Brief Report: Modeling the Impact of Voluntary Medical Male Circumcision on Cervical Cancer in Uganda.

BACKGROUND: In addition to providing millions of men with lifelong lower risk for HIV infection, voluntary medical male circumcision (VMMC) also provides female partners with health benefits including decreased risk for human papillomavirus (HPV) and resultant cervical cancer (CC). SETTING: We modeled potential impacts of VMMC on CC incidence and mortality in Uganda as an additional benefit beyond HIV prevention. METHODS: HPV and CC outcomes were modeled using the CC model from the Spectrum policy tool suite, calibrated for Uganda, to estimate HPV infection incidence and progression to CC, using a 50-year (2018-2067) time horizon. 2016 Demographic Health Survey data provided baseline VMMC coverage. The baseline (no VMMC scale-up beyond current coverage, minimal HPV vaccination coverage) was compared with multiple scenarios to assess the varying impact of VMMC according to different implementations of HPV vaccination and HPV screening programs. RESULTS: Without further intervention, annual CC incidence was projected to rise from 16.9 to 31.2 per 100,000 women in 2067. VMMC scale-up alone decreased 2067 annual CC incidence to 25.3, averting 13,000 deaths between 2018 and 2067. With rapidly-achieved 90% HPV9 vaccination coverage for adolescent girls and young women, 2067 incidence dropped below 10 per 100,000 with or without a VMMC program. With 45% vaccine coverage, the addition of VMMC scaleup decreased incidence by 2.9 per 100,000 and averted 8000 additional deaths. Similarly, with HPV screen-and-treat without vaccination, the addition of VMMC scaleup decreased incidence by 5.1 per 100,000 and averted 10,000 additional deaths. CONCLUSIONS: Planned VMMC scale-up to 90% coverage from current levels could prevent a substantial number of CC cases and deaths in the absence of rapid scale-up of HPV vaccination to 90% coverage.

Re-analysing tobacco industry funded research on the effect of plain packaging on minors in Australia: Same data but different results.

INTRODUCTION: Our objective was to re-analyse the data used in an industry-funded working paper to study the effect of plain packaging on youth smoking prevalence in Australia, allowing for other tobacco control measures introduced over the period 2001-2013, and using a more appropriate method of analysis. METHODS: Monthly smoking prevalence and sample sizes from repeat cross-sectional surveys were reconstructed from the working paper by reverse engineering of the industry-presented data, and analysed as a time series using logistic regression. Power analysis presented in the industry-funded working paper was re-calculated. RESULTS: Smoking prevalence among minors in Australia declined from 11.6% to 5.6% over the 13-year period examined; an overall 52% relative reduction or an average annual reduction of 5.5% (95% confidence interval 4.6% to 6.4%). There was a 12.1% (-4.8% to 26.2%) relative reduction in smoking prevalence when plain packaging was introduced, though the reduction was not statistically significant. Re-calculated power values were much lower than those reported in the industry-funded paper, confirming the inconclusiveness of its findings, as pointed out in previous critiques. CONCLUSIONS: Our findings suggest a decline of smoking prevalence in minors following the introduction of plain packaging in Australia. They differ substantially from those presented in an industry-funded study on the effects of plain packaging on smoking prevalence in minors in Australia, which used the same data.

Postoperative shoulder magnetic resonance imaging.

Magnetic resonance imaging (MRI) and MR arthrography have proven invaluable for managing the postoperative shoulder, particularly in relation to the rotator cuff and labrum. MRI has proven to be an accurate imaging technique for differentiating expected findings versus complications in the postoperative setting. The transition from metallic hardware to bioabsorbable suture anchors used in orthopedic surgery has rendered less metallic susceptibility artifact over the years, allowing more accurate interpretation of MR images. This article gives a pictorial review of various expected postoperative findings in the shoulder and complications related to repair of the rotator cuff and labrum.

Voluntary medical male circumcision: modeling the impact and cost of expanding male circumcision for HIV prevention in eastern and southern Africa.

