1
|
Sarier M, Sepin N, Emek M, Konuk EY, Kaplan T, Yuksel BA, Barut Z, Cakcak DS, Hoscan MB. Evaluation of the optimal sampling approach for HPV genotyping in circumcised heterosexual men with genital warts. J Infect Chemother 2023; 29:475-480. [PMID: 36731776 DOI: 10.1016/j.jiac.2023.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 12/17/2022] [Accepted: 01/25/2023] [Indexed: 02/03/2023]
Abstract
BACKGROUND Human papillomavirus (HPV) causes a serious socioeconomic burden globally. However, there is currently no consensus on the optimal sampling method for HPVDNA genotyping in circumcised heterosexual men. This study aimed to determine the diagnostic efficacy of 6 different anatomic sampling sites in HPV DNA polymerase chain reaction (PCR) testing of circumcised heterosexual men with genital warts. METHODS The study included circumcised heterosexual men who presented to our clinic with complaints of genital warts. Swab samples were obtained from the penile shaft (PS), scrotum, coronal sulcus (CS), and external urethral meatus (EUM). First-void urine (FVU) and genital wart biopsy (GWB) were also tested for HPV DNA by PCR. RESULTS A total of 32 patients (mean age: 36.9 ± 6.9 years) were included. None of the six samples studied was sufficient on its own to reveal all HPV types detected in a patient. When the samples were analyzed individually, GWB detected an average of 49.5% of total HPV types in a patient. This rate was 50.5% for PS, 40.4% for CS, 31.6% for scrotum, 26.3% for EUM, and 15.8% for FVU samples. The detection rate increased to 75.8% with combined testing of GWB and PS samples, 83.2% with GWB/PS/CS, 90.5% with GWB/PS/CS/scrotum, and 98.9% with GWB/PS/CS/scrotum/EUM samples. CONCLUSION No single anatomic region or sample type can detect all HPV types present in circumcised heterosexual men by PCR assay. The detection rate approaches 99% when wart biopsy is combined with swab sampling of the penile shaft, coronal sulcus, scrotum, and external urethral meatus.
Collapse
Affiliation(s)
- Mehmet Sarier
- Department of Urology, Istinye University, Istanbul, Turkiye; Department of Urology, Medical Park Hospital, Antalya, Turkiye.
| | - Nevgun Sepin
- Department of Clinical Microbiology and Infectious Disease, Training and Research Hospital Antalya Turkiye.
| | - Mestan Emek
- Department of Public Health, Akdeniz University, Antalya, Turkiye.
| | | | - Tugrul Kaplan
- Department of Obstetrics and Gynaecology, Medical Park Hospital, Antalya, Turkiye.
| | - Burcu Aykan Yuksel
- Department of Obstetrics and Gynaecology, Training and Research Hospital, Antalya, Turkiye.
| | - Zerrin Barut
- Department of Basic Medical Sciences Antalya Bilim University, Antalya, Turkiye.
| | | | - Mustafa Burak Hoscan
- Department of Dialysis, Vocational School of Health Services, Antalya Bilim University, Antalya, Turkiye.
| |
Collapse
|
2
|
Punjani N, Basourakos SP, Nang QG, Lee RK, Goldstein M, Alukal JP, Li PS. Genitourinary Infections Related to Circumcision and the Potential Impact on Male Infertility. World J Mens Health 2021; 40:179-190. [PMID: 34169676 PMCID: PMC8987143 DOI: 10.5534/wjmh.210043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 04/08/2021] [Accepted: 04/12/2021] [Indexed: 11/30/2022] Open
Abstract
Male circumcision (MC) is one of the oldest surgical procedures still completed today. Medical indications for MC include phimosis, recurrent balanitis, cosmesis, and infection prevention. In this review, we mainly focus on the role of MC in the prevention of human immunodeficiency virus, human papillomavirus, herpes simplex virus, gonorrhea, chlamydia, chancroid, and syphilis, and the subsequent impact of these genitourinary infections on male fertility. Overall, many compelling data support that MC may play an essential role in both genitourinary infection prevention and male fertility.
Collapse
Affiliation(s)
- Nahid Punjani
- Department of Urology, Center for Male Reproductive Medicine and Microsurgery, Weill Cornell Medicine, Cornell University, New York, NY, USA
| | - Spyridon P Basourakos
- Department of Urology, Center for Male Reproductive Medicine and Microsurgery, Weill Cornell Medicine, Cornell University, New York, NY, USA
| | - Quincy G Nang
- Department of Urology, Center for Male Reproductive Medicine and Microsurgery, Weill Cornell Medicine, Cornell University, New York, NY, USA
| | - Richard K Lee
- Department of Urology, Center for Male Reproductive Medicine and Microsurgery, Weill Cornell Medicine, Cornell University, New York, NY, USA
| | - Marc Goldstein
- Department of Urology, Center for Male Reproductive Medicine and Microsurgery, Weill Cornell Medicine, Cornell University, New York, NY, USA
| | - Joseph P Alukal
- Department of Urology, Columbia University, New York, NY, USA
| | - Philip S Li
- Department of Urology, Center for Male Reproductive Medicine and Microsurgery, Weill Cornell Medicine, Cornell University, New York, NY, USA.
