To test the diagnostic power of Pocket Size Imaging Device (PSID) in detecting early signs of right heart (RH) involvement in regular smokers (RS) free of overt cardiac involvement.One-hundred-forty-three regular smokers and 51 healthy controls, comparable for age and sex, underwent physical exam (PE), PSID exam and standard echocardiography. Based on a simplified Boston score, ≥1 of clinical signs  were considered indicative of RH involvement. A composite score (1 to 4) obtained by summing the points of four quantitative RH abnormalities detectable by PSID , was generated and ≥1 of PSID abnormal signs was considered indicative of RH involvement.Boston score was not significantly different between the two groups. By using PSID, smokers exhibited greater IVC diameter (p < 0.0001), right atrial diameter (p < 0.002) and higher PSID score (p < 0.005) than controls. Compared to PE, the additional diagnostic power of PSID  was 44.9 % in smokers. By dividing smokers in tertiles according to number of cigarettes per day, the third tertile showed the largest values of both IVC and right atrial dimension. Differences were confirmed by standard echocardiography. Reproducibility of PSID measurements and concordance of linear measurements between PSID and standard echo measurements was very good except for concordance of right ventricular basal diameter.PSID detects early ultrasound signs of RH involvement in regular otherwise healthy smokers in comparison with PE. An estimated 20 % of american adults are regular smokers , withoutPocket Size Imaging Device (PSID), an ultrasound machine which cannot be classified as a standard echocardiographic machine because of the impossibility of calculating cardiac volumes and quantifying valvular flow by pulsed or continuous wave Doppler, has a potential value as a screening tool , because2), arterial systemic hypertension (systolic blood pressure > 140 mm Hg and/or diastolic blood pressure > 90 mm Hg or current antihypertensive treatment) and dyslipidemia  were not exclusion criteria in both the groups. Patients with coronary heart disease, primary cardiomyopathies, more than mild heart valve disease, atrial fibrillation, congenital heart disease, autoimmune disease, diabetes mellitus and any kind of renal and/or hepatic diseases as well as patients taking beta-blocker drugs and/or diuretics were excluded. The study protocol was approved by the Institutional Ethical Committee of Federico II University Hospital and written informed consent was obtained from all participants.The study population included women and men aged > 40 years, smoking cigarettes since at least 5 years, asymptomatic for dyspnea. The non-smokers control group, recruited among the staff of the Federico II University hospital, included healthy subjects who had never smoked. Obesity  performed in our outpatient clinic by a clinician (CS);An ultrasound assessment by PSID , performed in the same outpatient clinic by two operators (VS-L or RE), blinded to the physical examination;A complete standard echo-Doppler assessment of the right ventricle, performed in the echo-lab by a cardiologist (MG) blind to both the physical exam and PSID assessment.In the same day (morning time between 9 and 11 am) all the participants underwent sequentially the following diagnostic steps:Smokers were requested to do not smoke at least two hours before the performance of the clinical exam and cardiac ultrasound (PSID and standard echo) assessment.The following four clinical signs of RH involvement were considered during physical exam: jugular vein distension, hepatomegaly with hepato-jugular reflux, peripheral pitting oedema, pulmonary crackles. The sum of the points of each sign  was performed to generate a simplified Boston score, as previously described .maximal (end-expiratory) IVC diameter > 2.0 cm [14],percent respiratory variation of IVC < 50 % , 14,RA maximal transverse middle diameter > 4.5 cm ,RV maximal transverse basal diameter > 4.2 cm .The following four parameters of right heart involvement were assessed by PSID: 1. maximal (end-expiration) inferior vena cava diameter (IVC) in subcostal view , 13, 2. tricuspid annular plane systolic excursion (TAPSE) [8],tricuspid inflow E/A ratio,systolic velocity (s’), early diastolic (e’) and atrial (a’) velocities of the tricuspid annulus by pulsed Tissue Doppler,retrograde maximal gradient of tricuspid regurgitation by CW Doppler , wheneveBy standard transthoracic echo-Doppler exam we measured the same above mentioned four parameters and the following additional parameters, determined according to standardized procedures of our laboratory :tricuspiBoth PSID and standard echocardiographic exams were performed in left lateral decubitus position.χ2 distribution with computation of exact p value by Monte Carlo method. The intra-class correlation analysis (rho) was used to test the concordance of the main parameters measured by PSID and standard echocardiographic machine and also intra- and inter-observer reproducibility of PSID measurements. The null hypothesis was rejected at a two-tailed p ≤ 0.05.Statistical analysis was performed by SPSS package release 12 . Data are presented as mean values ± SD. Inter-group comparison was obtained by one-factor ANOVA and The characteristics of the study population are listed in Table Table Table Table Additional analyses were performed by dividing the group of smokers in tertiles according to the number of cigarettes smoked per days . By these analyses both IVC and RA dimension were significantly larger in the third tertile  was significantly higher in regular smokers than in controls. In contrast, the simplified Boston score did not recognize any significant difference between the two groups. By comparing Boston and PSID score in smokers , PSID showed a 44.9 % increase in the capacity of detecting RH involvement in our regular smokers.The simple physical exam has obvious limitations for diagnosis of heart involvement in subclinical cardiac diseases , 29. A nAn additional finding of our study is provided by the analyses we performed dividing the smoker population according to tertiles of daily smoked cigarettes. These analyses was done to highlight possible graduality effect of smoking habit on PSID parameters. Both IVC and RA diameter were larger in the third tertile, i.e. in smokers of more than 20 cigarettes/day. These results, found also by using standard echo machine, highlight further the well known negative effect of cigarette smoking on cardiac and vascular structure . They poGlobally, the results of the present study are reinforced by the good intra- and inter-observer reproducibility of PSID measurements and by the good intra-class relation coefficients between PSID and standard echo measurements of the right heart. These coefficients were very good for all the quantitative parameters analyzed, with the exception of RV diameter. The difficulty of obtaining a definite border delineation of RV chamber size in apical 4-chamber view by using PSID can explain the weakness of RV diameter using PSID.a priori decided to do not use the simple color assessment of tricuspid regurgitation in our composite PSID score. Although tricuspid regurgitation can be visualized by color Doppler of PSID, the diagnostic accuracy of PSID in distinguishing marginal from clinically significant regurgitation has been found to be poor [The main limitation of the use of PSID in the explored clinical context was the impossibility of obtaining a non invasive estimation of tricuspid regurgitation gradient and of pulmonary arterial pressure. This contributes to differentiate substantially PSID from a standard echo instrumentation. Accordingly, we  be poor , 20, maiAnother limitation corresponds to the lack of any kind of estimation of RV systolic function and of RA volume by using PSID. Very recent 2015 echo recommendations on chamber quantification encourage the use of RA volume as the most reliable parameter of RA size . HoweverThe lack of data on lung function tests (e.g. spirometry) and on biomarkers (BNP and/or pro-BNP), not performed because of the screening nature of our asymptomatic smokers, could have been useful to better refine the clinical picture of these subjects and could be considered as a further study limitation.We demonstrate that the prompt technology of PSID provides the ability of detecting RH involvement in regular asymptomatic smokers. These data are consistent with an early RV longitudinal dysfunction observed in young, asymptomatic smoker buy using standard echo and strain rate imaging . Changes


Immunity plays an important role in controlling human papillomavirus (HPV) infection and associated lesions. Unlike infections caused by other viruses, natural HPV infection does not always result in a protective antibody response. Therefore, HPV antibodies are also considered markers of cumulative exposure. The aim of this study was to identify determinants of HPV16 seroreactivity at enrollment among women from the Ludwig-McGill cohort, a natural history study of HPV infection and risk of cervical neoplasia.HPV16 serology was assessed by ELISA for L1 and L2 capsid antigens, while HPV typing and viral load measurements were performed by PCR-based methods. The associations were analyzed by unconditional logistic regression.Of 2049 subjects, 425 (20.7%) were strongly seropositive for HPV16. In multivariate analysis, seroreactivity was positively correlated with age, lifetime number of sexual partners, frequency of sex, and HPV16 viral load, and negatively associated with duration of smoking.HPV16 seroreactivity is determined by factors that reflect viral exposure. Persistent infection by human papillomavirus (HPV) is a necessary cause of cervical cancer, but only a small proportion of HPV positive women develop cervical lesions. HPV infection is considered the most common sexually transmitted infection worldwide. Most sexually active individuals are likely to be exposed to HPV infection at some point in their lives . HoweverThe high frequency of HPV-related diseases in immunocompromised individuals underscores the important role of immune response to control HPV infection . Indeed,In contrast with other viral infections in which natural exposure results in a protective antibody response, only about half of the women infected with HPV have detectable levels of anti-HPV serum antibodies. Furthermore, about half of these HPV seropositive women produce neutralizing antibodies capable of preventing initial phases of infection . TherefoThe Ludwig-McGill cohort study is a longitudinal investigation of the natural history of HPV infection and related lesions of the uterine cervix. About 2,500 women were followed for up to 10 years. The aim of the present study was to identify determinants of HPV16 seroreactivity at enrollment among women from the Ludwig-McGill Cohort Study.A detailed description of the design and methods for subject recruitment, scheduled returns, epidemiologic data, medical procedures, and biological sampling has been described elsewhere . BrieflySerum samples were separated from clotted blood specimens and stored at -20°C until testing. An ELISA technique was used for semi-quantitative measurement of IgG antibodies to HPV16. Recombinant HPV16 virus-like particles, constructed with L1 capsid protein, were prepared in the baculovirus system. An initial batch was kindly donated by Dr. John Schiller, Laboratory of Cellular Oncology, U.S. NIH and subsequent batches were kindly donated by Dr. Kathryn Jansen, Merck Laboratories, USA. The ELISA protocol was performed as described elsewhere ,14]. Br. Br14]. Seroreactivity was expressed as normalized absorbance ratios (NAR) by dividing the mean blank-subtracted (net) optical densities (ODs) by the equivalent values of the control serum pool included in the same plate in triplicate, using different dilutions. An average NAR (AvgNAR) for each serum sample was then calculated based on two dilutions: AvgNAR = (NAR10+ NAR50)/2, where NAR10 and NAR50 are the results with the 1:10 and 1:50 dilutions, respectively. In a previous report we described the reproducibility of the assay and calculation of seroreactivity and demonstrated that this method is suitable to minimize measurement error in ELISA assays . We arbiSince our goal was to investigate the correlates of seroreactivity at baseline in the cohort, only the serum samples from the first two visits were considered. Of the 2462 eligible subjects at the enrollment visit, 2185 subjects were followed up at the second visit, 4 months later. Serological results were available for 1745 and 1656 women in the first and second visits, respectively. To maximize the availability of serological data for analysis we imputed to the woman the serological result from the second visit if the one for the enrollment visit was missing, which resulted in 304 imputations. Therefore, a total of 2049 subjects had baseline IgG seroreactivity anti-HPV16, under