Sexual Orientation and Cervical Cancer Screening Among Cisgender Women.

Importance: Lesbian, gay, and bisexual populations face barriers accessing health care in Chicago, Illinois. Objective: To describe the prevalence of up-to-date cervical cancer screening among lesbian, gay, and bisexual vs heterosexual cisgender women in Chicago. Design, Setting, and Participants: This retrospective, cross-sectional, population-based study of cisgender women residing in Chicago was completed from 2020 to 2022 using data from the Healthy Chicago Survey, which is conducted annually by the Chicago Department of Public Health. Participants included cisgender women aged 25 to 64 years with no history of hysterectomy. Respondents who self-identified as lesbian, gay, or bisexual or other than straight, lesbian, or bisexual were coded as lesbian, gay, or bisexual (LGB). Respondents who self-identified as straight were coded as heterosexual. Those who reported having a Papanicolaou test within the past 3 years were considered up-to-date with cervical cancer screening. Data analysis was performed from June to October 2023. Exposures: The primary exposure was sexual orientation. Covariates included age, income level, race, ethnicity, having a primary care practitioner (PCP), and insurance coverage. Main Outcomes and Measures: Prevalence ratios (PRs), log-based regression models, and interaction analysis were used to describe the association of sexual orientation with up-to-date screening. Results: The sample included 5167 cisgender women (447 LGB and 4720 heterosexual), aged 25 to 64 years, with no history of hysterectomy. Among LGB cisgender women, 318 (71.14%) reported previous cervical cancer screening compared with 3632 (76.95%) heterosexual cisgender women. The prevalence of up-to-date screening was 10% lower in the LGB group compared with the heterosexual group (PR, 0.90; 95% CI, 0.82-1.00). In regression analysis, having a PCP (PR, 1.43; 95% CI, 1.29-1.59) was associated with up-to-date screening. In interaction analysis, LGB cisgender women with a PCP were 93% more likely to be up-to-date compared with those without a PCP (PR, 1.93; 95% CI, 1.37-2.72). Conclusions and Relevance: In this cross-sectional study of cervical cancer screening rates between the heterosexual and LGB populations in Chicago, up-to-date cervical cancer screening was associated with having a PCP, regardless of sexual orientation, but this association was greater for LGB individuals. Although LGB populations were less likely to be screened, this disparity may be reduced with more consistent health care access and established care with PCPs.

Tubal Sterilization and Cervical Cancer Underscreening in the United States.

Background: Tubal sterilization is more commonly utilized by racial/ethnic minority groups and has been implicated in underscreening for cervical cancer. The objective is to determine if prior tubal sterilization is a risk factor for cervical cancer underscreening. Methods: National Survey of Family Growth dataset from 2015 to 2019 used for analysis; data were weighted to represent the 72 million women in the U.S. population aged 22-49. Chi-square tests, Fisher exact tests, and logistic regression were used for analysis. The primary predictor variable was tubal sterilization which was categorized into no previous sterilization, sterilization completed <5 years ago, and sterilization completed ≥5 years ago. The outcome variable was underscreened versus not underscreened. Other predictor variables included age, household income as a percent of federal poverty level, previous live birth, primary care provider, and insurance status. Results: Prevalence of tubal sterilization completed 5 or more years ago was 12.5% and varied by most measured characteristics in univariate analyses. Approximately 8% of women were underscreened for cervical cancer. In multivariable analyses, women with a tubal sterilization 5 or more years ago had 2.64 times the odds (95% confidence interval = 1.75-4.00) of being underscreened for cervical cancer compared with women who did not have a tubal sterilization. Conclusions: Approximately 4.3 million women ages 22-49 in the United States are potentially underscreened for cervical cancer and women with previous tubal ligation ≥5 years ago are more likely to be underscreened. These results may inform the need for culturally sensitive public health messages informing people who have had these procedures about the need for continued screening.

A qualitative study of primary care clinician's approach to ending cervical cancer screening in older women in the United States.

