N = 12) also participating in individual qualitative interview sessions. Thirty-two service providers and stakeholders completed quantitative surveys. Empirical and qualitative data with appropriate triangulation procedures provided interpretive information relative to a life-span development perspective. Study findings provide evidence of the need for future research efforts to address strategies that focus on the health and economic challenges of veterans before they are threatened with the possibility of homelessness. Implications of the study findings provide important information associated with the premise that human development occurs throughout life with specific characteristics influencing the individual's passage. Implications for aging/homelessness research are grounded in late-life transitioning and human development intervention considerations.The need for counseling and career/educational services for homeless veterans has captured political and economic venues for more than 25 years. Veterans are three times more likely to become homeless than the general population if veterans live in poverty or are minority veterans. This mixed methods study emphasized a life-span perspective approach for exploring factors influencing normative aging and life-quality of 39 homeless veterans in Alabama and Florida. Seven descriptive quantitative and qualitative research questions framed the investigation. Study participants completed a quantitative survey reflecting their preferences and needs with a subset of the sample ( N = 12 of the homeless veteran participants, and additional quantitative survey data from N = 32 service providers and stakeholders were retrieved to represent multiple perspectives for conducting triangulation of data procedures and interpretation. Specific materials and methods, including the background and theoretical framing of the investigation, study results, implications, and conclusions comprise the discussion.The special population of homeless veterans has become an alarming concern within America's aging population challenges. According to the National Coalition for Homeless Veterans , while o Key preliminary tasks for determining the materials and methods used in the study included an overview examination of the background and the literature considerations pertinent to the investigation and the theoretical underpinnings for the study. These preliminary efforts provided the impetus for the research questions and hypotheses as well as the rationale for the selection of specific materials and methods for the study.(i) homeless and lives or resides in a place not meant for human habitation, a safe haven, or in an emergency shelter; (ii) has been homeless and living or residing in a place not meant for human habitation, a safe haven, or in an emergency shelter continuously for at least 1 year or on at least 4 separate occasions in the last 3 years; and (iii) has an adult head of household (or a minor head of household if no adult is present in the household) with a diagnosable substance use disorder, serious mental illness, posttraumatic stress disorder, cognitive impairments resulting from a brain injury, or chronic physical illness or disability, including the cooccurrence of 2 or more of those conditions , page 4. The need for services for homeless veterans has captured political and economic venues for more than 25 years. Aging homeless veterans who are not identified as in need of services for substance abuse are not eligible for existing Veterans' Administration services that include safe housing or shelter services [ Recent efforts by the President Obama administration to prevent and end veteran homelessness by 2015 are in progress and are focused on the goal of “finding every veteran safe housing and access to needed services” . The priThe state of Florida is ranked third in the nation in 2011 for the largest number of aging homeless veterans , yet the numbers of services and special needs provided for Florida aging homeless veterans is lower than many states that serve far fewer number of homeless aging veterans .  The current study addressed the need to focus on the individual. The study investigated factors contributing to the expressed needs of homeless aging veterans  relative to specific individual characteristics from a life-span perspective. The individual's reactions and interactions with the environment relative to the various gains and losses experienced by the individual in life are specific to the types of characteristics and descriptive information indicative of a life-span perspective. This premise has underpinnings within the context of the life-span perspective of human development theory.  The theoretical framework for the study focuses on the individual and is grounded within the context of the life-span perspective of human development theory posited by Baltes , 12, 13. The specific purpose of this mixed methods study was to explore the individual characteristics and needs of aging homeless veterans in transition within Alabama and northwest Florida relative to a life-span perspective. The study included four focused objectives: (1) to examine homeless veterans' perspectives utilizing a quantitative survey research approach and a qualitative interview inquiry research approach framed within the life-span development theory perspective of Baltes , 12; (2)The theoretical framework assisted in guiding the development of the study within the context of examining the various constructs related to the individual's perspective of life-span development regarding specific gains, losses, and other influences as presented in Research Question  1. Is there a relationship between homeless veterans' levels of depression and the number of months they served in a war zone?Research Hypothesis  1. There is a relationship between homeless veterans' levels of depression and the number of months they served in a war zone.Research Question  2. Is there a relationship between whether or not a veteran served in a war zone and the homelessness status of the veteran?Research Hypothesis  2. There is a relationship between service or no service in a war zone and whether or not the veteran becomes homeless.Research Question  3. Is there a difference in the median rankings of perceptions of homeless veterans and service providers concerning VA accessibility?Research Hypothesis  3. There is a difference between homeless veterans and service providers in their median rankings perceptions concerning VA accessibility.Research Question  4. Is there a difference between the average perceptions of service providers in northwest Florida and service providers in Birmingham, Alabama, regarding their perceptions of VA community partnership integration?Research Hypothesis  4. There is a difference between the average perceptions of service providers in northwest Florida and service providers in Birmingham, Alabama, regarding their perceptions of VA community partnership integration.Research Question  5. How do the expressed needs of veterans in the current study differ from the expressed needs of veterans in the 2010 CHALENG studies?Research Hypothesis  5. There is a difference in the rank ordering of the expressed needs of current study homeless veteran participants  as compared with the CHALENG 2010 study participants.Research Question  6. What are the major contributing factors to veteran homelessness, focused on life and/or military experiences that have impacted homeless veterans' development considerations leading to their current living situations?Research Question  7. What are the immediate needs of homeless veterans? The study utilized an exploratory mixed methods investigation focused on the characteristics and needs of the aging homeless military veteran population. The study involved two sequential procedural phases. The objective of the first phase was to determine the specific characteristics, perceptions, and needs of the homeless veteran participants. Phase one employed a survey instrument used to obtain demographic, perceptions, and needs information relative to aging homeless veterans who are currently not receiving housing services within the Birmingham, Alabama, and Northwest Florida regions. In addition, quantitative surveys were completed by service providers of homeless veterans. The second phase of the study consisted of qualitative interviews with a voluntary sample of aging, homeless veterans. Both quantitative and qualitative data were included in the data analysis procedures for the study. Study participants included 39 homeless veterans and 20 service providers from the Birmingham, Alabama, and Pensacola, Florida, areas. Homeless veterans were recruited to participate from the resident population of nonprofit organizations servicing homeless veterans within the two locations. A subset of 12 homeless veterans (of the 39 homeless veterans who participated in the quantitative survey) agreed to participate in the one hour qualitative interview session within a private room with an interviewer. The 20 service providers who agreed to participate in the study were comprised of employees of shelters, ministers, counselors, attorneys, and anyone who had consistent service experiences with homeless veterans.  Both quantitative and qualitative instruments were obtained prior to the research effort. The quantitative survey instrument aligned with the national CHALENG 2010 study . The qua The quantitative phase that employed the use of the Community Veteran Assessment instrument focused on the participant's demographic characteristics, length of time of homelessness status, length of military service/branch, psychological considerations, reported illnesses or mental health considerations, and expressed needs and services. The Community Veteran Assessment instrument was used in the Community Homelessness Assessment, Local Education, and Networking Groups (CHALLENG) for Veterans project  and utilA semistructured interview using ten open-ended questions conceptually based in Baltes , 12, 13 N = 12) were interviewed in a separate area for privacy. Participants were provided information regarding available counseling services if needed while participating in the interview. Participants were also advised that they may discontinue participation at any time during the interview. Using the qualitative interview questionnaire, personal interviews of approximately 45–60 minutes each were conducted with the homeless veterans and service providers. Interview transcriptions were completed, representing more than 20 hours of personal interview discussions.  The mixed-methods research effort aligned with Baltes'  life-spa The sample for the study was comprised of 39 homeless veterans between the ages of 33 and 67 years. Seventeen homeless veterans from the Birmingham, Alabama, area and 22 homeless veterans from the Pensacola, Florida, area volunteered to complete surveys. The distribution of participants included approximately 64% Caucasian, 28% African-American, 5% Hispanic, and 3% Native American. Males outnumbered the females 5 : 1 with 33 males and six females. A complete demographic breakdown is presented in Data retrieved from the quantitative and qualitative instruments were analyzed relative to each of the seven research questions posited in the study. Each of the research questions is discussed relative to specific analysis of data procedures and study findings. Study findings are reported relative to each of the research hypotheses/questions and analysis of data discussions.  