| |
Collapse
|
3
|
Morris BJ, Moreton S, Krieger JN. Critical evaluation of arguments opposing male circumcision: A systematic review. J Evid Based Med 2019; 12:263-290. [PMID: 31496128 PMCID: PMC6899915 DOI: 10.1111/jebm.12361] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 04/03/2019] [Accepted: 05/12/2019] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To systematically evaluate evidence against male circumcision (MC). METHODS We searched PubMed, Google Scholar, EMBASE and Cochrane databases. RESULTS Database searches retrieved 297 publications for inclusion. Bibliographies of these yielded 101 more. After evaluation we found: Claims that MC carries high risk were contradicted by low frequency of adverse events that were virtually all minor and easily treated with complete resolution. Claims that MC causes psychological harm were contradicted by studies finding no such harm. Claims that MC impairs sexual function and pleasure were contradicted by high-quality studies finding no adverse effect. Claims disputing the medical benefits of MC were contradicted by a large body of high-quality evidence indicating protection against a wide range of infections, dermatological conditions, and genital cancers in males and the female sexual partners of men. Risk-benefit analyses reported that benefits exceed risks by 100-200 to 1. To maximize benefits and minimize risks, the evidence supported early infant MC rather than arguments that the procedure should be delayed until males are old enough to decide for themselves. Claims that MC of minors is unethical were contradicted by balanced evaluations of ethical issues supporting the rights of children to be provided with low-risk, high-benefit interventions such as MC for better health. Expert evaluations of case-law supported the legality of MC of minors. Other data demonstrated that early infant MC is cost-saving to health systems. CONCLUSIONS Arguments opposing MC are supported mostly by low-quality evidence and opinion, and are contradicted by strong scientific evidence.
Collapse
Affiliation(s)
- Brian J Morris
- School of Medical SciencesUniversity of SydneySydneyNew South WalesAustralia
| | | | - John N Krieger
- Department of UrologyUniversity of Washington School of MedicineSeattleWashington
| |
Collapse
|
4
|
Lee B, Lee SW, Kim DI, Kim JH. HPV prevalence in the foreskins of asymptomatic healthy infants and children: Systematic review and meta-analysis. Sci Rep 2017; 7:7050. [PMID: 28765591 PMCID: PMC5539194 DOI: 10.1038/s41598-017-07506-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 06/28/2017] [Indexed: 11/08/2022] Open
Abstract
The true HPV prevalence in the foreskins of infants and children has been little documented, but reporting on this prevalence is of great importance given its impact on the rationale for treating asymptomatic boys. We searched multiple databases from 1960 to 2016 for observational or prospective studies that reported on HPV prevalence in foreskins. We conducted a meta-analysis using a random-effects model to pool for HPV prevalence in the foreskins of infants and children. Eight studies, with a total of 556 infants and children with phimosis, were eligible for the meta-analysis. The pooled overall prevalence of general HPV, high-risk HPV, low-risk HPV, HPV 16/18, HPV 16, and HPV 18 were 17.3 (95%CI: 0.8-46.3), 12.1 (95% CI: 0.9-31.5), 2.4 (95% CI: 0.0-11.2), 4.8 (95% CI: 0.0-16.8), 1.7 (95% CI: 0.0-5.1), and 0 (95% CI: 0-0.5), respectively. The estimated HPV prevalence in foreskins was not zero among infants and children, which implies HPV transmission other than by sexual contact. Considering that high-risk HPV is detected in asymptomatic infants and children, future studies are warranted to determine whether preventive treatments in asymptomatic infants and children could be effective in preventing persistence or transmission of high-risk HPV.
Collapse
Affiliation(s)
- Bora Lee
- Department of Biostatistics, Clinical Trial Center, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
- Department of Statistics, Graduate School of Chung-Ang University, Seoul, Korea
| | - Sang Wook Lee
- Department of Urology, Soonchunhyang University Bucheon Hospital, Soonchuhyang University Medical College, Bucheon, Korea
| | - Dae In Kim
- Department of Pharmaceutical engineering, Soonchunhyang University, Asan, Korea
| | - Jae Heon Kim
- Department of Urology, Soonchunhyang University Hospital, Soonchuhyang University Medical College, Seoul, Korea.
| |
Collapse
|
5
|
Zhu YP, Jia ZW, Dai B, Ye DW, Kong YY, Chang K, Wang Y. Relationship between circumcision and human papillomavirus infection: a systematic review and meta-analysis. Asian J Androl 2017; 19:125-131. [PMID: 26975489 PMCID: PMC5227661 DOI: 10.4103/1008-682x.175092] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Male circumcision (MC) is reported to reduce human papillomavirus (HPV) prevalence in men. However, the efficacy remains imprecise. The aim of this study was to conduct a systematic review and meta-analysis to assess the relationship between MC and genital HPV infection and genital warts. PUBMED, EMBASE, and Web of Science were searched from inception to March 22, 2015. We identified 30 papers, including a total of 12149 circumcised and 12252 uncircumcised men who were evaluated for the association of circumcision with genital HPV or genital warts. Compared with men who were not circumcised, circumcised men may have had significantly reduced odds of genital HPV prevalence (odds ratio [OR]: 0.68; 95% confidence interval [95% CI]: 0.56-0.82). There was no significant association between MC and genital HPV acquisition of new infections (OR: 0.99; 95% CI: 0.62-1.60), genital HPV clearance (OR: 1.38; 95% CI: 0.96-1.97), and prevalence of genital warts (OR: 1.17; 95% CI: 0.63-2.17). This meta-analysis suggests that circumcision reduces the prevalence of genital HPV infections. However, no clear evidence was found that circumcision was associated with decreased HPV acquisition, increased HPV clearance, or decreased the prevalence of genital warts. More studies are required to evaluate adequately the effect of MC on the acquisition and clearance of HPV infections and prevalence of genital warts.