The United States Preventive Services Task Force (USPSTF) recommends that cervical cancer screening end in average-risk patients with a cervix at 65 years of age if adequate screening measures have been met, defined as having 1) at least three normal consecutive cytology (Pap) tests, or 2) two normal cytology tests and/or two negative high-risk human papillomavirus tests between ages 55-65; the last test should be performed within the prior 5 years. Up to 60 % of all women aged 65 years and older who are ending screening do not meet the criteria for adequate screening. The objective of this study was to understand the process and approach that healthcare clinicians use to determine eligibility to end cervical cancer screening. In 2021 we conducted semi-structured interviews in San Francisco, CA with twelve healthcare clinicians: two family medicine physicians, three general internal medicine physicians, two obstetrician/gynecologists and five nurse practitioners. Thematic analysis, using inductive and deductive coding, was utilized. Three major themes emerged: following guidelines, relying on self-reported data regarding prior screening, and considering sexual activity as a factor in the decision to end screening. All interviewees endorsed following the USPSTF guidelines and they utilized self-report to determine eligibility to end screening. Clinicians' approach was dependent in part on their judgement about the reliability of the patient to convey their screening history. Sexual activity of the patient was considered when making clinical recommendations. Shared decision-making was often utilized. Clinicians voiced a strong reliance on self-reported screening history to end cervical cancer screening.

Gender neutral HPV vaccination programs: Reconsidering policies to expand cancer prevention globally.

Human papillomavirus (HPV) infection is responsible for many cancers in both women and men. Cervical cancer, caused by HPV, is the fourth most common cancer among women worldwide, even though it is one of the most preventable cancers. Prevention efforts include HPV vaccination, however these programs remain nascent in many countries. In 2020 the World Health Assembly adopted the Global Strategy for cervical cancer elimination including a goal to fully vaccinate 90% of girls with the HPV vaccine by the age of 15. However, very few countries have reached even 70% coverage. Increased vaccine availability in the future may allow the opportunity to vaccinate more people. This could add to the feasibility of introducing gender-neutral HPV vaccination programs. Adopting a gender-neutral HPV vaccine approach will reduce HPV infections transmitted among the population, combat misinformation, minimize vaccine-related stigma, and promote gender equity. We propose approaching programmatic research through a gender-neutral lens to reduce HPV infections and cancers and promote gender equality. In order to design more effective policies and programs, a better understanding of the perspectives of clients, clinicians, community leaders, and policy-makers is needed. A clear, multi-level understanding of these stakeholders' views will facilitate the development of target policy and programs aimed at addressing common barriers and optimizing uptake. Given the benefit of developing gender-neutral HPV vaccination programs to eliminate cervical cancer and address other HPV associated cancers, we must build knowledge through implementation research around this topic to inform policy-makers and funders for future policy shifts.

Mediation of Racial and Ethnic Inequities in the Diagnosis of Advanced-Stage Cervical Cancer by Insurance Status.

Importance: Black and Hispanic or Latina women are more likely than White women to receive a diagnosis of and to die of cervical cancer. Health insurance coverage is associated with diagnosis at an earlier stage of cervical cancer. Objective: To evaluate the extent to which racial and ethnic differences in the diagnosis of advanced-stage cervical cancer are mediated by insurance status. Design, Setting, and Participants: This retrospective, cross-sectional population-based study used data from the Surveillance, Epidemiology, and End Results (SEER) program on an analytic cohort of 23 942 women aged 21 to 64 years who received a diagnosis of cervical cancer between January 1, 2007, and December 31, 2016. Statistical analysis was performed from February 24, 2022, to January 18, 2023. Exposures: Health inusurance status (private or Medicare insurance vs Medicaid or uninsured). Main Outcomes and Measures: The primary outcome was a diagnosis of advanced-stage cervical cancer (regional or distant stage). Mediation analyses were performed to assess the proportion of observed racial and ethnic differences in the stage at diagnosis that were mediated by health insurance status. Results: A total of 23 942 women (median age at diagnosis, 45 years [IQR, 37-54 years]; 12.9% were Black, 24.5% were Hispanic or Latina, and 52.9% were White) were included in the study. A total of 59.4% of the cohort had private or Medicare insurance. Compared with White women, patients of all other racial and ethnic groups had a lower proportion with a diagnosis of early-stage cervical cancer (localized) (American Indian or Alaska Native, 48.7%; Asian or Pacific Islander, 49.9%; Black, 41.7%; Hispanic or Latina, 51.6%; and White, 53.3%). A larger proportion of women with private or Medicare insurance compared with women with Medicaid or uninsured received a diagnosis of an early-stage cancer (57.8% [8082 of 13 964] vs 41.1% [3916 of 9528]). In models adjusting for age, year of diagnosis, histologic type, area-level socioeconomic status, and insurance status, Black women had higher odds of receiving a diagnosis of advanced-stage cervical cancer compared with White women (odds ratio, 1.18 [95% CI, 1.08-1.29]). Health insurance was associated with mediation of more than half (ranging from 51.3% [95% CI, 51.0%-51.6%] for Black women to 55.1% [95% CI, 53.9%-56.3%] for Hispanic or Latina women) the racial and ethnic inequities in the diagnosis of advanced-stage cervical cancer across all racial and ethnic minority groups compared with White women. Conclusions and Relevance: This cross-sectional study of SEER data suggests that insurance status was a substantial mediator of racial and ethnic inequities in advanced-stage cervical cancer diagnoses. Expanding access to care and improving the quality of services rendered for uninsured patients and those covered by Medicaid may mitigate the known inequities in cervical cancer diagnosis and related outcomes.

