text:
Rated 4.1 out of 5 by 370 reviewers.
Rated 4 out of 5 by BeckyD Sheraton Music I thought the hotel was very nice, the resort was very crowded and the waitress and the pool could of used some help since the resort was at full compacity. August 5, 2014
Rated 5 out of 5 by Debra51 Nice place Beautiful hotel, convenient to highways to get to downtown Nashville. Beautiful room, beautiful pool area, beautiful lobby. The reception staff could have been more helpful. August 4, 2014
Rated 4 out of 5 by bullish714 Nice Hotel Wonderful young lady at the front desk was exceedingly warm and friendly. August 7, 2014
Rated 5 out of 5 by OhMiss Great night's sleep. Gracious staff, great pillows and bed, food is always good. Just found out there is downtown shuttle available for a nominal fee. Great idea! August 4, 2014
Rated 2 out of 5 by Sandy97 Room was very clean! Was not happy that I stayed at this hotel 2 weekends in a row and requested to be by our friends. Even had to call and give them my friends confirm #'s. When I checked in they didn't have me by my friends. Same floor but opposite sides of the hotel. Was very disappointed! I had majority of my team stay here both weekends. This hotel was out of the way for us but heard it was a nice place. Don't know if I would stay again due to spending almost 400.00 and having all my friends stay here and not getting what I was promised. March 5, 2012
Rated 4 out of 5 by Jak72 Beautiful hotel and setting Beautiful hotel. Free parking was great. Rooms were very clean and staff was very friendly and helpful. The courtyard was beautiful. If wifi was free and a continental breakfast was included, I'd give it a 5. July 31, 2014
Rated 3 out of 5 by SDL58 not so good Front desk not helpful or informed. Bathroom shower drain was clogged. Stood in 3" of water each day to shower. Rooms were dimmly lit. Not enough convenient plugs for electronic devices. Best part of the hotel was your shuttle service. Which was timely, helpful and courteous. July 26, 2014
Rated 4 out of 5 by PorterTraveler Nice Facitilities, Attentive Staff I spent three nights here and loved my experience. Here's the pros: 1. The front desk lady was great. She recognized me as an SPG member, told me of the room upgrade, gave me some information about the hotel, and otherwise made me feel welcome. When I had to return with a bad key, she was equally attentive. 2. The room was great and had a very nice view of the courtyard. I loved walking out on the little porch and just looking out on the pool and trees. 3. Breakfast was very good. 4. Workout facilities were what I've come to expect from a Sheraton. Everything worked and there were a variety of muscle building and cardio options. 5. Location near the airport helps. 6. Wifi speed was pretty good. Not everything was perfect but they are relatively minor. The elevator could be slow at times, and it was sometimes hard to figure out how to find some things the first time. July 3, 2014
Rated 5 out of 5 by Oicu812 Awesome As always Sheraton provided a beautiful comfortable facility with an excellent staff that was friendly and helpful!!! August 3, 2014
Rated 4 out of 5 by Jdarrin Memorial Day I stayed in this hotel the first time on my wedding night because they offered free shuttle to the airport and free parking. We were upgraded to a suite when we told the front desk we had just gotten Married. This time we stayed in a courtyard room and it was a spacious room with a beautiful view of the courtyard. The staff was helpful and friendly but their was a bout a 1 hour period when we couldn't get an answer at the front desk. This hotel is a good value for the location. May 27, 2014
Rated 4 out of 5 by Esther14 Family Reunion My family was there for a family reunion. The staff were very friendly and accommodating to our needs. The exercise facility was very nicely equipped and clean. Our rooms were clean and comfortable. July 29, 2014
Rated 3 out of 5 by CIP3 Problems with Air Conditioner I have stayed here twice this summer and have not had a working air conditioner either time. Maintenance came twice this last time but still no cooling. Hotel desk staff did not seem overly concerned with repairs nor were they apologetic upon checkout. Never offered to move to another room although plenty were empty. July 19, 2014
Rated 4 out of 5 by layne12gun One of the Best I cannot say enough about this hotel. Very confortable and user friendly rooms. Great staff who were there to make sure the stay was as pleasureable as possible. Loved the GREEN bennifit plan and use it daily. The club rewards floor was very nice Great breakfast and late afternoon appetitizers. Shuttel service to the airport was wonderful.Pool Spa and work out room was very nice. Only negative was it is close to the airport and airport noise was a little loud at times. Otherwise great stay and highly reccomend May 28, 2012
