HPV infections are ubiquitous and particularly common among sexually active young women. However, there are regional and national variations in age-specific HPV prevalence, which have implications for cervical cancer control. Data on age-specific HPV prevalences for Ghana and most sub-Saharan countries are scanty. Therefore, this study primarily sought to determine the age-specific HPV prevalence among women in a Ghanaian community and to determine whether these prevalences determined with health-personnel and self-collected specimens were comparable.In this cross-sectional study, conducted between March 2012 and March 2013, cervical specimens were collected by self- and health-personnel collection from 251 women who were between the ages of 15 and 65 years. HPV present in these specimens were genotyped by a nested-multiplex PCR and Luminex fluoro-microspheres based method. Information on the demographic, sexual and reproductive characteristics of the women were also obtained. A Chi-square test of association was employed to determine the association of the distribution of age groups with each categorised sexual and reproductive characteristic and HPV risk type’s status.χ2 = 36.1; p = 0.001), high risk  and low risk  HPV prevalences. The age-specific HPV prevalence pattern for each of the HPV risk types, determined with self-collected specimen, showed three peaks , while those determined with health-personnel collected specimen, showed two peaks (at 20–24 years and ≥ 55 years) for each HPV risk type’s prevalence pattern. The high risk HPV prevalences determined with self-collected specimen were often higher than those determined with health-personnel specimen for the age groups between 25 and 45 years, who are mostly targeted for screening by HPV testing. Additionally, there were interesting variations in patterns of age-specific HPV genotype-specific prevalence between the two specimen collection methods.The age group distribution of the participants was significantly associated with overall  contains supplementary material, which is available to authorized users. Human Papillomaviruses are small, single coated, double stranded DNA virus that have been classified to belong to 30 species and about 200 distinct genotypes –3. Of thBased on a meta-analysis of 78 studies, which used health personnel collected specimen reported and data of women with normal cytology , and alsFor reasons not clearly understood, the variation in age-specific HPV prevalence trends for African countries seems to have both one peak  and two peaks  but not three peaks  prevalence. That is, in rural Nigeria, South Africa and Senegal an initial high peak among younger women was followed by a second small prevalence peak among mid-age women  –17. In oAn effective cervical cancer screening strategy, referred to as self-collection has gained a lot research attention in recent times –24. ThisAmong these studies, only the studies from South Africa  and UganIn this cross-sectional study of the multi-ethnic population of the Akuse sub-district, women were recruited between March 2012 and March 2013 by a house survey and invited for specimen collection either at the Akuse Government Hospital or at a specified location within the individual communities. In each of 17 communities, the major roads/paths through it were identified by the use of Google Map computer application and grouped in order of direction, from one end of the community to the other. Based on the crude estimate of the average number of houses and the population of women in each of the communities, it was assessed that visiting every 5th house or less will ensure a wide coverage of the communities. Therefore, starting from the first randomly selected road/path, every third house to the right and left of the road/path was visited. Not more than three women in each house, who met the inclusion criteria were invited to participate in the study, after explaining the study, the consent form and the options available to them as participants as well as giving them basic information about cervical cancer.Women between the ages of 15 and 65 years who had ever been sexually active and were willing to provide specimen by at least one of the two specimen collection methods (data not shown) were included in this study. Women having their menses were asked to come back 1 week after their menstrual period. Women who were pregnant (self-report), had undergone hysterectomy or cervical conisation were excluded from the study. Two trained Public Health Nurses assisted the study participants, by a one-on-one interview, to complete a study questionnaire that obtained information on the socio-demographic characteristics, sexual behaviour, sexual and reproductive history, menstrual factors, use of oral contraception and history of sexually transmitted infections and cervical cancer screening history.The study was conducted in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments and comparable ethical standards. The participants either read and signed an informed consent form (in English) or it was translated to a local language and explained to them with the assistance of a witness; the explanation in each of the four local languages  was performed by one particular person throughout the study. The informed consent included the main research goals, sample collection procedures, potential benefits and harms and privacy and confidentiality. The name and mobile phone number (s)  of the women were obtained and each was recorded at separate places alongside a unique identification code, after informed consent had been obtained. The study was approved as a part of a bigger study by the Ethics Review Committee of the Ghana Health Service (ID No GHS-ERC: 06/11/10).Each participant was instructed on how to use the Rover® Viba-Brush vaginal sampler, . The instructions were given verbally and in the language the participant understood  with demonstrations, using an illustrations on the packaging of the brush, that showed the steps and positioning of the body. The participants were asked to describe the process they going to following to the investigator, before they allowed to go to the private room to perform the specimen collection. The collected specimen was transferred into a sterile 15 mL screw-capped tube containing 5 mL PBS with 5 mM ethylene diamine tetraacetic acid (EDTA), pH 8.0. These specimens were designated as self-collected (SC) for HPV testing.The health personnel then performed a standardized pelvic examination and with the aid of a sterile plastic disposable speculum, a wooden spatula and a cytobrush collected cervical specimen according to the manufacturer’s instructions. The cytobrush was then rinsed in 50 μL of DNAgard®Tissue  and head of the wooden spatula was rinsed in the same 50 μL of DNAgard®Tissue. The specimen was designated as Health Personnel Collected (HPC). Both collected specimens were transported at 4 °C and thereafter store at −20 °C until used for HPV testing.The volume of specimen obtained by HPC was made-up to 1 mL with PBS and vortexed thoroughly. DNA was extracted from 200 μL of each specimen (SC and HPC) on the MagNA Pure LC automated system  using the MagNA Pure DNA Extraction Kit  according to the manufactures specification and a modification by adding 15 μL of RNase to the lysis buffer for each specimen. The negative controls included for each set of extraction were PBS, DNase/RNase free water and DNAGard while the positive control was a suspension of SiHa cells with an integrated HPV 16 genome. The specimen DNA quality was assessed by a real-time PCR amplification of the house keeping gene, RNase H in 10 μL of DNA extract and analysed with Light Cycler 480 and related software .The extracted DNA was amplified by a nested PCR reaction using PGMY09/PGMY11 and GP5+/GP6+ primers as previously described .The typing of 46 mucosal HPV types was carried out by a multiplex system based on the xMAP® technology as previously described by Zubach et al., . BrieflyAll the participants’ sexual and reproductive characteristics were categorised into the known groups widely reported for HPV risk factors analysis. The age of the participants were also categorised into groups of 5 year intervals. Frequencies and proportions were used to describe the distributions and summarize data of demographic characteristics and the categorized sexual and reproductive characteristics stratified by age groups . Chi-square test of association (at 95% confidence level) was used for the determination of the univariate association between the categorised participants’ characteristics and grouped age, and between grouped age and the HPV prevalence for each of the HPV risk types and for overall HPV. A bivariate and multivariate Chi-square association were subsequently determined for each of the HPV risk types and for overall HPV For the Chi-square analysis of the age at first sexual intercourse (AFSI) stratified by age group, the analysis was conducted, first, excluding women 20 years and younger and secondly, grouping the women within the age groups 15–19 and 20–24 to a new group labelled as < 25 years. For both analyses the association was significant by Chi-square test at 95% confidence level. The Cohen’s Kappa analysis was used to determine the extent of agreement between the two methods for the detection of the following; overall/any HPV type, high risk types and low risk types, using data of only 226 women who provided both specimen. For overall HPV type, agreement was defined as Individuals positive for any HPV genotypes in both samples. For high risk HPV, agreement was defined as Individuals positive for any of the high risk HPV genotypes in both. For the Low risk HPV, agreement was defined as Individuals positive for any of the Low risk HPV types in both samples. For of the three criteria it was not necessarily the same genotype in both samples.Of the 415 women contacted during the study, 258 women provided specimens. Of this number 4 self-collected (SC) and 3 health personnel collected (HPC) specimens were excluded because their labels were destroyed during handling of the samples. The quality of the specimens of the remaining 251 women was found to be appropriate for further analysis; although 17 of the 244 SC and 6 of the 233 HPC specimen were not consistently positive with triplicate analyses for the RNase H gene (2 of 3 were positive); these specimen were included in the HPV analysis. Overall 226 women provided both SC and HPC specimen. The distribution of the demographic characteristics of the 415 women and those of them who were HPV positive are shown in Table χ2 = 42.8, p = 0.0001). Also, the distributions of lifetime number of male sexual partners , the contraction of a sexually transmitted infection (STI) , use of condoms , current number of male sexual partners , number of pregnancies  and ever had an abortion  were all significantly associated with age. However, the use of OC was not significantly associated with age .Following the stratification of the distribution of the sexual and reproductive characteristics by age Table , it was χ2 = 36.1; p = 0.001), HR HPV positivity  and LR HPV positivity  detected with both self and health personnel collected specimen. The bivariate association controlling for each of the following potential confounders; Age at first sexual intercourse, Lifetime number of sexual partners, Current number of male sexual partners, Contracted a sexually transmitted infection in the past 10 years and Use of condom during sexual intercourses remained significant for each risk type and overall HPV prevalence obtained with self-collected specimen , HR HPV  and LR HPV . However, for health-personnel collected specimen, the association was significant for both overall HPV prevalence  and HR HPV prevalence  but non-significant for LR HPV prevalence . The trend of this distribution are as shown in the prevalence curves  in South African , DenmarkThe generally higher HR HPV prevalence with SC specimen as well as the additional peak (among the age group 40–44 years) of this curve Fig. , stronglComparing the prevalence curves, it is also clear that the mid-age 40–44 years) peak observed in the overall HPV curve for SC was due to the high prevalence of HR HPV for SC among the mid-age group, but not the prevalence of LR HPV. However, other studies have indicated that a higher overall HPV prevalence obtained with SC specimen are often due to a higher LR HPV detection , 25. The–44 yearsComparatively, the middle-age peak of overall HPV and HR HPV prevalences has been shown in some cohort studies with the suggestion that in addition to the persistence of previously acquired HPV infection, the acquisition of new HPV infection by these women accounted for such peaks in prevalence , 42. HowGenerally, the high prevalence among younger women (particularly those aged between 20 and 29 years) as has been widely accepted, is related to sexual behaviour, particular those associated with the initiation (AFSI) and conducts of sexual activities , 42, 43.The high HR HPV prevalence peak among women aged 55 years or older determined with both SC and HPC specimen has been shown only in selected geographical regions. For instance, a very similar age-specific overall HPV and HR HPV prevalence distribution has been reported in a community based study in China, where an initial major peak was observed among women aged 20–24 years, small increase among women aged 34–39 years, a second major peak among women aged 50–54 years . A studyIt was important to determine whether the observed difference between SC and HPC specimen prevalence curves, for both the overall and HR HPV prevalence curves, Figs.  and 2 reThe results and subsequent conclusions of our study must be viewed in the light of the fact that the number of participants was not even distributed the across age groups and was limited in some of the older age groups, as such resulted in wider 95% confidence intervals and in some cases did not allow for the further more rigours statistical analyses.Based on these findings, the existence of a bimodal and or a trimodal HPV prevalence in some Ghanaian population is to be expected in future investigations and also that the use of SC specimen is mostly likely going to provide more information in respect of the HR HPV burden. In respect of the difference between age-specific HR HPV prevalence curve, and concordance between SC and HPC, further investigations are needed to throw more light on the question, does the overall HPV prevalence (particularly determined with SC) and/or age of women influence the level of concordance between HR HPV test by SC and HPC specimen? Further investigation will shed light on the possible utility of HR HPV testing with SC or HPC in determining screening recommendations for this and other similar populations in low income countries..