Collapse
Affiliation(s)
- Yi-Ping Zhu
- Department of Urology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Fudan University Shanghai Medical College, Shanghai, China
| | - Zhong-Wei Jia
- Department of Urology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Fudan University Shanghai Medical College, Shanghai, China
| | - Bo Dai
- Department of Urology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Fudan University Shanghai Medical College, Shanghai, China
| | - Ding-Wei Ye
- Department of Urology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Fudan University Shanghai Medical College, Shanghai, China
| | - Yun-Yi Kong
- Department of Urology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Pathology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Kun Chang
- Department of Urology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Fudan University Shanghai Medical College, Shanghai, China
| | - Yue Wang
- Department of Urology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Fudan University Shanghai Medical College, Shanghai, China
| |
Collapse
|
6
|
Berhanu A, Alkhenizan A. Non-therapeutic infant male circumcision. evidence, ethics and international law perspective. Saudi Med J 2017; 38:213-214. [PMID: 28133698 PMCID: PMC5329637 DOI: 10.15537/smj.2017.2.18065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
[No Avaliable Abstract].
Collapse
Affiliation(s)
- Alamin Berhanu
- Research & Clinical Support Family Practice Clinic, Toronto, Ontario, Canada. E-mail.
| | | |
Collapse
|
7
|
[Actual controversies about circumcision]. Presse Med 2014; 43:1168-73. [PMID: 25218249 DOI: 10.1016/j.lpm.2014.04.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Revised: 03/24/2014] [Accepted: 04/09/2014] [Indexed: 01/13/2023] Open
Abstract
INTRODUCTION Circumcision, the oldest and most frequently performed surgery in the world, is the subject of controversies. The aim of this study was to conduct a general review of circumcision in the light of the ten questions most frequently raised in the medical community. METHODS Automated search of scientific articles published has been used by interviewing computer databases Medline and Embase from 1990 to 2013. RESULTS The results of three randomized controlled trials have provided information on preventive contributory role of this medical male circumcision. This intervention reduces the risk of acquiring HIV infection, HSV2 infection and the carrier prevalence of HPV. Male circumcision has proven to be effective in reducing the risks of penile cancer and cervical cancer in female partners of circumcised men, urinary tract infections in infants and children. Complications are rare. CONCLUSION The health benefits of circumcision balance the procedure's risks. Circumcision could be considered as a kind of "surgical vaccine", especially in developing countries to prevent the transmission of HIV infection.
Collapse
|
8
|
Morris BJ, Hankins CA, Tobian AAR, Krieger JN, Klausner JD. Does Male Circumcision Protect against Sexually Transmitted Infections? Arguments and Meta-Analyses to the Contrary Fail to Withstand Scrutiny. ISRN UROLOGY 2014; 2014:684706. [PMID: 24944836 PMCID: PMC4040210 DOI: 10.1155/2014/684706] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/04/2013] [Accepted: 02/04/2014] [Indexed: 02/06/2023]
Abstract
We critically evaluate a recent article by Van Howe involving 12 meta-analyses that concludes, contrary to current evidence, that male circumcision increases the risk of various common sexually transmitted infections (STIs). Our detailed scrutiny reveals that these meta-analyses (1) failed to include results of all relevant studies, especially data from randomized controlled trials, (2) introduced bias through use of inappropriate control groups, (3) altered original data, in the case of human papillomavirus (HPV), by questionable adjustments for "sampling bias," (4) failed to control for confounders through use of crude odds ratios, and (5) used unnecessarily complicated methods without adequate explanation, so impeding replication by others. Interventions that can reduce the prevalence of STIs are important to international health. Of major concern is the global epidemic of oncogenic types of HPV that contribute to the burden of genital cancers. Meta-analyses, when well conducted, can better inform public health policy and medical practice, but when seriously flawed can have detrimental consequences. Our critical evaluation leads us to reject the findings and conclusions of Van Howe on multiple grounds. Our timely analysis thus reaffirms the medical evidence supporting male circumcision as a desirable intervention for STI prevention.
Collapse
Affiliation(s)
- Brian J. Morris
- School of Medical Sciences and Bosch Institute, University of Sydney, Sydney, NSW 2006, Australia
| | - Catherine A. Hankins
- Department of Global Health, Academic Medical Centre and Amsterdam Institute for Global Health and Development, University of Amsterdam, 1100DE, Amsterdam, The Netherlands
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Aaron A. R. Tobian
- Department of Pathology, School of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA
| | - John N. Krieger
- Section of Urology University of Washington School of Medicine and VA Puget Sound Health Care System, Seattle, WA 98108, USA
| | - Jeffrey D. Klausner
- Division of Infectious Diseases and Program in Global Health, David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles, CA 90095, USA
| |
Collapse
|
9
|
Bharti AC, Shukla S, Mahata S, Hedau S, Das BC. Human papillomavirus and control of cervical cancer in India. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/eog.10.23] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
|
10
|
Svoboda JS, Van Howe RS. Out of step: fatal flaws in the latest AAP policy report on neonatal circumcision. JOURNAL OF MEDICAL ETHICS 2013; 39:434-441. [PMID: 23508208 DOI: 10.1136/medethics-2013-101346] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
The American Academy of Pediatrics recently released a policy statement and technical report on circumcision, in both of which the organisation suggests that the health benefits conferred by the surgical removal of the foreskin in infancy definitively outweigh the risks and complications associated with the procedure. While these new documents do not positively recommend neonatal circumcision, they do paradoxically conclude that its purported benefits 'justify access to this procedure for families who choose it,' claiming that whenever and for whatever reason it is performed, it should be covered by government health insurance. The policy statement and technical report suffer from several troubling deficiencies, ultimately undermining their credibility. These deficiencies include the exclusion of important topics and discussions, an incomplete and apparently partisan excursion through the medical literature, improper analysis of the available information, poorly documented and often inaccurate presentation of relevant findings, and conclusions that are not supported by the evidence given.
