Description of a new non-injectable connector to reduce the complications of arterial blood sampling.

Arterial cannulation is associated with complications including bacterial contamination, accidental intra-arterial injection and blood spillage. We performed a series of audits and experiments to gauge the potential for these, as well as assess the possible contribution of a new device, the Needle-Free Arterial Non-Injectable Connector (NIC), in reducing these risks. The NIC comprises a needle-free connector that prevents blood spillage and a one-way valve allowing aspiration only; once screwed onto the side port of a three-way tap, the device can only be removed with difficulty. We performed a clinical audit of arterial monitoring systems in our intensive care unit, which showed an incidence of bacterial colonisation of five in 86 (6%) three-way tap ports. We constructed a manikin simulation experiment of the management of acute bradycardia, in which trainee doctors were required to inject atropine intravenously. Ten of 15 (66%) doctors injected the drug into the three-way tap of the arterial monitoring system rather than into the intravenous cannula or the central venous catheter. In a laboratory study, we replicated the arterial blood sampling and flushing sequence from a three-way tap, with the syringes attached either directly to the three-way tap port or to a NIC attached to the port. The first (discard) syringe attached to the three-way tap was contaminated with bacteria. Bacterial growth was found in 17 of 20 (85%) downstream flushed samples (corresponding to the patient's circulation) when the three-way tap was accessed directly, compared to none of 20 accessed via the NIC (p < 0.0001). Growth was found on all of 20 (100%) ports accessed directly compared to none of 20 accessed via the NIC (p < 0.0001). The NIC effectively prevents bacteria from contaminating sampling lines. As its design also prevents accidental intra-arterial injection, we suggest that it can reduce complications of arterial monitoring.

The efficacy of field techniques for obtaining and storing blood samples from fishes.

Prompted by the dramatic increase in the use of blood analyses in fisheries research and monitoring, this study investigated the efficacy of common field techniques for sampling and storing blood from fishes. Three questions were addressed: (1) Do blood samples taken via rapid caudal puncture (the 'grab-and-stab' technique) yield similar results for live v. sacrificed groups of fishes? (2) Do rapidly obtained caudal blood samples accurately represent blood properties of fishes prior to capture? (3) Does storage of whole blood in an ice slurry for a working day (8·5 h) modify the properties of the plasma? It was shown that haematocrit, plasma ions, metabolites, stress hormones and sex hormones of caudal blood samples were statistically similar when taken from live v. recently sacrificed groups of adult coho salmon Oncorhynchus kisutch. Moreover, this study confirmed by using paired blood samples from cannulated O. kisutch that blood acquired through the caudal puncture technique (mean ±s.e. 142 ± 26 s after capture) was representative of fish prior to capture. Long-term (8·5 h) cold storage of sockeye salmon Oncorhynchus nerka whole blood caused significant decreases in plasma potassium and chloride, and a significant increase in plasma glucose. Previous research has suggested that these changes largely result from net movements of ions and molecules between the plasma and erythrocytes, movements that can occur within minutes of storage. Thus, blood samples from fishes should be centrifuged as quickly as practicable in the field for separation of plasma and erythrocytes to prevent potentially misleading data.

Safer arterial access.

Intra-arterial injection of drugs intended for intravenous delivery is a frequent and potentially devastating consequence of placing an arterial line in a patient. A system is described here that prevents this complication from occurring and its use is advocated in intensive care and operating theatre settings.

Congenital desmoplastic trichoepithelioma.

Desmoplastic trichoepithelioma (DT) is a rare benign adnexal neoplasm considered to have follicular differentiation. It usually presents as an asymptomatic, firm, annular plaque with a raised border. The most common site of occurrence is the face, usually on the cheek. Females are more often affected than males and the age range of patients previously reported is 8-79 years. We present a case of congenital desmoplastic trichoepithelioma. A girl was born at term to a healthy mother after an uneventful pregnancy and was noted to have widespread erythematous plaques with milia-like lesions over the right scalp, face and neck, with some areas of atrophic scarring. Histology and immunohistochemistry of incisional biopsies of the lesions were consistent with a diagnosis of DT. To our knowledge, this is the first reported case of congenital DT.

