ACH YEAR 471 000 CASES AND 233 000 deaths occur from cervical cancer worldwide, of which 80% occur in less-developed countries that have access to less than 5% of global cancer treatment resources. 1 The lifetime risk of a woman developing cervical cancer in a lowresource setting is approximately 2% to 4%. [2][3][4] Cytology-based screening programs have markedly reduced the incidence of cervical cancer in developed countries that have the infrastructure to support these programs. 5 However, screening programs have proven difficult to implement in low-resource settings. There are 2 predominant reasons why cytology-based programs have proven difficult to implement and sustain in low-resource settings. One is the nature of the screening test. 6 Highquality cytology laboratories are difficult to maintain and there are often substantial delays before the results become available. 7 Another is the extensive workup that is typically used for women with abnormal cytological results. In developed countries, women with abnor-

BV may account for a substantial fraction of new HIV infections in this setting. Treatment of BV and other interventions to promote normal vaginal flora warrant attention for HIV prevention.

Cross-sectional studies have suggested that intravaginal practices, such as douching or "dry sex," may increase women's susceptibility to infection with human immunodeficiency virus (HIV). The authors examined the temporal nature of this association in a cohort of South African women. At enrollment (2001-2002), 4,089 women were tested for HIV infection. Participants reported their intravaginal practices at a 6-month follow-up visit and were followed with repeat HIV testing for up to 24 months. Among the 3,570 women who were HIV-negative at enrollment, 26% reported some type of intravaginal practice, mostly washing inside the vagina with water and/or cloth as part of daily hygiene. During follow-up, 85 incident HIV infections were observed. Intravaginal practices were associated with prevalent HIV at enrollment (adjusted odds ratio = 1.50, 95% confidence interval: 1.22, 1.85), but during follow-up there was no association between intravaginal practices and incident HIV (adjusted hazard ratio = 1.04, 95% confidence interval: 0.65, 1.68). These findings may be explained by a reversal of the causal sequence assumed for this association, since intravaginal practices may be undertaken in response to vaginal infections that occur more commonly among HIV-infected women. Intravaginal practices appear unlikely to be a cofactor in the male-to-female transmission of HIV in this setting.

Our study directly compares the performance of liquid-based (LBC) and conventional cytology for detecting high-grade cervical intraepithelial neoplasia and cancer (CIN 21) in high-risk, previously unscreened women. As part of a larger randomized clinical trial assessing the efficacy and safety of a ''screen and treat'' program for cervical cancer prevention, 5,652 South African women, aged 35 to 65 years, were screened using either ThinPrep or conventional Papanicolaou cytology. The cytology method used (i.e., ThinPrep or conventional) was rotated on a 6-month basis for the duration of the study. Directly following collection of the cytology specimen, all women underwent colposcopy with endocervical curettage and biopsy of all colposcopic abnormalities. Assessment of cytology and histology results was blinded and results were compared using histology-confirmed CIN as the ''gold standard.'' The accuracy of LBC and conventional cytology was statistically equivalent, although the sensitivity of conventional cytology was at least 5 percentage points higher at all cutoff levels. For example, at a cytology cutoff level of low-grade squamous intraepithelial lesion, the sensitivity of LBC was 60.3% for CIN21 vs. 69.1% for conventional cytology and specificity was 94.1% and 94.5%, respectively. LBC specimens were significantly less likely to be ''satisfactory-but-limited-by'' (6.5% vs. 27.9%) but significantly more likely to be unsatisfactory (2.2% vs. 0.8%). Thus, in this high-risk population, the sensitivity of LBC is no greater than the sensitivity of conventional cytology. Because of the higher unit cost of LBC, low resource settings should carefully consider the potential benefits and drawbacks of LBC before adopting this new technology. ' 2005 Wiley-Liss, Inc.Key words: cervical cytology; papanicolaou (Pap) smear; liquidbased cytology; cervical intraepithelial neoplasia Conventional cytology, i.e., the Papanicolaou smear, has been the mainstay of cervical cancer screening since the 1960s and is credited with successfully reducing the incidence and mortality of invasive cervical cancer in many developed countries. 1,2 Nonetheless, the accuracy of this important screening tool remains controversial, with several large meta-analyses suggesting that both the sensitivity and specificity of cervical cytology is relatively low (30% to 87% sensitivity, 86% to 100% specificity). [3][4][5] As an alternative to conventional cytology, liquid based-cytology (LBC) was introduced in the mid-1990s. The purported advantages of LBC include a possible increase in the detection of high-grade cervical intraepithelial neoplasia (CIN 2,3 ), a reduction in the number of unsatisfactory and ''satisfactory-but-limited-by'' specimens, and providing residual cellular material for subsequent molecular testing (e.g., testing for ''high-risk'' types of HPV DNA). On the other hand, the unit cost of LBC methods is substantially more than that of conventional cytology. The substantial increase in unit cost is of particular concern in less-developed...