Collapse
Affiliation(s)
- J Steven Svoboda
- Attorneys for the Rights of the Child, 2961 Ashby Avenue, Berkeley, CA 94707, USA.
| | | |
Collapse
|
11
|
Affiliation(s)
- Andrew E Macneily
- Head, Division of Pediatric Urology, Department of Urological Sciences, University of British Columbia, Vancouver, BC
| |
Collapse
|
12
|
Sexually transmitted infections and male circumcision: a systematic review and meta-analysis. ISRN UROLOGY 2013; 2013:109846. [PMID: 23710368 PMCID: PMC3654279 DOI: 10.1155/2013/109846] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Accepted: 01/22/2013] [Indexed: 01/19/2023]
Abstract
The claim that circumcision reduces the risk of sexually transmitted infections has been repeated so frequently that many believe it is true. A systematic review and meta-analyses were performed on studies of genital discharge syndrome versus genital ulcerative disease, genital discharge syndrome, nonspecific urethritis, gonorrhea, chlamydia, genital ulcerative disease, chancroid, syphilis, herpes simplex virus, human papillomavirus, and contracting a sexually transmitted infection of any type. Chlamydia, gonorrhea, genital herpes, and human papillomavirus are not significantly impacted by circumcision. Syphilis showed mixed results with studies of prevalence suggesting intact men were at great risk and studies of incidence suggesting the opposite. Intact men appear to be of greater risk for genital ulcerative disease while at lower risk for genital discharge syndrome, nonspecific urethritis, genital warts, and the overall risk of any sexually transmitted infection. In studies of general populations, there is no clear or consistent positive impact of circumcision on the risk of individual sexually transmitted infections. Consequently, the prevention of sexually transmitted infections cannot rationally be interpreted as a benefit of circumcision, and any policy of circumcision for the general population to prevent sexually transmitted infections is not supported by the evidence in the medical literature.
Collapse
|
13
|
Chelimo C, Wouldes TA, Cameron LD, Elwood JM. Risk factors for and prevention of human papillomaviruses (HPV), genital warts and cervical cancer. J Infect 2012; 66:207-17. [PMID: 23103285 DOI: 10.1016/j.jinf.2012.10.024] [Citation(s) in RCA: 163] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2012] [Accepted: 10/21/2012] [Indexed: 02/07/2023]
Abstract
Genital HPV infection is associated with development of cervical cancer, cervical neoplasia, anogenital warts, and other anogenital cancers. A number of reviews have primarily addressed the role of HPV infection in cervical carcinogenesis, and differences in human papillomavirus (HPV) subtypes found in cervical cancer cases by histology and geographical region. This review provides an informative summary of the broad body of literature on the burden of HPV, the risk factors for HPV infection, genital warts and cervical cancer, and preventive measures against these conditions in females. Studies have identified the main risk factors for genital HPV infection in females as follows: acquisition of new male partners; an increasing number of lifetime sexual partners both in females and their male partners; and having non-monogamous male partners. Cervical cancer screening and HPV vaccination are the primary measures currently recommended to prevent cervical cancer. There is also an ongoing debate and conflicting findings on whether male circumcision and condom use protect against HPV infection and subsequent development of HPV-related illnesses in females.
Collapse
Affiliation(s)
- Carol Chelimo
- Section of Epidemiology and Biostatistics, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, Auckland 1142, New Zealand.
| | | | | | | |
Collapse
|
14
|
Status of High-risk Oncogenic Human Papillomavirus Subtypes Harbored in the Prepuce of Prepubertal Boys. Urology 2012; 80:423-6. [DOI: 10.1016/j.urology.2012.02.049] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2011] [Revised: 02/27/2012] [Accepted: 02/27/2012] [Indexed: 11/22/2022]
|
15
|
Male circumcision and genital human papillomavirus: a systematic review and meta-analysis. Sex Transm Dis 2012; 39:104-13. [PMID: 22249298 DOI: 10.1097/olq.0b013e3182387abd] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Human papillomavirus (HPV) infection is the principal cause of invasive cervical cancer. There is some evidence that male circumcision (MC) may protect against HPV infection and related disease in both men and women. The purpose of this study was to conduct a systematic review of the literature to assess the association between MC and genital HPV infection indicators including genital warts. METHODS A systematic search of Medline was conducted to identify all relevant studies from February 1971 to August 2010. Effect estimates were included in random effects models. RESULTS A total of 21 studies with 8046 circumcised and 6336 uncircumcised men were included in the meta-analysis. MC was associated with a statistically significant reduced odds of genital HPV prevalence (odds ratio = 0.57, 95% confidence interval: 0.42-0.77). This association was also observed for genital high-risk HPV prevalence in 2 randomized controlled trials (odds ratio = 0.67, 95% confidence interval: 0.54-0.82). No associations were found between MC and genital HPV acquisition of new infections, genital HPV clearance, or genital warts. CONCLUSIONS This meta-analysis shows a robust inverse association between MC and genital HPV prevalence in men. However, more studies are needed to adequately assess the effect of MC on the acquisition and clearance of HPV infections. MC could be considered as an additional one-time preventative intervention likely to reduce the burden of HPV-related diseases both in men and women, particularly among those countries in which HPV vaccination programs and cervical screening are not available.