Use Trends and Recent Expenditures for Cervical Cancer Screening-Associated Services in Medicare Fee-for-Service Beneficiaries Older Than 65 Years.

Importance: Since 1996, the US Preventive Services Task Force has recommended against cervical cancer screening in average-risk women 65 years or older with adequate prior screening. Little is known about the use of cervical cancer screening-associated services in this age group. Objective: To examine annual use trends in cervical cancer screening-associated services, specifically cytology and human papillomavirus (HPV) tests, colposcopy, and cervical procedures (loop electrosurgical excision procedure, cone biopsy, and ablation) in Medicare fee-for-service beneficiaries during January 1, 1999, to December 31, 2019, and estimate expenditures for services performed in 2019. Design, Setting, and Participants: This population-based, cross-sectional analysis included health service use data across 21 years for women aged 65 to 114 years with Medicare fee-for-service coverage (15-16 million women per year). Data analysis was conducted between July 2021 and April 2022. Main Outcomes and Measures: Proportion of testing modalities (cytology alone, cytology plus HPV testing [cotesting], HPV testing alone); annual use rate per 100 000 women of cytology and HPV testing, colposcopy, and cervical procedures from 1999 to 2019; Medicare expenditure for these services in 2019. Results: There were 15 323 635 women 65 years and older with Medicare fee-for-service coverage in 1999 and 15 298 656 in 2019. In 2019, the mean (SD) age of study population was 76.2 (8.1) years, 5.1% were Hispanic, 0.5% were non-Hispanic American Indian/Alaska Native, 3.0% were non-Hispanic Asian/Pacific Islander, 7.4% were non-Hispanic Black, and 82.0% were non-Hispanic White. From 1999 to 2019, the percentage of women who received at least 1 cytology or HPV test decreased from 18.9% (2.9 million women) in 1999 to 8.5% (1.3 million women) in 2019, a reduction of 55.3%; use rates of colposcopy and cervical procedures decreased 43.2% and 64.4%, respectively. Trend analyses showed a 4.6% average annual reduction in use of cytology or HPV testing during 1999 to 2019 (P < .001). Use rates of colposcopy and cervical procedures decreased before 2015 then plateaued during 2015 to 2019. The total Medicare expenditure for all services rendered in 2019 was about $83.5 million. About 3% of women older than 80 years received at least 1 service at a cost of $7.4 million in 2019. Conclusions and Relevance: The results of this cross-sectional study suggest that while annual use of cervical cancer screening-associated services in the Medicare fee-for-service population older than 65 years has decreased during the last 2 decades, more than 1.3 million women received these services in 2019 at substantial costs.

Assessing the interrelationship between stigma, social influence, and cervical cancer prevention in an urban underserved setting: An exploratory study.