There is a relationship between homeless veterans' levels of depression and the number of months they served in a war zone. r(12) = .070, P > .05. Therefore, study findings did not support a relationship between homeless veterans' depression levels and the length of time they served in a war zone. Research hypothesis one was analyzed using the Pearson correlation procedure to determine if there was a relationship between the veterans' levels of depression and the number of months served in a war zone. The results indicated no statistically significant relationship with There is a relationship between service or no service in a war zone and whether or not the veteran becomes homeless. χ2(1) = .650, P = .689. These results are also influenced by the small number of veteran participants in the study as demonstrated by the small cell frequencies resulting from the Chi Square Analysis findings. Data from research question two were analyzed using the nonparametric Chi Square analysis of data procedure to determine whether veterans' becoming homeless was related to whether or not they served in a war zone. Expected cell frequencies were examined to see whether there were any expected frequencies less than 5; the smallest expected frequency was 3.0. Therefore a Fisher exact test was performed, and these results indicated that there was no statistically significant relationship between whether or not veterans served in a war zone and their potential for becoming homeless: There is a difference between homeless veterans and service providers in their median rankings of their perceptions concerning VA accessibility.U test to determine the difference between homeless veterans and service providers in their median rankings of perceptions concerning VA accessibility. The results of the Mann-Whitney test indicated that there was a statistically significant difference between the homeless veterans (Mdn = 3.0) and service providers (Mdn = 4.0), U = 258.50, Z = −2.06, P = .04, and r = .27. The median rank for providers was significantly higher than the median rank for homeless veterans, indicating that the VA accessibility was perceived to be positively accessible to service providers, while homeless veterans' perceptions of the VA reflected significantly less positive levels of accessibility. Research question three was analyzed using the Mann-Whitney There is a difference between the average perceptions of service providers in Northwest Florida and service providers in Birmingham, Alabama, regarding their perceptions of VA community partnership integration.t-test procedure to determine mean differences in VA-Community partnership integration between the service providers from Birmingham, Alabama, and northwest Florida. The assumption of homogeneity of variance was assessed by the Levene test, F = 3.93, P = .064; this indicated no significant violation of the equal variance assumption; therefore, the pooled variances version of the t-test was used. The t-test for partnership integration indicated a significant difference in the means between Birmingham, Alabama, and Northwest Florida service providers with t(17) = − 2.64, P < .05, with Birmingham, Alabama, service providers M = 7.13, SD = 7.1 and northwest Florida service providers M = 8.73, SD = 8.7, on a scale of 0–10 (computed by the combined perceptions of VA accessibility and VA ability to coordinate services). The effect size, as indexed by η2, was .05; this is a medium effect. The 95% CI for the difference between sample means, M1-M2, had a lower bound of −2.88 and an upper bound of −0.32. This outcome suggests a stronger partnership between the VA and community service providers in the northwest Florida region as compared with community service providers' partnerships with the VA within the Birmingham, Alabama, area.Research question four was analyzed using the Independent There is a difference in the rank ordering of the expressed needs of current study homeless veteran participants  as compared with the national CHALENG 2010 study participants . U procedure was used to determine the difference in rank ordering of expressed needs of homeless veterans between current study participants and 2010 CHALENG study participants. There were no statistically significant differences in rank ordering of expressed needs of the current study homeless veterans from the Birmingham, Alabama, group when compared with the rank orderings of the CHALENG 2010 Birmingham, Alabama, group: U = 35.0, Z = 1.14, (P > .05). Similarly, a comparison of the current study homeless veterans participants' rank orderings of expressed needs from the northwest Florida group relative to the CHALENG 2010 northwest Florida group yielded no statistically significant differences in rank ordering, U = 50.0, Z = .00, (P > .05). A descriptive listing comparison of the top ten needs for each group is located in Research question five was analyzed by comparing homeless veteran participant expressed needs from each location  to the corresponding locations in the CHALENG 2010 study. The Mann-Whitney What are the major contributing factors to veteran homelessness conditions within Birmingham, Alabama, and northwest Florida? The qualitative analysis of data for research question 6 is integrated within the context and interpretation of research question 7. What are the immediate needs of homeless veterans who are located within the Birmingham, Alabama, and northwest Florida regions? N = 12 homeless veterans (a subset of the 39 homeless veteran study participants) who agreed to participate in the private interview sessions conducted by the researchers. Data gathered from interviews, recorded, transcribed, and then coded using thematic assessment, a data-driven research approach based on developing themes that answer a research question [Analysis of data procedures for research questions 6 and 7 involved the retrieval of qualitative data from the question , were anquestion , 12, 13.The life-long tenet of the life-span development perspective posits that development does not peak or decline at a certain age and some elements of development occur across the life-span rather than in the first few years of life . Life coAccording to the life-span development perspective , the setwoulda, coulda, shoulda led to my drug use and I eventually just hit the road.” Rita reported she is recovering and “I haven't had a drink in over a month.”The life-span development perspective model emphasizes the contextual tenet . ChanginThe multidimensional tenet of the life-span development perspective  was exemThe multidirectional tenet of the life-span development perspective model  was demoThe plasticity tenet of the life-span development perspective model  was reveThe biology and culture tenet of Baltes's  model waCapturing empirical and inquiry-based results that substantiate the life-span perspective relative to homeless aging veterans was supported by the study. Interview data, survey data, and triangulation analysis of data with interpretation provided evidence of major influences depicting the tenets and characteristics of Baltes  theory oThe scholarly significance of the study is highlighted within three contexts: (1) the role of the current study within the context of sensitive populations for conducting research; (2) the practical need for the current study within the context of prevention efforts aimed at homelessness; and (3) the connection of the theory of life-span development with the population focus of aging homeless veterans as the framework for conducting research within the context of adding a robust perspective for adding to the body of research aimed at poverty, homelessness, and aging veterans.  Rosenheck et al.  support  The practical major need for prevention efforts to end veteran homelessness moves beyond the scholarly significance for the study; that is, the need for research must address strategies that focus on the health and economic challenges of veterans before they are threatened with the possibility of homelessness. The Department of Veterans Affairs initiated the Veterans Homelessness Prevention Demonstration (VHPD) Program in five cities in the spring of 2011 and has targeted those veterans who have completed assignments in the Middleeast [ Connecting the application of research associated with homeless aging veterans to life-span development theory provides a strong venue for scholars interested in examining the constructs of the life-span development perspective. Aligning empirical and qualitative data with appropriate triangulation interpretive information to the seven tenets of Baltes life-span development perspective , 12, 13 President Obama's mandate to end veteran homelessness by 2015 is a strong declaration to the veterans who have served in the military and the providers who service them. In 2008 there were 154,000 homeless veterans and that number has been reduced to 59,000 in 2012 . Although tremendous reduction in the number of homeless veterans has occurred since 2008, there remains much room for progress to reaching the 2015 goal. Findings of this study helped to frame the focus of research on homeless veteran experiences, specific characteristics, and needs, and how these factors influence life-span development. Understanding the contributing factors and how this unique population differs from nonveterans who are homeless is necessary to accomplishing this goal. In addition, service providers and the VA working cooperatively to establish programs aimed at assisting homeless veterans who may not have a physical, mental, or substance abuse diagnosis are recommended as an emerging need for future programs aimed at ending homelessness for veterans. Aging homeless veterans and female homeless veterans are two populations that have not been specifically addressed in the literature yet with the Vietnam generation nearing their mid-60s and increasing numbers of women serving in the military, these populations are among the most vulnerable to homelessness. Litz  suggeste Considering homeless veterans from a life-span development perspective may help service providers understand how sociocultural, contextual, and biological factors impact a veteran's development and adaptation to the changes from a structured military environment to life as a civilian. Each veteran can also contribute to helping fellow veterans as “occupational experts” with multidimensional knowledge. The issue of homeless veterans is not just a matter of finding homes for those who currently lack housing, but also establishing proactive programs aimed at preventing homelessness for those most at risk.