Collapse
|
16
|
Larke N, Thomas SL, Dos Santos Silva I, Weiss HA. Male circumcision and human papillomavirus infection in men: a systematic review and meta-analysis. J Infect Dis 2011; 204:1375-90. [PMID: 21965090 DOI: 10.1093/infdis/jir523] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND We systematically reviewed the evidence for an association between male circumcision and Human Papillomavirus (HPV) infection and genital warts in men. METHODS PubMed and Embase were searched to 15 September 2010. The measure of effect was the adjusted odds ratio (OR) or rate ratio (RR) when present and the crude estimate otherwise. Random effects meta-analyses were used to calculate summary measures of effect. RESULTS We identified 23 papers about the association between circumcision and HPV DNA. Circumcised men were less likely to have prevalent genital HPV infection than uncircumcised men (summary OR, 0.57, 95% confidence interval [CI], 0.45-0.71) with between-study heterogeneity (P-heterogeneity = 0.006; I(2) = 50.5%; 19 studies). Similar summary associations were seen in clinical and methodological subgroups. The effect of circumcision was stronger at the glans/corona (OR, 0.47; 95% CI, 0.37-0.60) and urethra (OR, 0.35; 95% CI, 0.12-1.05) compared with sites more distal to the foreskin. There was weak evidence that circumcision was associated with decreased HPV incidence (summary RR, 0.75, 95% CI, 0.57-0.99; 3 studies) and increased HPV clearance (summary RR, 1.33; 95% CI, 0.89-1.98; 3 studies) but no evidence of an association with prevalent genital warts (OR, 0.93, 95% CI, 0.65-1.33; 15 studies). CONCLUSIONS Several countries are expanding access to voluntary medical male circumcision to reduce HIV prevalence. This could provide additional benefit in reducing HPV prevalence.
Collapse
Affiliation(s)
- Natasha Larke
- Medical Research Council Tropical Epidemiology Group, United Kingdom.
| | | | | | | |
Collapse
|
17
|
Darby R, Van Howe R. Not a surgical vaccine: there is no case for boosting infant male circumcision to combat heterosexual transmission of HIV in Australia. Aust N Z J Public Health 2011; 35:459-65. [PMID: 21973253 DOI: 10.1111/j.1753-6405.2011.00761.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To conduct a critical review of recent proposals that widespread circumcision of male infants be introduced in Australia as a means of combating heterosexually transmitted HIV infection. APPROACH These arguments are evaluated in terms of their logic, coherence and fidelity to the principles of evidence-based medicine; the extent to which they take account of the evidence for circumcision having a protective effect against HIV and the practicality of circumcision as an HIV control strategy; the extent of its applicability to the specifics of Australia's HIV epidemic; the benefits, harms and risks of circumcision; and the associated human rights, bioethical and legal issues. CONCLUSION Our conclusion is that such proposals ignore doubts about the robustness of the evidence from the African random-controlled trials as to the protective effect of circumcision and the practical value of circumcision as a means of HIV control; misrepresent the nature of Australia's HIV epidemic and exaggerate the relevance of the African random-controlled trials findings to it; underestimate the risks and harm of circumcision; and ignore questions of medical ethics and human rights. The notion of circumcision as a 'surgical vaccine' is criticised as polemical and unscientific. IMPLICATIONS Circumcision of infants or other minors has no place among HIV control measures in the Australian and New Zealand context; proposals such as these should be rejected.
Collapse
|
18
|
Morris BJ, Waskett JH, Gray RH, Halperin DT, Wamai R, Auvert B, Klausner JD. Exposé of misleading claims that male circumcision will increase HIV infections in Africa. J Public Health Afr 2011; 2:e28. [PMID: 28299069 PMCID: PMC5345501 DOI: 10.4081/jphia.2011.e28] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2011] [Accepted: 07/06/2011] [Indexed: 01/17/2023] Open
Abstract
Despite over two decades of extensive research showing that male circumcision protects against heterosexual acquisition of HIV in men, and that includes findings from large randomized controlled trials leading to acceptance by the WHO/UNAIDS and the Cochrane Committee, opponents of circumcision continue to generate specious arguments to the contrary. In a recent issue of the Journal of Public Health in Africa, Van Howe and Storms claim that male circumcision will increase HIV infections in Africa. Here we review the statements they use in support of their thesis and show that there is no scientific basis to such an assertion. We also evaluate the statistics used and show that when these data are properly analyzed the results lead to a contrary conclusion affirming the major role of male circumcision in protecting against HIV infection in Africa. Researchers, policy makers and the wider community should rely on balanced scholarship when assessing scientific evidence. We trust that our assessment may help refute the claims by Van Howe and Storms, and provide reassurance on the importance of circumcision for HIV prevention.