Risk-reducing bilateral salpingo-oophorectomy (RRBSO) increases survival in patients at high risk of developing ovarian cancer. While many general gynecologists perform this procedure, some argue it should be performed exclusively by specialists. In this retrospective observational study, we identified how often optimal techniques were used and whether surgeons’ training impacted implementation.We used the ACOG guidelines highlighting various aspects of the procedure to determine which elements were consistent with best practices to maximize surgical prophylaxis. All cases of RRBSO from 2006 to 2010 were identified. We abstracted data from the operative and pathology reports to review the techniques employed. Fisher’s exact test and chi-square were utilized to compare differences between groups .p < .0001). They were more likely to include a description of the upper abdomen—220/241 vs. 12/22 (p < .0001). Oncologists were more likely to utilize a retroperitoneal approach to skeletonize the infundibulopelvic ligaments—157/241 vs. 3/22 (p < .0001). When operations were performed by oncologists, the specimens were more often completely sectioned—217/241 vs. 16/22 (p = .003). The use of a retroperitoneal approach among gynecologic oncologists increased over the study period . There was no visible trend in performance improvement in any other area when looking at either group.Among 263 RRBSOs, 22 were performed by general gynecologists and 241 by gynecologic oncologists. Gynecologic oncologists were more likely to perform pelvic washings—217/241 vs. 10/22 (Gynecologic oncologists are more likely to adhere to best practice techniques when performing RRBSO, though there was room for improvement for both groups. Women carrying a deleterious mutation in the BRCA 1 or BRCA 2 genes have an elevated risk of developing ovarian, fallopian tube, and breast malignancies in their lifetimes . While bOptimal techniques for RRBSO have been defined –15. The At our institution, we care for a large population of women with a genetic predisposition to ovarian cancer, many of whom choose to undergo RRBSO. Both general gynecologists and gynecologic oncologists perform these procedures. We hypothesized that, because of their specialized training, gynecologic oncologists are more likely to adhere to practices that provide optimal prophylaxis for patients undergoing RRBSO. In this study, we evaluated how often ideal practices were followed and if the surgeon’s training was related to implementation.The study was reviewed by and run under the auspices of the NYU School of Medicine Institutional Review Board. All cases of RRBSO performed from 2006 to 2010 at NYU Langone Medical Center were identified through billing records by cross-referencing patients undergoing bilateral salpingo-oophorectomy  and those with a personal or family history of breast cancer (V10.3 or V16.3), family history of ovarian cancer (V16.41), or genetic predisposition to ovarian or breast cancer (V84.02 or V84.01). All surgeries were verified using both surgical and pathological reports. A patient record was eligible for inclusion if RRBSO had been performed. Patients were included if there was either a documented mutation in BRCA1 or BRCA2 or a strong family history of breast and/or ovarian cancer as documented by the operating surgeon or a genetic counselor. In our population, a “strong family history” was determined based on whether patients met the standard criteria for BRCA testing. Patients with known gynecological cancer, suspected gynecologic pathology as the indication for their surgery , or those without complete operative reports were excluded.p values less than 0.05 were considered statistically significant.The type of surgeon  and date of procedure were recorded. Operative reports were examined for the following documentation, based on best practice guidelines for RRBSO as stated in ACOG Practice Bulletin #89: were pelvic washings performed; was the upper abdomen inspected; were the peritoneal surfaces inspected; and was a retroperitoneal approach used to skeletonize the infundibulopelvic (IP) ligament , 16. TheTwo hundred ninety patients were originally identified for eligibility, of which 263 were evaluable. Twenty-seven patients were excluded from further study due to incorrect identification of surgery type (25) or incomplete medical record (2). BRCA mutation status was documented for each case, and the demographic characteristics of each group are shown in Table p < .0001). They were also more likely to include a description of the upper abdomen in the operative report 220/241 (91%) vs. 12/22 of general gynecologists . Oncologists were more likely to utilize a retroperitoneal approach to skeletonize the IP ligaments 157/241 (65%) when compared to generalists .Among 263 RRBSOs, 22 were performed by general gynecologists and 241 by gynecologic oncologists. Gynecologic oncologists were more likely to perform pelvic washings 217/241 (90%) when compared to generalists 10/22  vs. 16/22  performed by generalists were found to comply with all suggested RRBSO techniques. In comparison, 41% of all RRBSOs performed by gynecologic oncologists had complete adherence, and the trend toward complete adherence was statistically significant when analyzed by year . Further, practice improvement over time was noted for those cases performed by gynecologic oncologists, although ideal compliance remained around 40% for this group. Alternatively, there was no similar trend when analyzing the generalists’ surgical practices. This finding is likely secondary to the increased awareness of the surgical issues pertinent to these cases among gynecologic oncologists. This also highlights the importance of further awareness and proper training among all providers performing RRBSO. In many parts of the world, specialists may not be accessible, and proper training of generalists is imperative if correctly performed RRBSO is to be widely accessible.At our hospital a particular effort was made to formalize practices for pathologists sectioning these specimens; however, no formal training was instituted for the surgeons. Some of the aspects required to conform to ideal practices do not require specific surgical technique, e.g., correct documentation on the pathology request to ensure use of the “risk-reducing protocol” for specimen sectioning. Prior to performing these procedures, the pathologist should be consulted. If the required sectioning cannot be instituted, patients need to be referred to alternative institutions where this practice is standard, as new evidence further supports that this technique increases diagnosis of microscopic malignancy, and may even aid in the identification of premalignant conditions in certain populations , 25. OthThe use of peritoneal lavage at the time of prophylactic surgery for high-risk women has been previously reviewed , 21, 22.There are several limitations to this study. This is a single-institution, retrospective study, and therefore, its applicability to other institutions is unknown. Although we evaluated over 250 cases, the cases performed by general gynecologists made up a relatively small number. Additionally, we do not have consistent follow-up data on patients to determine the incidence of post-BSO primary peritoneal cancer and therefore cannot comment as to whether lack of adherence to best practices resulted in worse outcomes. Despite this, we believe there are clear trends shown in our data which warrant further investigation.In conclusion, we found that gynecologic oncologists were more likely to adhere to ideal practices for risk-reducing BSO. Guidelines published by both ACOG and SGO outline similar best practice techniques and acknowledge that this procedure can be performed by either generalists or gynecologic oncologists. In many geographic areas, patients will have better access to general gynecologists . Greater


Zea mays ssp. mexicana as one parental taxon, and an unidentified cultivated maize variety as the other. Analyses of plants grown from seeds collected in Spanish maize fields and experimental crosses under controlled conditions reveal that hybridization does occur between Spanish teosinte and cultivated maize in Spain, and that current hybridization is asymmetric, favouring the introgression of Spanish teosinte into cultivated maize, rather than vice versa.A novel weed has recently emerged, causing serious agronomic damage in one of the most important maize-growing regions of Western Europe, the Northern Provinces of Spain. The weed has morphological similarities to a wild relative of maize and has generally been referred to as teosinte. However, the identity, origin or genetic composition of ‘Spanish teosinte’ was unknown. Here, we present a genome-wide analysis of single-nucleotide polymorphism (SNP) data for Spanish teosinte, sympatric populations of cultivated maize and samples of reference teosinte taxa. Our data are complemented with previously published SNP datasets of cultivated maize and two Mexican teosinte subspecies. Our analyses reveal that Spanish teosinte does not group with any of the currently recognized teosinte taxa. Based on Bayesian clustering analysis and hybridization simulations, we infer that Spanish teosinte is of admixed origin, most likely involving  The inadvertent introduction of species closely related to major crop plants may lead to hybridization and the formation of weedy lineages2. Alternatively, weedy taxa can also evolve directly from a domesticated ancestor3, as in the case of some weedy rice populations5. Weedy lineages can incur massive yield losses and cause major costs6.Increasing human transfer of plants across geographical regions leads to frequent introductions of non-native plant species around the world. If these introduced taxa meet close relatives, hybridization and introgression can occur7. In 2009, farmers in Northern Spain (Aragon) began to observe plants in their maize fields that resembled cultivated maize before the onset of flowering but then developed highly branching phenotypes with small cobs and shattering seeds8. These traits are typical for teosinte, wild relatives of cultivated maize9. Until 2014, this so-called ‘Spanish teosinte’ has spread in Aragon and has also been reported from a neighbouring region in Catalonia11. About 750 ha of maize cultivation have been affected so far, mostly in Aragon11. Due to maize monocropping, density of Spanish teosinte can become high on affected fields and may cause severe maize yield losses and high economic costs12. In some regions of Aragon, this weed has become the prime agronomic problem for maize farmers10.Maize is the third most important crop plant in Spain with production reaching almost 4.7 million tonnesZea mays mays) was domesticated from its wild relative teosinte about 9,000 years ago in southern Mexico13. Domesticated maize, including high-yielding hybrid maize varieties grown in Europe, is strictly monopodic, with non-shattering kernels that remain tightly attached to the cob, in contrast to the shattering kernels of the cob-less, and highly branched, teosinte. Although maize cobs, or parts of them, can remain in the field and do germinate and grow feral, it is considered unlikely that they successfully establish feral populations beyond arable fields and without