the assumption that in a 4-month period there would not be any important fluctuations in serological results. Questionnaire-based information was derived from the interviews conducted at the enrollment visit.DNA was extracted from ecto- and endocervical cell samples and assessed for DNA quality by amplification of a 268-bp β-globin gene fragment . MY09/11Quantification of viral load in HPV-positive samples was performed by low-stringency PCR with HPV generic GP5/6 primers ,21]. DN. DN21]. The associations between HPV16 serological reactivity and socioeconomic determinants, lifestyle factors, reproductive health factors, or clinical and viral characteristics were measured by unconditional logistic regression. We calculated odds ratios (OR) and respective 95% confidence intervals (CI) to gauge the magnitude and precision of the associations. Age and HPV16 DNA positivity were considered potential confounders or mediators and were thus included as covariates to be adjusted for in all exploratory models. Age was considered as 4 categories . We also sought to identify a subset of independent correlates of anti-HPV16 seroreactivity via a stepwise multivariate logistic regression strategy with backwards elimination of variables (p = 0.15 for elimination). We used STATA statistical software (version 10.0) in all analyses.To analyze the predictors of serological response in the cohort, we arbitrary selected the top 20% of seroreactivity results of 2049 women who had HPV16 serological results. Consequently we identified 425 women for the purpose of the current analysis.Table Table Results for reproductive health characteristics that could influence HPV seroreactivity are presented in Table We also analyzed the associations between cervical HPV findings at enrollment and serological response to HPV16. Table Finally, we attempted to identify the most parsimonious set of correlates of HPV16 seroreactivity via multivariate analyses. As shown in Table In this study we analyzed the epidemiologic correlates of strong anti-HPV16 seroreactivity at the enrollment visits of women from the Ludwig-McGill Cohort Study. We defined the serological reactivity as strong if the subject's average NAR was in the upper quintile of anti-HPV16 ELISA seroreactivity. This definition is probably more stringent than methods used in early reports, but associations with similar factors were identified. Our results revealed that strong HPV16 seroreactivity increased with age, and other factors that reflect HPV exposure, as number of lifetime sexual partners, younger age at first intercourse and higher frequency of sex.The association of HPV16 serology with increasing number of sexual partners is well known ,22],,. MoreoveIn our analysis, seroreactivity increased with age. Although this association was not consistently found in other investigations ,26], as, as26], Although the Ludwig-McGill study is based on a multiple-measurement, prospective cohort investigation we focused on determinants of baseline seroreactivity using only serological results from a single time point (the enrollment visit), which prevented us from considering duration of infection in the analyses. This limitation in our ability to define when infections began prevented us from understanding the timing for serological responses to become observable following the initial exposure. Nevertheless, we observed a positive correlation between HPV16 seroreactivity and HPV16 DNA positivity alone or in coinfection with other types with strong evidence of type-restricted responses. We also observed some degree of cross-reactivity for infection with other types in Alphapapillomavirus 9 species (excluding HPV16), which can be expected because of the similarity of antigenic epitopes in L1 and L2 for members of that species.Porras and colleagues (2010) reported that a high viral load for HPV16 is positively correlated with anti-HPV16 antibody titer, suggesting that seroconversion could be a consequence of an increase in antigen exposure . We haveThe relation between the use of contraceptives and HPV seropositivity has been controversial. In our study, neither use of contraceptives , nor parity were significant determinants of seroreactivity. A positive influence of hormonal contraceptives on HPV16 seropositivity was described before . SpecifiOn the basis of this cross-sectional analysis we observed that strong baseline seroreactivity was positively correlated with age, lifetime number of sexual partners, frequency of sex, and HPV16 viral load, and negatively associated with duration of smoking. Taken together our data suggest that HPV16 seroreactivity is determined by factors that reflect viral exposure.PSAS analyzed and interpreted the data and drafted the manuscript; AVR managed the databases performed the statistical analysis and contributed to the draft of the manuscript; JMGC and PT carried out the serology detection; AT performed the viral load measurements; ELF conceived the study design and data analysis strategy; LLV participated in the study design and supervised the study. All authors read and approved the final manuscript.


Women in several countries will soon be covered by two preventive programmes targeting cervical cancer: HPV vaccination and cervical screening. The HPV vaccines are expected to prevent approximately 70 % of cervical cancers. It has been speculated, that HPV vaccinated women will not attend screening because they falsely think that the vaccine has eliminated their cervical cancer risk. The aim of this study was to investigate the association between HPV vaccination status and perceptions of cervical cancer risk; perceptions of vaccine effect; and intention to participate in cervical screening. Furthermore, to investigate associations between perceptions of cervical cancer risk and intention to participate in cervical screening.A random sample of Danish women from the birth cohorts 1993–1995 was invited to complete a web-based questionnaire concerning risk perceptions and intentions to participate in cervical screening. Main outcomes were: perceived lifetime-risk of cervical cancer; perceived HPV vaccine effect; and intention to participate in cervical screening.HPV vaccinated women more often than unvaccinated women intended to participate in screening: adjusted odds ratio (OR) for being HPV vaccinated when intending to participate in screening of 3.89 (95 % CI: 2.50–6.06). HPV vaccinated women perceived cervical cancer risk to be higher than unvaccinated women did: adjusted OR of 0.11 (95 % CI: 0.03–0.39) and 0.51 (95 % CI: 0.33–0.78) for being HPV vaccinated while having the lowest perception of risk (in two different pre-specified dichotomisations). HPV vaccinated women perceived the vaccine effect to be larger than unvaccinated women did: adjusted OR of 0.31 (95 % CI: 0.18–0.51) and 0.37 (95 % CI: 0.25–0.53) for being HPV vaccinated while having the lowest perception of vaccine effect (in two different pre-specified dichotomisations). There were no associations between perceived cervical cancer risk and intention to participate in screening.HPV vaccinated women more often than unvaccinated women intended to participate in screening and they perceived cervical cancer risk to be higher and the vaccine effect to be larger than unvaccinated women did. However, in our analyses, risk perceptions could not explain screening intentions neither among vaccinated nor among unvaccinated women.The online version of this article (doi:10.1186/s12889-016-3397-y) contains supplementary material, which is available to authorized users. Women in several countries will soon be covered by two preventive programmes targeting cervical cancer: HPV vaccination and cervical screening. Screening for cervical cancer has been followed by a reduction in cervical cancer incidence and mortality assumedly caused by screening . The twoWomen’s knowledge about cervical cancer is generally poor, and they overestimate their risk of cervical cancer and the effect of cervical screening –7. AfterTherefore, our aim was to investigate if there was an association between HPV vaccination status and perceptions of cervical cancer risk; perceptions of vaccine effect; and intention to participate in cervical screening. Furthermore, we investigated associations between risk perceptions and intention to participate in cervical screening.This study was carried out in Denmark. The Danish Health Authority recommends cytology screening triennially for women aged 23–49 years, and every 5 years in the age group 50–64 . ScreeniThe study population was females from the birth cohorts 1993, 1994 and 1995. A random sample of these cohorts was drawn using the public register Statistics Denmark. We received personal contact information drawn from public registers. Telephone numbers were matched on names and address. Those who did not have an obtainable publicly registered telephone number were excluded. The remaining potential respondents were sent an SMS (short text message) containing a link to the survey. No gifts, prices or other incentives were used. Data collection started 8 April 2015. Reminders were sent 8 days and 14 days after data collection started. The data collection ended 20 May 2015, when no further responses had been received for more than two weeks.Survey data were supplemented with socio-demographic data obtained from Statistics Denmark. The Danish Civil Registration System (CRS) contains information on all individuals with a permanent address in Denmark . Each inWe included the following socio-demographic register-based variables: Ethnicity, degree of urbanisation, completed educational level, parents’ educational level, and primary care contacts within the previous year . In order to obtain current information on the women’s educational level, we asked respondents about their on-going education in the questionnaire.A web-based questionnaire, compatible with smartphones and tablets, was developed with the programme Survey Xact.HPV unvaccinated woman and successively for an HPV vaccinated woman. In the second part of the questionnaire all potential respondents were randomised to one of four study arms receiving four different information modules, respectively. Finally, all respondents were asked about their intention to participate in cervical screening. The questionnaire did not allow respondents to go back and change their responses to previous questions, thus the questions concerning risk perceptions were not affected by the information modules later in the questionnaire.In the first part of the questionnaire, respondents were asked about their educational level and HPV vaccination status. Subsequently, they were asked about their perception of lifetime-risk of cervical cancer for an The results from the randomised trial of the effect of the information modules will be reported elsewhere . In the Think-aloud interviewing and cognitive probing [The first draft of questionnaire items was made through an iterative process involving consecutive discussions among all authors. The final version was generated via qualitative interviews with 12 women in the target group. A combination of two techniques was applied:  probing , 22, ensWe used four self-reported outcomes: Perceived lifetime-risk of cervical cancer conditional on negative HPV vaccination status; perceived lifetime-risk of cervical cancer conditional on positive HPV vaccination status; perceived HPV vaccine effect; and intention to participate in cervical screening.HPV unvaccinated woman  and ii) lifetime-risk of cervical cancer for an HPV vaccinated woman . Respondents were to provide their answer in terms of number of women per 1000 women that will develop cervical cancer before the age of 75. The answer was to be given on a slider ranging from zero to 1000.We asked respondents to report their perceptions of i) lifetime-risk of cervical cancer for an vaccinated cervical cancer risk with their estimate of unvaccinated cervical cancer risk multiplied with 100. Thus, we did not ask respondents directly about their perception of the vaccine effect. The rationale was to make the questionnaire as short and as easy to understand as possible. Furthermore, we wanted an intuitive answer; we did not expect the majority of the respondents to have the exact answer to this question.In our subsequent analyses, we calculated each respondent’s perception of the risk reduction in percentage attained by the HPV vaccine by dividing their estimate of In our analyses of association between risk perceptions and intention to participate in screening, we matched vaccination status with the relevant perceived cervical cancer risk.The distributions of the risk perception outcomes differed between HPV vaccinated and unvaccinated respondents Figs. , 3 and 4Perceived HPV vaccination effect was likewise dichotomised by three cut-offs: ≤0 % vs. >0 %; <60 % vs. ≥60 %; and <95 % vs. ≥95 %. The first cut-off grouped the cases where respondents reported