INK4a, BD ProEx C, and Cytoactiv HPV L1.Since the Pap test was introduced in the 1940s, there has been an approximately 70% reduction in the incidence of squamous cell cervical cancers in many developed countries by the application of organized and opportunistic screening programs. The efficacy of the Pap test, however, is hampered by high interobserver variability and high false-negative and false-positive rates. The use of biomarkers has demonstrated the ability to overcome these issues, leading to improved positive predictive value of cervical screening results. In addition, the introduction of HPV primary screening programs will necessitate the use of a follow-up test with high specificity to triage the high number of HPV-positive tests. This paper will focus on protein biomarkers currently available for use in cervical cancer screening, which appear to improve the detection of women at greatest risk for developing cervical cancer, including Ki-67, p16 Cervical cancer is the second most common cancer in women worldwide and remains a major cause of morbidity and mortality. Since the Pap test was introduced in the 1940s, there has been an approximately 70% reduction in the incidence of squamous cell cervical cancers in many developed countries by the application of organized and opportunistic screening programs. The efficacy of the Pap test, however, is hampered by high interobserver variability and high false-negative and false-positive rates . HoweverInvestigators have attempted by various means to enhance the sensitivity of the Pap test. First by the introduction of liquid-based methods to address issues of specimen collection and preparation, and later by the use of computer-assisted screening systems to address screening errors and to improve screening efficiency and disease detection. Testing for oncogenic, high-risk human papillomavirus (hrHPV) DNA has been accepted as an adjunct to borderline/ASC-US cytology in primary screening. The utility of HPV as a reflex test within the ASC-US patient population is largely reflected in its negative predictive value (NPV), where an HPV negative result indicates a low likelihood of finding CIN2+ lesions upon colposcopy . This trThe use of biomarkers in both cervical cytology and histology has demonstrated the ability to overcome issues with both false-positive and false-negative results, leading to improved positive predictive value of cervical screening results. Numerous protein biomarkers for the detection of cervical disease have been identified. Many of these proteins are involved in cell cycle regulation, signal transduction, DNA replication, and cellular proliferation (reviewed in –13). TheIn contrast to the cellular markers, the HPV L1 capsid protein is a virus-specific protein and a major stimulus of the immune system used within the HPV vaccines.INK4a, BD ProEx C, and Cytoactiv HPV L1. These biomarkers are reported to have a role in the triage of indeterminate cytology cases, discrimination of true high-grade cervical dysplasia from mimics in histology, and may serve as predictive markers to identify lesions most likely to progress to high-grade cervical disease and cancer. The staining characteristics and reported usage of the various biomarkers in cervical cancer screening are summarized in This paper will focus on protein biomarkers currently under investigation for use in cervical cancer screening that appear to improve the detection of women at greatest risk for developing cervical cancer, including Ki-67, p16Ki-67 is a nuclear and nucleolar protein expressed during the G1, S, G2, and M phase of the cell cycle, while not being present in resting cells (G0 phase), and can, therefore, provide an index of the cell growth fraction. While the function of the Ki-67 protein remains unclear, its expression appears to be an absolute requirement for progression through the cell-division cycle , 15. SinINK4a is a cell-cycle regulator, with its expression tightly controlled in normal cells. This tumor suppressor protein inhibits cycle-dependant kinases 4 and 6, which phosphorylate the retinoblastoma (Rb) protein [INK4a [INK4a is a sensitive and specific marker of dysplastic cells of the cervix and is a useful biomarker in cervical cancer lesion diagnosis and cervical screening [The protein p16 protein , 18. Usun [INK4a , 20, thecreening –25. MultBD ProEx C is a protein-based biomarker reagent  containing antibodies to the nuclear proteins minichromosome maintenance protein 2 (MCM 2) and topoisomerase II alpha (TOP2A), proteins that have been shown to accumulate in HPV-transformed cells. BD ProEx C staining is limited to the basal proliferating layer of normal cervical epithelium and is absent in differentiated and quiescent cells. In contrast, in cervical glandular and squamous dysplasia, BD ProEx C expression is dramatically increased, due to the increased transcription of S-phase genes (aberrant S-phase induction) resulting from the action of the oncogenic HPV E7 protein.The minichromosome maintenance (MCM) proteins function in the early stages of DNA replication through loading of the prereplication complex onto DNA and functioning as a helicase to help unwind the duplex DNA during de novo synthesis of the duplicate DNA strand , 27. Oriα (TOP2A) has been shown to be overexpressed in cervical neoplasia at both the mRNA and protein levels [Similar to the MCM2-7 markers, topoisomerase II-n levels –35. TOP2n levels .The BD ProEx C test was designed as a reflex test to identify CIN2+ disease in women with ASC-US and LSIL cytology results. The next generation test designed for primary screening applications, BD SurePath Plus, combines on one slide traditional Pap staining for cellular morphology, in combination with immunocytochemical detection of the overexpression of two biomarkers: MCM2 and MCM7 .The Cytoactiv Screening antibody detects the L1 capsid protein of all known HPV types. Together with the L2 protein, the L1 capsid protein forms a protective cover for the viral genetic material. In addition, it is a ligand for a surface receptor of the host cell in the basal/parabasal cell layer of the epithelium, gaining access to the basal epithelial layer as a result of epithelial erosions or mucosal ulcerations in the transformation zone susceptible to inflammation at the cervical/endocervical junction. HPV L1 expression is found in the early, productive phase of HPV infection but is progressively lost during cervical carcinogenesis. This loss of L1 expression may result from the integration of viral DNA into the human genome, which may disrupt the L1 gene or cause loss of L1 expression by segregating the viral promoter from the L1 gene, or may reflect an abnormality in transcription factor pathways or in control of L1 protein translation , 37.As the L1 capsid protein is one of main targets for T cell-mediated immune response, cells with a lack of L1 protein synthesis may escape immune system recognition, allowing disease progression. Promising data using the Cytoactiv test  supports this notion, with progressive disease more frequently detected in L1-negative intraepithelial lesions –41.INK4a, and BD ProEx C has been reported to facilitate the detection of abnormal cells within a Pap cytology sample based upon simple immunocytochemistry assay formats  randomized controlled trial in Italy, the performance of p16 triage of HPV primary screen-positive women was examined . SensitiINK4a and Ki-67, has been evaluated as a reflex test from borderline cytology results and in cytology negative, high-risk HPV positive cases [ The CINTec Plus biomarker cocktail, composed of antibodies against p16ve cases –52. In tve cases . As a trINK4a [The performance of BD ProEx C in the detection of CIN2+ disease in ASC-US+ BD SurePath liquid-based cytology specimens has been reported in five studies, with sensitivity, specificity, PPV, and NPV for detection of CIN2+ disease ranging from 56.5–98%, 72-97.6%, 27.4–97%, and 95–99.3%, respectively –57. A feINK4a , 23, 58 INK4a , 56 immuWhile the cytology-based Pap test is used as the screening test for cervical cancer, histopathological evaluation of a cervical biopsy from a woman with an abnormal Pap test is the “gold standard” for the diagnosis of cervical neoplasia. However, diagnosis variability has been documented among observers and depends, in part, on the grade of the abnormality . PreviouINK4a, and BD ProEx C immunostains are helpful in the assessment of cervical biopsies by decreasing interreader variability, assisting in the discrimination of true dysplasia from mimics, and identifying regions of focal disease that can be missed with H & E staining alone. Representative staining patterns of the biomarkers in cervical dysplasia are shown in INK4a staining pattern is more variable, with staining found in the nucleus, cytoplasm, or both, the significance of which is not fully understood at the present time.It has been shown that Ki-67, p16INK4a , and BDiewed in , 68–72 insistent –66  of invasive adenocarcinomas, 100% of AIS (29/29), and 32% (7/22) negative samples. ProEx C and Ki-67 both scored positive in all adenocarcinomas (15/15) and AIS (29/29), and in 36% (8/22) and 27% (6/22) of negative samples, respectively. p16 and Ki-67 individually stained positive in 94% (15/16) of glandular dysplasia cases, with 87.5% positivity (14/16) detected with ProEx C. The score differences between neoplastic and nonneoplastic samples were highly significant for each marker (P < 0.001), and each biomarker was shown to be useful for the diagnosis of neoplastic lesions of the glandular epithelial of the cervix uteri.Negri et al.  evaluateINK4a. The study concluded that BD ProEx C had a better overall performance in differentiating NILM versus HSIL/SCC compared with p16INK4a with the added benefit of having clean nuclear staining.In a study examining cell block preparations , BD ProEOne major issue in the management of cervical cancer is the evaluation of progression risk of dysplastic lesions. Patients with CIN1 must be periodically followed due to the risk of progression to high-grade lesions or carcinoma. As 70–80% of low-grade lesions spontaneously regress and not all high-grade lesions progress , some woA limited number of studies have reported that the application of Ki-67 immunoquantitative analyses of CIN1 and CIN2 can predict disease progression, with the best features to predict progression being the 90th percentile of the stratification index and the percentage of Ki-67 positive cells in the middle third layer of the epithelium , 75.INK4a positive low-grade lesions have a higher risk of progression than negative lesions, although this correlation was certainly not absolute [INK4a and ProEx C biomarkers in premalignant lesions to determine which markers could help in prediction of the progression of CIN1. Expression of both markers was significantly higher in the progression group compared to the regression group, being sensitive (86%) and moderately specific  in predicting CIN1 progression. Hariri and Hansen [INK4a to BD ProEx C and HPV ISH in CIN1 cases and found BD ProEx C to be a reliable marker for prediction of 6-year outcome, with an NPV of 95.3% compared with 88.6% for p16 and 87.5% for HPV ISH and a PPV of 51% compared with 40.4% and 67.9%, for p16 and HPV ISH, respectively.Recent prospective end point studies have shown that p16absolute –79. Addiabsolute  examinedd Hansen  comparedINK4a positivity, but only very focal Ki-67 staining, indicating a presence of a small subset of HSILs with low proliferative activity [Interestingly, CIN2/3 cervical histology specimens have been described with very strong p16activity , 83. CasINK4a, to confirm the association of the lesion with HPV, has been reported to serve as a prognostic marker that can differentiate between patients who will undergo a transition from a precursor lesion to cancer and those whose lesions will regress [HPV L1 is a capsidic protein that is expressed in the early, productive phase of HPV infection, but progressively lost during cervical carcinogenesis. An analysis of thin-layer preparations showed that the L1 capsid protein is produced in about 80% of mild-to-moderate dysplasias, whereas it could only be detected in about 25% of higher-grade dysplasias using immunological methods , due, in regress , 84. Whi regress .A number of protein biomarkers are currently available to assist in improving the clinical performance of cervical cancer screening. The recent introduction of prophylactic HPV vaccines will eventually reduce the incidence of cervical cancers and its malignant precursors, therefore, increase the importance of biomarkers in future cervical cancer screening programs to identify for treatment only those women truly at high risk for developing cervical cancer. It is anticipated that the use of these biomarkers can be applied both as a reflex test from an atypical Pap specimen but also as a primary screen to improve the overall accuracy of the Pap test. The introduction of HPV primary screening programs will necessitate the use of a reflex test with high specificity to triage the high number of HPV positive tests. It is believed that biomarkers will also serve an important role in the optimization of this alternative screening algorithm. Current translational research investigations are continuing to discover, characterize, and validate such biomarkers for these anticipated applications.