Collapse
Affiliation(s)
- Brian J. Morris
- School of Medical Sciences, University of Sydney, Sydney, Australia
| | - Jake H. Waskett
- Circumcision Independent Reference and Commentary Service, Radcliffe, Manchester, UK
| | - Ronald H. Gray
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Daniel T. Halperin
- Department of Global Health and Population, Harvard School of Public Health, Boston, MA, USA
| | - Richard Wamai
- Department of African-American Studies, Northeastern University, Boston, MA, USA
| | | | - Jeffrey D. Klausner
- Divisions of AIDS & Infectious Diseases, University of California, San Francisco, CA, USA
| |
Collapse
|
19
|
Macneily AE, Afshar K. Circumcision and non-HIV sexually transmitted infections. Can Urol Assoc J 2011; 5:58-9. [PMID: 21470518 DOI: 10.5489/cuaj.11009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Andrew E Macneily
- Department of Urologic Sciences, University of British Columbia, Vancouver BC
| | | |
Collapse
|
20
|
Morris BJ, Gray RH, Castellsague X, Bosch FX, Halperin DT, Waskett JH, Hankins CA. The Strong Protective Effect of Circumcision against Cancer of the Penis. Adv Urol 2011; 2011:812368. [PMID: 21687572 PMCID: PMC3113366 DOI: 10.1155/2011/812368] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2010] [Accepted: 03/09/2011] [Indexed: 01/30/2023] Open
Abstract
Male circumcision protects against cancer of the penis, the invasive form of which is a devastating disease confined almost exclusively to uncircumcised men. Major etiological factors are phimosis, balanitis, and high-risk types of human papillomavirus (HPV), which are more prevalent in the glans penis and coronal sulcus covered by the foreskin, as well as on the penile shaft, of uncircumcised men. Circumcised men clear HPV infections more quickly. Phimosis (a constricted foreskin opening impeding the passage of urine) is confined to uncircumcised men, in whom balanitis (affecting 10%) is more common than in circumcised men. Each is strongly associated with risk of penile cancer. These findings have led to calls for promotion of male circumcision, especially in infancy, to help reduce the global burden of penile cancer. Even more relevant globally is protection from cervical cancer, which is 10-times more common, being much higher in women with uncircumcised male partners. Male circumcision also provides indirect protection against various other infections in women, along with direct protection for men from a number of genital tract infections, including HIV. Given that adverse consequences of medical male circumcision, especially when performed in infancy, are rare, this simple prophylactic procedure should be promoted.
Collapse
Affiliation(s)
- Brian J. Morris
- School of Medical Sciences and Bosch Institute, Sydney Medical School, The University of Sydney, Sydney, NSW 2006, Australia
| | - Ronald H. Gray
- Population and Family Planning, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA
| | - Xavier Castellsague
- Institut Català d'Oncologia (ICO), IDIBELL, CIBERESP, RTICC, 08908 L'Hospitalet de Llobregat, Catalonia, Spain
| | - F. Xavier Bosch
- Institut Català d'Oncologia (ICO), IDIBELL, CIBERESP, RTICC, 08908 L'Hospitalet de Llobregat, Catalonia, Spain
| | - Daniel T. Halperin
- Department of Global Health and Population, Harvard School of Public Health, Boston, MA 02115, USA
| | - Jake H. Waskett
- Circumcision Independent Reference and Commentary Service, Radcliffe, Manchester M261JR, UK
| | | |
Collapse
|
21
|
Van Howe RS, Storms MR. How the circumcision solution in Africa will increase HIV infections. J Public Health Afr 2011; 2:e4. [PMID: 28299046 PMCID: PMC5345479 DOI: 10.4081/jphia.2011.e4] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2010] [Accepted: 12/09/2010] [Indexed: 11/23/2022] Open
Abstract
The World Health Organization and UNAIDS have supported circumcision as a preventive for HIV infections in regions with high rates of heterosexually transmitted HIV; however, the circumcision solution has several fundamental flaws that undermine its potential for success. This article explores, in detail, the data on which this recommendation is based, the difficulty in translating results from high risk adults in a research setting to the general public, the impact of risk compensation, and how circumcision compares to existing alternatives. Based on our analysis it is concluded that the circumcision solution is a wasteful distraction that takes resources away from more effective, less expensive, less invasive alternatives. By diverting attention away from more effective interventions, circumcision programs will likely increase the number of HIV infections.
Collapse
Affiliation(s)
- Robert S Van Howe
- Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Marquette, MI, USA
| | - Michelle R Storms
- Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Marquette, MI, USA
| |
Collapse
|
22
|
Regan DG, Philp DJ, Waters EK. Unresolved questions concerning human papillomavirus infection and transmission: a modelling perspective. Sex Health 2010; 7:368-75. [PMID: 20719229 DOI: 10.1071/sh10006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2010] [Accepted: 06/03/2010] [Indexed: 01/02/2023]
Abstract
Mathematical transmission models are widely used to forecast the potential impact of interventions such as vaccination and to inform the development of health policy. Effective vaccines are now available for the prevention of cervical cancer and other diseases attributable to human papillomavirus (HPV). Considerable uncertainties remain regarding the characterisation of HPV infection and its sequelae, infectivity, and both vaccine-conferred and naturally-acquired immunity. In this review, we discuss the key knowledge gaps that impact on our ability to develop accurate models of HPV transmission and vaccination.