a higher risk for a vaccinated woman than for an unvaccinated woman, producing a negative vaccination effect (indicating miscomprehension). The second cut-off was set at the lower limit of an approximately correct estimate of the expected vaccine efficacy which is approximately 70 % . The thiIntention to participate in cervical screening is an accepted outcome measure, previously used in the context of cervical screening . The queAnalyses of the relations between (i) HPV vaccination status and intention to participate in screening (ii) HPV vaccination status and risk perceptions and (iii) risk perceptions and intention to participate in screening were conducted applying logistic regression analysis. We conducted the unadjusted analyses as well as adjusted for the following socio-demographic variables: Year of birth, ethnicity, degree of urbanisation, completed educational level, self-reported on-going educational level, parents’ educational level, and primary care contacts within the previous year. Moreover, we adjusted for study arm including interaction between study arm and HPV vaccination status . All calculations were made in SAS v9.4.n = 988) with 25 % (n = 823) completing all parts of the questionnaire. We received 26 e-mails from potential respondents, who had received an SMS but were not in the target group . Eleven of these 26 persons had responded to the questionnaire and their responses were excluded from the analyses. Of the remaining 977, 949 (28.8 %) completed the question concerning HPV vaccination status and were included in the analyses  had a publicly registered telephone number. The overall response rate was 30.0 %  vaccinated cervical cancer risk, iii) the implied HPV vaccine effect are shown in Figs. unvaccinated cervical cancer risk was 261 per 1000    ts) Fig. . Thus, tts) Fig. .Fig. 2Ununvaccinated cervical cancer risk was statistically significant in the two pre-specified dichotomisations with the lowest cut-offs. (Adjusted OR of 0.11 (95 % CI: 0.03–0.39) for being vaccinated while being in the lowest risk perception group when cut-off was set at <11 per 1000 women; adjusted OR of 0.51 (95 % CI: 0.33–0.78) for being vaccinated while being in the lowest risk perception group when cut-off was set at <101 per 1000 women)  for being vaccinated while being in the lowest group when cut-off was set at <0 %; adjusted OR of 0.37 (95 % CI: 0.25–0.53) for being vaccinated while being in the lowest group when cut-off was set at <60 %)  of the pre-specified dichotomisations  with lower perception of cervical cancer risk to be less inclined to participate in screening.We found a strong association between HPV vaccination status and intention to participate in screening with more HPV vaccinated women than unvaccinated women intending to participate, even after adjusting for a number of socio-demographic variables. This is in line with the findings from a previous survey of Scottish school girls  and a coOur study suggests that HPV vaccinated as well as unvaccinated women have inflated perceptions of cervical cancer risk. Moreover, vaccinated women are much more inclined to participate in screening than unvaccinated women. This is concerning, since those who would benefit the most from screening might not participate, while healthcare resources are spent on those who benefits least. The implications for practice are mainly pertaining to future information interventions directed at women invited for cervical screening. Both groups of women should be provided with clear and balanced information about their personal cervical cancer risk (i.e. according to HPV vaccination status) and the benefits and harms of screening based on best available evidence, so that they have the best possible prerequisites to make an informed choice.


Given the variation in human papillomavirus (HPV) vaccine coverage across Canada, and debate regarding delivery of HPV vaccines in Catholic schools, we studied online comments on Canadian news websites to understand public perceptions of HPV and HPV vaccine.We searched English- and French-language Canadian news websites for 2012 articles that contained the terms “HPV” or “human papillomavirus.” Articles about HPV vaccinations that contained at least one comment were included. Two researchers independently coded comments, analyzing them for emerging themes.We identified 3073 comments from 1198 individuals in response to 71 news articles; 630 (52.6%) individuals expressed positive sentiments about HPV vaccination , 404 (33.7%) were negative , 34 (2.8%) were mixed  and 130 (10.8%) were neutral . Vaccine-supportive commenters believed the vaccine is safe and effective. Common themes in negative comments included concerns regarding HPV vaccine safety and efficacy, distrust of pharmaceutical companies and government, and belief that school-age children are too young for HPV vaccine. Many comments focused on whether the Catholic Church has the right to inform health policy for students, and discussion often evolved into debates regarding HPV and sexual behaviour. We noted that many individuals doubted the credibility of vaccine safety information.The majority of commenters do not appear to be against HPV vaccination, but public health messaging that focuses on both the vaccine’s safety profile, and its use as a means to prevent cancer rather than sexually transmitted HPV infection may facilitate its acceptance. Human papillomavirus (HPV) is a common sexually transmitted infection that affects more than 70% of sexually active men and women at least once during their lifetime . Within If we don’t attempt to change sexual behaviour that is responsible for transmission of the HPV, but attempt to solve the problem by getting a series of shots, then we don’t have to exercise self-control, nor develop virtue, but can use medicine to palliate our vices .Two HPV vaccines, Gardasil and Cervarix, are approved for use in Canada for females and the former is also approved for males. Both vaccines protect against HPV 16 and 18, two strains that account for approximately 70% of cervical cancers. In Canada, all provinces and territories (P/Ts) have implemented publicly-funded school-based HPV vaccination programs for at least one school-grade cohort of females using Gardasil, with vaccine coverage of 50–85% –6. In 20Following extensive debate, media coverage and public pressure from the advocacy group ‘HPV Calgary’ the ban in Calgary was rescinded in November 2012 . The schGiven the controversy around HPV vaccine, and increasing vaccine hesitancy in general, awareness of societal opinion towards HPV vaccination is important in order for public health to develop targeted health promotion activities and messaging. Nearly 35% of Canadians frequent online newspaper sites regularly, many of which allow readers to post comments in reaction to articles . Using ohttp://www.onlinenewspapers.com).We conducted a descriptive qualitative study using online responses to news articles as our means of data collection. We identified relevant news articles by searching both national (n = 4) and P/T (n = 658) news sites listed on an online world newspaper website ("HPV" or "human papillomavirus" (“VPH” or “virus du papilloma human”) anywhere in the article or its title; 2) predominantly concerned HPV vaccine; and 3) generated at least one comment. Duplicate comments were excluded. Comments were moderated according to ‘Terms and Conditions’ listed by each newspaper, and removed if considered abusive or offensive.We considered English and French news articles posted in 2012 that: 1) contained the terms We used the process of thematic analysis, which is a method for categorizing qualitative data. Thematic analysis uses codes to identify recurring topics to allow themes to emerge and was used due to its flexibility in analyzing large data sets . Two resWe followed a similar process to categorize comments by sentiment. J.A.P. and Y.F. independently reviewed 30% of comments, reaching consensus on each comment’s sentiment towards HPV vaccination: vaccination-supportive ("positive"), anti-vaccination ("negative"), conflicted feelings ("mixed"), or did not indicate an opinion . Y.F. then assessed sentiment for the remaining 70%. We summarized descriptive statistics, including the number of comments made across all comment boards per unique name, assuming each unique name represented a single individual. We recorded whether each comment included an HPV- or HPV vaccine-related statistic, a link to a website, or a personal story. We also noted other factors that may influence opinion of HPV and HPV vaccination, such as whether the individual self-identified as a healthcare worker (HCW), parent, or member of a particular religion.Finally, we did a post hoc analysis to determine if there was a relationship between the sentiment of the article and the sentiment of the majority of the comments.We identified 71 articles that met our inclusion criteria , Table 1A total of 152 (13%) of all commenters provided links to information sources or statistics, the majority of which (63%) were anti-vaccination . The mosSeveral themes were specific to vaccine-supportive or anti-vaccine comments , thalidomide, and diethylstilbestrol (DES) that were eventually withdrawn due to adverse effects, further fuelling their distrust of pharmaceutical companies and of the government’s approval process for vaccines and medications.Many individuals stated that the vaccine is ineffective since it only covers four out of more than 100 HPV strains. Others claimed that not enough time has elapsed since vaccine introduction to determine its effectiveness in preventing cervical cancer. These people criticized studies claiming the HPV vaccine’s efficacy, arguing that an appropriate endpoint was cervical cancer instead of precancerous lesions. Others wrote that the vaccine is only effective for five years and that the current age of vaccination is too young.Some commenters indicated HPV infection is harmless and cervical cancer is rare, concluding that risks of the vaccine outweigh any possible vaccine benefits. They stressed that in healthy people, HPV infections resolve without treatment, and that Pap smears and proper hygiene is sufficient to reduce cervical cancer incidence.Many of the negative comments claimed that HPV vaccination would be unnecessary if people changed their sexual behaviour. Suggestions included practicing abstinence, having fewer sexual partners, and using condoms. Many of these individuals also mentioned that changing sexual behaviour is preferable to the HPV vaccine as it will prevent more than just HPV infections.We noted several themes that were debated throughout the comment boards, but were not specific to those of a certain opinion of HPV vaccination.Diverse comments centered on decision-making, some maintaining that parents alone should decide whether their children receive the HPV vaccine, while others stated vaccination decisions should be made by public health officials with the most knowledge. A few commenters indicated that adolescents themselves should make their own decisions.Anti-vaccine comments claimed that the literature demonstrating vaccine safety and efficacy was biased due to pharmaceutical industry influence. Vaccine-supportive comments asserted that anti-vaccination sources promoted fear and paranoia, and were self-reported and non-reputable.Ten news articles referred to a study that did not find an association between HPV vaccination and promiscuity. In response, many expressed anger, indicating that this study wasted research money for what should have been obvious results. A number of anti-vaccine individuals agreed that the vaccine will not lead to promiscuity, but opposed the vaccine for reasons listed in the “Negative sentiment themes” section. Other anti-vaccine commenters stated their continued belief that the vaccine will promote promiscuity by giving the impression that sex is not dangerous.Vaccine-supportive commenters expressed that parents should discuss the HPV vaccine, the limitations of Pap smears, and safe sex practices with their children. Those against the HPV vaccine stressed the importance of sexual education as an alternative to vaccination.Many individuals, including some vaccine-supportive commenters, opposed school-based HPV vaccination programs, asserting that schools are not meant to provide medical care, and are not equipped to handle reactions that may arise post-vaccination. These commenters felt that sufficient access to the HPV vaccine exists outside of schools, and criticized HPV Calgary  for opposing the Calgary Catholic School Board’s position. Some individuals considered HPV vaccinations in Catholic schools as problematic, citing their perception that the vaccine’s association with sexual behaviour contradicts the moral education students receive. Many of these commenters were only against HPV vaccination in Catholic schools, but supported the vaccine