Rated 4 out of 5 by petproblem Pet Policy I had never stay in a hotel with my pet. So prior to making reservations I had done my homework on their Pet Policy. I read several reviews, read the complete pet policy on the web site and even ask about the pet policy when I made my reservations. Only to find out when I arrived that I can not leave my pet unattended in the room. My opinion this should have pet disclosed prior to check in. This could have turned into a very difficult situation, luckily my mom was available to dog sit while I was working. July 29, 2013
Rated 5 out of 5 by mjpcjp beautiful hotel This hotel was gorgeous, from the moment driving up to the front door and to walking in the lobby. The rooms were very clean and the staff very friendly and helpful. The breakfast buffet was very good, tho a few more selections would have been nice. The shower was wonderful. The only negative thing we could say about this hotel was one side of the bed was very unconfortable to sleep on. Both my husband and I slept on this side and both had uncomfortable nights. But above all, we both would rate this a 10. July 6, 2013
Rated 5 out of 5 by Don35 USSCO BOOTCAMP Excellent hotel and convention center area. close to airport and other attractions. July 31, 2014
Rated 4 out of 5 by neekee I need some help Hotel was nice, but there was no one there to help me with my luggage July 30, 2014
Rated 4 out of 5 by cindyz11 noisy room, no coffee we changed rooms since our first one overlooked the freeway, and the windows obviously had very poor insulation. the room change went smoothly. the coffee station only had decalf. I really need some real coffee in the am. July 21, 2014
Rated 4 out of 5 by Hanna2772 Great hotel that is kid friendly The hotel was beautiful. The staff was nice and inviting. The indoor and outdoor pools were very clean ,nice, and for kids as well as adults. The courtyard is beautiful along with all the other areas within the hotel. The only 2 things that bothered me were the curtains were sheer which let in a lot of light at night and our rooms air conditioner wasn't working correctly so our room was warmer than I would have liked. I definitely would recommend this hotel and would stay there in the future. July 12, 2012
Rated 5 out of 5 by BarbaraP Nice Resort-like Hotel I like this hotel! There is always some type of music event going on. The hotel is very big though and the walk to the rooms is often long. Nice, well-kept pool area. The rooms are spacious with nice balconies, and the beds are very comfortable. The staff at the hotel is very helpful as well. July 14, 2014
Rated 5 out of 5 by Osobaboso Comfortable Beds - Friendly Staff Not being familiar with Nashville, I quickly wrote this hotel off as just another airport property. I was more than pleasantly surprised. The room was large and spacious and the beds amazing. I actually became ill during my stay and spent a very comfortable day tucked under the bed linens. The staff is amazing and unbelievably friendly. I cannot say enough about Jason in the Hickory Grill. He is so hospitable and his service was impeccable. The breakfast buffet was a daily treat. Other than being a small journey to get into the city proper, the only other thing I say is a negative is that the layout of the property can make it a small hike to get to your room if you are opposite of the lobby elevators. Oh, and when we checked in the balcony door was open, but that was more wierd than a problem. March 4, 2013
Rated 4 out of 5 by Kyfiddler Rooms are great, but food is way overpriced! The property is nice, the rooms are very comfortable, and the food in the restaurant/bar is good, but the prices for food are way overpriced! An entree salad is over $15, and at the food concession at the convention area, a can of soda and a banana was $7.00. Really? July 15, 2014
Rated 5 out of 5 by DW1956 Close to Airport, good layout. Indoor and out door pool, very modern exercise equipment. July 28, 2014
Rated 5 out of 5 by doghouse Service was excellent Outstanding service from check-in to departure. Except for 1 breakfast I ate and drank in the lounge are vs. the restaurant. Was very well taken care of. The new York steak was the food highlight of my trip. I ordered it med-rare. It was outstanding. The only problems with my room were: 1) The hair dryer had no heat. Had my own so didn't worry about it. and 2) of the 3 lights over the sink 2 of them were burnt out. If I was staying there with someone I would have wanted them replaced. February 25, 2012