Few studies have assessed barriers to human papillomavirus (HPV) vaccination uptake and adherence, particularly among women of Appalachian Kentucky, a population with higher rates of cervical cancer, lower rates of HPV vaccination, and lower socioeconomic status compared with the rest of the nation. The objective of this study was to address women’s reasons for declining the HPV vaccine and, among women who initiated the vaccine series, barriers to completion of the 3-dose regimen.We recruited 17 women aged 18 to 26 from a Federally Qualified Health Center who participated in in-depth, semistructured telephone interviews. All interviews were audio-recorded and transcribed verbatim; analysis of the interview transcripts was an iterative process conducted by all 3 authors.We identified 3 primary barriers: 1) a knowledge gap wherein women are both uninformed and misinformed about cervical cancer, HPV, and the HPV vaccine, all of which affect vaccination behaviors; 2) environmental and tangible barriers ; and 3) ambiguous information sources, which contribute to misinformation and subsequently affect vaccination decisions.Health professionals should use clear and purposeful communication about how cervical cancer develops, the purpose and safety of the HPV vaccine, and the necessity of completing the 3-dose series. Health promotion campaigns and services tailored for young women in Appalachian Kentucky that focus on increasing knowledge and eliminating barriers are needed. Prevention of human papillomavirus (HPV) infection and subsequent development of cervical cancer is achievable through vaccination against HPV types 16 and 18. Two vaccines are available, both given as 3 doses over 6 months and approved for women aged 9 to 26; however, vaccination rates remain low for adolescent girls and young adult women , which is an approach to understanding theoretical constructs relevant to knowledge, attitudes, perceptions, behavioral intention, and behavior ; severalOn the basis of consultation with the medical director of a regional Federally Qualified Health Center (FQHC) in Appalachian Kentucky, investigators designed a study protocol that identified female clinic patients aged 18 to 26, through a medical chart review, who had either declined the HPV vaccine or had started the vaccine series but failed to complete doses 2, 3, or both in the required time. We asked to review medical charts from March 2008 through September 2009 because an HPV vaccine promotion, which provided the vaccine free to eligible women, occurred during this time. FQHCs provide care for medically underserved people for free or on a sliding scale; more than 275,000 Kentuckians, 63% of them women, used an FQHC in 2010 . ApproxiAll eligible women  were invited to participate in the telephone interviews. Despite multiple recruitment attempts (mail and telephone), only 18 women enrolled; recruitment was challenging because of the study population’s transient nature . One interview was excluded from analysis because of inaccurate medical records; the final sample was 17 women. All of the women were white, and the mean age was 22 years; only 2 women had health insurance. Eight study participants were married. Nine of the women initiated the vaccine series, and 8 declined the vaccine.Telephone interviews that lasted approximately 30 minutes were conducted between June through August 2010; each participant was compensated $30. Participants provided informed consent before starting and recording the interviews. Participants answered every interview question (including responses of “I don’t know”). The interview guide (Appendix) was informed by previous literature ,23, the The interviewer (L.A.M.) read the transcripts to verify accuracy and remove any personal identifiers. Pseudonyms were created for participants to designate vaccination status; participants who declined the vaccine were given a final initial identifier of “D” , and participants who received at least 1 dose were given a final initial identifier of “V” .All 3 authors analyzed the interview transcripts via an iterative process. Using the IBM framework and literature on cervical cancer, HPV, and HPV vaccination, we developed a codebook that was used to initially code the interviews. All 3 authors read each transcript line by line using the initial coding frame. The authors then met to discuss the initial coding and discussed divergent or unique findings, which led to the generation of a final codebook (still informed by the IBM framework). The first author (L.A.M.) recoded the transcripts using the final codebook, gathering key examples for each emerging finding.Both groups of women, those who declined the vaccine and those who initiated the vaccine, had similar knowledge levels related to cervical cancer, HPV, and HPV vaccination and similar environmental and social normative barriers. Participants discussed 3 barriers to vaccination, which were consistent with the IBM’s behavioral antecedents: 1) knowledge barriers to HPV vaccination, with a distinct difference between misinformation and being uninformed; 2) environmental and tangible barriers to HPV vaccination such as transportation and everyday responsibilities; and 3) social and normative influences on HPV vaccination.Uninformed is defined as lacking knowledge whereas misinformed is defined as having incorrect knowledge. Four women were uninformed about cervical cancer; they answered, “I don’t know” when asked about cervical cancer and how it develops. Women also lacked knowledge about HPV; 5 women responded “I don’t know” to HPV questions, 4 women were uninformed about HPV transmission, and 2 women who were unvaccinated had never heard of the HPV vaccine. Some women were misinformed about these issues. For example, when asked about the causes of cervical cancer, Susan D stated it develops “from being really [sexually] active” and “tissue scarring.” Rebecca D said she has “always heard tanning beds” can cause cervical cancer. Brenda D said, “I’ve actually heard that using [a] douche can cause cervical cancer.” Whitney V said cervical cancer “could be hereditary, possibly.” These examples represent the range of misinformation about cervical cancer, espoused by both vaccinated and unvaccinated women.Participants were misinformed as well as uninformed about cervical cancer, HPV, and the HPV vaccine. Women in this sample were misinformed about HPV, even confusing it with cervical cancer and the HPV vaccine. When asked about HPV, Rebecca D said it is “a shot that prevents cervical cancer”; Whitney V said HPV is “a type of cancer.” Susan D shared that HPV “is a disease that can kill you.” Finally, some women were unsure about the vaccine dosing schedule; for example, Leah V said, “When I took the first dose, I didn’t know there was 2 more doses.”Environmental barriers to medical services are not uncommon in this region. Three women indicated that transportation was problematic. Elizabeth V shared that “me and my fiancé, neither one have a driver’s license, so we don’t have a car. . . . We’re dependent on my mother to take us [places].” Monica V stated, “I don’t drive; my husband’s the only one that drives, and he works full time.” Felicia V said she doesn’t “have any transportation,” and this was a barrier for getting subsequent HPV doses. Even women who had transportation indicated that lack of transportation could be problematic for their peers to return for follow-up vaccinations.a.m. until 8 p.m. in the evening, so it’s hard” to make time for HPV vaccination. School, work, and child care responsibilities are common in this population of young women, making this age group difficult to reach.Many young women also shared that their everyday responsibilities prohibited them from completing the HPV vaccine series. A major barrier was child care. Elizabeth V shared that she was unable to return for subsequent doses because “My oldest son is going to school, and me, I had to take care of a newborn.” Likewise, Jane V said, “I want to get this [HPV vaccination] done, but I always put my daughter first. So if she’s sick or has to go to the doctor, I always take her before I do myself.” School and work responsibilities were also barriers to series completion for these women. Leah V explained, “I work 6 days a week . . . from 9 Despite challenges to vaccination, women were supportive of making the vaccine more widely available in the community at places like the local Walmart, community college, and community festivals. For example, when asked if providing the HPV vaccine at different community locations could help other women like her to receive the vaccine and return for subsequent doses, Elizabeth V said “that would catch a lot of women in this age group.” Additionally, Jane V indicated, “I would definitely do something like that. . . . I think that’s an excellent idea.” Shannon D also agreed, saying “that would be good” to deliver the vaccine in the community. Diane D suggested that “someone [should be] there to counsel on the risks and benefits” as well. Overall, environmental barriers related to everyday responsibilities and transportation issues were common; however, there was support for opportunities to give the vaccine in the community.Religious beliefs did not influence vaccination decisions in this sample. Furthermore, 12 women, regardless of vaccination status, did not discuss their vaccination decision with family. When women did discuss their vaccination decisions with family, they were mostly neutral or positive. Whitney V remembered, “I spoke with my family about it and my husband.” Similarly, Amanda V discussed her decision to get vaccinated with her family and they “agreed that it would be a good precaution.” There was 1 instance of a family member bringing up the vaccine to a young woman. Sarah D shared, “My mom actually had mentioned [the HPV vaccine] to me before . . . when she found out she had cervical cancer . . . but I never [personally] asked [about it].” In this case, the positive conversation did not lead to vaccination.Although known social influences such as family and religion did not affect these women’s decision to vaccinate, ambiguous sources from which these women received information about cervical cancer, HPV, and the HPV vaccine were commonly mentioned. Many women referenced “they” when discussing their information sources. “They” make up a piece of Appalachian Kentucky women’s social and normative network — a mix of cultural perceptions and health information obtained from family, friends, mass media, and health care providers. For instance, Mary V shared that she was instructed to stop taking the HPV vaccine because “there’s a big rumor . . . going around about them saying [the shots] done something; you couldn’t have kids.”Brenda D, who believed that douching can cause cervical cancer, went on to say that “they told me not to do that [get the HPV vaccine] because it could cause [cervical cancer], they said so.” Another instance of ambiguous information sources was evidenced by Ashley V, who said she heard the HPV vaccine “ caused a lot of people to die in Arizona. . . . A lot of people were taking the shot got sick and died,” and she heard this from “other women.” When asked what local health clinics should do to increase vaccine uptake and adherence for young women like her, Ashley V believed it was the health care providers’ responsibility to inform young women about these health issues and clear up any misconceptions. She said that providers should “make sure that they’ve answered all their questions . . . [that] they have laid out the facts.” As supported by the IBM, we found 3 major barriers to HPV vaccination. First, we found a knowledge gap among both unvaccinated and partially vaccinated women related to cervical cancer, HPV, and the HPV vaccine, which affected women’s decisions to vaccinate or continue vaccinating, confirming previous research ,24. AlthSecond, tangible barriers prevented these women from receiving the vaccine or completing the series. Women identified lack of transportation as a barrier. Busy schedules and other priorities such as family, work, and school were also barriers. The young women in our study are starting their adult lives, going to school, getting married, and having children, often while living on a constrained budget and in an area of the country where they may be geographically isolated from a health clinic. These factors combine to create a hard-to-reach population that is less likely to return to clinics for subsequent vaccine doses. To increase vaccine uptake and adherence, public health practitioners in this area should design programs that partner with communities to deliver this vaccine. Community-based approaches for reducing cancer disparities in Appalachian Kentucky show that local residents can provide insight into local health issues and possible locally tailored solutions . Others Third, we found social and normative influences as barriers. Some findings were unexpected: the women in our sample denied that religion and family influenced their vaccination decision, despite research indicating the opposite . These sLimitations of this study include the small sample size; women in this age group are often transient, making recruitment challenging. Rural Appalachian women may be reticent to participate in research, which also may have affected our sample size ,29. FinaOur results have implications for public health practitioners and health care providers, particularly in rural communities. We make 2 suggestions for future research and practice for health professionals working in Appalachian Kentucky and similar medically underserved communities. First, it is imperative that providers use clear and purposeful communication about how cervical cancer develops, the purpose and safety of the HPV vaccine, and the necessity of completing the 3-dose series. Second, the dual knowledge gap (being misinformed or uninformed or both) highlights the importance of doing formative research, especially for health educators, clinicians, and lay health advisors. Practitioners who are designing health promotion materials and programs must assess both gaps.