otherwise.Conversely, many commenters were very supportive of school-based HPV vaccine delivery, claiming that schools are the most convenient and effective place to administer vaccinations for school-age children. In addition, some mentioned that the inconvenience of going to a clinic on three occasions for the complete vaccine schedule was a deterrent, particularly for at-risk populations, such as families of lower socioeconomic status. Many commenters stressed that religion should not affect health policy, and that since Catholic schools are publicly funded in Canada, Catholic schools should have to implement public health programs.The topic of HPV vaccination in Canada involves myriad issues, and generated extensive media attention in 2012. Our results indicate that the majority of online commenters are supportive of HPV vaccination. However, anti-vaccine commenters are vocal in their opposition. This group is opposed to the vaccine for various reasons, including distrust of the pharmaceutical industry and government, safety and efficacy concerns regarding the vaccine, and the belief that vaccination is not necessary because HPV is harmless, or because effective alternatives to vaccination exist, such as changing sexual practices, improving hygiene, and bolstering sexual education. Other commenters were not opposed to the vaccine, but objected to vaccine delivery in Catholic schools.Credibility of source was one of the most common themes across comment boards. Comments from various vaccine-supportive and anti-vaccine individuals expressed immense distrust of information sources. Nearly 13% of commenters referenced mistrust of vaccine-related data, including sources that are typically considered to be non-reliable, such as YouTube and Wikipedia, as well as more scientifically established sources such as the CDC. We also noted many inaccuracies across the comment boards, including the perceived severity of HPV, the link between HPV and cervical cancer, and the prevalence of cervical cancer. This suggests public health campaigns should strive to gain public trust and disseminate reliable information. It may be valuable for public health messaging to increase use of social media channels—which is not yet in regular practice —to disseAlthough most of the newspaper articles were positive towards HPV vaccination, nine articles were anti-vaccination. These negative articles were more likely to have a majority of comments opposed HPV vaccination. However, the anti-vaccination articles were mostly from smaller local news sites and attracted overall fewer comments. This indicates that news media have an important role in influencing public opinion regarding vaccination.More than half of commenters who identified themselves as parents were against the vaccine, indicating that some parents may have concerns about the vaccine that have not yet been sufficiently addressed. One common theme expressed by commenters was freedom of choice regarding HPV vaccination, and that ultimately parents should decide whether their children are vaccinated. Future vaccination campaigns should emphasize that this is a voluntary program, and that parents should feel sufficiently informed before making a decision.Pediatrics in October 2012 that debunked the purported association between HPV vaccination and promiscuity [Ten newspaper articles referenced the study published in miscuity . InteresTraditionally, surveys have been used to collect information about health attitudes, but this method can be costly, untimely, and have limited generalizability. Our study is a notable contribution to data collected from social media to analyze public perceptions of vaccinations ,17–19. TThere are a number of limitations of our study. We used comments in response to news articles as our sole source of public perception data. Future studies should consider alternate social media forms such as Facebook, Twitter, and blogs, to confirm findings. Our search strategy may have missed some relevant news articles from smaller, local news outlets. The demographics of commenters are unknown, and given the electronic medium allowing responses from anywhere, we are uncertain about the representativeness of these results to the wider Canadian public. Those who chose to comment online may have differing opinions than the general population; studies using other methods are needed to verify findings. Finally, while we assumed that every unique commenter name represented a single individual, some individuals may have used multiple names while commenting on the articles. Therefore, we might have overestimated the number of commenters, which also impacts the generalizability of our results.Our study demonstrated that the majority of commenters in our analysis were supportive of the HPV vaccine, although a substantial group remains opposed. Misinformation regarding the vaccine’s risks and benefits, as well as the severity of both HPV disease and cervical cancer, was common on the online comment boards. Public health messaging that focuses on both the HPV vaccine’s safety profile, and its use as a means to prevent cancer rather than sexually transmitted HPV infection may facilitate its acceptance.S1 Table(DOCX)Click here for additional data file.S1 Dataset(XLSX)Click here for additional data file.


Paraconiothyrium variabile) decolorization of Acid Blue 92; a monoazo dye, using response surface methodology (RSM). So, a D-optimal design with three variables, including pH, enzyme activity, and dye concentration, was applied to optimize the decolorization process. In addition, the kinetic and energetic parameters of the above mentioned enzymatic removal of Acid Blue 92 was investigated.In recent years, enzymatic-assisted removal of hazardous dyes has been considered as an alternative and eco-friendly method compared to those of physicochemical techniques. The present study was designed in order to obtain the optimal condition for laccase-mediated  occurred at pH 8.0, laccase activity of 2.5 U/mL, and dye concentration of 75 mg/mL. The obtained results of kinetic and energetic studies introduced the laccase-catalyzed decolorization of Acid Blue 92 as an endothermic reaction  with Paraconiothyrium variabile laccase as an efficient biocatalyst for decolorization of synthetic dye Acid Blue 92.To sum up, the present investigation introduced the  The wide usage of synthetic dyes in industries such as textile, paper, plastics, printing, leather, cosmetics, and pharmaceuticals has led to releasing dye containing effluents, rich in complex aromatic structures into the environment ,2. AlmosLaccases  are multi-copper containing oxidase mainly found in fungi, plants, and some bacterial strains ,10. The The response surface methodology (RSM) which is utilized broadly in biotechnological processes, involves a collection of useful statistical and mathematical techniques for analyzing the causal relationship between independent variables, responses, and their interactions through the construction of polynomial mathematical models which leads to time and cost saving . SeveralIn the present study, a D-optimal model for RSM as a very useful design method was applied to obtain maximal removal of Acid Blue 92 assisted by laccase. Furthermore, the kinetic and thermodynamic parameters of laccase-mediated dye removal reaction were investigated. The microtoxicity experiments were also performed in order to evaluate the toxicity of untreated and laccase-treated dye.Paraconiothyrium variabile (PvL) was purified using the method previously described by Forootanfar et al.  × 100; where Ai is the initial absorbance of the reaction mixture and At is the absorbance after incubation time ; where OD600S is the OD600 of sample and OD600C is the OD600 of control. All experiments were performed in triplicate and mean of the obtained results was reported.In order to evaluate the toxicity of produced metabolite(s) following laccase treatment, a series of microtoxicity study was performed. Firstly, a preculture of three Gram-positive bacterial strains , temperature (B), the enzyme activity (C), dye concentration (D), and incubation time (E) on the decolorization yield in order to select the most effective variables on laccase-catalyzed decolorization of Acid Blue 92. The respective high +1) and low (−1) levels for each coded factor defined in Table  and low 2 and, C2 as significant model terms . The quadratic model explained the statistical relationship between the selected variables and the response in terms of coded factors was best fitted with the following equation.Based on the results of the fractional factorial design, three variables, including pH (A), enzyme activity (C), and dye concentration (D) were found to have a greater influence on the decolorization of Acid Blue 92 assisted by laccase. Therefore, the D-optimal RSM exploited to optimize the affecting decolorization factors. The responses generated from performing a total of 20 runs are presented at Table Ganoderma lucidum preferred the acidic range for dye elimination and its decolorization activity decreased significantly at pH levels above 6.0 [Trametes trogii BAFC 463 mediated by 1-hydroxybenzotriazole was achieved at pH 7.0 [Bacillus pumilus strain W3 was achieved at pH 9.0 [Trametes pubescens) positively affected the decolorization of Reactive Black 5. Ashrafi et al. [By solving the equation 1) and analyzing three dimensional response surface graphs Figure , the optbove 6.0 . Howeverbove 6.0  reportedt pH 7.0 . In contt pH 9.0 . The efft pH 9.0  reported and analIn order to determine the correctness of the model, five verification experiments were performed using the statistically optimal condition. The results showed maximum decolorization efficiency of 90.2%, which is about 99% of the predicted value, implying a strong similarity between experimental and predicted values calculated from the model that confirms the precision and validity of the model.Km and Vmax values were 0.48 mM and 227 mM/min mg, respectively. In the study of Ashrafi et al. [Km (14.8 μM) found for the anthraquinone-based dye of Disperse Blue 56 followed by the monoazo dye of Acid Red 18 and the triazo dye of Direct Blue 71 with Km value of 25 μM and 800 μM, respectively. In general, the azo dyes that are classified as monoazo, diazo, and triazo, have been identified as recalcitrant colorants for oxidation using laccases compared to that of anthraquinone-based dyes [The linear relationship between the initial velocity and dye concentration Figure  indicatei et al.  who inve al. [Km 4.8 μM fosed dyes .Figure 4Energetic results are illustrated in Figure M. luteus, S. aureus, B. subtilis, E. coli, P. aeruginosa, and S. typhi was found to be 60 ± 1.9, 49 ± 1.4, 51 ± 1.3, 42 ± 1.1, 30 ± 1.1, and 37 ± 0.8, respectively. However, the GI% for laccase treated dye solution was 31 ± 3.9, 34 ± 2.8, 27 ± 2.5, 20 ± 2.3, 17 ± 0.4, and 14 ± 0.9 in in the presence of M. luteus, S. aureus, B. subtilis, E. coli, P. aeruginosa, and S. typhi, respectively, which was significantly lower for all bacterial strains. Due to the probable toxicity of produced metabolite following physicochemical or enzymatic treatment of synthetic dyes, many protocols have been developed for determination the toxicity of dyes and related compounds based on the growth inhibition of bacterial (B. megaterium and E. coli), yeast (Saccaromyces cerevisiae), or animal cells , and phytotoxicity studies on plant seeds (Oryza sativa or Triticum aestivum) [B. cereus in the presence of sample obtained from enzymatic elimination of Remazol Brilliant Blue R (an anthraquinone dye) using the purified laccase of Pleurotus ostreatus. The growth of B. megaterium and E. coli were reported to be 99% and 94%, respectively, in the presence of laccase-treated Malachite Green (a triphenylmethane dye). In general, azo dyes have been shown to be more resistant to enzymatic removal compared to other classes of synthetic dyes (like anthraquinone dyes) and provide higher toxicity after enzymatic removal [The obtained results of toxicity evaluation of untreated and laccase-treated dye solution showed that when Acid Blue 92 was used, the calculated GI% in the presence of estivum)  who dete removal . HoweverResponse surface methodology is an important tool to optimize the conditions for textile dye wastewater treatment. Such statistical approach reduces the number of runs and provides valuable information on possible interactions between the variables and response. The present study was designed to optimize the reaction condition for laccase- catalyzed decolorization of Acid Blue 92. The results indicated pH, enzyme activity, and dye concentration as the most important variables in the enzymatic decolorization of Acid Blue 92. Further studies should be performed on the decolorization of dyes from different families such as triphenylmethan, indigo, and anthraquinone dyes, extensively employing in the textile and chemical industries.