human support9. Hence, cultivated maize is generally considered to have little to no risk of causing concerns as a volunteer or feral weed14.Maize  and includes highly variable species and subspecies that occur in scattered populations in many areas across Mexico and Central America (Mesoamerica)Zea, which consists of five species: 1) perennial diploid (2n = 20) Z. diploperennis, 2) perennial tetraploid (2n = 40) Z. perennis, 3) annual diploid (2n = 20) Z. luxurians, 4) annual diploid (2n = 20) Z. nicaraguensis, and 5) the annual species Zea mays. The latter encompasses four annual diploid (2n = 20) subspecies: (i) ssp. mays, the domesticated maize, (ii) ssp. mexicana, (iii) ssp. parviglumis, and (iv) ssp. huehuetenangensis19. Z.m. ssp. mexicana and Z.m. ssp. parviglumis are most closely related to domesticated maize, the latter subspecies being called ‘Balsas’ teosinte and considered the ancestor of cultivated maize9. All teosintes are believed to be endemic to Mesoamerica20 where cultivated maize and teosintes often grow in geographic proximity and flower synchronously. Overall, Z.m. ssp. mexicana grows in cooler, drier central highlands, mostly above 1800 m, while Z.m. ssp. parviglumis grows in warmer, wetter lower elevations in the river valleys of southern and western Mexico, mostly below 1800 m15.Teosinte and maize belong to the same genus, 21. Hybridization appears to be most common between domesticated maize and Z.m. ssp. parviglumis22 but gene flow does not occur reciprocally, which may explain why teosintes continue to coexist even when growing in close vicinity to much larger maize populations21. When teosinte pollen is applied to maize silks, resulting hybrids are vigorous and highly fertile23. However, when teosinte is pollinated by maize pollen, plants of Z.m. ssp. mexicana set seed very inconsistently or not at all22. Similarly, Hufford et al. found evidence of adaptive introgression of Z.m. ssp. mexicana alleles into maize during its expansion to the highlands of central Mexico, but observed very little evidence for adaptive introgression in the other direction, from cultivated maize into Z.m. ssp. mexicana24.Although it is known that all teosintes can hybridize with maize, this typically occurs at low rates even when teosinte is abundant‘Teosinte crossing barrier’ (Tcb)23 which may reproductively isolate at least some teosinte species from maize. Aylor et al. postulated that gene flow and subsequent introgression of maize alleles into teosinte populations most likely occur when teosinte first pollinates maize20. The resultant hybrids would then backcross with teosinte which could lead to the introgression of maize alleles into the teosinte background. They speculated that the pollination from teosinte to maize most likely represents the rate-limiting step in the introgression of maize alleles into teosinte20. However, this has not been investigated yet to any conclusive extent, even though teosinte and maize have intensively been studied from a population genetics perspective, including studies utilizing DNA samples recovered from archaeological specimens27.This asymmetrical pollination success is under the control of a gene called the Z.m. ssp. mexicana11. Spanish teosinte can produce long-lasting seed banks, and its control either by mechanical means, crop rotation or herbicide treatment has proven difficult11. Knowing the origin of the novel weed in Spain may help to prevent introductions of further seed material, to monitor the spread of this weed, and to take targeted control measures in the future. The taxonomic identity of the Spanish teosinte, its introduction history, as well as its ecology and potential risks for local and neighbouring European farming systems remain largely unknown. To develop effective measures for monitoring, control and prevention, data on these aspects are fundamental. Here, we addressed the following research questions: (i) to what taxon can teosinte-like plants collected in Spain be assigned?, (ii) what is the potential origin of these Spanish teosinte lineages?, (iii) is there evidence for on-going hybridization between Spanish teosinte and commercially cultivated maize in Spain? To answer these questions, we collected Spanish teosinte and hybrid-like seeds (autumn 2014 and 2015) and leaf samples of Spanish teosinte and cultivated maize (summer 2015) in the region of Aragon, Spain, and genotyped these together with teosinte reference plants using the MaizeSNP50 BeadChip, a widely used resource for high-density genotyping of maize and its wild relatives30.So far, the Spanish authorities have speculated that the introduced teosinte is et al.29. Similarly, reference samples of Z.m. ssp. mexicana and ssp. parviglumis obtained from USDA grouped with samples of these species previously investigated by Pyhäjärvi et al.28  leading to the emergence of Spanish teosinte could have taken place inadvertently in any of the Mesoamerican regions where native The risk of further hybridization events between commercial maize and Spanish teosinte is worth considering in light of the possibility of further development of even more invasive weed than the population currently found in Northern Spain. The plants grown from hybrid-like seeds, which we collected in the field in Spain, proved indeed to be intermediate between cultivated maize and teosinte, having elongated lateral branches and producing bunches of ears, often combined with tassels. These samples grouped together 23. Lu et al. observed that in silk carrying the Tcb, pollen tubes had clustered callose plugs and their growth was slower in comparison to pollen tubes of compatible crosses37. Such crossing incompatibility may also exist between commercial maize and Spanish teosinte. From our exploratory crossing experiments, we can confirm that hand-pollination of Spanish teosinte with maize pollen results only rarely in viable seeds (unpublished results). Thus, while the crossing barrier may reduce the frequency with which such hybrids are formed in the field, it is important to note that it does not preclude their formation, even though at low rates. Therefore, we expect that more intensive sampling, over a longer period of time, may likely reveal the existence of maize-to-teosinte introgressants, especially if on-going hybridization between teosinte and maize leads to the formation of hybrids that are more compatible with a teosinte mother plant, as postulated by Aylor et al.20.Surprisingly, we have not detected any hybrids among the plants that we sampled directly in the field. A plausible explanation is that when maize is pollinated by teosinte, the seeds do not easily shatter, with many of them being harvested together with the commercially grown maize. Pollination occurring in the other direction, from cultivated maize to teosinte, is known to be significantly less viable, due to the control of Further studies are needed to fully understand the evolutionary origin and demographic processes involved in the formation of Spanish teosinte. In particular, much more intensive sampling, both spatially and temporally, could reveal the amount of genetic and phenotypic diversity, as well as the extent to which the population of Spanish teosinte is changing, including through hybridization with cultivated maize. However, we now have a basis of understanding that enables necessary practical measures to confront the challenge of this serious, possibly invasive, weed. With this understanding, it should be possible to establish monitoring and mapping efforts to track, and hopefully contain, the spread of the weed. Whether this weed remains a serious problem only in the Spanish region where it is now confined, or whether it expands to other maize-growing areas in Europe and beyond may be determined by the degree with which these questions are pursued.Teosinte and hybrid-like seeds were collected from two different sites in the region of Zaragoza, Spain in autumn 2014 and 2015. In summer 2015 we surveyed the maize producing region around Zaragoza and collected leaf samples from three fallow and five standing maize fields. We sampled 3–20 plants per field  in climate chambers at ETH Zurich. Once matured, leaf samples were collected from 34 plants  and 14 teosinte plants grown from the seeds collected in Spain under controlled conditions in a climate chamber . The adventitious roots were sampled, lyophilized and stored on silica gel for further molecular analysis. Three seeds from one cob from a maize plant (mother) pollinated by teosinte were germinated and sampled in the same way as the reference material.38, and quantified using NanoDrop (Thermo Science). For the experimental crosses, DNA for the mother plant (Bt maize) was pooled from 6 different plant samples using the same concentration levels, similarly, for the father plant (teosinte) DNA from 14 different plant samples was pooled together. Genotyping was conducted at the UC Davis Genome Center using the MaizeSNP50 BeadChip and Infinium HD Assay .DNA was extracted from dried leaf and root material with CTAB buffer, following a slightly modified protocol described in Doyle and Doylehttp://dx.doi.org/10.5061/dryad.60210). To the dataset we added published and publically available data on Z.m. ssp. mexicana and ssp. parviglumis individuals28 and commercial maize varieties29 . Gen Train score had to be larger than 0.7 to retain a SNP leading to 41,784 SNPs. SNP data were deposited in the Dryad repository . Our samples from Spain were assigned into three different categories: Spanish maize, Spanish teosinte, and hybrid, based on the morphological traits shown in Fig. Genotype data was then imported into R42 was conducted with different K’s and 10 replications using the admixture model with correlated allele frequencies. The analysis was performed separately for all Spanish maize varieties, hybrid, Spanish teosinte genotypes, Z.m. ssp. mexicana and ssp. parviglumis (Fig. Z.m. ssp. mexicana, ssp. parviglumis, Z. luxurians, Z. diploperennis, Z. perennis and Z. nicaraguensis (Supplementary Fig. 43.STRUCTURE analysismis Fig.  and for Z.m. ssp. mexicana we use the hybrid function of adegenet40 with 10 individuals each.To simulate the putative hybrids between the Spanish maize and Supplementary Information