Rated 5 out of 5 by SMCJuly2014 Week Long Conference I was fortunate to attend a week long conference at the Sheraton Music City in Nashville this past week. The facilities were great and the customer service was excellent. I will stay at this same location during next years convention. Thanks for a great experience. July 14, 2014
Rated 5 out of 5 by CA0411 Great Stay The room was great. I did expect a refrigerator from the website, but other than that is was just as it looks on the site. The balcony was wonderful! I would highly recommend the stay to everyone! July 19, 2014
Rated 4 out of 5 by B111 Excellent food and friendly staff. The staff in the restaurant and in the bar are very outgoing and pleasant. July 26, 2014
Rated 3 out of 5 by LK616 check-in It took over one hour in line to check in! Issues relating to a convention. I saw three folks in the office standing around when they could have been helping at the front desk. This was the very worst check in I have ever experienced. My room was not in the condition one would expect, dirty bath towel thrown over toliet, bedspread not fully on bed. The hotel itself was very nice, public areas were well kept and other than check in staff, the folks really demonstrated hospitality.. August 13, 2012
Rated 5 out of 5 by pp489 Hotel My hotel stay was awesome! The staff was friendly and the food was surperb. I really enjoyed myself on my business trip. July 23, 2014
Rated 4 out of 5 by Yuyin64 very good experience and member recognition They upgrade me for a suite and because of my birthday hotel give me a bottle of wine... July 24, 2014


text:
Home » Opinion » Editorials
Lies exposed: The false Benghazi narrative
Read into the record at Wednesday's hearing was a State Department email in which Acting Assistant Secretary for Near Eastern Affairs Beth Jones told Secretary of State Hillary Clinton's office on Sept. 12 that "the group that conducted the attacks, Ansar al Sharia, is affiliated with Islamic terrorists." Yet four days later, Rice told the American people the complete opposite. Clinton herself told the father of one of the slain Americans that the film was to blame.
Hicks said that when he questioned why the story about the movie was being peddled, Clinton's Chief of Staff Cheryl Mills made it clear to him that he should drop that line of questioning.
This is strong evidence that the Obama administration deliberately misled the American people about a terrorist attack on American soil weeks before a presidential election. Maybe now the questionable Benghazi narrative peddled by the Obama administration will get the scrutiny it has deserved from the start.
- Keene State College is holding several events next week to mark World AIDS Day - 0
- Report offers Derry 5 choices for grades pre-K to 8 - 0
- Keene State to lead national initiative on economic inequality - 0
- Manchester schools cut classes short for Wednesday due to weather - 2
- Manchester school board OK's contract for driver's ed program - 1
- Enrollments declining in Hudson, but school budget increases still expected - 0
- New NHIA president painting a picture of expansion - 0
- Former White House Chief of Staff Andy Card to be president of Franklin Pierce College - 3
- Students prepare to set sail at Tri-City Christian Academy - 0
Londonderry schools outline budget that ups spending 1.58%READER COMMENTS: 0
- Celtics Insider: Celtics rule Smart out of tomorrow's game against Chicago - 0
- Berube the backbone of Monarchs' team 'D' - 0
- Packers QB Revis will pose a challenge for Patriots - 3
- Hudson may start charging for non-transport ambulance calls - 0
- NH suffers 4th worst outage on record - 2
- Camping out didn't pay for shoppers - 0
- Newsreel: Concord economic forecast; Tech Council hosts forum; UNH Fairchild Dairy honored - 0
- Londonderry-based MegaFood launches transparency project in vitamin industry - 0
- Grant program to help Granite State students with loans - 0
Bruins pleased with start in spite of injuriesREADER COMMENTS: 0
NH suffers 4th worst outage on record
Camping out didn't pay for shoppers

subset: commoncrawl


text:
Arlington County Manager
Arlington's Office of the County Manager is responsible for County operations and management of a broad range of services.
Notified About
restripe road ArchivedArlington va - Arlington
roadwork completed awhile ago. road needs to be restriped
Graffiti Open3901 Potomac Ave Alexandria, VA - Alexandria city
Graffiti on rail road bridge visible from Potomac Ave.