Cigarette smoking increases the risk of illness and early death for people with coronary heart disease. In 2010, Brown estimated prevalence rates for smoking among veterans and nonveterans with or without coronary heart disease in the United States, based on the 2003 through 2007 data from the Behavioral Risk Factor Surveillance System (BRFSS). Recent changes in BRFSS methods promise more accurate estimates for veterans. To inform assessment of efforts to reduce smoking, we sought to provide prevalence rates for smoking behaviors among US veterans with coronary heart disease and to compare rates for veterans with those for civilians.We conducted a cross-sectional analysis of participants who responded to BRFSS from 2009 to 2012. Accounting for complex BRFSS sampling, we estimated national prevalence rates by sex for smoking status, frequency, and quit attempts; for those with and those without coronary heart disease; for civilians; for veterans and active duty personnel combined; and, after adjusting for BRFSS mingling of active duty personnel and veterans, for veterans only. We examined differences between veterans and civilians by using age-standardized national estimates.Among men with coronary heart disease, more veterans than civilians smoked and more were daily smokers, but veterans were no more likely to attempt to quit. Among women with coronary heart disease, we found no differences between civilians and veterans.Cigarette smoking is more prevalent among male veterans with coronary heart disease than among their civilian counterparts. Not distinguishing active duty personnel from veterans can materially affect prevalence estimates intended to apply solely to veterans. Cigarette smoking puts people with coronary heart disease at increased risk of illness and death ,2. FortuBrown reported age-standardized prevalence rates for current cigarette smoking in the United States among veterans and nonveterans with coronary heart disease and those without it . His anaThe primary data sources for this analysis were BRFSS individual-level public use files for 2011 and 2012. We used individual-level BRFSS data for 2009 and 2010 to adjust our estimates for 2011 and 2012. We pooled data for 2011 and 2012 and for 2009 and 2010.BRFSS monitors prevalence of major behavioral health risks among the noninstitutionalized adult population of the United States using a voluntary, annual, cross-sectional, random-digit–dialed telephone survey . The samP values  to ensure correct computation of variance and the SAS DOMAIN command to specify subgroups of the population. We calculated two-tailed 95% confidence intervals. Reading the overlap of confidence intervals yields only approximate P values . For thiThe BRFSS questions used in this analysis are available online . Like BrWe defined a veteran as someone no longer in the Armed Forces of the United States. This definition is consistent with the federal definition and with the basic criteria for receiving benefits from the US Department of Veterans Affairs (VA); those currently on active duty are not eligible for VA benefits. We defined a civilian as someone who never served on active duty in the US Armed Forces.From 2009 through 2012, the BRFSS question ascertaining military service was worded identically; it asked, “Have you ever served on active duty in the United States Armed Forces, either in the regular military or in a National Guard or military reserve unit?” However, the response categories changed during this period. In 2011 and 2012, the responses to this question did not distinguish current service (active duty personnel) and past service (veterans). From 2003 through 2007 — the period that Brown analyzed — BRFSS also did not distinguish current and past service ,16. The Given the available data, we estimated 2011–2012 prevalence rates  for veterans and active duty personnel combined and we formally tested the differences between the rates for civilians and for veterans and active duty personnel combined. We used 2009–2010 data to adjust the 2011–2012 point estimates to exclude the effect of active duty personnel, thus deriving adjusted point estimates of prevalence rates for veterans.To determine the adjustment, we estimated 2009–2010 prevalence rates twice — with active duty personnel first excluded and then included; the ratio between these rates is our estimate of the effect of the inclusion of active duty personnel. We assumed this effect was the same in 2011–2012 as in 2009–2010. For example, if the ratio between the 2009 and 2010 rate excluding active duty personnel and the 2009–2010 rate including such personnel was 0.95, we assumed that the comparable ratio for 2011–2012 rate was also 0.95; and we reduced the 2011–2012 estimate including active duty personnel by multiplying it by 0.95.We assessed the sensitivity of the 2011–2012 unadjusted results to the inclusion of active duty personnel by comparing the adjusted and unadjusted estimates. For simplicity, we rounded both the unadjusted and adjusted rates to the nearest whole percentage point before comparing them. We report adjusted rates only if they differed (after rounding) from the unadjusted rates. Because the adjustment was based on an aggregate ratio, rather than individual-level data, it is not possible to directly assess the statistical significance of a difference involving an adjusted rate. We treat an adjusted difference as statistically significant only if 1) the corresponding, unadjusted difference was statistically significant and 2) the magnitude of the adjusted difference was no smaller than that of the unadjusted difference.Starting with the 2011 survey, BRFSS methodology fundamentally changed. Among other changes, a sampling frame based on cellular telephone numbers was added to represent better the growing segment of the US population that does not have a landline. Estimates of smoking prevalence based only on landline surveys are biased .Because the age distribution of veterans does not match the age distribution of civilians, one must control for age when comparing these 2 groups in formal tests of differences between civilians and a combination of veterans and active duty personnel, and  between civilians and veterans. To control for age, our primary analysis uses age-standardized estimates that are based on the US adult population in 2010–2012 . IdenticThe participants in this study were BRFSS respondents from 2009 through 2012. Veterans, active duty personnel, and civilians who responded in 2011–2012 were the primary participants. Veterans and active duty personnel who responded in 2009 and 2010 were participants in the sensitivity analysis.The public use files of the BRFSS contain no personal identifiers. We did not seek human subject approval because it is not necessary in these circumstances.Descriptive estimates of the smoking behavior of the populations of interest  appear below and are not age standardized.Coronary heart disease was not uncommon among women in 2011–2012. We estimated that 5.2%  of female veterans and active duty personnel had coronary heart disease in 2011–2012. After adjustment to exclude active duty personnel and rounding (hereafter adjustment), the point estimate for veterans is 6%. Among female civilians, 5.3%  had coronary heart disease in 2011–2012.We estimated that 27.9%  of female veterans and active duty personnel with coronary heart disease currently smoked cigarettes in 2011–2012; after adjustment, the estimate for veterans was 27%. We estimated that 19.7%  of female veterans and active duty personnel with coronary heart disease smoked every day; after adjustment, the estimate for veterans was 18%. Thus, daily smokers are roughly two-thirds of female veterans with coronary heart disease who smoke. About 7 in 10  female veterans and active duty personnel with coronary heart disease who smoked had attempted to quit during the previous 12 months (this estimate was unchanged by adjustment). We estimated that 31.2%  of female veterans and active duty personnel with coronary heart disease were former cigarette smokers in 2011–2012. After adjustment, the estimate for veterans was 32%. About 4 in 10  female veterans and active duty personnel with coronary heart disease never smoked (unchanged by adjustment).Among civilian women with coronary heart disease, we estimated that 20.5%  were current smokers and that 14.7%  smoked every day. Among current smokers, 68.3%  had a quit attempt. About a third  of civilian women with coronary heart disease were former smokers. Nearly half  of female civilians with coronary heart disease never smoked.Coronary heart disease was relatively common among male veterans and active duty personnel in 2011–2012. We estimated that 16.5%  of male veterans and active duty personnel had coronary heart disease in 2011–2012. The comparable rate for male civilians was 5.9% .We estimated that 16.9%  of male veterans and active duty personnel with coronary heart disease smoked cigarettes in 2011–2012 (unchanged by adjustment) and that 12.7%  smoked every day (unchanged by adjustment). Thus, daily smokers are about three quarters of male veterans with coronary heart disease who smoke. Approximately 6 in 10  male veterans and active duty personnel with coronary heart disease who smoked had a quit attempt (unchanged by adjustment). We estimated that 59.2%  of male veterans and active duty personnel with coronary heart disease were former cigarette smokers in 2011–2012 (unchanged by adjustment). Less than a quarter  of male veterans and active duty personnel with coronary heart disease never smoked. After adjustment, the estimate for veterans was 23%.Among male civilians with coronary heart disease, we estimated that 24.5%  were current smokers and 17.3%  of such civilians smoked every day. Among these current smokers, 63.0%  had a quit attempt. Approximately 4 in 10  male civilians with coronary heart disease were former smokers. About a third  of male civilians with coronary heart disease never smoked.We present primarily age-standardized estimates; these are supplemented with discussion of the age-band analysis. The age-standardized estimates are for veteran and active duty personnel and civilians, along with adjusted estimates for veterans only. The age-band estimates appear online in Among those with coronary heart disease, we found differences between veteran and active duty personnel and civilians in smoking status and frequency for men, but not for women. Current smoking among male veterans and active duty personnel with coronary heart disease was more prevalent than among their civilian counterparts; the magnitude of the difference was large and increased with adjustment to exclude active duty personnel . This diAmong current smokers with coronary heart disease, we found no difference in the prevalence of a quit attempt after adjustment between veterans and civilians of either sex . Among wAmong both women and men without coronary heart disease, we found differences between veterans and active duty personnel and civilians in smoking status and frequency, but not quit attempts. Among both sexes, fewer veterans and active duty personnel without coronary heart disease than their civilian counterparts had never smoked and fewer were former smokers; with adjustment, the differences between veterans and civilians increased slightly or were unchanged . Higher We also estimated that both male and female veterans and active duty personnel without coronary