai (12.8%).21 However, it was lower than the 17.8% found among female adults in mainland China.22 Although the diagnostic criteria for MetS in those previous studies were the same as ours, MetS prevalence increased as age increased.19 Therefore, the disparity could partially be a result of the different demographic characteristics of the populations studied. In addition, the health effects of work could also be involved when comparing our prevalence rate with other nonoccupational populations.Our cohort study showed that the MetS prevalence was 11.39%  among the female occupational population in Hunan, China. The prevalence of MetS varies in different countries and is approximately 7% to 56% in females worldwide.23 The incidence rate among Chinese females has not yet been addressed. Our results showed that the 12-month cumulative incidence of any type of HPV among the occupational population in China is 7.28% , which is lower than that in other countries in North America24 and Europe.25 These differences in incidence may be partially attributable to differences in HPV detection methods, the infecting HPV genotypes, and the characteristics of the populations studied. The median HPV clearance time was approximately 6 to 12 months.26 A total of 48.33%  of the subjects with normal cytology in our study had cleared their infections within 12 months, which was similar to previous studies.26The women enrolled in our study were cytological normal, and the prevalence of any type of HPV was 15.31% , which was similar to the normal cytology population in China (14.80%–16.79%).14 and Kuo and Fujise15 have discussed the relationship between MetS and HPV infection. By comparing the prevalence of MetS between 1141 women with HPV infection and 1309 without infection, Kuo and Fujise concluded that no significant association exists between MetS and HPV.15 Liu et al14 enrolled 1987 women with data on MetS and observed no statistically increased risk of HPV infection among nonobese women with MetS. However, a lower risk of HR-HPV infection among obese women with MetS was observed in his study. There are several concerns when comparing our study with those 2 studies. First, the primary infecting HPV genotypes among the Chinese population are quite different from that of Caucasians; the genotypes of HPV may play an important role in the pathogenesis of HPV incident and persistent infection.25 Whether the association between MetS and HPV varies from HPV genotype to genotype requires further research. Second, the U.S. Food and Drug Administration (FDA) has approved the use of an HPV vaccine since 2006. Some of the subjects enrolled in Liu's study had received the vaccine,14 and the study did not discuss whether the strength of the association between obesity with MetS and HPV prevalence was altered by considering the HPV vaccination history. Although we did not collect information on HPV vaccination, the Chinese FDA has not yet approved the vaccine. Moreover, the costs of HPV vaccination would be very expensive for our subjects, involving not only 3 vaccines but also 3 round-trip travelling fees. The number of subjects receiving the vaccine would therefore be small. Thus, if there was vaccination information bias in our study, the effects of this bias would be subtle and unlikely to fully explain the association identified between MetS and HPV incident infection among the obese group, or the association between MetS and HPV persistence. Third, in our study, the samples used for HPV-DNA tests were collected by health professionals; however, self-collected vaginal swabs were used in the studies by Liu and Kuo. Self-collected samples may still suffer to some extent from under-recognizing HPV infection,15 and thus, nondifferential misclassification and underestimating the association may potentially be confounding factors in Kuo's study. Moreover, obese women may have trouble reaching their genital regions because of redundant vaginal wall prolapse.27 Thus, the quality of self-collected samples among obese women may require further evaluation, and differential misclassification may be involved in Liu's analysis. Further prospective research is required to confirm the role of metabolic alterations in the natural history of HPV infection. Possible biological mechanisms underlying the differential association among obese women with MetS and nonobese women with MetS may involve aggravated insulin resistance, chronic inflammation, and oxidative stress in obese people with MetS.28To the best of our knowledge, our study is one of the first investigations to prospectively examine the associations between MetS and the risk of cervical HPV incidence and persistent infection. Only 2 retrospective studies performed by Liu et al28 Previous studies have reported that elevated estrogen and adipokines produced by adipose tissue and elevated systemic levels of inflammatory cytokines could