In the US, incidence and mortality from cervical cancer disproportionately affects racial/ethnic minorities and low-income women. Despite affordable access to primary and secondary prevention measures at Federally Qualified Health Centers (FQHCs), Human Papillomavirus (HPV) vaccination and screening rates are low, suggesting the presence of non-financial barriers to uptake in this population. This explanatory sequential mixed-methods study sought to explore factors that influence the acceptability of cervical cancer prevention services among parents and legal guardians of vaccine-eligible girls attending an urban FQHC and to assess social influences related to cervical cancer prevention. Participants included eight mothers, one father, and two grandparents/legal guardians. Nine participants self-identified as Black/Afro-Caribbean, or African American, two as Latinx, and one as Native American. The quantitative data suggested discordance between participants' cervical cancer prevention knowledge and their practices. Most indicated that their daughters had received the HPV vaccine but were unsure about HPV transmission modes. Qualitative data revealed that participants were comfortable disclosing information on HPV infection and vaccination status, and most women were likely to share information related to cervical cancer testing and diagnosis. Few comments indicated personal stigma on the part of participants, but there was frequent expression of perceived public stigma (shaming and blaming women), gender differences (men are indifferent to risk), and distrust of the healthcare system. Findings highlight several concepts including the disharmony between knowledge and practice, prevalent perceived public stigma, cumbersome attitudes on the part of men regarding HPV and cervical cancer, and distrust of the healthcare system.

Changing Preferences for a Cervical Cancer Screening Strategy: Moving Away from Annual Testing.

Background: While annual cytology has not been recommended for many years, it remains many patients' preferred screening strategy for cervical cancer. Patient education and provider recommendations have been found effective in aligning professional society guidelines with patient preferences. We assessed whether an educational video with value elicitation exercises (utility assessments) changed screening strategy preferences among patients who had an initial preference for annual screening. Materials and Methods: We conducted an interventional study of English- or Spanish-speaking women 21-65 years of age, recruited from two women's health clinics in San Francisco, California (n = 262). Participants were asked about their preferred method of screening before viewing a 7-minute educational video and using a computerized tool that elicited values for 23 different health states related to cervical cancer screening. Directly afterward, they were again asked about their preferred screening strategy. Multivariable regression analysis was utilized to identify independent predictors of changing preferences. Results: Of 246 enrollees, 62.6% (154/246) had an initial preference for annual cytology; after viewing the video and completing the values elicitation exercises, about half (72/154, 47%) preferred a strategy other than annual screening. Having attended college and being screened every 3 to 5 years in the recent past were independent predictors of changing preferences away from annual screening. In sensitivity analyses, 53.2% of average-risk participants changed preferences away from annual cytology (p < 0.01). Conclusions: Viewing an educational video and conducting a series of value elicitation exercises were associated with a substantially decreased likelihood of preferring annual screening. These findings underscore the importance of patient-centered education to help support informed patient preferences.

Differences in Hypertension Medication Prescribing for Black Americans and Their Association with Hypertension Outcomes.

BACKGROUND: National guidelines recommend different pharmacologic management of hypertension (HTN) without comorbidities for Black/African Americans (BAA) compared with non-BAA. We sought to 1) identify if these recommendations have influenced prescription patterns in BAA and 2) identify the differences in uncontrolled HTN in BAA on different antihypertensive medications. METHODS: We constructed a linked retrospective observational cohort using 2 years of electronic health records data, comprising of patients aged 18 to 85 with HTN on 1- or 2-drug regimens, including angiotensin-converting enzyme inhibitors (ACE), angiotensin receptor blockers (ARB), thiazide diuretics, or calcium channel blockers (CCB). We examined prescribing differences and HTN control in BAA versus non-BAA. RESULTS: Among 10,875 patients identified, 20.6% were identified as BAA. 46.4% of BAA had uncontrolled HTN (≥140/90 mmHg) compared with 39.0% of non-BAA (P < .001). 61.8% of BAA were treated with 1-drug compared with 68.4% of non-BAA. Of BAA on monotherapy: 41.3% were on thiazide, 40.1% on CCB, and 18.6% on ACE/ARB. Of non-BAA on monotherapy, 27.7% were on thiazide, 30.1% were on CCB, and 42.3% were on ACE/ARB. Of BAA patients on 1 drug, 45.2% had uncontrolled HTN compared with 38.0% of non-BAA (P < .001). Of BAA on 2 drugs, 48.2% had uncontrolled HTN compared with 41.1% non-BAA (P < .001). For each drug regimen, there was more variation in HTN control within each group than between BAA and non-BAA. CONCLUSIONS: Providers seem to be following race-based guidelines for HTN, yet HTN control for BAA remains worse than non-BAA. An individualized approach to HTN therapy for all patients may be more important than race-based guidelines.

Trends in the use of cervical cancer screening tests in a large medical claims database, United States, 2013-2019.

