Ann Intern Med 2000;132:810–9 Commissioned by the federal Agency for Healthcare Research and Quality, this meta‐analysis reviewed articles comparing Pap testing with a reference standards, such as histology, colposcopy, repeat cytology, or combinations these techniques. These data were used to complete 2 × 2 tables to calculate indices of accuracy. Many studies were derived from colposcopy clinics; patients without prior abnormal smears have a lower prevalence of abnormality. In the 12 studies with least biased estimates, Pap test sensitivity ranged from 30–87% and specificity from 86–100%. Results varied depending on the threshold designation of abnormality for cytology (ASCUS vs. LGSIL vs. HGSIL) and for comparison test (CIN1 vs. CIN2–3). Comment: As the authors point out, the utility of cytologic screening in cervical cancer prevention lies not in the accuracy of a single smear, since sensitivity is less than ideal, but in the accuracy of lifetime screening. A single smear should not be relied on to determine the presence or absence of disease. (LSM)

Obstet Gynecol 2000;96:645–52 I am very concerned that if we do not take the rapidly escalating cost of cervical cancer screening seriously, eventually those parties responsible for paying the costs (government agencies, managed care organizations, and commercial insurance) will begin to restrict our ability to screen at appropriate intervals. If you are at all concerned about this issue, I would strongly suggest that you wade through this very interesting but complicated article. (KLN)

Abstract-Objective:To review the risk of MS exacerbations after infectious episodes potentially preventable by vaccination, and the risks and benefits of immunizing patients with MS. Methods: The authors searched MEDLINE (1966 to January 2001; U.S. National Library of Medicine, Bethesda, MD), HealthSTAR, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) database (Cinahl Information Systems, Glendale, CA) for English-language articles. Each study was summarized and rated for quality of evidence. Then feasible data were pooled and analyzed in metaanalysis. Results: The risk of contracting common infectious diseases in patients with MS is not well established. There is strong evidence for an increased risk of MS exacerbations during weeks around an infectious episode. There is strong evidence against an increased risk of MS exacerbation after influenza immunization. There is no evidence that hepatitis B, varicella, tetanus, or Bacille Calmette-Guerin vaccines increase the risk of MS exacerbations. Insufficient evidence was found for other vaccines. Conclusions: Evidence supports 1) strategies to minimize the risk of acquiring infectious diseases that may trigger exacerbations of MS; and 2) the safety of using influenza, hepatitis B, varicella, tetanus, and Bacille Calmette-Guerin (BCG) vaccines in patients with MS. NEUROLOGY 2002;59:1837-1843 Although the direct or the indirect pathogenic role of numerous infectious agents is debated, 1,2 there is evidence that MS exacerbations occur around infectious episodes, which could potentially be prevented by vaccination. 3,4 However, there are concerns about the safety of immunization in patients with MS, particularly about the risk of relapses after vaccination. To address these concerns, the MS Council for Clinical Practice Guidelines commissioned a systematic review to obtain background for guidelines on immunization and convened an expert panel to establish guidelines. This systematic review has three objectives. First, we aim to provide the information on the need to vaccinate patients with MS by evaluating the risk of MS exacerbation after potentially preventable infections. Second, we review the available evidence on safety and efficacy of vaccines in patients with MS. Finally, we provide an overview of the guidelines for vaccinating patients with MS. Two topic questions were formulated to address the need to vaccinate patients with MS: 1) Are vaccine-preventable infectious diseases more frequent in patients with MS than in the general population? 2) Do vaccine-preventable infectious diseases increase the risk of MS exacerbations?Two other topic questions addressed the risks and the benefits of immunizing patients with MS: 3) Does vaccination increase the risk of exacerbations of MS, and is there a difference in this risk between live attenuated and inactivated vaccines? 4) Are vaccines as effective in patients with MS as in the general population?Search strategy and inclusion process. We reviewed English language MEDLINE (from 1966 to

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