Incidence of acneform reactions after laser hair removal.

There have been several studies published on the side effects of laser hair removal, but none specifically looked at acneform reactions. The aim of this study is to obtain an accurate assessment of the incidence of acneform reactions after laser hair removal in relation to skin type, laser type, site of treatment, polycystic ovarian syndrome history (PCOS), age, and sex of the patient. This is a multi-centre prospective study of patients presenting for laser hair removal. Data were gathered using a questionnaire completed by the staff who performed the treatment. The incidence of acneform reactions was 6%. The following variables showed a statistically significant effect on the percentage of patients with reactions: age, with younger patients more likely to develop lesions; those treated with the Nd:YAG laser type were more likely to develop lesions than those treated with the alexandrite; and the Fitzpatrick skin type V showed the highest incidence of acneform lesions, followed by skin types II and IV. History of PCOS, number of prior treatments, use of aloe vera cooling gel, and the sex of the patient had no apparent effect on the incidence of acneform lesions. Acneform reactions are relatively common after laser hair removal; however, in the majority of cases, the severity of the reaction was mild and lasted for a short duration.

Peritoneal macrophage and blood monocyte functions after open and laparoscopic-assisted cecectomy in rats.

BACKGROUND: It has been well established that open abdominal surgery results in systemic immunosuppression postoperatively; in contrast, laparoscopic surgery is associated with significantly better preserved systemic immune function. However, when intraperitoneal (local) immune function is considered, laparoscopic procedures done under a CO2 pneumoperitoneum (pneumo) have been shown to result in greater immunosuppression compared to that of open surgery. Few studies have simultaneously assessed systemic and local immune function. The purpose of this study was to assess peripheral blood mononuclear cell (PBMC) and peritoneal macrophage tumor necrosis factor-alpha (TNF-alpha) levels, H2O2 production, and MHC class II antigen expression after open and laparoscopically assisted cecectomy in a rat model. METHODS: A total of 75 Sprague Dawley rats were used for three separate experiments. For each study, rats were randomly divided into three groups: anesthesia alone (AC), laparoscopic-assisted cecectomy (LC), and open cecectomy via full laparotomy (OP). A CO2 pneumo was used for laparoscopic operations. On postoperative day 1 the animals were sacrificed, macrophages were harvested via intraperitoneal lavage, and PBMCs were isolated from whole blood obtained by cardiac puncture. In experiment 1, macrophages and PBMC from each animal were stimulated with lipopolysaccharide, after which TNF-alpha levels of the supernatant were determined. In experiment 2, after stimulation with PMA, H2O2 release was assessed by measuring fluorescence. In experiment 3, via flow cytometry, the number of cells with surface MHC class II proteins were determined. Data from the three groups in each experiment were compared using analysis of variance Tukey-Kramer tests. RESULTS: Macrophages and PBMC from rats in the OP group released significantly more TNF-alpha than cells from rats in the LC ( p < 0.05) or AC ( p < 0.05) groups. Macrophages from rats in the OP group released significantly less H2O2 than cells from the AC ( p < 0.01) and LC ( p < 0.05) groups. There was no difference between the AC and LC results. No significant differences in PBMC H2O2 release were noted among any of the groups. OP group macrophages expressed significantly less MHC class II antigen than did AC group macrophages ( p < 0.05). No differences were noted among the LC results and either the OP or AC group's outcomes. No differences were noted in PBMC MHC class II expression among any of the groups. CONCLUSIONS: In all instances, the LC group's macrophage results were similar to the AC group's results. OC group macrophages produced significantly more TNF-alpha and less H2O2 than both the AC and LC groups. MHC class II protein expression was less for the OC group than for the AC group. OC group PBMCs produced more TNF-alpha. No differences in PBMC H2O2 release or MHC class II expression were noted. Laparoscopic methods better preserves the baseline values of the parameters studied.

Increased rates of pulmonary metastases following sham laparotomy compared to CO2 pneumoperitoneum and the inhibition of metastases utilizing perioperative immunomodulation and a tumor vaccine.