Uneven Road. Archived3900 S Four Mile Run Dr Arlington, VA 22206, USA - Nauck
Road work left rocks and dirt. Road is uneven and tough on tires.
entry door button not working Archived1301-1399 N Stafford St Arlington, Virginia - Ballston-Virginia Square
Exterior door to Washington and Lee HS is not operating.
Power outage Archived3700 N John Marshall Drive Arlington, VA - Williamsburg
Power Outage Archived1211 S Eads St Arlington, VA - Aurora Highlands
Power out since 6pm Monday.
Road patch too low OpenS Wakefield St Arlington, VA - Barcroft
Road patch heading south on S. Wakefield St. across Columbia Pike is too low and jarring to drive over. Please raise it to be level with the road.
Nobody waves or says hi Archived5448 22nd St N Arlington, VA - Tara-Leeway Heights
I sit on my porch and all i get is side way glances and grumbled hellos
Graffiti Archived4534 37th Street North Arlington, VA 22207, USA - Olde Glebe
Graffiti on transformer box.
4704 Arlington, VA - Claremont
Oct 14th CPRO 6:30PM@4704 Columbia Pike to talk to renters about "improvements to the Pike"...affordable housing at risk.
Power Outage Archived1600 S Eads Street Arlington, VA - Aurora Highlands
Still no power :(
Power outage Open1600 S. Eads Street Arlington, VA - Aurora Highlands
Just lost power in Crystal City


text:
Power Slot Cryo Brake Rotors 126.69001CSR
- Our Price: $150.15
- Shipping:FREE SHIPPING
- Part Number: 126.69001CSR
$150.15Free Shipping
Select your vehicle details above to ensure item compatibility.
Ships between 12/29/14 - 01/09/15
Front Right Cryo Brake Rotor
- Part #: 126.69001CSR
Power Slot 126.69001CSR fits:
- 2006-2010 Hummer H3
- 2009 Hummer H3T
More like this
There are no reviews for this application.
See All Power Slot Cryo Brake Rotors Reviews.


text:
Attica 21 Barcelona Mar
No availability found through our partners. Please contact the business directly or check some of our recommended alternatives.
How has this hotel rated in the past?
- Swimming pool
- Room service
- Free High-Speed Internet
- Beach
- Wheelchair accessibility
- Business Services
Travelers also recommend:
TripAdvisor Reviews Attica 21 Barcelona Mar
Travel Blogs from Barcelona
Weather: cloudy but still warm in France Off to Barcelona today! Looking forward to it because everyone has said good things. We did the normal routine, up, packed, down to breakfast and spoke to a nice family from Malaysia who are now living in London and were holidaying in South of France. They had been to NZ a few times so was interesting to chat to them. The nice B&B man Le us print our plane tickets for the next couple of flights and then ...
... date of completion is 2030, but there is no guarantee it will be done by then.
Gaudi was truly a genius. The way he used natural light in his buildings, and employed designs from nature — Catalan arches to support roof structures — similar to backbones in animals, or parabolic shapes as ropes hang from two points on a ceiling — is masterful.
La Sagrada Familia has wonderful natural lighting, with stained ...
Down Time and Mistakes
... like one more load of clean clothes. The last bonus is that I did get to have paella in Spain. :). The kids got over it in no time, while I still felt stressed from the rushing. I also had a glass of wine with my paella for the first time since we've been here and realized that I need to drink a little more and relax a little more. No harm done - we're on vacation!! But I will now be furiously booking the rest of our train routes in the next few days. ...
Barcelona What a way to enter Spain
... 8211; one car only barely made it into the ferry garage because the pile of containers on its roof was so high!
Arriving in Barcelona we had read that it was hard to get a taxi from the docks as most people bring their cars, naturally Steve scoffed at this and of course we ended up having a fairly long walk to a nearby hotel to get one.
First thing you notice is how wide and clean the streets are and we soon found the most popular ...