OBJECTIVE: To examine trends in the use of cervical cancer screening tests during 2013-2019 among commercially insured women. METHODS: The study population included women of all ages with continuous enrollment each year in the IBM MarketScan commercial or Medicare supplemental databases and without known history of cervical cancer or precancer (range = 6.9-9.8 million women per year). Annual cervical cancer screening test use was examined by three modalities: cytology alone, cytology plus HPV testing (cotesting), and HPV testing alone. Trends were assessed using 2-sided Poisson regression. RESULTS: Use of cytology alone decreased from 34.2% in 2013 to 26.4% in 2019 among women aged 21-29 years (P < .0001). Among women aged 30-64 years, use of cytology alone decreased from 18.9% in 2013 to 8.6% in 2019 (P < .0001), whereas cotesting use increased from 14.9% in 2013 to 19.3% in 2019 (P < .0001). Annual test use for HPV testing alone was below 0.5% in all age groups throughout the study period. Annually, 8.7%-13.6% of women aged 18-20 years received cervical cancer screening. There were persistent differences in screening test use by metropolitan residence and census regions despite similar temporal trends. CONCLUSIONS: Temporal changes in the use of cervical cancer screening tests among commercially insured women track changes in clinical guidelines. Screening test use among individuals younger than 21 years shows that many young women are inappropriately screened for cervical cancer.

Prioritizing cervical cancer screening services during the COVID-19 pandemic: Response of an academic medical center and a public safety net hospital in California.

The expeditious diagnosis and treatment of high-grade cervical precancers are fundamental to cervical cancer prevention. However, during the COVID-19 pandemic healthcare systems have at times restricted in-person visits to those deemed urgent. Professional societies provided some guidance to clinicians regarding ways in which traditional cervical cancer screening might be modified, but many gaps remained. To address these gaps, leaders of screening programs at an academic medical center and an urban safety net hospital in California formed a rapid-action committee to provide guidance to its practitioners. Patients were divided into 6 categories corresponding to various stages in the screening process and ranked by risk of underlying high-grade cervical precancer and cancer. Tiers corresponding to the intensity of the local pandemic were constructed, and clinical delays were lengthened for the lowest-risk patients as tiers escalated. The final product was a management grid designed to escalate and de-escalate with changes in the local epidemiology of the COVID-19 pandemic. While this effort resulted in substantial delays in clinical screening services as mandated by the healthcare systems, the population effects of delaying on both cervical cancer outcomes as well as the beneficial effects related to decreasing transmission of severe acute respiratory coronavirus 2 have yet to be elucidated.

Inequalities in Cervical Cancer Screening Uptake Between Chinese Migrant Women and Local Women: A Cross-Sectional Study.

INTRODUCTION: Uptake of cervical cancer screening services in Chinese migrant workers is unknown and may be lower than non-migrant workers in China. METHODS: We conducted a cross-sectional study among migrant and non-migrant women aged 21-65 at 7 provinces across China and administered a questionnaire investigating knowledge and attitudes regarding cervical cancer, human papillomavirus (HPV), and HPV vaccine. We used multivariable logistic regression to evaluate odds of previous cervical cancer screening in migrant workers. RESULTS: 737 women participated in the study. Mean age was 41.9 ± 7.2 years. 50.2% of the participants were migrant workers. 27.6% of the migrant workers reported previous cervical cancer screening compared to 33.2% of local participants. 36.6% migrant workers reported awareness of HPV compared to 40.2% of local participants. In adjusted analysis migrant status was not associated with increased odds of previous cervical cancer screening (aOR = 1.11 95%CI: 0.76-1.60). High school or higher education compared to less than high school education and employer-sponsored insurance compared to uninsured were associated with increased odds of previous cervical cancer screening (aOR = 2.15 95%CI: 1.41-3.27 and aOR = 1.67 95% CI: 1.14-2.45, respectively). Having heard of HPV compared to no awareness of HPV was associated with increased odds of cervical cancer screening (aOR = 2.02 95%CI: 1.41-2.91). Awareness of HPV among migrant workers was associated with increased odds of cervical cancer screening compared to migrant and local participants without awareness (aOR = 2.82 95% CI: 1.70-4.69 and 2.97 95%CI: 1.51-5.83, respectively). CONCLUSIONS: Efforts to increase education opportunities, provide insurance, and promote HPV awareness could increase cervical cancer screening uptake in migrant women in China.

Delayed Visits for Contraception Due to Concerns Regarding Pelvic Examination Among Women with History of Intimate Partner Violence.