Exploring the presence and role of human papillomavirus (HPV) in head and neck cancer (HNC) is a necessary step to evaluate the potential impact of HPV prophylactic vaccines.To assess the prevalence and oncogenic role of HPV in HNC in Senegal.25. Tubulin analysis was performed to assess DNA quality. HPV DNA-positive cases were tested for p16INK4a expression.This is a multicenter cross-sectional study. Paraffin-embedded blocks of cases diagnosed with invasive HNC between 2002 and 2010 were collected from 4 pathology laboratories in Senegal. Presence of HPV DNA was determined by PCR and DEIA, and genotyping performed with LiPAINK4a overexpression.A total of 117 cases were included in the analysis: 71% were men, mean age was 52 years old (SD ±18.3), and 96% of cases were squamous cell carcinoma. Analysis was performed on 41 oral cavity tumors, 64 laryngeal tumors, 5 oropharyngeal tumors and 7 pharyngeal tumors. Only four cases  harbored HPV DNA. HPV types detected were HPV16, HPV35 and HPV45. However, among HPV-positive cases, none showed p16Our findings indicate that HPV DNA prevalence in HNC in Senegal is very low, suggesting that HPV is not a strong risk factor for these cancers. Additional larger studies are needed to confirm these findings and explore other potential risk factors specific to the region. Head and neck cancer (HNC) is the eighth most common cancer worldwide with approximately 650,000 new cases and 350,000 deaths reported each year . In addiIn sub-Saharan Africa, knowledge on the role of HPV in HNC is very limited. Actually, 84% of the existing information on HPV and HNC is derived from studies in Europe and North America . The aim25) . The LiPA25 detects 25 high-risk and low-risk HPV types . Additionally, amplification of the human tubulin gene was performed to determine DNA quality of DEIA negative samples. In HPV DNA-positive samples, p16INK4a overexpression was evaluated using CINtec histology kit  in order to verify the potential causal role of HPV in positive cases. Overall HPV detection percentages and 95% confidence intervals (95% CI) were estimated. Data analyses were performed with STATA 11.0. Ethical approval was obtained from the Ministry of Health of Senegal.This is a cross-sectional study designed and coordinated by the Catalan Institute of Oncology in Barcelona and is part of a large international study on HPV in HNC. Four major centers in Dakar, Senegal, have provided consecutive cases diagnosed with HNC from 2002 to 2010: Centre Hospitalier Universitaire A. Le Dantec, Hôpital Principal de Dakar, Hôpital Général de Grand Yoff and the pathology laboratory at Cheikh Anta Diop University. For each specimen, after pathological confirmation of invasive diagnosis, a paraffin tissue section was treated with 250 μl of freshly prepared Proteinase K solution to extract DNA. SPF-10 polymerase chain reaction (PCR) was performed using 10 μl of a 1:10 dilution of the crude DNA extract in a final reaction volume of 50 μl. The amplified PCR products were tested using a probe hybridization step with a cocktail of conservative probes that can recognize around 54 mucosal HPV genotypes using a microtiter plate format for the detection of HPV DNA through a DNA enzyme immunoassay (DEIA) . Optical densities (OD450) were read on a microtiter plate reader and categorized as HPV DNA negative, positive, or borderline. After PCR, 10 μl of the DEIA HPV DNA positive amplimers were used to perform the reverse hybridization line probe assay  and three laryngeal SCC (2 HPV45 and 1 HPV16). However, none of these cases showed p16INK4a overexpression: 3 cases showed no p16INK4a staining and one HPV45 laryngeal cancer case showed focal staining of less than 25% of cells with low-moderate intensity.The overall HPV prevalence was 3.4%; 95% CI = 0.9%-8.5%. Table INK4a expression suggested that HPV was not involved in the oncogenic process of the tumors. Expression of p16INK4a is strongly seen in HPV-associated tumors but nearly absent in HPV-negative carcinomas [To our knowledge, this is the first study to explore the presence of viral DNA and cellular protein expression in head and neck tumors in West Africa. HPV DNA was detected in 3.4% (95% CI = 0.9%-8.5%) of studied cases but further analyses testing for p16INK4a. Both studies agree on significant ethnic and biological disparities in HPV prevalence, after adjusting for clinical and sociodemographic characteristics, and support the validity of our study. Further studies are needed to elucidate the mechanism of HPV clearance in African-American and African populations, which share common ancestral origins.Similar low HPV prevalences have been reported in the African-American community in the USA. In a prospective study conducted by Settle et al. , overallThese findings are very different from what has been reported previously in other regions of the world. In a systematic review by Kreimer et al.  compilinLow HPV prevalence in invasive HNC in Senegal suggest that other established risk factors such as alcohol and tobacco consumption may play a more significant etiological role than HPV infection in HNC. However, the prevalence of tobacco use in Senegal is relatively low with estimates of 19.9% in men and 1.3% in women . Alcohol2 and CO [For example, indoor air pollution causes 6,300 deaths each year in Senegal due to daily exposure to smoke from open burning of wood and charcoal in homes . More th2 and CO . Accordi2 and CO .Another potential risk factor could be the consumption of “ataya”, a strong and bitter hot tea comparable to “yerba mate” in South America, which has been associated with an increased risk of developing cancer of the oral cavity, larynx and esophagus . On averPoor oral hygiene is another potential risk factor that has been documented  and coulOccupational exposure such as jobs in the construction, metal, textile, ceramic, logging, and food industries has been associated with the development of laryngeal cancer . In SeneOur study has some methodological limitations. At sample collection stage, some cases were identified eligible for the study but corresponding blocks were not found as they were sent to laboratories abroad for histopathological evaluation. Additionally, several archival records were lost in one of the main laboratories due to a fire. However, these issues affected all cases regardless of patient characteristics or diagnosis. Another major limitation is the lack of individual data on risk factors: no information on patients besides their gender, age and pathological information were available in the registries. Finally, the small sample size (n = 5) for oropharyngeal tumors may have affected our positivity rate. It is recognized that the highest associations of HPV in HNC have been shown in the oropharynx, particularly in the tonsils, with a positivity of 57% to 82% compared to 0.8% to 9% in other anatomic sites .INK4a expression. Additionally, we evaluated the quality of our specimens by means of cellular tubulin detection and subsequently excluded the HPV DNA negative and tubulin negative cases from the statistical analyses. Lastly, all of the study cases were selected from the main anatomy and pathology laboratories in Senegal. Thus, our cohort is representative of the target population as the vast majority of patients are diagnosed in participant centers.Our study has several strengths comprising the combined use of highly sensitive assays for HPV DNA detection and a marker of HPV related transforming process such as p16In Senegal, HPV prevalence in HNC is very infrequent and HPV infection is not associated with carcinogenesis. Therefore, HPV prophylactic vaccines would not have any impact on HNC incidence. Our findings need to be further validated with supplementary studies that include larger case series and the assessment of region-specific risk factors. Additional data will allow to close the gap of knowledge between Western countries and the sub-Saharan African region and to assist health authorities in implementing public health strategies.HT served as a consultant and on advisory boards and received speaker fees and travel assistance from Merck-Frosst Canada and Glaxo Smith Kline Pharmaceuticals, Belgium. LA occasionally received travel grants to attend conferences granted by Merck and Sanofi Pasteur MSD. XC received travel grants for scientific meetings and honorarium for consultancy occasionally granted by GlaxoSmithKline, Merck, Sanofi Pasteur MSD. XB received travel grants to conferences/symposia/meetings and honorarium occasionally granted by GlaxoSmithKline, Merck, Sanofi Pasteur MSD, Roche or Qiagen. SS received travel grants to conferences/symposia/meetings occasionally granted by GlaxoSmithKline, Sanofi Pasteur MSD or Qiagen. Other co-authors have no potential conflict of interest to declare.CN collected data, performed data analysis and drafted the manuscript. SJ, XC, FXB and LA initiated and designed the study. LA, HT and SJ guided data analysis, interpreted data and edited the paper. XC and FXB made substantial contributions to the manuscript and contributed to data interpretation. NN, YD and MJD interpreted data and edited the paper. JEK performed the laboratory tests and MA the histopathological evaluation. ST managed and cleaned the database. All authors read and approved the final manuscript.