Cervical cancer (CC) is one of the most common cancers in women and virtually all cases of CC are a result of a persistent infection of human papillomavirus (HPV). For disease detected in early stages there is curing treatment but when diagnosed late with recurring disease and metastasis there are limited possibilities. Here we evaluate HPV impact on treatment resistance and metastatic disease progression.Prevalence and distribution of HPV genotypes and HPV16 variants in a Swedish CC patient cohort (n=209) was evaluated, as well as HPV influence on patient prognosis. Tumor samples suitable for analysis (n=204) were genotyped using two different real-time PCR methods. HPV16 variant analysis was made using pyrosequencing.Results showed that HPV prevalence in the total series was 93%. Of the HPV-positive samples, 13% contained multiple infections, typically with two high-risk HPV together. Primary cure rate for the complete series was 95%. Recurrence rate of the complete series was 28% and distant recurrences were most frequent (20%). Patients with tumors containing multiple HPV-strains and particularly HPV genotypes belonging to the alpha 7 and 9 species together had a significantly higher rate of distant tumor recurrences and worse cancer-specific survival rate. Cervical cancer (CC) is internationally one of the most common cancers in women, in 2012 over 500 000 new cases were estimated and in several developing countries it is the most common cause of cancer-related mortality in women .The majorities ∼80%) of CC are squamous cell carcinomas (SCC), which typically develop in the transition zone where endocervical glandular cells meet ectocervical squamous cells. The second most common histological subtype is adenocarcinomas (AC) (∼20%), occurring in the endocervix and therefore being harder to detect in an early stage. Other epithelial carcinomas, like adenosquamous carcinomas (ASC), account for a small percentage of the total number of CC. There has been an increase in incidence of AC in CC, both in total and in proportion to SCC , 5. Virt0% of CC Specific HPV genotypes causing CC have been linked to poor prognosis in the patient. For example, HPV18 have in a number of studies been associated with high level of disease recurrence and poor survival , 16, whiThe aim of this study was to evaluate the prevalence and distribution of HPV genotypes and HPV16 variants in a Swedish patient cohort, diagnosed with cervical carcinoma and treated with radiation therapy. The study also aimed to assess HPV genotype and HPV16 variant influence on the patient prognosis.Five patients of the total study population (n=209) were excluded due to inadequate tumor tissue samples or histological reevaluation. In the total series of 204 patients the mean age was 60 years (range 23-90). Most tumors were SCC 84%, n=172), followed by AC  and ASC . By FIGO staging, 44 (22%) tumors were stage I, 125 (61%) tumors stage II, and 24 (12%) tumors stage III and 11 (5%) tumors stage IV. Genotyping results could be obtained in 203 out of the 204 samples and the sample with invalid genotyping result was excluded. After repeated testing, use of alternate genotyping approach and exclusion of reclassified cases, 93% (188/203) of the tumors were positive for HPV  harbored hrHPV genotypes belonging to the alpha 7 species, 61% (114/188) harbored hrHPV belonging to alpha 9 species and 5% (10/188) of the tumors harbored hrHPV of both alpha species. In the alpha 7 positive group, multiple infections were present in 2% (1/52) of the tumors, while in the alpha 9 positive group multiple infections were present in 11% (13/114) of the cases. Only a few of the tumors positive for hrHPV harbored HPV belonging to the alpha groups 5 and 6.Patient characteristics , tumor size (mm) and tumor stage (early: FIGO I-II vs. advanced: FIGO III-IV) did not differ between patients with tumors containing single HPV genotypes compared to multiple genotypes or patients with tumors containing HPV from one of the alpha 7 or 9 species compared to both alpha 7 and 9 species Table .The primary cure rate for the complete series was 95%. There was no significant difference in primary cure rate in regards to single or multiple infections , comparisons between specific genotypes or alpha species groups . Specifically, for HPV18 and HPV45, the primary cure rate was 100%.Recurrence rate of the complete series was 28% and distant recurrences were most frequent (20%). The overall recurrence-rate was significantly higher for patients with tumors containing multiple HPV strains (44%) compared to tumors with single infections (24%) . Also, overall recurrence-rate was significantly higher for patients with tumors containing HPV from both alpha species 7 and alpha 9 (80%) compared to alpha species 7 or 9 alone (25%) . The overall recurrence-rate for tumors positive for HPV18 and HPV45 was 46% and 47%, respectively.There was a significant association  between multiple HPV infections and distant recurrences. The distant recurrence rate for single strain tumors was 15% while 40% for multiple-strain tumors. In a logistic multivariate regression analysis, presence of multiple HPV genotypes was still an independent and significant predictive factor for distant recurrences  after correction for tumor stage, tumor size, and histology  worse for patients with tumors containing multiple HPV genotypes (41%) compared to single HPV genotypes (74%) Figure . In a CoThere were no significant differences in 5-year cancer-specific survival rate between tumors containing HPV types belonging to alpha 9 species (75%) and tumors containing alpha 7 species (65%) . However, tumors containing HPV types belonging to both alpha 9 and alpha 7 (n = 10) had significantly worse 5-year cancer-specific survival (11%)  compared to alpha 7 or 9 alone Figure .HPV18 positive tumors were associated with an inferior 5-year survival rate (49%) compared to HPV18 negative tumors (73%) . HPV18 was significantly  more common in adenocarcinomas (50%) than in squamous cell carcinomas (14%). There was no significant association between prognosis and any other individual HPV-genotype.Variant determination was successfully performed in 87/93 (94%) of HPV16 positive samples. The majority were of EAS origin: 94% (82/87), while 5% (4/87) belonged to the NA/AA lineage and 1% (1/87) to AFR1 lineage. Among the EAS lineage samples, all were of the European sublineage (EUR). Within EUR the HPV16 reference, European prototype (Ep) was most commonly found (n=36) followed by samples with E-G350 (n=34), EG131G (n=5), EG131 (n=3), and E-C109G (n=3) polymorphisms. One tumor contained a double infection of both E-G350 and Ep.Despite few cases, EUR samples with E-G131G polymorphism had the lowest long-term survival probability, but with no significant differences from the other tested EUR samples .This study aimed to evaluate the prevalence and distribution of HPV genotypes in a Swedish CC patient cohort, and also to assess HPV genotype and HPV16 variant influence on the patient prognosis. Detection and genotyping was initially made with a real time PCR method targeting the HPV L1 gene and samples with negative result were retested targeting the viral E6/E7 genes. Alternate genotyping approach was used to avoid false negative results due to disruption or loss of the initially targeted L1 gene, which could be a result of viral integration into the human genome . The totSanjose et al [Bachtiary et al [Multiple infections were seen in 13% of all HPV positive cases, considerably higher than reported for a European multinational study by de se et al  (7%). Inry et al  on the oSchmitt et al [An ongoing HPV infection can be a risk factor for acquiring additional HPV infections , 25 and tt et al  showed 2Munugala et al [Bachtiary et al [In the present study, patients with tumors containing more than one HPV genotype had an unfavorable prognosis. Both significantly higher distant recurrent rate and worse cancer-specific survival rate was noted compared to patients with tumors containing single HPV genotypes. la et al  reportedry et al , but conry et al . HPV posry et al , vagina ry et al  and cervry et al . In the ry et al , 30, 32.Further, the results from this study show that patients with tumors harboring HPV genotypes from both alpha 7 and 9 species had a significantly higher distant recurrence rate and significantly lower 5-year cancer-specific survival rate compared to patients with tumors containing HPV genotypes from one of the alpha 7 or 9 species. The impact of HPV alpha species on prognosis has been sparsely investigated, but Wang et al  could inDespite the fact that most cervical carcinomas are the result of a persistent HPV infection, specific genotypes have shown to be more prone of risk for disease and progression. Here, HPV18-positivity was associated with inferior survival compared to tumors not containing HPV18. Similar results have been presented by Kim et al  from theNo significant impact of HPV16 variant influence on the patient prognosis was noted and nearly exclusively samples of EUR sublineages were found. A numeric low long-term survival was found in the E-G131G and NA/AA positive tumors samples. A similar finding of low survival association to the HPV16 E-G131 polymorphism has been shown in vulvar carcinomas , but theThe cervical cancer incidence has been decreasing in the western countries and with primary and secondary prevention including vaccine and HPV screening it is believed to be a downward trend. In early stages of cervical cancer there is curing treatment with good prognosis however cervical cancer diagnosed in late stages and recurring disease with metastasis have poor prognosis and limited possibilities for effective treatment . EvaluatWe acknowledge some limitations with the present study. The study cohort includes patients diagnosed over two decades, where treatment standards have evolved which could potentially affect the outcome. A larger study group would potentially support accounted results.In conclusion, we found in this Swedish series of cervical cancer treated with radiotherapy the HPV prevalence to be 93%. Of the HPV-positive samples, 13% contained multiple infections typically with two hrHPV together. Patients with tumors containing multiple HPV-strains and particularly HPV genotypes belonging to the alpha 7 and 9 species together had a significantly higher rate of distant tumor recurrences and a worse cancer-specific survival rate. Further analysis of p53 and HPV-viral load in cervical tumors containing multiple HPV could be of interest for investigating potential biological mechanisms.The study population included 209 patients diagnosed with cervical cancer and treated with radiotherapy  between 1992 and 2014 at the Department of Oncology at Örebro University Hospital, Sweden. Of the total study population 204 patient samples were suitable for analysis. In this patient group 58% were treated with concomitant chemotherapy. The mean follow-up time of patients alive (n=113) was 61 moths (range 3-229 months) and the median follow-up times was 45 months. Patient samples were biopsies or resections collected from Örebro University Hospital, Uppsala University Hospital and the central hospitals in Eskilstuna, Falun, Gävle and Karlstad. Staging of the tumors were made at the time of diagnosis using the staging system of the International Federation of Gynecologists and Obstetricians . Relevant clinical data were obtained from patient records at the Department of Oncology, Örebro University Hospital.The study was given ethical approval by the regional ethics committee board in Uppsala (D nr 2008/122).Formalin-fixed and paraffin-embedded (FFPE) tumor tissue samples were selected by a pathologist (MK) using slides made at time of diagnosis. Sections of tissue blocks  were de-waxed with xylene and used for DNA extraction with QIAamp DNA mini kit  following the manufacturer’s instructions.in-vitro diagnosis with analysis of cervical swab and liquid based cytology specimens in EU. The method has previously been tested on archival FFPE material by Lillsunde et al and proven to be highly sensitive for FFPE samples [Detection and genotyping was performed with Anyplex™ II HPV28 , a real time PCR method detecting 28 genotypes  and the human gene Beta-globin (HBB). Amplicon lengths were between 100-200 bp within the viral L1 gene. The samples were run according to manufacturer's instruction as described before . Anyplex samples . All samSamples with two-time negative or invalid results using the L1 based approach (Anyplex™ II HPV28) were analyzed with a real-time PCR method targeting the viral genes E6 or E7. Reactions were carried out with a Taqman real-time PCR in eight separate reactions for every sample in the 7500 fast real-time PCR system . Samples were analyzed for 12 hrHPV , 2 lrHPV (HPV6 and 11) and the housekeeping gene β-globulin as previously described [Patient samples with negative results after both genotyping methods and with available alternative tissue block were reanalyzed twice with method targeting L1 and once with methods targeting E6/E7 according to procedure described above. HPV negative patient samples without alternative material available or with a consistent negative result after genotyping were evaluated by a pathologist (MK).Samples positive for HPV16 were analyzed with PCR and pyrosequencing to determine HPV16 variants. Analysis was performed by targeting seven positions in the viral E6 gene  .Survival analyses were made using Kaplan-Meier survival methods and the curves were compared with the log-rank or Chi-square analysis. Comparisons of proportions were made with Person’s chi-square test and means were compared with independent t-test. Multivariate analysis of different prognostic factors was performed using the Cox proportional hazards model for survival outcome and logistic regression analyses for binary outcome. For the statistical tests a p < 0. 05 were considered to be statistically significant. For statistical analyses the Statistica software package  was used.