heart disease were daily smokers than their civilian counterparts; after adjustment, the difference between civilians and veterans increased slightly .Results by age band. Among women we identified few clear patterns of significant differences across age bands between veterans and active duty personnel and civilians , despite the different periods covered, changes in BRFSS methodology, and our adjustment for inclusion of active duty personnel . For vetOne limitation of this analysis is that not all veterans, as defined here, are eligible for VA benefits. Most VA benefit programs exclude former service members who were dishonorably discharged; other eligibility requirements vary from one VA program to another. No BRFSS data are available on type of discharge or on any other eligibility criteria for VA benefits.Adjustment to exclude active duty personnel is a strength of the current analysis, especially given that the characteristics of active duty personnel and those of veterans are unlikely to have changed appreciably between 2009–2010 and 2011–2012. Nonetheless, this adjustment has limitations. The data used in the adjustment were collected before major changes to BRFSS methodology in 2011, including the addition of the cellular telephone sample. For the adjustment, we assumed that the ratios of estimates excluding and including active duty personnel were the same in 2011–2012 as in 2009–2010. The available data do not permit an assessment of the extent to which differences in BRFSS methodology may invalidate that assumption. Another limitation related to the adjustment is that tests of statistical significance must rely on the unadjusted estimates. The BRFSS question on service in the US Armed Forces needs to be revised so that active duty personnel readily can be distinguished from veterans in future analyses of BRFSS data.Another limitation of this analysis is that the number of observations on young veterans and active duty personnel with coronary heart disease is limited. The limited number of observations for younger age bands, especially among women, could introduce error into our age-adjusted estimates because the available observations may poorly represent young veterans and active duty personnel generally. Our estimates for each of the 10 separate age bands are useful in assessing the extent of possible error due to limited numbers of observations in some age bands. As indicated above, the age-band estimates for women with coronary heart disease do not show clear patterns, suggesting that the age-adjusted estimates for such women should be interpreted with caution. Among men with coronary heart disease, on the other hand, the pattern of differences across age bands between veterans and active duty personnel and civilians generally tracks the pattern of age-adjusted differences between the 2 bands. The single exception apparently is not due to erratic results but rather to a curvilinear relationship across age bands. We obtained generally consistent results using 2 techniques to control for age, which suggests that our estimates for men with coronary heart disease are robust.This analysis is based on survey data, which have inherent limitations that may affect our estimated prevalence rates. First, response rates were lower than desirable in many states and territories participating in the BRFSS . HoweverAlthough smoking status is routinely measured through self-report, these measures are sometimes questioned under the assumption that smokers tend to underestimate the amount smoked or even deny smoking. Roughly 2 decades ago, a meta-analysis on validity of self-reported smoking found wide variation in reporting of smoking status but concluded that self-reports were accurate in most studies . These aIn recent years, the VA’s Veterans Health Administration (VHA) has devoted much effort to reducing smoking among those veterans in VHA care . PerhapsSmoking cessation is critical for smokers with coronary heart disease, and clinicians have a responsibility to help patients with coronary heart disease reduce and ultimately quit smoking. For male veterans with coronary heart disease — who are more likely to smoke than their civilian counterparts — the need is particularly great. The rates of quit attempts among current smokers with coronary heart disease for both veterans and civilians are encouraging and suggest that patients and providers are aware of the need to quit. The rates of current smoking, however, suggest that more effective interventions may be necessary for veterans with coronary heart disease so that motivation to quit results in successful smoking cessation.


Despite comparable screening rates for precancerous lesions, higher incidence and mortality related to cervical cancer in minority women persists. Recent evidence suggests that minority women with precancerous cervical lesions harbor a wider range of human papillomavirus (HPV) genotypes, many of these distinct from HPV16/18, those most commonly found in Caucasian women. The goal of the analysis was to determine if inflammatory cytokines and chemokines varied by HPV 16/18 versus other genotypes in cervical cancer tissues from Tanzanian women.HPV genotypes and concentrations of chemokines and cytokines were measured from homogenized fresh tumor tissue of thirty-one women with invasive cervical cancer (ICC). Risk factors for cervical cancer including age, parity, hormonal contraceptive use and cigarette smoking were obtained by questionnaire. Generalized linear models were used to evaluate differences between chemokines/cytokine levels in women infected with HPV16/18 and those infected with other HPV genotypes.After adjusting for age, parity and hormonal contraceptives, IL-17 was found significantly more frequently in invasive cervical cancer samples of women infected with HPV16/18 compared to women infected with other HPV genotypes (p = 0.033). In contrast, higher levels for granular macrophage colony-stimulating factor (p = 0.004), IL-10 (p = 0.037), and IL-15 (p = 0.041) were found in ICC tissues of women infected with genotypes other than HPV16/18 when compared to those of women infected with HPV16/18.While the small sample size limits inference, our data suggest that infection with different HPV genotypes is associated with distinct pro-inflammatory cytokine expression profiles; whether this explains some of the racial differences observed in cervical cancer is still unclear. Future studies are needed to confirm these findings.The online version of this article (doi:10.1186/s13027-015-0005-1) contains supplementary material, which is available to authorized users. Despite major reductions in incidence and mortality over the last decade, an estimated 12,340 cases of invasive cervical cancer (ICC) continue to be diagnosed in the United States annually, with the highest incidences in Hispanic and African American women when compared to European American women [Reasons for continued racial/ethnic disparities in ICC incidence and mortality are still unclear, although published data in the last few years suggest that among women with precancerous lesions, African Americans may harbor human papillomavirus (HPV) genotypes distinct from those found in European American women -7. HowevIt is known that HR-HPV initiates local Th2 inflammation at an early stage, involving antibody forming cells, which fosters an immunosuppressive microenvironment that aids tumor progression . Indeed,In this analysis we examined a wide spectrum of cytokines and chemokines present in ICC tissues from Tanzanian patients to determine if cytokine levels differed by HPV genotype (HPV 16 or 18 vs. other HPV genotypes).http://www.afro.who.int/en/tanzania/who-country-office-tanzania.html). KCMC is a tertiary care facility that serves a catchment area of ~10 million individuals. Eligible participants were 18 years or older and had no history of an abnormal Pap test. ICC patients comprised new cases with no history of cervical abnormalities who were also 18 years or older and were referred for colposcopic directed evaluations. A trained nurse interviewer enrolled a total of 249 women; all but 2 approached agreed to participate (99% response rate). Of these, 12 patients were excluded due to missing or inadequate Pap smear, refusal of an HIV-1 antibody test, and diagnosis of an unrelated co-morbid condition. The final number of participants, n = 215 (86%), included participants who completed questionnaire, and the availability of CIN status, and HPV genotype data. Among the n = 215 participants, n = 40 were histologically confirmed ICC cases and n = 37 were further genotyped for any HPV infection. Of these n = 37, we excluded 4 cases that did not harbor HPV infection and 2 cases with insufficient tissue available to homogenize. Thus, thirty-one women had adequate tissue to successfully measure cytokine/chemokine profiles from homogenized tissue.Study procedures were approved by Research Ethics Boards at KCMC and Duke University School of Medicine Institutional Review Board, and all study participants signed an informed consent explaining the nature of the study. The patients included in the present analyses were part of a case–control study aimed at identifying epigenetic marks (DNA methylation and gene expression profiles) associated with progression from CIN-1 to invasive cancer. Detailed methods of patient identification and enrollment have been described elsewhere ,17. BrieA trained nurse-interviewer obtained informed consent from all participants, and administered a standardized 40-minute questionnaire in person. The questionnaire collected information on socio-demographic characteristics , type of marriage (polygamy vs. monogamy), tribe, educational attainment, cigarette smoking, alcohol intake, reproductive history , sexual history , and medication and supplement use.Biopsies of lesions were obtained during colposcopy for all cancers for histological evaluation as part of routine patient care, and ICC was diagnosed by Hematoxilin and Eosin staining. A portion of tumor samples was aliquoted and immediately placed on dry ice, for research purposes. Following specimen collection, routine cervical visual inspection was also performed and treatment conducted according to standard clinical protocol.http://www.asccp.org/). Once a month, medical charts were reviewed by KCMC staff pathologist for HIV-1 test and cyto-pathological results, to classify cases using the Bethesda classification system [Papanicolaou smears and biopsy specimens were processed and read by the staff pathologist at KCMC using standard conventions according to ASCCP guidelines as appropriate  using a Qiagen TissueRuptor , centrifuged to pellet debris, and the supernatant removed and frozen at −80°C. Frozen samples were shipped to the ProteoGenomics Facility at the Medical University of South Carolina on dry ice, for analysis using the Human Cytokine Magnetic 30-Plex panel  according to manufacturer’s instructions, which included room temperature incubation, with agitation, of samples with antibody beads in 96-well plates; room temperature incubation with biotinylated detector antibodies; and room temperature incubation with streptavidin-R-pycoerythrin. Between incubation steps were decanting and washing steps, using a magnetic plate separator. Finished plates were scanned using a Luminex Multiplex Bead Array system . Standards provided with the Cytokine panel were serially diluted to 7 concentrations according to