Collapse
Affiliation(s)
- David G Regan
- The National Centre in HIV Epidemiology and Clinical Research, The University of New South Wales, Coogee, NSW 2034, Australia.
| | | | | |
Collapse
|
23
|
Veldhuijzen NJ, Snijders PJ, Reiss P, Meijer CJ, van de Wijgert JH. Factors affecting transmission of mucosal human papillomavirus. THE LANCET. INFECTIOUS DISEASES 2010; 10:862-74. [PMID: 21075056 DOI: 10.1016/s1473-3099(10)70190-0] [Citation(s) in RCA: 104] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Human papillomavirus (HPV) is the most common sexually transmitted infection. The effect of HPV on public health is especially related to the burden of anogenital cancers, most notably cervical cancer. Determinants of exposure to HPV are similar to those for most sexually transmitted infections, but determinants of susceptibility and infectivity are much less well established. Gaps exist in understanding of interactions between HPV, HIV, and other sexually transmitted infections. The roles of mucosal immunology, human microbiota at mucosal surfaces, host genetic factors and hormonal concentrations on HPV susceptibility and infectivity are poorly understood, as are the level of effectiveness of some primary or secondary preventive measures other than HPV vaccination (such as condoms, male circumcision, and combination antiretroviral therapy for HIV). Prospective couples studies, studies focusing on mucosal immunology, and in-vitro raft culture studies mimicking HPV infection might increase understanding of the dynamics of HPV transmission.
Collapse
Affiliation(s)
- Nienke J Veldhuijzen
- Academic Medical Center of the University of Amsterdam, Department of Internal Medicine, Amsterdam Institute of Global Health and Development, Amsterdam, The Netherlands.
| | | | | | | | | |
Collapse
|
24
|
Garland SM. Prevention strategies against human papillomavirus in males. Gynecol Oncol 2010; 117:S20-5. [PMID: 20138347 DOI: 10.1016/j.ygyno.2010.01.027] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2010] [Accepted: 01/20/2010] [Indexed: 12/22/2022]
Abstract
Sexually transmitted human papillomavirus (HPV) infection is very common in men and women. Oncogenic HPV is strongly associated with cancers and high-grade dysplasias of the anogenital tract, including the anus, penis, and also a proportion of oropharyngeal cancers. In reducing male disease burden, some consider screening and treatment for high-grade anal dysplasia (AIN) to prevent anal cancer in high-risk populations. Such strategies have wide implications for the workforce, and require more evidence for the optimal management of AIN. Male sexual behavior, with consequent HPV infection and disease contribute to considerable disease burden in females. Hence, inclusion of males in prophylactic HPV vaccination programs should prevent HPV-related disease in males as well as substantially reducing disease burden in females. Clinical trial data in males 16-26 years for the quadrivalent vaccine show it is well tolerated, induces a strong type-specific immunological response comparable to that of females, and reduced vaccine HPV-type-related genital infection, as well as disease. Cost-benefit analyses and mathematical modeling show that the most cost-effective strategy involves routine administration of this vaccine to 12-year-old females, with catch-up vaccination of 12- to 24-year-olds, with the most effective strategy in disease reduction including men and/or boys in the program. Such a vaccination strategy including 12-year-old boys is projected by 2050 to reduce HPV 16 infection by 88-94% in females and 68-82% in males, plus the aforementioned male HPV- related cancers by 22-27%. Therefore, inclusion of males in an HPV vaccination program is likely to have significant health and economic benefits over and above those observed from current female-only programs. However, comprehensive cost-benefit analyses are needed to determine the efficacy of these programs in the overall population. Such analyses will be crucial for the design, acceptance, and implementation of these vaccination programs into clinical practice globally.
Collapse
Affiliation(s)
- Suzanne M Garland
- Department of Microbiology and Infectious Diseases, The Royal Women's Hospital, Parkville, Victoria, Australia.
| |
Collapse
|
25
|
Foreskin development in 10 421 Chinese boys aged 0-18 years. World J Pediatr 2009; 5:312-5. [PMID: 19911150 DOI: 10.1007/s12519-009-0060-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2008] [Accepted: 03/09/2009] [Indexed: 02/01/2023]
Abstract
BACKGROUND Few studies on foreskin development and the practice of circumcision have been done in Chinese boys. This study aimed to determine the natural development process of foreskin in children. METHODS A total of 10 421 boys aged 0 to 18 years were studied. The condition of foreskin was classified into type I (phimosis), type II (partial phimosis), type III (adhesion of prepuce), type IV (normal), and type V (circumcised). Other abnormalities of the genitalia were also determined. RESULTS The incidence of a completely retractile foreskin increased from 0% at birth to 42.26% in adolescence; however, the phimosis rate decreased with age from 99.7% to 6.81%. Other abnormalities included web penis, concealed penis, cryptorchidism, hydrocele, micropenis, inguinal hernia, and hypospadias. CONCLUSIONS Incomplete separation of foreskin is common in children. Since it is a natural phenomenon to approach the adult condition until puberty, circumcision should be performed with cautions in children.