BACKGROUND: Subcutaneous tumor growth and establishment is increased after laparotomy; significantly smaller increases have been noted after CO2pneumoperitoneum (CO2 pneumo). Less is known about the impact of surgery on the fate of blood borne tumor cells. The extent of surgical abdominal wall trauma also correlates with the extent of early postoperative immunosuppression and the inflammatory response. These changes may favor lung metastases (mets) formation. This study's hypotheses were: (a) a reduction in surgical trauma or (b) a perioperative (periop) tumor vaccine or nonspecific immune up-regulation would limit lung mets formation. An intravenous tumor cell injection lung met model was used to test these hypotheses. METHODS: Study 1 determined the incidence of lung mets after sham laparotomy (OP) and CO2 pneumo. Three groups were studied (n=25/group) : Anesthesia control (AC), CO2 pneumo, and OP. 1 x 105 TA3Haushka adenocarcinoma cells were inoculated via tail vein injection into all mice immediately after surgery. Study 2 determined the impact of perioperative immunomodulation on lung mets formation. Five groups were studied (n=20/group) : AC, OP, OP + Monophosphoryl Lipid A (MPLA), OP + lysed tumor cells (LTC), or OP + MPLA + LTC. The vaccine consisted of 5 x 105 lysed TA3Ha tumor cells (LTC) and was given 5 times preop and once postop to the vaccine groups. MPLA, the nontoxic moiety of lipopolysaccharide, was used both as a vaccine adjuvant in the OP + MPLA + LTC group and as a nonspecific perioperative immune up-regulator in the OP + MPLA group. Five periop injections of MPLA were given to the OP + MPLA group. All mice were given tail vein injections of tumor cells after surgery. Fourteen days after surgery all mice were sacrificed, the lungs transected en bloc, and India ink injected into the trachea. The lungs were placed in Fekete's solution to counterstain the tumor foci white. The number of surface lung metastases was determined by two blinded observers, separately. RESULTS: In Study 1, there were significantly more lung tumors in the OP group (median=31.5) than the AC group (median=9; p<0.05) or the CO2 Pneumo group (median=6.5; p<0.05). There were no significant differences in the number of metastases between the AC and the CO2 Pneumo groups or in the incidence of animals in each group with 1 or more lung mets. In Study 2 significantly fewer metastases were noted for the Op + LTC group (median=3; p<0.05) and the OP + LTC + MPLA group (median=0; p<0.05) when compared to the OP group (median=20). Although the OP + MPLA group mice had fewer metastases (median=4) than the OP group, this difference was not significant. Significantly fewer of the OP + LTC + MPLA group mice developed one or more lung tumors than in the OP, OP + MPLA, and the OP + LTC groups. CONCLUSIONS: Full sham laparotomy was associated with more postoperative lung metastases than CO2 pneumo or anesthesia alone in this murine model. Up-regulation of the immune system in the perioperative period with lysed tumor cells, alone or in combination with MPLA, resulted in significantly fewer postoperative lung metastases. MPLA alone resulted in a less marked reduction of lung metastases.

Colonoscopy in mice.

INTRODUCTION: Current investigational models of murine colitis and colon cancer necessitate sacrifice of animals in order to obtain colonic tissue. The purpose of this study was to develop a safe method of murine colonoscopy that would allow serial evaluation and mucosal biopsies of the same animal. METHODS: Nine mice (two C3H, two C57/BL6, and five IL-10 deficient) were studied a total of four times each over 4 weeks. Three mice [APC (Min +/-)] were examined three times each. Mice were gavaged with 1 cc of a polyethylene glycol solution on the day prior to colonoscopy. Solid chow was withheld and the mice were maintained on Pedialyte. Mice were anesthetized with ketamine and xylazine. A flexible pediatric cystoscope (2.1-mm diameter) with a single biopsy channel was introduced per anum, and the colon was gently insufflated with air to a mean pressure of less than 5 mmHg. Saline irrigation was used when necessary. A single biopsy was obtained from the rectosigmoid colon during each examination. RESULTS: A total of 46 examinations were carried out. One mouse died after being anesthesized for the fourth examination, and two mice [one IL-10 knockout and one APC (Min+/-)] died one day after the 3rd examination. No other complications were noted. The average length of insertion was 3 cm. Transillumination allowed for localization of the endoscope tip. Biopsies, although quite small, were sufficient for pathologic evaluation and diagnosis. CONCLUSIONS: Murine colonoscopy is a safe and feasible technique. It permits consecutive visual and histopathological examinations, and it allows the investigator to monitor the response of the murine colon to experimental interventions.