BACKGROUND: Concern regarding pelvic examinations may be more common among women experiencing intimate partner violence. OBJECTIVE: We examined women's attitudes towards pelvic examination with history of intimate partner violence (pressured to have sex, or verbal, or physical abuse). DESIGN: Secondary analysis of data from a cluster randomized trial on contraceptive access. PARTICIPANTS: Women aged 18-25 were recruited at 40 reproductive health centers across the USA (2011-2013). MAIN MEASURES: Delays in clinic visits for contraception and preference to avoid pelvic examinations, by history of ever experiencing pressured sex, verbal, or physical abuse from a sexual partner, reported by frequency (never, rarely, sometimes, often). We used multivariable logistic regression with generalized estimating equations for clustered data. KEY RESULTS: A total of 1490 women were included. Ever experiencing pressured sex was reported by 32.4% of participants, with 16.5% reporting it rarely, 12.1% reporting it sometimes, and 3.8% reporting it often. Ever experiencing verbal abuse was reported by 19.4% and physical abuse by 10.2% of participants. Overall, 13.2% of participants reported ever having delayed going to the clinic for contraception to avoid having a pelvic examination, and 38.2% reported a preference to avoid pelvic examinations. In multivariable analysis, women reporting that they experienced pressured sex often had significantly higher odds of delaying a clinic visit for birth control (aOR 3.10 95% CI 1.39-6.84) and for reporting a preference to avoid pelvic examinations (aOR 2.91 95% CI 1.57-5.40). We found no associations between delay of clinic visits or preferences to avoid a pelvic examination and verbal or physical abuse. CONCLUSIONS: History of pressured sex from an intimate partner is common. Among women who have experienced pressured sex, concern regarding pelvic examinations is a potential barrier to contraception. Communicating that routine pelvic examinations are no longer recommended by professional societies could potentially reduce barriers and increase preventive healthcare visits.

Discussing Cervical Cancer Screening Options: Outcomes to Guide Conversations Between Patients and Providers.

Purpose. In 2018, the US Preventive Services Task Force (USPSTF) endorsed three strategies for cervical cancer screening in women ages 30 to 65: cytology every 3 years, testing for high-risk types of human papillomavirus (hrHPV) every 5 years, and cytology plus hrHPV testing (co-testing) every 5 years. It further recommended that women discuss with health care providers which testing strategy is best for them. To inform such discussions, we used decision analysis to estimate outcomes of screening strategies recommended for women at age 30. Methods. We constructed a Markov decision model using estimates of the natural history of HPV and cervical neoplasia. We evaluated the three USPSTF-endorsed strategies, hrHPV testing every 3 years and no screening. Outcomes included colposcopies with biopsy, false-positive testing (a colposcopy in which no cervical intraepithelial neoplasia grade 2 or worse was found), treatments, cancers, and cancer mortality expressed per 10,000 women over a shorter-than-lifetime horizon (15-year). Results. All strategies resulted in substantially lower cancer and cancer death rates compared with no screening. Strategies with the lowest likelihood of cancer and cancer death generally had higher likelihood of colposcopy and false-positive testing. Conclusions. The screening strategies we evaluated involved tradeoffs in terms of benefits and harms. Because individual women may place different weights on these projected outcomes, the optimal choice for each woman may best be discerned through shared decision making.

Barriers and facilitators to HPV vaccine uptake among US rural populations: a scoping review.

PURPOSE: Compared to US urban populations, rural residents have a higher incidence of HPV-related cancer and lower HPV vaccine coverage. This study determined what is known about barriers and facilitators to vaccine uptake in US rural settings. METHODS: A scoping review was conducted to describe individual, interpersonal, organizational, and community/societal barriers and facilitators to HPV vaccine initiation and completion among US rural populations and to identify gaps in the current research. A systematic search was conducted using PubMed/MEDLINE and CINAHL databases. RESULTS: A total of 1,083 abstracts were reviewed and 13 articles met the inclusion criteria. Major themes at the individual-level included caregiver and vaccine-recipient demographics, other immunizations received, pap test history, awareness/knowledge of cervical cancer, HPV vaccine, or HPV infection, attitudes and motivation to vaccinate, STD diagnosis, sexual behavior, cervical cancer history, contraceptive use, and cancer fatalism. Interpersonal themes focused on provider influence and communication, caregiver and peer influence, and social support for the caregiver. At the organizational-level, themes included health insurance, provider characteristics, school-based interventions, and provider/practice-based interventions. The only community/societal factor examined related to a social marketing campaign. CONCLUSION: Additional research is needed on interpersonal, organizational, and community/societal factors, as well as an expanded focus on rural males. Future studies should account for rural heterogeneity by expanding the geographic areas studied. Our findings detailing factors found to be associated with HPV vaccine uptake will help inform future clinical, health services, and community research, as well as interventions and policy efforts.