Somethin' Like San Diego
... asking, and she pointed out my backpack. According to her, the thieves in Spain were the best in the world and if I had anything precious in my pack it might as well be gone. Shifting my bag from my back, I thanked her for the heads up…I didn't realize how much thievery existed in these parts. After the tid-bit of advice, she hung around for a moment and we talked about what was worth seeing or doing if we only had one day. She noted there was a huge market in the heart ...


text:
Keep track of all your favorite poker players right here at PokerNetwork.
My morning Joe
In the conference on civil defense I emphasized:we must be united and demonstrate each day our actions, preparedness goo.gl/ELhZgf
A TED playlist to watch: Who are the hackers? ted.com/playlists/10/w…
Forget multitasking, try monotasking on.ted.com/Cardini
How much of a legend is Faulkner!!! #notevenhomeyet #stillalegend
Finished the day with over 60 bigs. With 90 minutes left I had 5bbs McKenzie With Back-To-Back Aces pkrn.ws/11BvAbK via @PokerNews
I was down to 5k late in the day when QQ <AA then this happened pokernews.com …/appt…/main-event/chips.108598.htm #ANZPTAuckland
So pleased that #Kickboxer hasn't aged with time. GOLD! @JCVDonline #classic
High level conference on civil defense in hybrid wars. Direct transmission goo.gl/xu66nt with @edwardlucas pic.twitter.com/pgEhNse8pk
Well done to our 21 remaining Corporate Games survivors - see you back @CrownPoker 4pm Saturday!
@PokerStarsAPPT @PokerStars as a regular attendee of your tour events, I am disgusted by this series and the incompetent local staff
@PokerStarsAPPT then dealers mucked her cards twice without action. Tournament had no antes. Floor told me all numbered do earlier this wk.
@PokerStarsAPPT Tania was angleshot at ANZPT Auckland costing her a pile of equity today, fllor rules for angle shooter, then dealer 1/2
I'm at Emporium Melbourne in Melbourne, VIC swarmapp.com/c/goGY5Y4xtXK
@CrownPoker can we have ANZPT Auckland at Crown instead next year please? Good dealers and floorstaff, you don't notice until they're gone
ANZPT Auckland has been the most poorly run series I have attended. The local incompetence reflects poorly on the ANZPT and I won't be back.
Anniversary dinner!!! (@ Om Nom in Melbourne, Vic) swarmapp.com/c/97cZeSxnJgG
Great to see Vic Pro @anthonyhousto19 or better known as "Muscles" in Top 5 of @PGAofAustralia Masters heading into weekend! #gymjunkie
A little isolated focus in the range this arvo! Great Practise makes Perfect! #goodtogetbackintoit… instagram.com/p/vpsoUeKPqa/
All done #APPTAuckland Day 1C - 29 remain from 79 - Terangi Matenga leader 170,400. 80 back at 12.15pm draw available psta.rs/1HiWwOP
|Full Tilt Poker
|William Hill Poker
|PKR Poker
|Titan Poker
|Poker Heaven
|Unibet Poker
|Betfair Poker
PokerNetwork is home to one of the most active poker forums online. With all the latest online poker news from both Australia and around the world, PokerNetwork is your home for the latest and greatest offers.Follow us on other sites
|Online Poker Linux Poker RoomsMac Friendly RoomsLeagues
|News Poker Tweets
|Poker Rules Poker Tournament RulesTexas HoldemPoker Glossary
|Freerolls 888poker Super XL Series$10,000 Freerolls @ PokerStars$10,000 Freeroll @ Full TiltFree €10 Tokens @ Titan Poker
|Live Reporting 2014 WSOPAussie Millions
|Hall of Fame Information and NomineesList Of ChampionsAustralian Poker Hall of Fame 2009Australian Poker Hall of Fame 2010Australian Poker Hall of Fame 2011
|Poker ForumVideosBlogs
© 2013 PokerNews Ltd. All rights reserved.SitemapContact UsPrivacy PolicyDisclaimerCareer


text:
A collection of responses to pickup lines, and just bad ones in general!
We've just released huge update to the iOS app! Now, access all your favorite text and photo sites like Anti-Joke, DIYLOL! A few things didn't make the original cut (like comments) but they'll be back soon. Best of all, the app is now FREE! Get it here.