War-related traumas can lead to orthopedic and neurological disorders in victims. However, the scope of such disorders may expand months or even years after the trauma. Orthotic treatment as a rehabilitation process aims to enable people with disabilities to reach and maintain their optimal physical, sensory, intellectual, psychological, and social functional levels. This study aimed to investigate the rate of using orthoses among Iranian veterans with neuromuscular and skeletal disorders of the ankle and foot. Furthermore, the priorities of orthotic treatment in those veterans were explored.This qualitative study was a national health needs assessment conducted in 11 provinces of Iran during 2011–2016. A stakeholder research group was established to survey the veterans in respect to their demographic variables, activities of daily living, current health conditions, and rate of using orthoses.n = 538), medical shoes (n = 447), lower limb orthoses on the contralateral side (n = 320), spinal orthoses (n = 273), and upper limb orthoses (n = 86).Overall, 907 of the 1124 veteran participants completed the survey (response rate: 80.7%). Most of the veterans were men (97.7%), and their age and disability rate were 52.07 ± 8.13 years and 31.92% ± 14.93%, respectively. Nearly 42% of the veterans had experience in using orthoses on a daily and weekly basis. As physical ambulation was the main problematic activity in veterans, most of them were using medical shoes and foot orthoses. Nearly 37% of veterans were in need of some type of lower limb orthoses on the contralateral side to compensate for their hip inequality. In sequential order, the most in need orthoses for veterans were foot orthoses (In spite of the high demands for orthoses among Iranian veterans with ankle and foot disorders, the use of orthoses is insufficient. Hence, there is a discrepancy between the current rate of orthoses use and its ideal situation, and more resources should be provided for service providers to be able to serve veterans. Moreover, veterans should be educated regarding orthoses, their use, and their impacts on the user’s health status. The findings of a needs assessment of orthoses can be used in strategic planning and decision making to improve health care services for Iranian veterans. War-related traumas can lead to orthopedic and neurological disorders in victims. However, the scope of such disorders may expand months or even years after the trauma . The quaThe Iraq-Iran war 1980–1988) was one of the longest wars of the twentieth century and spanned the western and southwestern borders of Iran. It caused nearly 219,000 deaths, hundreds of thousands injured people, displaced millions, and caused billions of dollars in destruction in Iran 980–1988 .The health needs and priorities of people with some kind of disability can be assessed systematically using multi-stakeholder focus-group workshops and remote monitoring technologies . In thisOrthotic treatment as a rehabilitation process aims to enable people with disabilities to keep and reach their optimal functional level in the physical, sensory, intellectual, psychological, and social aspects . HoweverThis qualitative study was a national health needs assessment conducted by the Janbazan Medical and Engineering Research Center (JMERC) in 11 provinces of Iran from April 2011 to April 2016. Figure Because the care and self-care of veterans are multidisciplinary and lifelong issues, a stakeholder research group consisting of trained surveyors, an orthopedic surgeon, an occupational therapist, and an orthotist and prosthetist was established to complete the questionnaires . The surThe participating veterans were selected using a judgmental sampling method from the VMAF database. The inclusion criteria were veterans with the existence of any neuromuscular or skeletal disorder of the ankle and foot and with the motivation to participate in the survey. Those selected veterans were invited to participate in 2–4 survey days in the capital city of each province. The number of days required to conduct the survey was determined based on the population of veterans who met the inclusion criteria in each province. On survey days, after trained surveyors gathered demographic data and took histories, the activities of daily living and gait quality were assessed by an occupational therapist. Thereafter, the health status of participant veterans was evaluated using clinical and orthopedic examinations by an orthopedic surgeon. Finally, the usability of orthoses and the quality of the current orthoses were evaluated by an orthotist and prosthetist. The exclusion criterion was the existence of cognitive disorder of the participant based on the evaluation by the occupational therapist. However, in the present study, there was no exclusion due to cognitive disorder. In addition, incomplete questionnaires with missing data were excluded. All aspects of the study were approved by the ethics committee of JMERC. Moreover, written informed consent was obtained from all veterans prior to enrollment.Descriptive statistics were analyzed using SPSS, version 16.0.  to report the frequency, percentage frequency, mean, and standard deviation of variables.Of the 2500 veterans with ankle and foot disorders who were invited to participate, 1124 enrolled in the study. In 217 cases, the questionnaires were incomplete and excluded from subsequent analyses. Therefore, the results of this study are reported based on the data obtained from 907 veterans (response rate: 80.7%). Figure n = 886; 97.68%), and their mean ± standard deviation (SD) of age and VMAF disability rate were 52.07 ± 8.13 and 31.92 ± 14.93, respectively.The demographic characteristics of participant veterans are presented in Table Almost all of the veterans (98.35%) were married, and most had pre-diploma and diploma educational levels. The unemployment rate in participant veterans was high (58.32%), and more than 46% of them were supported by the VMAF, receiving monthly compensation and pension based on their disability rating. Most of the veterans (67.26%) were living in regions with level terrain around their home. Moreover, the climate conditions were mild for more than 52% of the participating veterans.The clinical characteristics of the participating veterans are presented in Table Of the 887 participant veterans who answered the question regarding their experience with orthosis use, 42.73% confirmed they had such an experience. The daily and weekly use of orthoses was 6.59 ± 3.75 h and 6.21 ± 1.68 days, respectively. Nearly 30% of the employed veterans used orthoses during work. The results revealed that the participation of veterans in social activities, sports, and recreation was weak (29.50%). Of those veterans who participated in social activities, sports and recreation, 34.83% were using a type of orthosis during such activities.n = 99). As seen from Table With respect to the fitting quality of the current shoe, the evaluation was conducted for 508 veterans. Nearly 57% of the veterans had unacceptable shoes based on the orthotist’s opinion. Similarly, the fitting quality of the current orthosis was unacceptable in nearly 54% of the veterans who were evaluated by an orthotist and prosthetist , medical shoes (n = 447), lower limb orthoses on the contralateral side (n = 320), spinal orthoses (n = 273), and upper limb orthoses (n = 86).In sequential order, the most in-need orthoses for veterans were foot orthoses (n = 462) of the participating veterans were suffering from associated injuries in addition to their ankle and foot injuries. Considering the mean age of the participating veterans, 52.07 years, it can be expected that Iranian health care providers should focus more on providing facilities for elderly veterans in the near future. Uneven surfaces can make walking more difficult in people with disabilities and can potentially decrease their participation in social activities [The present study clearly showed the high demands for orthoses among Iranian veterans with ankle and foot disorders. The complexity of war injuries is due to their association with other disorders that may affect the whole life of a victim. Nearly 50% , knee orthoses, insoles, and medical shoes are three main priorities of orthosis use for the contralateral side to compensate for ankle and foot disorders. In this regard, 71 veterans were using assistive devices other than orthoses to keep their balance and prevent falls. Furthermore, as found in the present survey, leg length discrepancy can lead to lower back pain, which can be controlled to some extent by spinal orthoses (~ 30%), i.e., lumbosacral orthoses (n = 261).Ankle and foot disorders are common risk factors for falling and balance disturbance . In addin = 52).The results of the self-maintenance scale determined that physical ambulation was the most problematic activity for veterans. Fortunately, most of the veterans (> 72%) reported independence in feeding, bathing, grooming, dressing, toileting, and physical ambulation. The easiest activity for veterans was feeding (95.04%). Although the need for upper limb orthoses in our selected sample of veterans was low, the wrist hand orthoses were the most in-need orthoses  and health care needs  in Iranian veterans with ankle and foot disorders. The findings of the survey revealed a discrepancy between the current health care status and the ideal one in respect to orthosis use in Iranian veterans. The findings of the present needs assessment can be used in strategic planning and decision making to improve the health care services provided to Iranian veterans.