The immunologic consequences of laparoscopy in oncology.

The last decade has seen the publication of many studies regarding the impact of both traditional open methods and minimally invasive techniques on a variety of immune function parameters. Clearly, major surgery results in period of cell-mediated immunosuppression that can have an impact on the patient's recovery that would best be avoided. Although there are conflicting data among studies regarding some immune parameters there is general agreement in regards to other variables. The DTH and LPA studies uniformly have shown that open methods result in significantly more immunosuppression than laparoscopic techniques. It seems that the choice of surgical approach does not impact on the absolute number of lymphocytes or lymphocyte subpopulations. There is evidence of a short-lived (less than 1 day) greater shift towards Th2 function, mainly through suppression of the Th1 lymphocyte population, after open surgery than after closed procedures. Regarding circulating monocytes, laparotomy seems to result in greater decreases in HLA-DR expression and monocyte-mediated cytotoxicity while at the same time activating monocytes to elaborate more TNF-alpha and superoxide anion than laparoscopic methods. The data regarding peritoneal macrophages is most confusing; however, most studies do agree that laparotomy results in increased release of cytokines and respiratory burst mediators. The degree to which CO2 pneumoperitoneum suppresses macrophage function is uncertain because, although some studies have shown that CO2 pneumoperitoneum suppresses macrophage function in regards to control animal results, other studies found that the CO2 and control group results are similar. It also is impossible to draw a firm conclusion in regards to the bacterial clearance studies presently. Similarly, the data regarding NK cell counts and function conflict also to the point that a definite conclusion cannot be made. Serum cortisol levels are similar after both types of surgery. The clear majority of the data suggests that open surgery is associated with significantly higher levels of IL-6 and CRP. Minimally invasive methods are less stressful, as judged by these parameters. It seems that one way to avoid or minimize immunosuppression after surgery is to use minimally invasive methods. In theory, based on the animal evidence reviewed in the previous text, laparoscopic cancer resection methods may be associated with improved long-term oncologic outcome. There is no human evidence to support this hypothesis. Middle range results from nonrandomized human cancer colectomy studies, thus far, have yielded outcomes similar to those following open surgery. The incidence of incisional tumor recurrences is similar after both open and closed approaches. The results of the randomized prospective colectomy trials are anxiously awaited. If, as is the case with closed methods, merely preserving the majority of an animal's immune function after surgery lowers the chances of tumor cells establishing metastases, then purposefully stimulating the immune system perioperatively may be a way to avoid the detrimental effects of laparotomy. Such up-regulation of immune function also might improve further the oncologic results after minimally invasive cancer surgery. The early postoperative period may be an ideal window for immune-based anticancer therapies because the tumor burden is at its absolute lowest immediately following resection of the primary. There is strong evidence in the animal setting that a whole host of agents that broadly stimulate the immune system are effective in reducing significantly the incidence of tumor metastases and the growth of tumors after surgery. There also is preliminary evidence that suggests that preoperative tumor vaccines may be an effective means of establishing specific immune responses against the tumor before resection. In theory, the combination of nonspecific perioperative immune up-regulation and preoperative tumor vaccines would provide the patient with the ability to kill tumor cells immediately following surgery period through specific and innate (i.e., nonspecific) immune responses. The arrival of advanced laparoscopic methods for the resection of cancers has led to research that has made it clear that surgery has important detrimental immune consequences. This work also has suggested novel means to avoid postoperative immunosuppression. Minimally invasive methods may be associated with oncologic advantages that go well beyond less pain, a quicker recovery, and a shorter length of stay. More basic science and human studies are needed to shed more light on this intriguing area.