TaEXPA1 homoeologs varied dynamically at different stages and organs, and epigenetic modifications contribute to the expression divergence of three TaEXPA1 homoeologs during wheat development. Nevertheless, their functions remain to be clarified. We found that over expression of TaEXPA1-A, -B and -D produced similar morphological changes in transgenic Arabidopsis plants, including increased germination and growth rate during seedling and adult stages, indicating that the proteins encoded by these three wheat TaEXPA1 homoeologs have similar (or conserved) functions in Arabidopsis. Collectively, our present study provided an example of a set of homoeologous genes expression divergence in different developmental stages and organs in hexaploid wheat but functional retention in transgenic Arabidopsis plants.Common wheat is a hexaploid species with most of the genes present as triplicate homoeologs. Expression divergences of homoeologs are frequently observed in wheat as well as in other polyploid plants. However, little is known about functional variances among homologous genes arising from polyploidy. Expansins play diverse roles in plant developmental processes related to the action of cell wall loosening. Expression of the three  Polyploidization plays an important role in plant evolution. It has been demonstrated that approximately 70% of flowering plants experienced polyploidization events during their evolution T. aestivum, 2n = 6x = 42, genome constitution AABBDD) is an allopolyploid that was formed through hybridization and successive chromosome doubling of three ancestral diploid species (2n = 14), T. urartu (AA), Aegilops speltoides (SS ≈ BB), and Ae. squarrosa (DD) Bx genes (TaBx1–TaBx5) were highly conserved in the coding sequences and in the exon/intron structures, but were transcribed differentially in which the homoeologs from the B genome generally contributed the most to Bx biosynthesis in hexaploid wheat QWAP2A fully recovered their flower organs similar to the wild-type, WAP2D showed less recovery, and qWAP2A rescued the least mutant flower phenotype Hexaploid bread wheat  from hexaploid wheat. Chromosome mapping using aneuploid lines revealed that the TaEXPA1-A, TaEXPA1-B and TaEXPA1-D genes located on chromosomes, 1A, 1B, and 1D, respectively. The orthologs of TaEXPA1 also were found in the three ancestral diploid species. We demonstrated that epigenetic modifications contribute to the expression divergence of three TaEXPA1 homoeologs during wheat development TaEXPA1 homologous genes in wheat. In present study, we found that over expression of TaEXPA1-A, -B and -D produced similar morphological changes in transgenic Arabidopsis plants, including increased germination and growth rate during seedling and adult stages, indicating that the proteins encoded by these three wheat TaEXPA1 homoeologs have similar (or conserved) functions in Arabidopsis.In previous study, we identified three Triticum aestivum) was used in this study. Wheat seeds were germinated on moist filter papers and transplanted into pots to grow in the greenhouse under a 12-hr photoperiod provided by cool white fluorescent and incandescent light (intensity≥3000 lx). The plants were watered with a 1/10-strength Hoagland’s solution when necessary. The Columbia (Col-0) ecotype of Arabidopsis thaliana was used as the wild type. All genotype plants were grown in a growth room with a 16-h light/8-h-dark cycle at 22 to 24°C for general growth and seed harvesting.The hexaploid wheat genotype Nongda 3338 , and 3 TaEXPA1 homoeologs of wheat. The GenBank accession numbers of selected expansins can be found in the All deduced amino acid sequences were aligned using Clustal method with the MEGA4.0 program Wheat Nongda 3338 were planted in pots in silt-loam/coarse soil mix and grown in green house. In two-leaf stage, the first leaf in the bottom, the second fully expanded leaf in the middle and the third unexpanded leaf were collected, and designated as mature, fully expanded and juvenile leaves, respectively. Total RNA extracted from different leaves for the gene expression analysis, using Trizol RNA isolation protocol . First-strand cDNA synthesis was performed using 2 µg of DNase-digested total RNA with oligo (dT) primer according to the protocol for RT-PCR first-strand synthesis .TaEXPA1 homoeologous genes, TaEXPA1 homoeologs. The PCR efficiencies of each primer pair were determined from standard curve experiments. Any amplification with detected primer dimers from melt-curve analysis was excluded from the data analysis β-actin was amplified as an endogenous control.Real-time qPCR experiments using SYBR Green PCR master mix (Applied Biosystems) on 96-well optical reaction plates with optical adhesive covers (ABI PRISM) were designed, performed, and analyzed using the StepOnePlus Real-Time PCR system with its accompanying StepOne Software . Gene-specific primers for quantitative PCR were designed based on nucleotide polymorphisms in the cDNA sequences of three TaEXPA1 homoeologous genes, genomic DNA fragments of the genes were cloned downstream of the cauliflower mosaic virus 35S promoter in pB2GW7 vectors. Binary vectors were introduced into Agrobacterium tumefaciens GV3101. Six-week-old Arabidopsis plants were transformed via Agrobacterium-mediated transformation by the floral-dip method To examine heterologous expression of Seed lots to be compared were harvested on the same day from individual plants grown in identical environmental conditions. Seeds of each genotype were sterilized and cold treated for 3 d in the dark, then sown in triplicate  on MS medium. The plates incubated in a climate-controlled room . Germination was scored after 16 h imbibitions, we used radicle tip break through the seed coat as the seed germination standard. The number of geminating seeds was counted and converted into germination rate per 8 hour intervals for both transgenic lines and wild type plants. The average germination percentages ± SE of triplicates were calculated.For leaf size measurement and analysis of Col-0 wild-type and transgenic plants, cotyledons and sixth leaves were harvested and measured digitally on photographs taken using a digital camera (Nikon D90) with a standard 15-cm ruler for scaling on a black background. Acquired photographs were processed using Photoshop (Adobe version CS5) with manual tracing of leaf outlines to generate leaf silhouettes. Based on these measurements, leaf area was calculated.All genotype plants were grown in a growth chamber with a 16-h light/8-h-dark cycle at 22°C. Plants were grown for 3 weeks after sowing and were measured. The actual times were 22, 25 and 29 days after sowing (DAS). The fresh rosette was cut with a pair of scissors just above ground and for weight determination with electronic balance and calculation of the amount of green biomass. Plant height was measured from the base of the plant  to the tip using a cotton thread. The actual times were 29, 32 and 35 DAS. Each line 15 plants were selected for fresh weight and height analysis.TaEXPA1 homeologous genes showed a significant conservation of the intron/exon organization within the open reading frame (ORF). The structures of three TaEXPA1 homeologous genes were also confirmed by the identification of potential exon/intron junction sequences, which were consistent with the universal rule GT.AG. The ORF sequences of three TaEXPA1 genes showed single nucleotide substitutions only, whereas the introns had more frequent base substitutions and insertions/deletions  of the transgenic Arabidopsis plants with that of wild-type plants. These results showed that leaf lamina areas were all significantly increased in the overexpression of three TaEXPA1 homoeologous genes plants  based on overall sequence similarity and shared structural features TaEXPA1 homoeologous genes TaEXPA1-A, TaEXPA1-B and TaEXPA1-D from hexaploid wheat TaEXPA1 homeologous genes and α-expansins of Arabidopsis and rice was further investigated by neighbor-joining phylogenetic analysis. These α-expansins were classified into six different classes according to the phylogenetic tree, among which three TaEXPA1 homoeologs belong to the class III with AtEXPA2, AtEXPA8 and OsEXPA2, OsEXPA4, OsEXPA6, OsEXPA11  represent α-expansins, while TaEXPB1–TaEXPB5 and TaEXPB7–TaEXPB10 belong to the β-expansin class TaEXPA1 homoeologs were silenced in seedling roots, but TaEXPA1-A and -D were expressed in seedling leaves TaEXPA1 homoeologs was further investigated in seedling leaves of different development stages. Interestingly, TaEXPA1-A and TaEXPA1-D homoeologs appeared to be highly expressed in the young leaves, as compare to fully expanded leaves. In Arabidopsis, it was reported that expansin genes play important role during leaf development. Collectively, it can be concluded that the highly expression of TaEXPA1 in the young leaves may impact cell proliferation or expansin, then affect leaf development in turn.Up to date, many wheat expansin genes were identified and their expression were analyzed. For example, 18 expansin genes were isolated from wheat and nine of them  were analyzed between transgenic lines and wild-type, further analysis of other processes, such as pollination, floral opening, meristem dynamics, fruit softening, as well as in adaptive responses to submergence, GA and wounding, will provide more valuable information for the function retention of three TaEXPA1 homoeologs.Plenty of studies have shown that polyploidization is often accompanied by changes in genomic structure and gene expression, including loss of function, gene silencing and homoeologous gene expression diversification t stages –6. TheseExpansin genes have been isolated from a variety of plant species and are a large multigene family expansin are expressed in various parts of plants at different developmental stages. For example, LeEXP4 was shown to be expressed specifically in the endosperm cap tissue enclosing the radicle tip LeEXP8 and LeEXP10 were expressed in the embryo. The tissue localization and expression patterns of both LeEXP8 and LeEXP10 suggested that they played roles in the initial elongation stage of the radicle and seedling growth GmEXP1 was expressed mainly in the regions undergoing cell division and elongation in the primary and secondary roots, suggesting a role in root elongation in soybean expansin gene expression is reflected in the similarly diverse expression patterns found in wheat, in which three TaEXPA1 homoeologs were differentially expressed in different tissues and developmental stages TaEXPA1 homoeologs suggested that TaEXPA1 may play multiple roles in wheat development. In present study, we found that germination rate and primary root length of transgenic plants were faster than control plants, suggesting that TaEXPA1 gene plays an important biological role in control of seed germination and initial elongation of the radicle. A previous study demonstrated that AtEXP10 is expressed predominantly in young growing petioles and leaf blades, overexpression of AtEXP10 produced larger rosettes and matured earlier as compared to the control plants, and leaf size was substantially reduced in antisense lines with suppressed AtEXP10 expression EXPA1, −3, −5, and −10) demonstrated that expansins are required for leaf growth TaEXPA1 homoeologs in Arabidopsis increased leaf size during the seedling stage, combined higher mRNA abundance of TaEXPA1-A and TaEXPA1-D gene in tender leaves than mature leaves, suggesting that TaEXPA1-A and -D genes may play an important biological role in leaf growth in wheat. However, transgenic study using heterologous Arabidopsis system only provides the function of protein from transgene in Arabidopsis plants. Therefore, the relationship of TaEXPA1 genes to leaf growth in wheat is still an area to be further elucidated.Figure S1Alignment of genomic and their corresponding cDNA sequences of three TaEXPA1 homoeologous genes. Exons and introns are showed in shaded and gray texts, respectively; ATG and TAG boxes are the start and stop codon, respectively.(TIF)Click here for additional data file.Figure S2Identification of TaEXPA1-A, TaEXPA1-B and TaEXPA1-D gene expression in homozygous T3 transgenic Arabidopsis by RT-PCR. 1 represented wide-type Arabidopsis; 2–4 represented overexpression TaEXPA1-A transgenic line of OEA-2-12, OEA-8-10, and OEA-11-12, respectively; 5–7 represented TaEXPA1-B transgenic line of OEB-4-6, OEB-9-9, and OEB-17-5, respectively; 8–10 represented TaEXPA1-D transgenic line of OED-5-3, OED-7-5, and OED-12-7, respectively.(TIF)Click here for additional data file.Figure S3Cytological observation showed that the epidermal cell size of transgenic plants and wild-type did not differ significantly, while the transgenic plants rosette leaves were significantly greater than the wild-type, implying that transgenic plants were larger mainly due to an increased number of cells. Bar = 100 µm.(TIF)Click here for additional data file.Table S1The GenBank accession numbers of selected expansions.(DOC)Click here for additional data file.Table S2Gene-specific primer pairs used in PCR.(DOC)Click here for additional data file.