Bangladesh, with a population of 160 million and nearly half being women, has the 4th highest rate of cervical carcinoma deaths in the world. It is projected that ∼500,000 of these women would die of this entirely preventable cancer by 2030. HPV vaccination is not widely offered in Bangladesh. This pilot study is designed to find out the prevalence of rare and multi-viral high-risk HPV (hrHPV) subtype(s) infection which may help strategize a large scale vaccination program in tackling cervical carcinoma in the country.Forty cases of cervical High-Grade squamous intraepithelial lesion (HSIL) and Squamous cell carcinoma (SqCa) were collected. DNA was extracted from tissue representing HSIL and SqCa and multiplex PCR was run to identify all 15 hrHPV subtypes along with known positive controls.Of the total, 27 cases were biopsies/cones and 13 were hysterectomies including 5 HSIL and 35 SqCa. Infection caused by rare subtypes, hrHPV 45 and 52, were found in only two cases. Multi-subtype infection, detected in 28 % cases, was limited to HPV16/18 in all cases but one; one case showed hrHPV16/52 combination.A remarkable homogeneity of hrHPV 16 infection is noted in women with HSIL & SqCa in this country in these limited samples. This finding is in sharp contrast to the reports from western countries of frequent multi-viral and rare subtype hrHPV infection. This pilot study suggests that a vaccination program may be highly effective in controlling cervical cancer there. A larger study, however, is required to ratify the findings. Cervical Cancer Global Crisis Card reports that Bangladesh ranks 4th in cervical carcinoma deaths in the world after India, China and Brazil (WHO). Incidence of cervical cancer is 19.2 per 100,000 women in Bangladesh , 4.probable high-risk types [Human papillomavirus (HPV) infection causes cervical cancer and its precursor lesions in majority, if not all, cases . Persistsk types .International Agency for Research on Cancer (IARC) reported HPV 16 to be the most common type worldwide followed by HPV 18, and together accounting for >70 % of ICC cases . EpidemiOnly a handful of studies are available in the literature on the prevalence of hrHPV in Bangladesh. These studies were carried out in selected patient population, such as, in female sex workers  and womeMulti-viral hrHPV infection has been reported to be associated with cervical dysplasia  and carcThe current study attempts to identify the prevalence of all 15 hrHPV subtypes in HSILs and SqCa, presence of rare subtypes, and determine the frequency of multi-viral subtype infection from lesional tissue. This information would fill-up the void that exists in epidemiological data now present on HPV infection in this country. This information may also prove beneficial for the mass scale HPV vaccination program in controlling HPV infection and eventually saving numerous young lives in this country.This is a retrospective collaborative pilot study. The collaborating departments are the Departments of Pathology, Women & Infants Hospital/Alpert Medical School of Brown University, Providence, RI, USA; BSM Medical University (BSMMU), Dhaka, Bangladesh; and Physicians Reference Laboratory, Overland Park, KS, USA.After obtaining approval from the Institutional review board of BSMMU, Dhaka, Bangladesh and Institutional Review Board of Women & Infants Hospital, 40 cases comprising of 35 SqCa and 5 cervical HSIL (CIN 2/3) diagnosed during August 2013 – January 2014 at the Department of Pathology of BSMMU, were selected for the study. Paraffin embedded tissue blocks were retrieved from the archive of Department of Pathology, BSMMU and sent to the Women & Infants Hospital, Providence, RI, USA without any patient unique identifiers. At Women & Infants hospital, Hematoxylin and eosin stained sections from each case were reviewed by one pathologist (MRQ) to confirm the diagnosis and affirm the presence of lesional areas for DNA extraction.E7, an oncogene in the HPV genome, which usually gets integrated into the host chromosome and plays a critical role in cervical carcinogenesis. The oncogenes E6 and E7 are stable unlike capsid gene L1, which is reported to be lost during integration.Five to 10, 5 μm tissue sections were obtained to extract DNA from the selected areas of formalin-fixed paraffin embedded (FFPE) tissue samples by using QIAmp DNA FFPE Kit. HPV testing was done using the proprietary COMPLeTe Care HPV test , a multiplex real-time PCR test that simultaneously detected, typed and quantified all 15 high-risk HPV (hrHPV) subtypes. The tested subtypes were 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 73, and 82, as reported by a consensus from several epidemiologic studies . The tarBoth absolute viral load and cell numbers were calculated from the quantitative standards included in each run with the patient samples. The viral loads and ß-globin amounts were determined on the basis of the crossing point (Cp) or crossing threshold (Ct) values above their corresponding baselines in relation to the quantitative standards . Viral lA total of 40 cases were studied, including 35 SqCa and 5 HSIL. The age distribution is shown in Table N = 39) in this series were successfully amplified by multiplex PCR indicating the hrHPV identification rate of 97.5 % in SqCa and HSIL specimens in this study. HPV 16 was detected in 38 of 39 cases (97.4 %), either alone or in combination with HPV 18 (25.6 %). HPV 18 has been identified only in combination with HPV 16. Rare subtypes, HPV 52 and HPV 45, were identified only in two cases. HPV 52 was identified in combination with HPV 16 and HPV 52 (2.5 %). The remaining case had a single infection by HPV 45.All but one case (N = 23) or in combination with HPV 18 (N = 9), or in combination with HPV 52 (N = 1). The single remaining case (2.9 %) showed amplification of only HPV 45. Thus, of the total of 34 SqCa, HPV 18 was present in 9 (26.5 %) patients and HPV 52 in only one patient (2.9 %), both as multiple subtype infections.Of the 35 cases of SqCa, DNA was amplified in all but one case. Out of the HPV positive 34 cases, 33 (97 %) had infection with HPV 16, either alone (All the five cases of HSIL had infection with HPV 16 (100 %), and one of them also had co-infection with HPV 18 (20 %).Multi-subtype infection, mainly of HPV 16/18, was present in 11 out of 39 28 %) cases; ten of these were SqCa and one was a case of HSIL. The normalized viral load of each HPV subtype per 1000 cells is shown in Tables 8 % casesCervical carcinoma induced mortality and morbidity is high and it is the second highest cause of cancer-related deaths in women in Bangladesh . HPV vacAs expected, hrHPV was detected in 97.5 % cases of SqCa and HSIL examined. One test (2.5 %) failed which could very well be attributed to any technical glitch. HPV 16 was detected in overwhelming majority of cases , either alone or in combination with HPV 18 and HPV 52. Interestingly HPV 18 was identified only in combination with HPV 16 in 10 cases (25.6 %). Only in two cases, rare subtypes, e.g., HPV 52 and HPV 45 were identified. HPV 52 was identified in combination with HPV 16. The remaining one case had a single stand-alone infection by HPV 45. Although the rare subtypes HPV are detected in fewer numbers of cases now, they may potentially play an important role in future in post-vaccination era. Of note that some cross protection may be expected against these two rare subtypes of HPV by the quadrivalent and bivalent HPV vaccines available in the country. Recently Nahar and her colleagues reported HPV 66 in the country . Of noteThe current study has found that the rare hrHPV subtypes are highly uncommon in this cervical carcinoma prevalent country. A remarkable homogeneity of HPV 16 infection (97.4 %) in Bangladeshi women with cervical SqCa and HSIL has been documented in this pilot study. This is significantly different from the epidemiologic data reported from the western countries where rare HPV subtypes are more frequently encountered . A largeMulti-subtype HPV infection was detected in 28 % cases in this study. Fortunately, this was noted only as a combination of HPV 16/18 and a single case of HPV16/52. Multiple HPV subtypes infection consisting of rare subtypes of HPV are more frequently reported in studies from Western countries [Viral load of hrHPV is found to have significant association with the development of HSIL and the risk is said to be enhanced with higher baseline HPV DNA . Viral lRoutine screening has successfully decreased hrHPV related female genital tract lesion in the Western world. But Bangladesh, being a developing nation, lacks comprehensive infrastructure for mass screening and early intervention of HPV infection. Therefore, mass immunization against the most prevalent hrHPV subtypes may be an effective way to address the issue. Fortunately even with its limited resources, Bangladesh has established an efficient infrastructure for grass-root level immunization program and has shown tremendous success in childhood vaccination program. Without enduring additional cost it appears possible that Bangladesh can bring down cervical cancer deaths using the existing infrastructure of childhood immunization program. Knowing specific hrHPV subtypes in dysplastic and neoplastic tissues would help the health care workers to fight against the current subtype(s) induced disease and also prepares for future should or when the rare subtype(s) emerge.A remarkable homogeneity of hrHPV 16 infection is noted in women with HSIL & SqCa in this country in this pilot study. This finding is in sharp contrast to the reports from western countries of frequent multi-viral and rare subtype hrHPV infection. This study suggests that a vaccination program would be highly effective in controlling cervical cancer should a larger study ratify the findings of this pilot study.