BACKGROUND: There is strong evidence showing that voluntary medical male circumcision (VMMC) reduces HIV incidence in men. To inform the VMMC policies and goals of 13 priority countries in eastern and southern Africa, we estimate the impact and cost of scaling up adult VMMC using updated, country-specific data. METHODS AND FINDINGS: We use the Decision Makers' Program Planning Tool (DMPPT) to model the impact and cost of scaling up adult VMMC in Botswana, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia, Zimbabwe, and Nyanza Province in Kenya. We use epidemiologic and demographic data from recent household surveys for each country. The cost of VMMC ranges from US$65.85 to US$95.15 per VMMC performed, based on a cost assessment of VMMC services aligned with the World Health Organization's considerations of models for optimizing volume and efficiencies. Results from the DMPPT models suggest that scaling up adult VMMC to reach 80% coverage in the 13 countries by 2015 would entail performing 20.34 million circumcisions between 2011 and 2015 and an additional 8.42 million between 2016 and 2025 (to maintain the 80% coverage). Such a scale-up would result in averting 3.36 million new HIV infections through 2025. In addition, while the model shows that this scale-up would cost a total of US$2 billion between 2011 and 2025, it would result in net savings (due to averted treatment and care costs) amounting to US$16.51 billion. CONCLUSIONS: This study suggests that rapid scale-up of VMMC in eastern and southern Africa is warranted based on the likely impact on the region's HIV epidemics and net savings. Scaling up of safe VMMC in eastern and southern Africa will lead to a substantial reduction in HIV infections in the countries and lower health system costs through averted HIV care costs.

Prostate cancer and vasectomy: a hospital-based case-control study in China, Nepal and the Republic of Korea.

BACKGROUND: The study of a possible relationship between vasectomy and prostate cancer has yielded mixed results. Data from developing countries are limited. STUDY DESIGN: We conducted a hospital-based case-control study in China, Nepal and the Republic of Korea to evaluate the risk of prostate cancer after vasectomy. RESULTS: Prostate cancer in 294 cases (confirmed by independent pathologists) and 879 matched controls were included. The odds ratio of prostate cancer in men with a history of vasectomy was 1.21 [95% confidence interval (95% CI)=0.79, 1.87]. No significant trend was observed in risk by time since vasectomy or age at vasectomy. The odds ratio for localized disease was 1.02 (95% CI=0.53, 1.95); the odds ratio for later stages was 1.41 (95% CI=0.78, 2.53). No confounding factor was identified. The study illustrated differential misclassification of disease by vasectomy status; reference pathologists determined that 28% of men with a history of vasectomy, compared with 17% of men without a history of vasectomy, were misdiagnosed with prostate cancer by local pathologists. CONCLUSION: Vasectomy is not associated with an increased risk of prostate cancer in developing countries where the rate of the disease is low.

A clinical composite score accurately detects meniscal pathology.

PURPOSE: Five common tests were used to diagnose meniscal tears when used as a composite score. We evaluated how effectively the composite examination, when performed in the presence of an anterior cruciate ligament (ACL) injury or degenerative joint disease (DJD), determined the presence of meniscal tears. METHODS: Data were collected prospectively on all patients at our clinic with a primary knee complaint. Independent variables included the presence or absence of the following: (1) a history of "catching" or "locking" as reported by the patient, (2) pain with forced hyperextension, (3) pain with maximum flexion, (4) pain or an audible click with McMurray's maneuver, and (5) joint line tenderness to palpation. Comprehensive patient demographic data were collected including ligamentous examinations and other intra-articular pathologies found at arthroscopy. Composite examination findings were correlated with the presence or absence of meniscal pathology. RESULTS: We evaluated 635 knees in 576 patients for historical and physical findings. Of the knees, 209 underwent arthroscopic surgery and 426 did not. Chi(2) Analysis showed a significant relation between the number of positive diagnostic tests and the presence of meniscal tears (P = .001). Five positive findings on composite examination yielded a positive predictive value of 92.3%. Positive predictive values remained greater than 75% with composite scores of at least 3 in the absence of ACL and DJD pathologies. The presence of an ACL injury decreased the positive predictive value of 5 composite findings to 67%, whereas the presence of DJD increased predictability to 100%. CONCLUSIONS: When all 5 symptoms and signs were positive, there was a 92.3% positive predictive value of finding a meniscal tear. Although positive predictive values decreased with a concomitant ACL injury and increased with DJD, there was a higher rate of false-positive findings (ACL) and false-negative findings (DJD). LEVEL OF EVIDENCE: Level II, development of diagnostic criteria with consecutive patients and gold standard.