Collapse
|
26
|
|
27
|
Dickson NP, Ryding J, van Roode T, Paul C, Herbison P, Dillner J, Skegg DCG. Male circumcision and serologically determined human papillomavirus infection in a birth cohort. Cancer Epidemiol Biomarkers Prev 2009; 18:177-83. [PMID: 19124496 DOI: 10.1158/1055-9965.epi-08-0353] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Circumcision has been reported to protect against infection with human papillomavirus (HPV) in men, but results have been inconsistent. We followed males in a birth cohort born in Dunedin, New Zealand, in 1972 and 1973 from age 3 to 32 years. Seropositivity at age 32 years for the oncogenic types HPV-16 and 18, and the nononcogenic types 6 and 11, was studied in relation to maternal reports of circumcision status at age 3 for 450 men. Seropositivity to any of these types was associated with lifetime number of sexual partners (P = 0.03), and lower moral-religious emphasis of the family of origin (P < 0.001). Circumcision was not found to be protective, with the adjusted odds ratio (95% confidence interval) for HPV6/11/16/18 seropositivity among the circumcised compared with the uncircumcised being 1.4 (0.89-2.2).
Collapse
Affiliation(s)
- Nigel P Dickson
- Department of Preventive and Social Medicine, University of Otago Medical School, P.O. Box 913, Dunedin, New Zealand.
| | | | | | | | | | | | | |
Collapse
|
28
|
Nielson CM, Schiaffino MK, Dunne EF, Salemi JL, Giuliano AR. Associations between male anogenital human papillomavirus infection and circumcision by anatomic site sampled and lifetime number of female sex partners. J Infect Dis 2009; 199:7-13. [PMID: 19086813 DOI: 10.1086/595567] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Male circumcision may lower men's risk of human papillomavirus (HPV) infection and reduce transmission to sex partners. Reported associations between circumcision and HPV infection in men have been inconsistent. METHODS Four hundred sixty-three men in 2 US cities were tested at 6 anogenital sites and in semen for 37 types of HPV. Men were eligible if they reported sex with a woman within the past year, no history of genital warts or penile or anal cancer, and no current diagnosis of a sexually transmitted infection. Participants completed a self-administered questionnaire. Circumcision status was assessed by the study clinician. Logistic regression was used to examine associations between circumcision and HPV detection at each site and in semen, with adjustment for potential confounders. RESULTS Seventy-four men (16.0%) were uncircumcised. Adjusted odds ratios (AORs) for any HPV genotype and circumcision were 0.53 (95% confidence interval [CI], 0.28-0.99) for any anatomic site/specimen, 0.17 (95% CI, 0.05-0.56) for the urethra, 0.44 (95% CI, 0.23-0.82) for the glans/corona, and 0.53 (95% CI, 0.28-0.99) for the penile shaft. AORs were <1.0 but not statistically significant for the scrotum, semen, anal canal, and perianal area. CONCLUSIONS Circumcision may be protective against HPV infection of the urethra, glans/corona, and penile shaft.
Collapse
|
29
|
Is neonatal circumcision clinically beneficial? Argument against. NATURE CLINICAL PRACTICE. UROLOGY 2009; 6:74-5. [PMID: 19153572 DOI: 10.1038/ncpuro1292] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2008] [Accepted: 12/05/2008] [Indexed: 11/08/2022]
|
30
|
Hernandez BY, Wilkens LR, Zhu X, McDuffie K, Thompson P, Shvetsov YB, Ning L, Goodman MT. Circumcision and human papillomavirus infection in men: a site-specific comparison. J Infect Dis 2008; 197:787-94. [PMID: 18284369 DOI: 10.1086/528379] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Lack of circumcision has been identified as a risk factor for male genital human papillomavirus (HPV) infection, although this association has not been consistently supported. METHODS Specimens for HPV testing were collected from a cohort of 379 (primarily heterosexual) adult males. HPV prevalence in the glans penis and coronal sulcus, penile shaft, scrotum, semen, and urine was compared by circumcision status. RESULTS Overall, HPV DNA prevalence ranged from 6% in semen to 52% in the penile shaft. The prevalence of any HPV infection in the glans/corona was significantly higher in uncircumcised men (46%) than in circumcised men (29%) (odds ratio [OR], 1.96 [95% confidence interval (CI), 1.02-3.75], adjusted for demographic characteristics and sexual history). Uncircumcised men also had an increased risk of oncogenic HPV infection (adjusted OR, 2.51 [95% CI, 1.11-5.69]) and infection with multiple HPV types (adjusted OR, 3.56 [95% CI, 1.50-8.50]). Among uncircumcised men, HPV prevalence in the foreskin (44%) was comparable to that in the glans/corona, and type-specific positivity was observed between the 2 sites (kappa=0.52). CONCLUSIONS Uncircumcised men have an increased risk of HPV infection, including with oncogenic HPV, specifically localized to the glans/corona, possibly because of its proximity to the foreskin, which may be particularly vulnerable to infection.
Collapse
Affiliation(s)
- B Y Hernandez
- Cancer Research Center of Hawaii, Honolulu, HI 96813, USA.
| | | | | | | | | | | | | | | |
Collapse
|
31
|
Vardi A, Guy L, Boiteux JP. Circoncision et VIH. Prog Urol 2008; 18:331-6. [DOI: 10.1016/j.purol.2008.03.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2007] [Accepted: 03/11/2008] [Indexed: 11/27/2022]
|
32
|
|
33
|
Castellsagué X, Albero G, Clèries R, Bosch FX. HPV and circumcision: A biased, inaccurate and misleading meta-analysis. J Infect 2007; 55:91-3; author reply 93-6. [PMID: 17433445 DOI: 10.1016/j.jinf.2007.02.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2007] [Accepted: 02/19/2007] [Indexed: 10/23/2022]
|