BackgroundThis study was designed to quantify the resources used in reestablishing contact with women who missed their scheduled cervical cancer screening visits and to assess the success of this effort in reducing loss to follow-up in a developing country setting.MethodsWomen were enrolled in this Cape Town, South Africa-based screening study between 2000 and 2003, and all had scheduled follow-up visits in 2003. Community health worker (CHW) time, vehicle use, maintenance, and depreciation were estimated from weekly logs and cost accounting systems. The percentage of women who attended their scheduled visit, those who attended after CHW contact(s), and those who never returned despite attempted contact(s) were determined. The number of CHW visits per woman was also estimated.Results3,711 visits were scheduled in 2003. Of these, 2,321 (62.5%) occurred without CHW contact, 918 (24.8%) occurred after contact(s), and 472 (12.7%) did not occur despite contact(s). Loss to follow-up was reduced from 21% to 6%, 39% to 10%, and 50% to 24% for 6, 12, and 24-month visits. CHWs attempted 3,200 contacts in 530 trips. On average, 3 CHWs attempted to contact 6 participants over each 111 minute trip. The per-person cost (2003 Rand) for these activities was 12.75, 24.92, and 40.50 for 6, 12, and 24-month visits.ConclusionCHW contact with women who missed scheduled visits increased their return rate. Cost-effectiveness analyses aimed at policy decisions about cervical cancer screening in developing countries should incorporate these findings.

BackgroundAdherence is crucial for public health program effectiveness, though the benefits of increasing adherence must ultimately be weighed against the associated costs. We sought to determine the relationship between investment in community health worker (CHW) home visits and increased attendance at cervical cancer screening appointments in Cape Town, South Africa.Methodology/Principal FindingsWe conducted an observational study of 5,258 CHW home visits made in 2003–4 as part of a community-based screening program. We estimated the functional relationship between spending on these visits and increased appointment attendance (adherence). Increased adherence was noted after each subsequent CHW visit. The costs of making the CHW visits was based on resource use including both personnel time and vehicle-related expenses valued in 2004 Rand. The CHW program cost R194,018, with 1,576 additional appointments attended. Adherence increased from 74% to 90%; 55% to 87%; 48% to 77%; and 56% to 80% for 6-, 12-, 24-, and 36-month appointments. Average per-woman costs increased by R14–R47. The majority of this increase occurred with the first 2 CHW visits (90%, 83%, 74%, and 77%; additional cost: R12–R26).Conclusions/SignificanceWe found that study data can be used for program planning, identifying spending levels that achieve adherence targets given budgetary constraints. The results, derived from a single disease program, are retrospective, and should be prospectively replicated.

The histopathological diagnosis of cervical intraepithelial neoplasia grade 2,3 (CIN 2,3) is subjective and prone to variability. In our study, we analyzed the impact of utilizing a biomarker (p16 INK4A ) together with histopathology to refine the ''gold standard'' utilized for evaluating the performance of 3 different cervical cancer screening tests: cervical cytology, human papillomavirus (HPV) DNA testing and visual inspection with acetic acid (VIA). Cervical biopsies from 2 South African cervical cancer screening studies originally diagnosed by a single pathologist were reevaluated by a second pathologist and a consensus pathology diagnosis obtained. Immunohistochemical staining for p16 INK4A was then performed. The estimated sensitivity of some cervical cancer screening tests was markedly impacted by the criteria utilized to define CIN 2,3. Use of routine histopathology markedly underestimated the sensitivity of both conventional cytology and HPV DNA testing compared to an improved gold standard of consensus pathology and p16 INK4A positivity. In contrast, routine histopathology overestimated the sensitivity of VIA. Our results demonstrate that refining the diagnosis of CIN 2,3 through the use of consensus pathology and immunohistochemical staining for p16 INK4A has an important impact on measurement of the performance of cervical cancer screening tests. The sensitivity of screening tests such as HPV DNA testing and conventional cytology may be underestimated when an imperfect gold standard (routine histopathology) is used. In contrast, the sensitivity of other tests, such as VIA, may be overestimated with an imperfect gold standard. ' 2006 Wiley-Liss, Inc. Key words: cervical intraepithelial neoplasia; p16 immunohistochemistryThe histolopathologic interpretation of cervical intraepithelial neoplasia (CIN) is subjective and prone to considerable variation. This is documented by numerous studies investigating intraobserver and interobserver variability among groups of pathologists evaluating cervical biopsies. [1][2][3][4] In general, agreement between pathologists is excellent for invasive lesions, moderately good for CIN 3 and poor for CIN 1 and CIN 2. 3 This results in marked difficulties in separating normal biopsies from CIN 1 and in distinguishing between CIN 1 and CIN 2,3 based on histopathology alone. 4 Recognition of this variability has led to concerted efforts to identify novel biomarkers capable of more reproducibly distinguishing between normal and CIN lesions and in reducing the variability in grading of CIN lesions. A number of potentially diagnostically useful biomarkers have been identified using conventional immunohistochemical approaches and tissue microarrays. 5-9 These include altered expression of selected MHC antigens; increased expression of Ki-67, telomerase and desmogleins and reduced expression of nm23-H1, a candidate tumor suppressor gene. [10][11][12][13][14] One of the more promising biomarkers is p16 INK4A , a cyclin-dependent kinase inhibitor involved in control of the cell ...

In covering the Emergency Department, the Plastic Surgeon can be faced with the mandibular fracture patient. Although the timely repair of the fracture usually leads to normal function and appearance, occasionally the surgeon is faced with the untoward sequelae of the mandible fracture. Post-traumatic mandibular deformities include non-union, malunion, malocclusion, TMJ dysfuction, and facial asymmetry. The difficulty in treatment of these deformities can be compounded by edentulous mandibles, substance abuse, and approach controversies such as the timing of the repair and surgical versus non-surgical management. Knowledge of the post-traumatic mandibular deformities by the treating physician not only assists in their management but may also allow for their prevention.