increase the risk of persistent HPV infection.30 Consistent with those studies, an increased risk of HPV persistence among MetS was also observed in our study.Excess adipose tissue, chronic inflammation, insulin resistance, and oxidative stress are the common characteristics of MetS.11 Our prospective study further demonstrates that the increased the risk of HPV incident infection may be one of the pathways for this association. Hyperglycemia or low HDL-c is not associated with HPV prevalence or cervical cancer.12 A significant association between hyperglycemia, low HDL, and HPV infection was also not observed in our study. Several studies have identified elevated blood pressure among cervical cancer patients.13 However, we found no statistical association between elevated blood pressure and HPV incident or persistent infection. None of the previously published studies were prospective, and a lack of temporality was inherent in those data. HPV infection is an independent risk factor for cardiovascular diseases such as preeclampsia31 and coronary artery disease.15 Therefore, reverse causality may be involved in those retrospective studies.Previous studies have observed an increased risk of cervical cancer among women with hypertriglyceridemia.25 Hence, the generalizability of our results may be limited to the Chinese population. Additionally, we have followed the subjects for only 12 months, the median duration of HPV persistence among MetS-exposed and nonexposed groups require further long-term investigation.Strengths and limitations should be considered when interpreting our study findings. Our study is an occupational population-based prospective cohort study, which minimizes selection, recall, and reverse causation bias. The data contained detailed demographic and lifestyle information, allowing for simultaneous adjustments for several important potential confounding factors. The diagnosis of MetS in our study was based on medical exams, not self-report, and cervical samples were collected by health professionals, not self-collected, which minimizes potential exposure and disease misclassifications. However, the limitations of our study should also be considered when interpreting the study findings. The detection of the same HPV type in women at both exams may be partially due to recurrent infection with the same HPV type. We were unable to determine whether repeated type-specific HPV positivity represented true persistence or reinfection. The major infecting HPV types among the Chinese population are quite different from that of Caucasians; the types of HPV may play an important role in the pathogenesis of HPV incident and persistent infection.Our study found that the prevalence rate of MetS was 11.39% among the Hunan female occupational population. MetS was associated with an increased risk of persistent cervical HPV infection and also with an increased risk of HPV incident infection when obesity was presented. These findings have important implications for designing cervical cancer prevention strategies.


Although HPV infections are common, intravesical HPV is a rare condition, with only 20 reported cases .Objectives: The aim of this video is to present a case treated with transurethral resection (TR).A 38-year-old woman, with a history of urinary tract infections. She denied other diseases and complained of painful urination. The genital examination, cervical cytology and colposcopy were normal. Urinalysis showed leukocytosis, but a negative culture. The ultrasound was normal. A cystoscopy was performed, showing polypoid growth on the bladder mucosa followed of the TR. Histopathologic analysis (HA) confirmed IHPV , associated a Bladder Squamous Metaplasia (BSM). The patient recurrence-free was for 5 years when a cystoscopy demonstrated BSM, which was resected. The patient had not any other sites  of recurrence during the period of follow-up.The condyloma, caused by types 6 and 11, is more frequent in the genital mucosa and anal area . IHPV prTR may be a safe option for definitive IHPV treatment. However, the patients must be followed as in cases of the superficial carcinoma of transitional epithelium.Available at: ARTICLE INFO Available at:http://http://www.intbrazjurol.com.br/video-section/almeida_395_396/Int Braz J Urol. 2016; 42 (Video #3): 395-6 This interesting video by Almieda and colleagues highlights a rare occurrence of HPV infection within the bladder mucosa diagnosed after transurethral resection. It further characterizes the diffuse nature of HPV-associated manifestations, which can cause cancer at multiple anatomic sites in men and women, including cervical, oropharyngeal, anal, vuluvar, vaginal, and penile malignancies. In this particularly case, the patient remained recurrence-free for 5 years, which reinforces the heterogeneity of HPV-associated disease and its malignant potential based on the anatomic site of infection . We appl