Vaccinated girls perceived HPV infection as more severe (p = 0.01), had more insight into women’s susceptibility to the infection (p = 0.02), perceived more benefits of the vaccine as protection against cervical cancer (p<0.01) and had a higher intention to engage in HPV-preventive behaviour (p = 0.01). Furthermore, boys and girls were almost equally sexually experienced, although fewer girls had used condom during first intercourse with their latest partner (p = 0.03). Finally, HPV vaccinated girls were less likely to have unprotected sex (p<0.01). In summary, catch-up HPV vaccination among young girls was associated with a European background and high maternal education level, as well as more favourable beliefs towards HPV prevention and less sexual risk-taking. Further preventive measures should therefore be directed at the migrant population.In 2012, human papillomavirus (HPV) vaccination was introduced free of charge in the Swedish national school-based vaccination programme for 10-12-year-old girls, and as catch-up vaccination for young women. In Sweden, there is an ongoing discussion about including boys in the national vaccination programme. Few studies are undertaken about adolescents’ knowledge, beliefs and HPV vaccination status in relation to socioeconomic status and sexual experience. Thus, the aim was to examine HPV catch-up vaccination status in adolescents in relation to 1) socioeconomic factors, 2) beliefs and knowledge about HPV prevention, and 3) sexual behaviour. The Health Belief Model was used as a theoretical framework. Upper secondary school students (n = 832) aged 16, randomly chosen from a larger sample, were invited to participate in conjunction with the general health interview with the school nurse. A total of 751/832 (90.3%), girls  and boys  completed the questionnaire. HPV vaccination was associated with ethnicity and the mothers’ education level; i.e. girls with a non-European background and girls with a less educated mother were less likely to have received the vaccine ( One decade has passed since the vaccines Gardasil and Cervarix against human papillomavirus (HPV) were introduced. These vaccines have primarily been developed to prevent infection with HPV types 16 and 18, the types responsible for roughly 70% of all cervical cancer, affecting more than 500 000 women annually , 3.Despite the successful impact of these vaccines worldwide, their introduction has sparked debate not only about possible side effects of the actual vaccines, but even more on assumed effects on the behaviour of the young people being vaccinated –6. A feaPrevious research indicates that several factors are important for HPV vaccination status, i.e. demographic and socioeconomic factors, individual beliefs and knowledge as well as behavioural aspects. Lower socioeconomic resources correlate with lower vaccine uptake. A Danish register study showed lower HPV vaccine initiation and completion among girls with an immigrant background and girls with mothers with lower educational level . A similAdolescents have low knowledge about HPV, especially about the link between sexual behaviour, HPV and HPV-related cancer –18. AccoIn 2010, HPV vaccination was offered free of charge to all girls born 1999 or later, and in 2012 the vaccine was introduced into the school-vaccination programme for all girls aged 10–12 years, and as catch-up vaccination for young women. Boys were not included in the vaccination programme at the time. These measures have had considerable impact: it is estimated that presently almost 80% of all girls receive the vaccination . School Two years ago, we conducted a cluster randomized controlled study , with thAs already mentioned above, HPV vaccination status was associated with socioeconomic factors, individual beliefs, and behavioural aspects such as risk-taking and sexual experience. This study has therefore focused on the baseline data of the participants of the intervention study.Our aims were dual:To describe sexual experiences in 16-year-old adolescent girls and boys in general and for the former group also in relation to catch-up HPV vaccination status, (see item 2).To investigate HPV vaccination status in female adolescents in relation to a) sociodemographic factors, b) individual beliefs and knowledge about HPV prevention, and c) sexual experiences.It was hypothesised that vaccination against HPV was associated with a more favourable socioeconomic situation, more favourable beliefs towards HPV prevention, and less risk-taking. It was also hypothesised that there would be differences between boys and girls regarding sexual experiences and behaviour.This cross-sectional study is a part of the project Prevention of HPV in a school-based setting , with trSweden is a multicultural country of 10 million inhabitants; about 23% of the population at large, and almost 30% of those below age 18 years of age, have an immigrant background with at least one parent born abroad. The most common countries of origin outside the Nordic countries are Afghanistan, Ethiopia, Iraq, Iran, Somalia and Syria–thus, many of these families have experienced war , 33. AlmIn 2014, school nurses working in upper secondary schools (n = 59) in Sweden were invited to participate in the project via direct contact at the national conference for school nurses. We also sent information about the study by email to the heads of the school health in the respective municipalities (n = 9). The north and the south extremities of the country were excluded for logistic reasons. In the end 20 school nurses, working in 18 schools situated in five counties  in mid and western Sweden, were included. In a Supplemental file (In the second stage classes were randomised to be involved and thereafter adolescents in the included classes were invited to participate. The school nurse informed adolescents (n = 832) (both girls and boys) about the project orally and with a leaflet before the health interview started. Adolescents who agreed to participate gave informed written consent and completed a questionnaire individually in a separate room at the school nurse’s office. It took about 10–15 minutes to complete the questionnaire.Eligible for inclusion were first-year upper secondary school students, aged 15 years or more, attending the general health interview with the school nurse. Students with severe cognitive learning disabilities and development disorders  and students who were not able to read and write in Swedish (e.g. recently arrived immigrants) were excluded. For details of the procedure and randomisation see Grandahl et al . Notablyperceived susceptibility, perceived severity, perceived benefit, perceived barriers, perceived self-efficacy and cues to action. In HBM, socio-demographic factors such as age, sex, ethnicity and education level as well as knowledge are recognised as modifying factors for the individual’s behaviour [HBM was used as a theoretical framework for this project. According to HBM, a person’s health behaviour can be explained by individual beliefs regarding health actions. HBM includes the following central constructs: ehaviour . The theehaviour –40 and sehaviour .The questionnaire was based on previous research , 42, 43.We conducted the study according to the Declaration of Helsinki. All participants received oral and written information before giving their written consent. The participants were informed that participation was voluntary, that they could withdraw at any time, for any or no given reason, without incurring any negative consequences for themselves. They were also informed that only the researchers would have access to the data and that all data would be presented on a group level. Contact details to the researchers were provided in case of further questions. According to the Swedish law children above 15 years of age who understand what participation means have the right to give their own informed consent regarding participation in research. Therefore, informed consent was not obtained from the parents. We asked permission to conduct the study from both the head of the school health in each municipality and from the heads of the individual schools. Approval was acquired from The Regional Ethical Review Board of Uppsala University (D.nr.2013/324).“I intend to use a condom if I have sex with a new partner” and “I intend to attend Pap-smear testing”. We created a knowledge score by computing the responses to ten of the statements about HPV and the HPV vaccine. Each of the statements could yield a maximum of four points if the respondent totally agreed with a correct or totally disagreed with an incorrect statement. The response alternatives “neither agree nor disagree” and “do not know” were given zero points. The total knowledge score could thus add up to a maximum of 40 points. We investigated differences between groups  with Chi-square test and Fisher’s exact text for nominal-scaled variables, with Mann Whitney U-test for ordinal-scaled variables and with Student’s t-test for continuous variables. In order to make comparisons, we collapsed some of the variables into dichotomous variables. Country of origin was thus dichotomised into European and non-European; parents’ education into low (up to 12 years of schooling) and high; parents’ occupation into either working/studying or neither; smoking and snuff use into either and none; and alcohol binge drinking into never and sometimes. We used a multivariate logistic regression model to investigate factors associated with HPV vaccination status among the girls. Sociodemographic variables such as parents’ country of origin, education, and occupation correlated highly, as did the HPV-related variables. We therefore chose to enter only two non-correlating sociodemographic variables; country of origin and mother’s education, the calculated knowledge score and the variable “discussed HPV with other than parents” in the multivariate regression model. A p-value of p<0.05 was considered statistically significant. The missing values were few and did not exceed 3% for any of the items.Data were analysed using SPSS for IBM  , 391 girls and 360 boys, agreed to participate. Around half of the respondents had had sexual intercourse as shown in There were no differences in separate knowledge items about HPV and HPV vaccination among vaccinated or non-vaccinated girls. However, when computed together to form a knowledge score, vaccinated girls scored higher .Differences between HPV vaccinated and non-vaccinated girls with respect to background variables, sexual experience and other HPV related variables were also examined. The results of the bivariate analyses are shown in A multivariate logistic regression model including selected variables differing significantly in the bivariate analysis was performed as described in the Methods section. The result is displayed in p<0.01), and less unprotected latest intercourse  compared to their non-vaccinated peers. No difference was found in relation to first intercourse (16.5% vs. 22.2%). The girls’ intention to prevent HPV infection in the future did not differ with respect to demographic variables, such as country of birth or parental factors.Finally, we examined sexual risk-taking in relation to HPV vaccination status and found that vaccinated girls had less unprotected first intercourse with their latest partner . This very important finding needs to be emphasized, since the fear that HPV vaccination could promote “promiscuity” is a recognized obstacle against vaccination , 5, 7. OThe questionnaire was validated and a high response rate of 90.3% was obtained . The strThe participants completed the questionnaire in a separate room at the school nurse’s office. The questionnaires were properly completed and no extraordinary outliers were found in the data. As in all studies using self-reported questionnaires, there is a risk of participant over- or under-reporting and recall bias, although we consider this risk small in the present study. Furthermore, this survey had a cross-sectional design, which did not allow for conclusions regarding causes and effects. Finally, we did not know exactly when the included adolescents received the vaccination in relation to their sexual experiences.In Sweden, HPV vaccination is included in the national vaccination programme offered free of charge by school-nurses in the school health services. The lower degree of HPV catch-up vaccination among immigrant girls needs to be emphasized since in Sweden, many girls come from low-income countries with poor vaccine coverage. In order to bridge the gap and enhance informed consents based on actual facts rather than emotional, cultural, or religious beliefs this study suggests that we can recommend that parents and adolescents are provided with the evidence-based fact that HPV vaccination neither contributes to earlier sex debut nor to more risk-taking sexual behaviour. Since the school health and especially the school nurses are key persons for successful HPV vaccination programmes this information could be distributed by them. Since the knowledge about HPV and HPV vaccine still is low we also recommend that pupils, both boys and girls, are informed about the virus and the vaccine not only at time for the vaccination, but continuously during their school period. This is in line with the national goal of equal health for the entire population. Uniquely, the school health services reach all adolescents regardless of socioeconomic status or country of origin.Catch-up HPV vaccination among young girls was associated with a European background, a high maternal education level, more favourable beliefs towards HPV prevention, and less sexual risk-taking. Further preventive measures should therefore be directed at migrant adolescent girls and boys and their parents.S1 File(DOCX)Click here for additional data file.S1 Fig(JPEG)Click here for additional data file.S2 File(SAV)Click here for additional data file.