Human papillomavirus and long-term oral contraceptive use increase the risk of adenocarcinoma in situ of the cervix.

We examined United States Surveillance, Epidemiology, and End Results incidence data and conducted a population-based case-control study to examine the role of human papillomavirus (HPV) and oral contraceptive (OC) use in the etiology of adenocarcinoma in situ of the cervix (ACIS). One hundred and fifty women diagnosed with ACIS and 651 randomly selected control women completed in-person interviews. The presence of HPV DNA in archival ACIS specimens was determined by E6 and L1 consensus PCR. Serum samples from case and control subjects were collected at interview, and antibodies to HPV-16 L1 and HPV-18 L1 were detected by virus-like particle capture assays. The overall prevalence of HPV DNA was 86.6%, with 39.0% positive for HPV-16 DNA, 52.4% positive for HPV-18 DNA, and 13.4% positive for more than one HPV type. The age-adjusted relative risk of ACIS associated with HPV-18 seropositivity was 3.3 (95% confidence interval 2.2-4.9). No increased risk was associated with antibodies to HPV-16 L1. Among women born after 1945, the relative risk increased with duration of OC use, with the highest risk for 12 or more years of use (odds ratio, 5.5; 95% confidence interval, 2.1-14.6) relative to nonusers. The detection of HPV DNA in 86.6% of ACIS and the strong association of ACIS with HPV-18 L1 seropositivity underscore the importance of HPV, particularly HPV-18, in the etiology of ACIS. In addition, long-term OC use may contribute to the pathogenesis of these tumors in some women.

Human papillomavirus 16 and 18 L1 serology compared across anogenital cancer sites.

Human papillomavirus (HPV) DNA has been detected in the great majority of cancers of the uterine cervix and anus, whereas the association of HPV DNA with cancer at other anogenital sites has produced less consistent results. This study was designed to compare HPV exposure among anogenital cancer cases and matched controls. Cases (1782) of anogenital cancer diagnosed in the Seattle area from 1978 to 1998 were identified and interviewed. Their responses were compared with those of 2383 age- and sex-matched controls. Blood was drawn at interview from both cases and controls and tested for antibodies to HPV-16 and HPV-18. Tissue blocks were tested for HPV DNA for 649 cases. Serum antibodies to HPV-16 were associated with in situ and invasive cancer at all sites among men and women with the exception of in situ penile cancer. Anti-HPV-18 antibodies were associated with cancers at all sites among women. The increased risk of cancer associated with HPV-16 seropositivity ranged from odds ratio = 1.8 (95% confidence interval, 1.4-2.5) for adenocarcinoma of the cervix to odds ratio = 5.9 (95% confidence interval, 3.4-10.3) for anal cancer in men. Associations between seroprevalence and cancers were stronger when analyses were restricted to HPV-16- or HPV-18 DNA-positive cases. HPV DNA was detected in >80% of cancers from all sites tested. HPV-16 DNA was the type most frequently detected at all sites (range, 40.9-82.2%). HPV-18 DNA was detected in 44.7% of adenocarcinomas of the cervix but detected much less often (2.6-18.1%) at other sites. These findings support an important role for HPV infection in anogenital cancer at all sites. Differences in the proportion of seropositives among HPV-16 DNA-positive cases by site suggest either that the immune response varies by site or that cancer development may lead to changes in antibody responses in a site-specific fashion.

Comparison of human papillomavirus types 16, 18, and 6 capsid antibody responses following incident infection.

The relationship between human papillomavirus (HPV) DNA in the genital mucosa and serum IgG to HPV-16, -18, and -6 was studied in a cohort of 588 college women. Among women with incident HPV infections, 59.5%, 54.1%, and 68.8% seroconverted for HPV-16, -18, or -6, respectively, within 18 months of detecting the corresponding HPV DNA. Transient HPV DNA was associated with a failure to seroconvert following incident HPV infection; however, some women with persistent HPV DNA never seroconverted. Antibody responses to each type were heterogeneous, but several type-specific differences were found: seroconversion for HPV-16 occurred most frequently between 6 and 12 months of DNA detection, but seroconversion for HPV-6 coincided with DNA detection. Additionally, antibody responses to HPV-16 and -18 were significantly more likely to persist during follow-up than were antibodies to HPV-6.