HPV is related to a number of cancer types, causing a considerable burden in both genders in Europe. Female vaccination programs can substantially reduce the incidence of HPV-related diseases in women and, to some extent, men through herd immunity. The objective was to estimate the incremental benefit of vaccinating boys and girls using the quadrivalent HPV vaccine in Europe versus girls-only vaccination. Incremental benefits in terms of reduction in the incidence of HPV 6, 11, 16 and 18-related diseases  were assessed.The analysis was performed using a model constructed in Microsoft®Excel, based on a previously-published dynamic transmission model of HPV vaccination and published European epidemiological data on incidence of HPV-related diseases. The incremental benefits of vaccinating 12-year old girls and boys versus girls-only vaccination was assessed (70% vaccine coverage were assumed for both). Sensitivity analyses around vaccine coverage and duration of protection were performed.Compared with screening alone, girls-only vaccination led to 84% reduction in HPV 16/18-related carcinomas in females and a 61% reduction in males. Vaccination of girls and boys led to a 90% reduction in HPV 16/18-related carcinomas in females and 86% reduction in males versus screening alone. Relative to a girls-only program, vaccination of girls and boys led to a reduction in female and male HPV-related carcinomas of 40% and 65%, respectively and a reduction in the incidence of HPV 6/11-related genital warts of 58% for females and 71% for males versus girls-only vaccination.In Europe, the vaccination of 12-year old boys and girls against HPV 6, 11, 16 and 18 would be associated with substantial additional clinical benefits in terms of reduced incidence of HPV-related genital warts and carcinomas versus girls-only vaccination. The incremental benefits of adding boys vaccination are highly dependent on coverage in girls. Therefore, further analyses should be performed taking into account the country-specific situation. In addition to clinical benefits, substantial economic benefits are also anticipated and warrant further investigation as do the social and ethical implications of including boys in vaccination programs. There is a wealth of published literature relating to reductions in the clinical and economic burden of cervical cancer, due in part to the success of pap screening programs and the introduction of the HPV vaccines. This has meant that the burden of other HPV-related cancers, particularly those occurring in males, is often overshadowed and as such is less well characterized [ubtypes) . AdditioThe burden of HPV-related non-cervical cancers is, in many settings, comparable to or greater than that associated with cervical cancer. For example, in France the total cost 2006/2007 EUR) of HPV-related cancers was EUR 240 million, of which only EUR 84 million was attributable to invasive cervical cancer . Further/2007 EURet al. reported that in 2004 the direct costs of genital warts were USD 104 million for females and USD 119 million for males [et al. reporting that 16.7% of patients had used using sick leave due to genital warts [In addition to HPV-related cancer, HPV 6 and 11 are responsible for 90% of cases of genital warts, which are in turn responsible for an estimated 9–10% of all visits to sexual health clinics [or males . Similaror males . Genitalal warts ,15.Two vaccines exist that provide protection against HPV-related diseases, a bivalent vaccine that provides protection against HPV 16 and 18 and a quadrivalent vaccine that provides protection against HPV 6, 11, 16 and 18. Although HPV vaccination was first approved for use in females, the quadrivalent vaccine has subsequently demonstrated efficacy in terms of preventing HPV-related disease in males and is approved and recommended for use in males in both the US and Australia for the prevention of anal cancer, anal intraepithelial neoplasia and genital warts. In a 2011 study in over 4,000 males aged 16–26 years, the efficacy of the quadrivalent vaccine against HPV 6, 11, 16 or 18-related external genital lesions was 92.4% among heterosexual men and 79.0% among men who had sex with men. Moreover, no HPV 16/18-related lesions were reported in the vaccine group  [et al. indicated that a gender-neutral vaccination program (vaccinating 12-year old boys and girls) would result in an incremental reduction in the incidence of HPV 16/18 infection of 16% in females and 23% in males versus female only vaccination over a 70 year-long period  [A large number of cost-effectiveness analyses conducted in a number of different settings have shown that vaccination of females is cost-effective in comparison with no vaccination; however, there are relatively few data relating to the incremental benefits of vaccinating both males and females in comparison with female only vaccination programs. The consensus among the few studies that have been conducted is that gender-neutral vaccination programs are likely to further reduce the incidence of HPV-related disease in both males and females ,18. For overage) .et al. suggested that increasing vaccine coverage among girls was a more effective strategy in terms of reducing overall rates of HPV infection than vaccinating boys [On a population level, the effectiveness of vaccination programs has been shown to be dependent on uptake rates and national strategies in relation to vaccination vary between settings. Organized school-based vaccination programs have a very high uptake in the target population, although only 13% of young women in the European Union are covered by such programs. In settings where vaccination is provided on demand (e.g. Germany and France) vaccination rates are approximately 50% . Introduing boys . As suchet al. [et al. [et al. constructed a population dynamic model to account for both the direct and indirect effects of vaccination. Within the model, the population is divided into groups based on age and gender, which allows the patterns of HPV transmission among sexually active groups to be modeled accurately. Structurally, the model can be considered as containing three key components: HPV transmission, cervical cancer development and the occurrence of genital warts. Our analysis was performed based on a two-stage calculation. As a first stage, the US-based dynamic transmission model of Elbasha et al. was run for each vaccination strategy assessed (in this instance 12-year old girls-only vaccination program and a 12-year old girls and boys vaccination program). A screening only scenario was also run, which provided a common baseline comparator. The dynamic transmission model outputs absolute incidence of HPV-related disease cases per year and is run over a 100-year time span for each of the two vaccination strategies.Epidemiological estimates for HPV-related disease were based mainly on a previously published dynamic transmission model . In sumet al. 2008 [et al. 2010 [In the second stage, the annual proportional reductions in disease incidence due to a given vaccination strategy versus baseline scenario (screening only) were derived for each HPV-related disease within Microsoft Excel 2003. These proportional reductions were then applied to European incidence data reflecting incidences prior to HPV vaccination implementation. The present analysis is then able to derive avoided outcomes (i.e. cases of HPV-related diseases avoided) versus screening only for both the 12-year old girls-only vaccination program and the 12-year old girls and boys  vaccination program. The difference between the girls-only and gender-neutral vaccination is also presented. Internal validation of this two-step procedure was achieved by being able to replicate US and UK results from Dasbach al. 2008  and Elbaal. 2010 .The analysis incorporated female-specific conditions including HPV 6/11/16/18 related cervical, vulvar and vaginal intraepithelial neoplasia states and carcinoma, penile intraepithelial neoplasia and carcinoma in males and genital warts, anal intraepithelial neoplasia and carcinoma, and head and neck cancers in both males and females.et al. [et al. [Epidemiological input data relating to the incidence of HPV-related disease in Europe were derived from previously published epidemiologic studies by Bonnani et al.  and Hart [et al.  (Table 1Vaccine efficacy for transient and persistent infections and compliance input data used were derived from a previously published model  and are The vaccine (both for the girls-only and boys and girls vaccination programs) was assumed to be administered to 12-year olds. A number of assumptions were made with regard to the vaccine coverage, compliance and duration of vaccine protection Table . A vacciApart from vaccination-related parameters, all US and disease-specific parameters related to underlying demographic US population , HPV transmission and progression to disease, cervical and vaginal screening programs were assumed to be applicable to European settings .et al. 2007 [et al. 2008 [et al. 2008 [The use of US-based input parameters for application in the European setting seems reasonable when comparing vaccination impact at different points in time, in terms of cervical cancer incidence, published either with the US base case model  or its al. 2008 ). Componal. 2008 ). The UKet al. 2010 [Sensitivity analyses were performed around cumulative vaccination coverage rate, ranging from 50% to 100% for both girls-only and girls and boys vaccination strategies (versus 70% in the base case) as well as compliance alternatively assumed to be ‘perfect’, e.g. 100% . Sensitivity analysis was also performed around duration of vaccine protection, in which a scenario of a shorter duration of protection equal to 32 years was assessed in line with the duration of protection assumed in a previously published analysis .A final analysis was performed in which the girls-only vaccination program with 50% vaccine coverage was compared with the base case boys and girls vaccination program (with 70% vaccine coverage rate assumed). This comparative analysis was carried out to illustrate the potential impact of a higher coverage rate among boys than girls.Results are presented for a steady state situation: at 100 years, when maximum vaccination effect is reached. Additional results at 50 years are provided in Table The results of the base case analysis showed that in Europe, assuming a theoretical mean cumulative vaccination coverage rate of 70%, the introduction of a girls-only vaccination strategy was associated with a notable reduction in the incidence of HPV-related diseases in both males and females in comparison with screening alone Table . With scThe benefits associated with the introduction of a boys and girls vaccination program were substantial, with the greatest benefits being reported in terms of the reduced incidence of genital warts. Vaccination of boys and girls led to additional 35,164 and 87,900 cases of genital warts being avoided in females and males, respectively . Extending vaccination to boys would therefore prevent an additional 3,911 male cases compared with girls-only vaccination (65% reduction)  in comparison with screening alone. Similarly, the vaccination of girls and boys was associated with a 68% reduction in the incidence of penile cancer, versus screening alone .The vaccination of girls and boys would also lead to a benefit in terms of additional disease prevention among women as a consequence of indirect protection. In terms of the incidence of HPV-related