Since mid-2006, a licensed human papillomavirus (HPV) vaccine has been available and recommended by the Advisory Committee on Immunization Practices (ACIP) for routine vaccination of adolescent girls at ages 11 or 12 years . HPV vacSince 2006, NIS-Teen has collected vaccination information for adolescents aged 13–17 years in the 50 states, the District of Columbia, and selected areas,Vaccination coverage was assessed for each dose of the HPV vaccination series. For girls and boys, respectively, and for each vaccine series dose, HPV vaccination coverage estimates in 2013 were significantly higher compared with 2012 .To evaluate receipt of ≥1 dose of HPV vaccine by age 13 years among adolescent girls, data during 2007–2013 NIS-Teen survey years were combined and analyzed by birth cohort.The percentage of parents reporting that they received a recommendation for the HPV vaccine from their clinician was significantly higher in 2013 compared with 2012 for both parents of girls (64.4% compared with 61.0%) and parents of boys (41.6% compared with 28.0%). More parents of vaccinated teens  reported receiving a recommendation compared with parents of unvaccinated teens .The 2013 NIS-Teen asked parents who reported they were not likely to vaccinate their teen in the 12 months after interviews or were unsure of their vaccination plans  to identify the main reason why their teen would remain unvaccinated. The top five responses from the parents of girls and parents of boys were the same, differing only in order of frequency . More thIn the United States, postlicensure vaccine safety monitoring and evaluation are conducted independently by federal agencies and vaccine manufacturers. From June 2006 through March 2014, approximately 67 million doses of HPV4 were distributed in the United States, and from October 2009 through March 2014, a total of 719,000 doses of HPV2 were distributed. Overall, HPV4 has accounted for approximately 99% of doses distributed since 2006. Multiple studies have provided evidence supporting HPV vaccine safety  recommended three critical goals that must be achieved to increase HPV vaccination coverage in the United States, including 1) reducing missed clinical opportunities to recommend and administer HPV vaccines; 2) increasing parents’, caregivers’, and adolescents’ acceptance of HPV vaccination; and 3) maximizing access to HPV vaccination services. CDC, in partnerships with state and local immunization programs, is working with health professional organizations to reduce missed opportunities for HPV vaccination and support clinicians’ capacities to give HPV vaccination recommendations consistent with national vaccination recommendations.The President’s Cancer Panel 2012–2013 report released in February 2014  vaccination for girls and boys at ages 11 or 12 years. The 2012 National Immunization Survey-Teen indicated only 53.8% of girls and 20.8% of boys aged 13–17 years had received ≥1 dose of HPV vaccine.What is added by this report?Vaccination coverage significantly increased in 2013; 57.3% of girls and 34.6% of boys received ≥1 dose of HPV vaccine. The percentage of parents reporting that they received a clinician recommendation for the HPV vaccine was significantly higher in 2013 compared with 2012 for both parents of girls (64.4% versus 61.0%) and parents of boys (41.6% versus 28.0%). Analysis of provider records showed that if HPV vaccine had been administered at health care encounters when other recommended vaccines were administered, ≥1 HPV vaccination coverage by age 13 years for the most recent birth cohort of girls could have been as high as 91%. National safety monitoring data continue to indicate that the HPV vaccine is safe.What are the implications for public health practice?Despite the availability of safe and effective HPV vaccines, many adolescents have not been vaccinated. Vaccination coverage of adolescent girls by age 13 years increased across seven birth cohorts but missed vaccination opportunities persist. Improving practice patterns so that clinicians and their staff members use every opportunity to recommend HPV vaccines for boys and girls and address questions from parents is necessary to reduce vaccine-preventable HPV infections and cancers caused by HPV.http://www.cdc.gov/vaccines/youarethekey), a tip sheet for talking about the HPV vaccine with parents, and continuing education programs for pediatricians and family physicians regarding the clinical impact of persistent HPV infection and the importance of vaccinating adolescents at ages 11–12 years. To improve public acceptance of HPV vaccination, CDC continues to use research data to create an evidence-based communication campaign to reach the target audiences. Although it is still too early to evaluate the impact of activities implemented since publication of the 2012 NIS-Teen results , but some bias might remain in weighted estimates. Second, vaccination histories reported by providers might be incomplete, which would contribute to underestimation of vaccination coverage. Third, evaluation of missed opportunities only included health care encounters in which a vaccination was administered, and thus estimates of potential coverage would be underestimated if there were additional health care encounters in which a vaccination could have been administered. Finally, VAERS is a passive reporting system that accepts reports from anyone, including health care providers, patients, or family members. VAERS cannot determine cause and effect; a report of an adverse event to VAERS does not mean that a vaccine caused the event. Underreporting might occur, and serious medical events are more likely to be reported than minor ones.The cohort analysis presented in this report combines data from subjects over multiple survey years; the denominator for the 2000 cohort might not be the same as the denominator for females aged 13 years included in the 2013 NIS-Teen data . In addiProgress with HPV vaccination is occurring, but at a slow pace. In 2013, only 57.3% of girls and 34.6% of boys had initiated the HPV vaccine series. CDC will continue its efforts to partner with state and local immunization programs, professional organizations, cancer organizations, and other stakeholders to educate parents and clinicians. Collaborative efforts remain critical to promoting HPV vaccination so that the nation’s adolescents are protected against vaccine-preventable, HPV-associated cancers.


The goal of this Special Issue was to obtain expert viewpoints on unresolved, controversial or emerging topics related to the natural history, evolution, biology, and disease association of HPV infection. The resulting articles cover a wide range of thought provoking topics.There are over four hundred different papillomavirus (PV) types, which replicate in mucosal and cutaneous stratified epithelial surfaces giving rise to a wide range of lesions. Papillomaviruses have a remarkable life style that relies on the differentiation state of the host epithelium; they infect the basal cells of the epithelium and establish a quiescent infection in the proliferative cells. As the infected cells differentiate, the productive life cycle is activated, and viral-laden squames are eventually released from the surface of the epithelium. To support this life style, PVs interact with, and manipulate, many key cellular pathways. In this Issue, Puustusmaa and colleagues present an intriguing study in which they searched the biosphere for distant homologs of PV protein domains in a quest to discover the origin of papillomaviruses . Suarez Over three hundred human papillomavirus (HPV) types have been described and HPV infection is ubiquitous. However, many questions remain about infection, progression and resolution of HPV-associated disease. Gravitt and Weiner present a natural history model across the lifespan of an infected individual, with a particularly focus on the role of viral latency . Alizon A subset of alpha-HPVs are oncogenic and are the causative agent of approximately 5% human cancers. Viral manipulation of host pathways can inadvertently promote oncogenesis and several articles in the Special Issue address this. Katzenellenbogen describes the role of telomerase activation in HPV infection and oncogenesis , while WHPV-associated cancers acquire profound changes and phenotypes that are important for carcinogenesis and could impact prognosis and treatment. Morgan and colleagues reevaluate the status of integrated and extrachromosomal HPV genomes in head and neck cancer  and LitwWe thank the authors and reviewers for giving their time, and sharing their expertise, to contribute to this stimulating collection of articles. We hope that the Special Issue has provided insight into many aspects of HPV infection and will inspire future questions, ideas and research.