The p53 Arg72Pro polymorphism, human papillomavirus, and invasive squamous cell cervical cancer.

A. Storey et al. [Nature (Lond.), 393: 229-234, 1998)] reported a 7-fold increased risk of cervical cancer associated with having an Arg/Arg polymorphism at codon 72 of p53 compared with the Pro/Arg heterozygotes (odds ratio, 7.4; 95% confidence interval, 2.1-29.4). Complementary in vitro studies suggested that the HPV E6 oncoprotein more readily targets the arginine form, as opposed to the proline form, of p53 for degradation. We investigated the impact of this polymorphism in a population-based case-control study of invasive cervical cancer. Using a PCR assay to detect the p53 codon 72 polymorphism, we tested blood samples from 111 women with invasive squamous cell cancer of the cervix identified by a population-based registry and 164 random-digit telephone-dialed controls. The distribution of the genotype among control women was 38% heterozygous, 7% proline homozygous, and 55% arginine homozygous, and among the cases was 38%, 6%, and 56%, respectively. There was no increased risk of squamous cell invasive cervical cancer associated with homozygosity for the arginine allele (odds ratio, 1.0; 95% confidence interval, 0.6-1.7). Furthermore, there was no modification of this result by human papillomavirus (HPV) DNA status of the tumor, age, or smoking status. Among controls, there was no association between the polymorphism and HPV-16 L1 seropositivity. However, among case subjects, the codon 72 polymorphism may be related to HPV 16L1 seropositivity status.

Oral cancer risk in relation to sexual history and evidence of human papillomavirus infection.

BACKGROUND: Experimental models and analyses of human tumors suggest that oncogenic, sexually transmittable human papillomaviruses (HPVs) are etiologic factors in the development of oral squamous cell carcinoma (SCC). We conducted a population-based, case-control study to determine whether the risk of this cancer is related to HPV infection and sexual history factors. METHODS: Case subjects (n = 284) were 18-65-year-old residents of three counties in western Washington State who were newly diagnosed with oral SCC from 1990 through 1995. Control subjects (n = 477) similar in age and sex were selected from the general population. Serum samples were tested for HPV type 16 capsid antibodies. Exfoliated oral tissue collected from case and control subjects and tumor tissue from case subjects were tested for HPV DNA. Odds ratios (ORs) were calculated after adjusting for age, sex, cigarette smoking, and alcohol consumption. RESULTS: Among males only, oral SCC risk increased with self-reported decreasing age at first intercourse, increasing number of sex partners, and a history of genital warts. Approximately 26% of the tumors in case subjects contained HPV DNA; 16.5% of the tumors contained HPV type 16 DNA. The prevalence of oncogenic HPV types in exfoliated oral tissue was similar in case and control subjects. The ORs for HPV type 16 capsid seropositivity were 2.3 (95% confidence interval [CI] = 1.6-3.3) for all oral SCCs and 6.8 (95% CI = 3.0-15.2) for oral SCCs containing HPV type 16 DNA. The joint association of cigarette smoking and HPV type 16 capsid seropositivity with oral SCC (OR = 8.5; 95% CI = 5.1-14.4) was stronger than predicted from the sum of individual associations with current smoking (OR = 3.2; 95% CI = 2.0-5.2) and seropositivity (OR = 1.7; 95% CI = 1.1-2.6). CONCLUSIONS: HPV type 16 infection may contribute to the development of a small proportion of oral SCCs in this population, most likely in combination with cigarette smoking.

Pain control following elective gastrointestinal surgery: is epidural anesthesia warranted?