cancer in women, in the base case analysis girls-only vaccination was associated with a reduction in HPV 16/18-related carcinomas of 84% versus screening alone; however, gender-neutral vaccination increased this figure to 90%. Overall, in females in the absence of vaccination there were 32,562 cases of HPV-related carcinomas, girls-only vaccination reduced this figure to 5,217 cases, but vaccination of girls and boys reduced the incidence of HPV-related carcinoma even further to 3,155 cases per year , vaccination of boys would allow a further reduction of female HPV-related cancer cases .Sensitivity analyses were restricted to parameters previously shown to be key drivers of epidemiological outcomes, i.e. vaccine coverage rates and the duration of protection Elbasha, 2010 ). Varyin010 . VarIn a scenario in which a vaccine efficacy of 100% was assumed , a 69% decrease in male HPV-related carcinomas  would be achieved with a girls-only vaccination program, whereas a 61% reduction would occur in the base case girls-only vaccination . When focusing on the impact of girls-only vaccination on cervical cancer, reductions of 85% and 86% were estimated in the base case and 100% vaccine efficacy scenarios, respectively. Extending vaccination to boys assuming a 100% vaccine efficacy would lead to a 96% reduction in the remaining burden in both male and female carcinomas  compared with an 89% reduction assuming base case vaccine efficacy. This comparison confirms that vaccine efficacy related parameters estimates are key drivers of the results of modeling studies.In a scenario that assumed 100% compliance , girls-only vaccination would reduce cervical cancer burden by 91% (in comparison with 85% in the base case girls-only vaccination scenario) and extending vaccination to boys would lead to a 91% reduction of male HPV-related carcinomas (versus an 86% reduction in the base case girls-only vaccination scenario). A final sensitivity analysis aimed at exploring the leveraging effect of the introduction of HPV vaccination for boys on the vaccine uptake among girls was performed. It may be expected that vaccinating boys may increase the coverage rate among girls. When the base-case boys and girls vaccination (70% coverage) is compared with girls-only vaccination (50% coverage), such a “snow-ball” effect would prevent an estimated 13,019 carcinoma cases  and more than 160,000 cases of genital warts  [et al. to 100 years in the present study in line with previous work) [Differences in model structure and assumptions related to the natural history of HPV transmission and development of the disease, as well as differences in clinical outcomes,  make direct comparisons between the outcomes of different models challenging. For example, Brisson 0 years) . Equilibus work) ,18. Giveet al., which primarily applied these calculations in terms of HPV-16 infection incidence data. The results suggest that in Europe, vaccination of boys and girls could prevent over 5,500 cases of HPV-related cancer annually (versus girls-only vaccination). Here, we present the number of HPV cancer cases avoided that are specifically due to HPV types 16 and 18. A previous analysis in the UK setting comparing quadrivalent and bivalent HPV vaccines assumed both vaccines provided some cross-protection against carcinomas caused by non-vaccine HPV subtypes. If vaccination does provide some cross protection for non-vaccine HPV types then potential clinical benefits estimated here may be conservative. However, research on cross-protection is currently ongoing and as such it was not included in this analysis [Whilst previous modeling studies have focused on the reduction of the incidence of HPV infections and cervical cancer, data relating to the impact on vulvar, vaginal, penile, anal and head and neck cancer have until now been lacking. While girls-only vaccination would substantially reduce the incidence of HPV-related cancer in females and in some extent in males (due to herd immunity), vaccination of boys in addition to girls is associated with a substantial incremental benefit for both males (direct benefits) and females (indirect benefits). Indeed, in our base case, the estimated proportion of the maximum possible vaccine-conferred benefit to males  from gender-neutral vaccination, which would be achieved by a girls-only vaccination program, was as high as 71%. Nevertheless, this proportion may be reduced to 64% in scenarios assuming a lower vaccine coverage among girls (50%), and even further if a lower coverage rate occurred in conjunction with a waning effect (32 year long duration of protection). Such proportions refer to “proportional benefit achieved” as described by Smith analysis .With regard to the impact on genital warts, vaccination of boys and girls would reduce the incidence of genital warts by approximately 90%, which would likely lead to considerable economic benefits in terms of costs and resource use, indeed the economic burden of genital warts has been reported as being comparable to that of HPV related cancer and it has also been estimated that currently up 10% of visits to sexual health clinics are due to genital warts . AdditioPrevious studies have shown that vaccine coverage in girls is a key driver of outcomes in both males and females ,19. VaccThe results of the current analysis, together with the results of previous modeling analyses suggest that vaccination of boys and girls would be associated with the greatest benefit in settings where vaccine uptake among girls is low such as those countries that do not have a nationally coordinated vaccination program for females ,26. Howeet al. 2011 [The analysis presented here is associated with both strengths and limitations. Limitations of the current analysis include the fact that it does not consider the incidence of precancerous states such as cervical, vulvar, vaginal, anal or penile intraepithelial neoplasia, or capture temporal trends in HPV-related disease, such as the increasing incidence of head and neck cancer and anal cancer. Moreover, there is substantial uncertainty in the proportion of head and neck carcinoma attributable to HPV, which may be a contributing factor in the differences in the magnitude of clinical benefit reported across different studies. The present analysis was based on a proportion of 19% of head and neck cancers being attributable to HPV-16/18. This figure might be overestimated even if it is in line with estimates assumed in another recent modeling study by Smith Additionally, this analysis does not consider the quality of life benefit associated with the reduction in the incidence of HPV-related disease, which is also likely to be substantial. A further limitation of this analysis is that it is an exploratory analysis that presents mean findings relating to Europe as a whole and also that the model used here and applied to the European setting was based on a US-based dynamic transmission model with input data derived from the US setting, which may potentially limit its applicability to the European setting. In particular, the US-base case scenario  is supposed to be consistent with what would be a European base case . This is a strong underlying assumption given the specificities of screening implementation in the US and Europe in particular, in addition it is assumed that sexual behavior patterns and the age-structure of the population is similar between settings. Another limitation concerns the structure of the model in that it consists of a number of independent submodels (according to disease type), and incorporates the assumption that only subjects who are at risk of developing the disease can become persistently infected. As such, this means the transmission dynamics for female-only conditions  are different from those where both males and females may be affected  and from the male only penile cancer submodel. In addition, within Europe there are wide variations in vaccine uptake rates, screening coverage, HPV prevalence and transmission rates, and as shown here, vaccination uptake rates are a key driver of outcomes.One of the key strengths of the analysis is that it assesses the benefits of male vaccination in all carcinomas that have an established causal link with HPV 6, 11, 16 and 18 whereas many previous analyses have focused primarily on the impact of vaccination in terms of cervical cancer incidence. The current analysis incorporates an extended number of HPV-related disease endpoints including subtypes of head and neck cancer and as such reflect the potential maximum clinical benefits that could be gained from different HPV vaccination scenarios . It is also likely that the potential maximum clinical benefit reported in the current analysis would have been even greater if pre-cancerous states had been included in the analysis. Another strength is that this is the first analysis to present the potential public health impact at EU level of vaccinating boys and girls.Further country-specific analyses that fully deal with uncertainty are required in order to guide policy decisions relating to the incremental benefits of vaccination of boys and girls. Until such data are available on a country by country basis, a pooled European-wide analysis may provide useful estimates, as well as serving as a valuable comparator for such analyses.This analysis is the first to assess the impact of gender-neutral vaccination in Europe; however, as noted country-specific analyses that take into account national vaccination policies, coverage rates and socio-ethical implications of different strategies may be required to assess the impact of gender-neutral vaccination at a national level.These European-level results suggest that vaccination of boys and girls against HPV 6, 11, 16 and 18 would be associated with a marked incremental benefit in terms of a reduction in the incidence of HPV-related cancers and genital warts in males  and would help decreasing the remaining burden of both HPV-related cancers and genital warts in females . These figures represent the maximal potential benefit associated with vaccination due to the incorporation of an extended range of HPV-related cancers in the model, but may warrant updating in future analyses owing the current uncertainty that exists with regard to the proportion included cancers, in particular head and neck cancer that can be attributed directly to HPV.Additionally, the incremental benefit is likely to be greatest in settings where vaccine coverage rates in females are not the highest. In addition to the clinical benefit, the notable reduction in the incidence of HPV-related disease is also likely to be associated with a substantial reduction in the economic burden associated with HPV-related cancers and genital warts.This study was supported by funding from Sanofi Pasteur MSD, Lyon, France. Xavier Bresse and Nathalie Largeron are employees of Sanofi Pasteur MSD. Rémi Marty and Stephane Roze are employees of HEVA, which has received consulting fees from SPMSD and Jayne Smith-Palmer is an employee of Ossian Health Economics and Communications, which has also received fees from SPMSD.RM developed the Microsoft Excel 2003 impact model. XB, NL, RM and SR designed the study plan and XB and NL provided inputs data from the underlying transmission dynamic model. RM and XB performed the analyses. JSP wrote the manuscript. All authors read and approved the final manuscript.This study was supported by funding from SPMSD SNC, Lyon, France.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2407/13/10/prepub