manufacturer’s protocols, and included in the 96-well plate with tumor samples for processing. Specimens were run in duplicate and the ranges of detected values and coefficients of variation (CV) for IL-17, GMCSF27, IL-10 and IL-15 were 1.47-198.1 pg/ml, %CV 0–110.96%; 1.35-215.12 pg/ml %CV 0.35-57.47; 2.53-327.55 pg/ml, %CV 0–27.08%; and 50.94-796.76pmg/ml, %CV 0.23-26.44%, respectively. Additional file The goal of the analysis was to determine if cytokines and chemokines examined varied significantly based on infection with HPV 16 or 18 or other genotypes. All women infected with HPV 16 or 18, regardless of infection with other HPV genotypes were designated to have HPV 16/18. All women with no detectable HPV16 or 18 were designated ‘other’. One woman with no detectable HPV was excluded from analysis. T-tests were used to examine if there were differences in cytokine/chemokine abundance between women infected with HPV16/18 and those infected other HPV genotypes. The natural logarithm of cytokines/chemokines values was used in all the analyses. Of the 30 cytokines and chemokines examined, those significantly different (p < 0.05) were further evaluated in generalized linear regression models (GLM) to adjust for potential influence of hormonal contraceptives use, parity and age; among the 31 cancer cases analyzed, 2 reported smoking and all were multiparous. Regarding lifetime sexual partners, as previously described [Table The prevalence of HPV16 or 18 was comparable in the overall sample of 40 representing all ICC cases previously reported [Among a panel of 30 cytokines and chemokines including IL-15, IL-4, IL-2, IL-1RA, IL-1B, IL-5, IL-6, IL-7, IL-8, EGF, IL-13, IL-12, IL-10, IL-2R, IL-17, HGF-35, TNF-alpha, IFN-alpha, IFN-gamma, CCP1/MCp1, MIP-1B, MIPI-1A, VEGF, FGF-B, FGF-12, MIG-63, GMCSF27, IP-10, G-CSF, and RANTES, measured in homogenized cervical cancer tissues, we detected a trend for differences between cytokines/chemokines and HPV16/18 status; in general, pro-inflammatory cytokines/chemokines were higher in women infected with HPV 16/18 compared to those infected with HPV genotypes other than HPV16/18. However only four cytokines varied significantly between ICC harboring HPV 16 or 18 vs. ICC harboring non HPV 16 or 18  after adjusting for oral contraceptives and parity; these findings were significant even after applying the stringent Bonferroni correction (0.05/30 = 0.0017). However, further adjusting for age somewhat weakened these associations although they remained statistically significant (p = 0.033)  may be more likely to progress from HPV infection to ICC.Our finding that pro-inflammatory IL-17 levels in cervical tissues were significantly higher in women infected with HPV 16 and/or 18 is in agreement with other studies that reported an association between increased IL-17 levels and cervical cancer cell growth both in human and in animal studies ,23. FurtPrevious studies have reported on the dual biological function of IL-10 as an anti-inflammatory  and anti-angiogenic  agent, which reflects the conflicting data in cervical cancer . IncreasOur study has several limitations including the small number of ICC cases examined and thus we cannot draw definitive conclusions. Even though we had data on HIV-1 infection, data on Th2/Th1 response, haematological evidence of autoimmune disorders and other immunological records were not available, thus while unlikely, we cannot rule out that some of the differences found could be due in part to immune disorders, as well as the fact that women infected with HPV 16/18 were on average infected with a higher number of HPV genotypes than the group without HPV 16/18. A key question that remains to be answered, if interventions aimed at reducing disparities are to be effective, is whether or not race/ethnicity differences observed are the consequence of a higher propensity for infection with specific HPV type variants in different race/ethnic groups. If so, this may suggest differences in immunological response to HPV or co-infections. However, our cohort included only African women whose cytokine profile may not be comparable to that in ICC samples of white women. Although, we had 31 ICC cases with confirmed HPV infection obtained directly from the lesion.These findings indicate that distinct HR-HPV genotypes may induce different immune responses that facilitate progression from CIN to ICC, which may vary by race/ethnicity. Such inflammatory markers could be useful in risk stratification to discriminate women likely to progress among those with abnormal cytological findings and HPV infection. Future studies in multiethnic cohorts are needed to confirm this hypothesis.


HPV FOCAL is a randomized trial  comparing high-risk (hr) HPV testing vs. liquid-based cytology (LBC) for cervical cancer screening of women aged 25–65. We compared the Digene Hybrid Capture® 2 High-Risk HPV DNA Test® (HC2) and the Roche cobas® 4800 HPV Test (COBAS) for primary screening.n = 6,172) were screened at baseline by HC2 and COBAS and by LBC 24 months later. We assessed HPV genotyping and reflex LBC for colposcopy triage of baseline HPV positive women.Women  and positive agreement was 77.5 %. Baseline CIN2 and CIN3+ rates based on HPV screening were 8.6/1,000 and 6.6/1,000 respectively; 24 month rates were 0.7/1,000 and 0.4/1,000 (LBC screening). HC2 and COBAS were concordant positive for 91 % of round 1 CIN2 and 98 % of CIN3+. CIN3+ was significantly associated with HPV 16 , but not HPV 18 , vs. non-HPV 16/18 HPV at baseline. There was no significant association between HPV genotype and CIN2. CIN3+ was significantly more likely for high-grade , but not low-grade , vs. negative LBC. No significant association was observed between LBC grade and CIN2. HPV 16 and 18 were associated with 33 % of CIN2 and 68 % of CIN3+ identified at baseline.For hrHPV positive women, abnormal reflex LBC is appropriate for colposcopy triage. In addition, immediate referral of women with HPV 16/18 and normal cytology may allow for earlier detection of CIN2+ lesions which would not be detected until after follow-up testing.The online version of this article (doi:10.1186/s12885-015-1959-5) contains supplementary material, which is available to authorized users. Persistent infection with high-risk (hr) human papillomavirus (HPV) genotypes is recognized as the cause of cervical cancer , 2 and mA challenge is that hrHPV testing identifies women with both persistent and transient HPV infections, with most of the latter clearing spontaneously within 2 years . For thaIn this study, we compared the performance of the Digene Hybrid Capture® 2 High-Risk HPV DNA Test® (HC2) to that of the Roche cobas® 4800 HPV Test (COBAS) for primary cervical screening within the HPV FOCAL randomized trial. We assessed CIN outcomes following reflex cytology and HPV genotyping for colposcopy triage.The HPV FOCAL Trial design has been described previously  Fig. 1)1). BriefAll trial subjects provided written informed consent and the study was approved by the University of British Columbia/BC Cancer Agency Clinical Research Ethics Board.Cervical specimens collected in PreservCyt®  by participating family physicians in Metro Vancouver and Greater Victoria BC were used for both hrHPV testing and LBC. For Safety Arm enrollment and 12 month follow-up specimens, separate aliquots for HC2 (6 mL) and COBAS (2 mL) were removed from the PreservCyt® vial prior to any other processing. At the 24 month exit screen, aliquots for reflex HC2 testing were obtained after cytology processing. At enrollment, all specimens were tested by HC2 , COBAS  and the Roche Linear Array HPV Genotyping Test . HC2 generates a qualitative result for the presence or absence of one or more of 13 hrHPV genotypes . We used a relative light unit/cutoff (RLU/CO) ratio of ≥1.0 to indicate a positive HC2 result. Specimens which had no visible cell pellet at the preparation stage were rejected as inadequate and reported as HC2 invalid. COBAS generates individual qualitative results for HPV 16, HPV 18 and a pool of 12 other hr (OHR) HPV genotypes . LA generates individual qualitative results for the same 14 hrHPV genotypes as COBAS together with 23 additional HPV genotypes which are defined for the purposes of this study as low-risk (lr) HPV. LA was performed using residual extracts from COBAS testing. COBAS and LA were performed blinded at the time of collection and were not used for subject management. Specimens with initially invalid COBAS results were re-tested to confirm the invalid result. LBC slides were prepared and stained for all subjects at enrollment but were not screened and interpreted unless the subject was HC2 positive. COBAS and LA results were unblinded and compared with HC2 after Safety Arm women exited the trial at 2 years. LBC slides were then screened and interpreted retrospectively for women with baseline HC2 negative/COBAS positive and HC2 negative/LA positive results. For the latter group, specimens positive by LA for at least one hrHPV genotype were classified as hrHPV positive and those positive for only lrHPV genotype(s) were classified as lrHPV positive.ppos = (2a)/(N + a - d) and negative agreement by pneg = (2d)/(N – a + d), where N is the number tested, a is the number positive by both tests, and d is the number negative by both tests ) vs. 23 % [11/48] for CIN2), whereas the proportions were the same for HPV 18 (15 % [7/48] vs. 15 % [6/40]). Conversely, subjects positive only for non-HPV 16/18 OHR HPV had a higher CIN2 proportion compared to CIN3+ (67 % [32/48] vs. 33 % [13/40]).Since HC2−/COBAS+ women were not referred to colposcopy at round 1, assessment of the contributions of HPV genotype and reflex LBC to CIN2 and CIN3+ outcomes was performed only for HC2+/COBAS+ subjects  compared to those with low-grade vs. NILM LBC. In contrast, there was no significant difference for CIN2 for those with either high-grade or low-grade vs. NILM LBC (p = 0.15). There were no significant interactions between HPV genotype and LBC (data not shown).For reflex LBC, those with high-grade vs. NILM LBC were significantly more likely to have CIN3+ . Despite the occurrence of discordant baseline HC2 and COBAS results, 43/44 round 1 CIN3+ were among those who were both HC2 and COBAS positive. If women had been managed on both HC2 and COBAS results, it is possible that additional CIN lesions might have been identified at baseline among those HC2−/COBAS+. In agreement with our findings, a comparison study by Cuzick et al.  of the pThe round 1 CIN2 and CIN3+ rates based on primary hrHPV screening  were higher than in the HPV FOCAL Control Arm  which had round 1 rates of 6.0/1,000 and 5.0/1,000 respectively . The CINWhile our study had a lower COBAS positivity rate than ATHENA (8.8 % vs. 12.6 %) , in bothFor concordant HC2/COBAS positive subjects, CIN3+ was significantly more likely when LBC was high-grade vs. NILM. Reflex LBC dysplasia was not significantly different for CIN2. CIN3+ was significantly more likely for HPV 16 vs. non-HPV 16 HPV positive subjects, while no significant differences in CIN3+ were found for HPV 18 vs. non-HPV 16/18 OHR genotypes. There was no significant difference between the CIN2-associated HPV genotypes. These findings are in agreement with the ATHENA trial which concluded that a combination of HPV 16/18 genotyping and reflex cytology is a suitable triage strategy for hrHPV positive women .Specimens with discordant HC2/COBAS results had RLU/CO ratios and Ct