Fifty-nine patients undergoing elective major gastrointestinal surgery were entered into a prospective, randomized trial between January 1993 and July 1994 comparing the effectiveness, side effects, and hospital costs of postoperative epidural anesthesia (Group 1, n = 29) and intramuscular narcotic injections (Group 2, n = 30). Epidural catheters were inserted by a team that supervised catheter care and infusion rates in the postoperative period. The nonepidural group received intramuscular injections on a regular basis. Patients filled out visual analog scales to measure levels of pain ( 1 = minimal, 10 = maximal) every eight hours. Patient activity, bowel, and urinary function were recorded by the nursing staff. Control of pain (as measured by the daily average visual analog score) was more effective in Group 1 (P < .001) on postoperative days 1-3 (1.3 vs 3.6 on day 1, 0.7 vs 2.6 on day 2, 0.9 vs 3 on day 3). There was no significant difference in mean values between groups 1 and 2 with respect to first ambulation on the hospital ward, onset of liquid diet, intake of solid food, first spontaneous voiding, first bowel movement, length of hospitalization, or charge of hospitalization ($13,439 +/- 7,452 vs $11,821 +/- 6,630). We conclude that epidural anesthesia significantly lessens incisional pain following major elective lower gastrointestinal surgery when compared to analgesic injections alone. However, while not statistically significant, the overall charge was increased by 14% in the epidural group. This finding should be examined in light of the relatively low pain level in patients receiving narcotic injections alone.

Cofactors with human papillomavirus in a population-based study of vulvar cancer.

BACKGROUND: Human papillomavirus (HPV) has been previously associated with vulvar cancer. In a population-based study, we examined whether exposure to HPV, cigarette smoking, or herpes simplex virus 2 (HSV2) increases the risk of this cancer. METHODS: Incident cases of in situ (n = 400) and invasive (n = 110) squamous cell vulvar cancer diagnosed among women living in the Seattle area from 1980 through 1994 were identified. Serum samples were analyzed for antibodies against specific HPV types and HSV2. HPV DNA in tumor tissue was detected by means of the polymerase chain reaction. In most analyses, case subjects were compared with population-based control subjects (n = 1403). Relative risks of developing vulvar cancer were estimated by use of adjusted odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: Increased risks of in situ or invasive vulvar cancer were associated with HPV16 seropositivity (ORs = 3.6 [95% CI = 2.6-4.8] and 2.8 [95% CI = 1.7-4.7], respectively), current cigarette smoking (ORs = 6.4 [95% CI = 4.4-9.3] and 3.0 [95% CI = 1.7-5.3], respectively), and HSV2 seropositivity (ORs = 1.9 [95% CI = 1.4-2.6] and 1.5 [95% CI = 0.9-2.6], respectively). When the analysis was restricted to HPV16 DNA-positive tumors (in situ or invasive), the OR associated with HPV16 seropositivity was 4.5 (95% CI = 3.0-6.8). The OR for vulvar cancer was 18.8 (95% CI = 11.9-29.8) among current smokers who were HPV16 seropositive in comparison with never smokers who were HPV16 seronegative. CONCLUSIONS: Current smoking, infection with HPV16, and infection with HSV2 are risk factors for vulvar cancer. Risk appears particularly strong among women who are both current smokers and HPV16 seropositive.

The natural history of human papillomavirus type 16 capsid antibodies among a cohort of university women.

To study the temporal relationship between serum antibody response and human papillomavirus type 16 (HPV-16) infection, a cohort of 325 university women were scheduled for examinations at 4-month intervals. At every examination, interviews were completed, cells were obtained for polymerase chain reaction-based testing and for Pap screening, and serum was obtained for testing with a HPV-16 capsid-capture ELISA. Seroreactivity was associated with detection of HPV-16 DNA and with increased numbers of sex partners. The median time to seroconversion was 8.3 months among women with incident HPV-16 infections. Within 16 months following HPV-16 DNA detection, 93.7% of women with prevalent and 67.1% of women with incident infections seroconverted. After seroconversion, antibody responses were maintained during follow-up among HPV-16 DNA-positive women. Women who seroconverted were 5.7 times (95% confidence interval = 2.4-13.4) more likely to have squamous intraepithelial lesions associated with the detection of HPV-16 DNA than were women who did not seroconvert.