Reduced bioavailable manganese causes striatal urea cycle pathology in Huntington's disease mouse model.

Huntington's disease (HD) is caused by a mutation in the huntingtin gene (HTT), resulting in profound striatal neurodegeneration through an unknown mechanism. Perturbations in the urea cycle have been reported in HD models and in HD patient blood and brain. In neurons, arginase is a central urea cycle enzyme, and the metal manganese (Mn) is an essential cofactor. Deficient biological responses to Mn, and reduced Mn accumulation have been observed in HD striatal mouse and cell models. Here we report in vivo and ex vivo evidence of a urea cycle metabolic phenotype in a prodromal HD mouse model. Further, either in vivo or in vitro Mn supplementation reverses the urea-cycle pathology by restoring arginase activity. We show that Arginase 2 (ARG2) is the arginase enzyme present in these mouse brain models, with ARG2 protein levels directly increased by Mn exposure. ARG2 protein is not reduced in the prodromal stage, though enzyme activity is reduced, indicating that altered Mn bioavailability as a cofactor leads to the deficient enzymatic activity. These data support a hypothesis that mutant HTT leads to a selective deficiency of neuronal Mn at an early disease stage, contributing to HD striatal urea-cycle pathophysiology through an effect on arginase activity.

Evaluation of multiple primary and combination screening strategies in postmenopausal women for detection of cervical cancer in China.

As China's population ages, the importance of determining prevalence of cervical disease and accurate cervical cancer screening strategies for postmenopausal women is increasing. Seventeen population-based studies were analyzed to determine prevalence of cervical neoplasia in postmenopausal women. All women underwent HPV DNA testing, visual inspection with acetic acid (VIA) and cytology testing. Diagnostic values for primary and combinations screening methods included sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), referral rate and area under curve (AUC) were calculated using directed biopsy or four quadrants biopsy as reference standard. Premenopausal and postmenopausal women had equal HPV infection and cervical neoplasia rates (p > 0.05). HPV DNA testing CIN3+ sensitivity, specificity, PPV, NPV, referral rate and AUC were 97.9% (95% CI: 90.2-99.9%), 84.2% (95% CI: 82.8-85.5%), 9.9% (95% CI: 7.4-12.8%), 100% (95% CI: 99.8-100%), 17.2% (95% CI: 15.9-18.7%), 0.911, respectively. VIA values were 41.7% (95% CI: 28.4-55.9%), 94.5% (95% CI: 93.6-95.3%), 11.8% (95% CI: 7.5-17.3%), 98.9% (95% CI: 98.5-99.3%), 6.2% (95% CI: 5.3-7.1%) and 0.681, respectively. Values for VIA with HPV triage were 39.6% (95% CI: 26.6-53.8%), 99.2% (95% CI: 98.8-99.5%), 45.2% (95% CI: 30.8-60.4%), 98.9% (95% CI: 98.5-99.3%), 1.5% (95% CI: 1.1-2.0%) and 0.694, respectively. VIA and HPV DNA co-test values were 100% (95% CI: 94.0-100%), 79.5% (95% CI: 78.0-81.0%), 8.0% (95% CI: 6.0-10.3%), 100% (95% CI: 99.9-100%), 21.9% (95% CI: 20.4-23.4%) and 0.898, respectively. VIA sensitivity decreases significantly in postmenopausal women compared to premenopausal performance. HPV DNA testing maintains performance between pre- and postmenopausal women and is the most accurate primary modality for screening postmenopausal populations in low resource areas of China.

Optimal Cutoff Scores for Alzheimer's Disease Using the Chinese Version of Mini-Mental State Examination Among Chinese Population Living in Rural Areas.