values significantly closer to the test limits of detection than concordant positive specimens. It seems reasonable that specimens likely to have lower viral loads  would be more likely to produce discordant results with different assays. Furthermore, some of these discordant results likely reflect false-positives , which aOur finding that 45 % of HC2 positive women with NILM LBC at baseline cleared their hrHPV infections after 12 months is consistent with the published literature , 32, 33.Specimens containing only lrHPV types frequently had low-grade LBC abnormalities [11 % (57/516) of HC2 and 3 % (17/542) of COBAS positive results] which may have implications for selection of a primary HPV screening assay if LBC is to be used for triage. Since lrHPV’s have a negligible association with CIN2+ , these iAn important limitation of this study was the inability to obtain CIN outcomes at round 1 for women with HC2−/COBAS+ discordant results, since baseline COBAS results were blinded until after study exit. This precluded comparison of the sensitivity and specificity of the HC2 and COBAS assays. In addition, had these women been referred to colposcopy at baseline, it is possible that additional CIN lesions would have been detected, as was observed for the HC2+/COBAS− group. Furthermore, no hrHPV testing was performed at the 24 month study exit except for HC2 triage of women with ASCUS LBC. Although one CIN2 was identified at round 2 among baseline HC2−/COBAS+ women, it is possible that the use of only LBC at round 2 was not sufficiently sensitive to demonstrate whether this group of women had underlying CIN lesions not detected by HC2 at baseline. A future analysis of the FOCAL Intervention Arm where women were screened with HC2 and COBAS at both enrollment and the 48 month exit screen may provide further insight. However, Intervention Arm COBAS enrollment results were also blinded and not used for subject management, but both HC2 and COBAS were used for colposcopy referral at the 48 month exit screen. Furthermore, there is an opportunity to follow these women for significant CIN outcomes over longer time periods once they exit the trial and return to the centralized cervical screening program. Long term follow-up of Swedescreen subjects after a baseline hrHPV positive screen showed that incidence rate ratios for CIN2+ remained high for greater than nine years , especiaAnother limitation relates to the retrospective cytology interpretations. Reflex LBC for HC2 positive women was performed as it would be in a real setting, whereas LBC slides for HC2 negative, COBAS and/or LA positive women were examined approximately two years later. This could have biased the LBC interpretations relative to those conducted in real-time.This study demonstrated that over a 2 year screening interval with hrHPV testing at baseline, followed by LBC screening at 24 months, 94 % of CIN2+ detected over the two screening rounds were hrHPV positive at baseline. Women were managed at round 1 only on their HC2 and corresponding LBC results, but 43/44 CIN3+ were detected among those HC2+/COBAS+. It is possible that additional CIN cases would have been detected among HC2−/COBAS+ subjects if COBAS results had also been used for subject management. Of the CIN2+ identified in Round 1, 55 % had abnormal cytology and an additional 17 % were HPV 16 or 18 positive at baseline, demonstrating the added benefit of immediate referral of women with these genotypes to potentially identify CIN2+ earlier than by follow-up testing of those with NILM cytology. Therefore, the results of this study support the use of reflex LBC together with HPV16/18 genotyping for colposcopy triage of hrHPV positive women.  However, as the cohort of HPV vaccinated women reaches cervical screening age, the benefits of HPV 16/18 genotyping for triage will be diminished.


In recent decades, the incidence of spinal cord injuries has increased. In a systemic review on epidemiology of traumatic spinal cord injury in developing countries reported 25.5/million cases per year.To assess the quality of life (QOL) of the veterans among Iran-Iraq war with chronic spinal cord injuries (SCI) and to evaluate long-term impressions of SCI on their quality of life.Fifty-two veterans, all male, with chronic spinal cord injury from Iran-Iraq war (1980-1988) were interviewed and examined. The mean age of veterans at the time of interview was 49.3 years (38 to 80 years). Veterans were assessed by using a 36-item short-form (SF-36), hospital anxiety and depression scale (HADS) and the Barthel index. The presence or absence of pressure sores and spasticity were documented as well.The mean age of veterans at the time of study was 49.3 years. Pearson's correlation test showed that depression and anxiety have a reverse association with mental component summary (MCS) scale and physical component summary (PCS) scale scores, respectively. Regression analysis showed a negative effect of depression and pressure sore on PCS. Moreover, no association was found between the duration of injury and age with quality of life.Lower QOL was found among veterans with chronic SCI. More researches on health-related quality of life (HRQOL) are needed to give us a better understanding of changes in life of patients with SCI and the ways to improve them. In recent decades, the incidence of spinal cord injuries has increased. In a systemic review on epidemiology of traumatic spinal cord injury in developing countries, Rahimi-Movaghar et al. reported 25.5/million cases per year (95% CI: 21.7–29.4/million/year). According to this report, 82% of all SCIs were male with a mean age of 32.4 years , 9. In IThe purpose of this study was to evaluate QOL and related issues in Iranian veterans with chronic war-related SCI living in Mashhad.A cross-sectional study was performed on Iran-Iraq war veterans with spinal cord injuries in Mashhad, the second most populated city of Iran. Fifty-two (74%) of 72 veterans with chronic spinal cord injury from 1980s war living in the city of Mashhad participated in our survey. All of them were registered in our research center of Mashhad University of Medical Sciences in Mashhad, Iran, and they consented to face-to-face interview. Our inclusion criteria were spinal cord veterans who injured in the battlefields of Iran-Iraq war during 1980 to 1988. Exclusion criteria were veterans with spinal cord injuries who did not agree to participate in the study and veterans who had their spinal cord injury in civil bombardments during the 8-year war. Demographic data of all participants were recorded. Further information regarding educational and recreational activities of the subjects was also collected. Eventually, the study was approved by the Research and Ethical Research Committee of Mashhad University of Medical Sciences. Quality of life (QOL) was assessed using a 36-item short-form health survey (SF-36), a Likert type scale, some with 2 or 3 and others with 5 or 6 points. Moreover, emotional situation of participants and their level of activity were assessed using the hospital anxiety and depression scale (HADS) which is a 4-point Likert type scale and the Barthel index , respectively . Data reChi-square analysis was applied for categorical variables. Fisher’s exact test was applied for 2 × 2 tables to characterize the significance level. When one item was continuous and another one was categorical, analysis of variance (ANOVA) and t-tests were used. A correlation analysis (Pearson's correlation) was performed when both scales were continuous. Kolmogorov-Smirnov test was conducted to examine the normal distribution of data. Descriptive statistics were also used for demographic evaluation. The SF-36 main subscales of our sample were compared to SCI variables using paired t-tests. First, we compared the 8 SF-36 factor scores of veterans with healthy controls. Our second comparison was between the veterans' scores and the presence of spasticity, presence of pressure sores and the Barthel index, anxiety and depression score (HADS), lesion level and the ASIA grades. To find the effect of different domains on the quality of life of participants, regression analysis was used. At first, the ANOVA test was performed to find the applicability of the regression model for PCS and MCS scores. P < 0.05 was considered statistically significant in all analyses.All participants were male, married, and injured about 3 decades ago (1980-88). The mean age at the time of SCI was 23.6 years, ranging between 15 and 55 years (SD = 8.2). The mean age of veterans at the time of interview was 49.3 ranging between 38 and 80 years (SD = 7.94). Most of the participants (88.5%) had paraplegia. About one third of paraplegic and tetraplegic veterans had complete spinal cord injury (ASIA A). Regarding the level of education, 4 were higher than high school level, and the rest were at the level of high school or lower. Apart from this, a half of the cases [26 SCI veterans] improved their level of education after occurrence of SCI. In addition to this, more than three-quarters of them [40 SCI veterans] were either retired or unemployed. The remainders were student, teacher or an employee. Sixty-nine percent of the participants were involved in sport activities, and 23% were employed. Regarding factors related to mobility, the mean Barthel index score (activity of daily living) was 57.6 with a range of 0-90 (SD = 23.5). Only two patients were able to walk without assistance. Three veterans used crutches and 47 used wheelchairs for ambulation. Associations between independent variables related to SCI and education were examined regarding the two summary scales of the SF-36 (PCS and MCS). The test showed P values of 0.715 and 0.974 for mental component summary (MCS) and physical component summary (PCS) scales, respectively. As a result, we concluded that these scales are normally distributed and can be examined by parametric tests. We found a significant difference in physical functioning as measured by PCS scores between participants with complete and incomplete cord lesions, and those with or without pressure ulcer and/or colostomy . PearsonHigher levels of anxiety were associated with lower PCS scores and depression was negatively associated with MCS scores. We also compared the subscales of the SF-36 between SCI veterans and the normal population (4800 Iranian persons). We concluded a significant difference in scores of these 2 groups except for the vitality index and mental health . To findThere was no difference in PCS score in paraplegic and tetraplegic patients. The same result occurred for MCS. Accessible facilities and recreational programs for tetraplegic patients have helped them overcome structured barriers to social participation. Pearson's correlation test for age, time since injury (year), anxiety and depression showed that anxiety and depression had a reverse effect on MCS and PCS scales, respectively. Similar to studies by Cushman et al. and Barker et al. this test also revealed that there was no association between time since injury and age with quality of life , 15. SaaIt might be due to supportive community they live in, the support of Foundation of Martyrs and Veterans Affairs, as well as irrelatively high income level. Moreover, from this comparison, it was seen that the pain score of SCI veterans (BP) was almost a half of the normal group. As more perceived pain by veterans can be associated with more anxiety and depression  and as a