To explore the optimal cutoff score for initial detection of Alzheimer's Disease (AD) through the Chinese version of Mini-Mental State Examination (CMMSE) in rural areas in China, we conducted a cross-sectional study within the Linxian General Population Nutritional Follow-up study. 16,488 eligible cohort members participated in the survey and 881 completed the CMMSE. Among 881 participants, the median age (Interquartile range) was 69.00 (10.00), 634 (71.92%) were female, 657 (74.57%) were illiterate, 35 (3.97%) had 6 years of education or higher, and 295 (33.48%) were diagnosed with AD. By reducing the CMMSE criteria for illiterate to 16 points, primary school to 19 points, and middle school or higher to 23 points, the efficiency of Chinese version of Mini-Mental State Examination can be significantly improved for initial detection of AD in rural areas in China, especially in those nutrition deficient areas.

Curative effect of bevacizumab combined with chemotherapy in advanced or recurrent uterine sarcoma.

The aim of this study was to investigate the clinical effect of bevacizumab (BEV) combined with chemotherapy in advanced or recurrent uterine sarcoma. The clinical data of 4 patients with advanced or recurrenct uterine sarcoma, who received treatment with BEV combined with chemotherapy in our hospital between May, 2006 and May, 2014, were retrospectively analyzed. We estimated the chemotherapy response rate [complete response (CR) + partial response (PR)], clinical benefit rate [CR + PR+ stable disease (SD)], progression-free survival (PFS) and overall survival (OS), and evaluated treatment safety and toxicity reactions. Of the 4 patients, 1 achieved CR, with a disease-free survival time of 96 months; 1 achieved PR, with a PFS of 13 months and an OS of 25 months; 1 achieved SD, with a PFS of 9 months and an OS of 24 months; and 1 developed progressive disease, with a PFS of 3 months and an OS of 9 months. The response rate (CR+PR) was 50%, and the clinical benefit rate (CR+PR+SD) was 75%. Treatment-related adverse reactions occurred in all 4 patients, including bone marrow suppression and gastrointestinal reactions. Of the 4 patients, 1 developed grade 4 bone marrow suppression (thrombocytopenia), whereas the remaining 3 patients developed grade 2 bone marrow suppression (leukopenia). Of the 4 cases, 2 developed grade 2 gastrointestinal reactions, and the remaining 2 patients grade 1 gastrointestinal reactions. Therefore, BEV combined with chemotherapy was able to effectively control advanced or recurrent uterine sarcoma, was well-tolerated, and is considered to be a safe and effective candidate treatment for this type of tumor.

Novel BAC Mouse Model of Huntington's Disease with 225 CAG Repeats Exhibits an Early Widespread and Stable Degenerative Phenotype.

BACKGROUND: Unusually large CAG repeat expansions (>60) in exon one of Huntingtin (HTT) are invariably associated with a juvenile-onset form of Huntington's disease (HD), characterized by a more extensive and rapidly progressing neuropathology than the more prevalent adult-onset form. However, existing mouse models of HD that express the full-length Htt gene with CAG repeat lengths associated with juvenile HD (ranging between ~75 to ~150 repeats in published models) exhibit selective neurodegenerative phenotypes more consistent with adult-onset HD. Objective: To determine if a very large CAG repeat (>200) in full-length Htt elicits neurodegenerative phenotypes consistent with juvenile HD. METHODS: Using a …bacterial artificial chromosome (BAC) system, we generated mice expressing full-length mouse Htt with ~225 CAG repeats under control of the mouse Htt promoter. Mice were characterized using behavioral, neuropathological, biochemical and brain imaging methods. RESULTS: BAC-225Q mice exhibit phenotypes consistent with a subset of features seen in juvenile-onset HD: very early motor behavior abnormalities, reduced body weight, widespread and progressive increase in Htt aggregates, gliosis, and neurodegeneration. Early striatal pathology was observed, including reactive gliosis and loss of dopamine receptors, prior to detectable volume loss. HD-related blood markers of impaired energy metabolism and systemic inflammation were also increased. Aside from an age-dependent progression of diffuse nuclear aggregates at 6 months of age to abundant neuropil aggregates at 12 months of age, other pathological and motor phenotypes showed little to no progression. CONCLUSIONS: The HD phenotypes present in animals 3 to 12 months of age make the BAC-225Q mice a unique and stable model of full-length mutant Htt associated phenotypes, including body weight loss, behavioral impairment and HD-like neurodegenerative phenotypes characteristic of juvenile-onset HD and/or late-stage adult-onset HD.