"[£100 car challenge] Hammond: I've managed to procure an x-ray of Jeremy's hand and it's 5 points off for a broken bone remember; look at...."
via: Clarksonisms
via: Pointless Inventions
"When ever i watch a movie with my parents i hope to god there is no nudity or awkward sex talk."
©2008-2014 Anti-Pickup Line. All rights reserved.
A Horse Head Huffer Production.
Rails Hosting provided by BlueBox


text:
Story: Nov 18, 2014
New film studies prof helps students appreciate film as art ...
CIA Exhibition: Nov 07, 2014
Fall 2014 Exhibitions
Story: Nov 15, 2014
Students capture two of the top prizes in museum's surreal d...
Events: Dec 05, 2014
Student Holiday Craft Sale
Social: a day ago via Facebook
Registration opens on Monday, Nov. 25 for the Cleveland Institute of Arts 2D3D national art and design competition for high school students. There are 13 cash ...
Story: Nov 04, 2014
New CIA building taking shape; set for December completion
Story: Nov 03, 2014
New Uptown Residence Hall featured in CIA video
Story: Aug 18, 2014
CIA again named to "Best in the Midwest" list
Academics . Continuing Education + Community Outreach . Courses
Media Arts + Visual Culture: Installation
Course No. ACD 486 Credits: 3.0
Faculty David Hart | Gary D. Sampson
This course investigates the emergence, prominence and impact of the installation as a new medium in contemporary art. "Media arts" or "new media" include but are not limited to video and experimental film, performance, interactive art, digital media, and especially the installation, which itself embraces a wide range of media. We will focus on the growth of the installation from "environments" in the 1960s into a distinct artistic medium used widely since the 1980s. We will discuss the work of many recognized artists and some less familiar artists from around the world as well as corresponding theories of media within the broader field of visual culture. Using a wide range of installations as examples, particular attention will be given to the implications that new media, especially digital media, have for the creative process and the critical social issues that they raise. Visual Culture Emphasis course.
Leslie McCombs
Assistant Director of Continuing Education + Community Outreach
While at CIA, you'll learn from the masters through our rigorous, world-class curriculum and connect with working professionals to begin your career.


text:
Hello and welcome to WoodFloorRestoration.net. This is your one stop destination for Wood Floor Restoration you've been looking for. We carry all styles, including White Pine Flooring and Brazilian Cherry Flooring. It does not matter what you're looking for we can help you find it with the lowest prices online only found here at WoodFloorRestoration.net. Let us help you meet your shopping needs while providing you with the best selections available online today. All this in a simple to use shopping interface. Checkout securely online with the help of WoodFloorRestoration.net now!
Your Price: $87.96
Your Price: $55.12
Your Price: $349.99
NARROW Search Results for "Wood Floor Restoration" by:


text:
Sunday, 12 Dec 2010 02:10 PM
China can't raise interest rates because of the risk of attracting inflows of cash that would fuel inflation, said Wu Xiaoling, a former deputy governor of the central bank.
"The global low interest-rate environment prevents China's central bank from raising interest rates," Wu said in a speech at a hedge fund conference in Shanghai Saturday. Emerging markets face capital inflows and "excessive money supply is one of the important reasons for China's inflation," she added.
Economists at firms including Australia and New Zealand Banking Group Ltd. and UBS AG. have, in contrast with Wu's view, said that China is likely to raise rates this weekend. China's central bank Friday increased lenders' reserve requirements for the sixth time this year as part of efforts to curb inflation that rose to a 28-month high in November.
In October, the central bank pushed up lending and deposit rates for the first time since 2007.
Analysts have focused on the possibility of another increase this weekend because of today's release of November data. Consumer prices rose 5.1 percent from a year earlier and producer prices jumped 6.1 percent, a statistics bureau report showed.
Wu, the deputy director of the Financial and Economic Affairs Committee of the National People's Congress, said M2, the broadest measure of money supply, may rise 19 percent this year.
© Copyright 2014 Bloomberg News. All rights reserved.
Powered by
"But Wait! There's More!!!"
Anybody that swallows this garbage has the I.Q....
Obama for many whites stepping into the voting booth, 2008 was considered the...
"Digital money is money that exists solely in cyberspace. Unlike fiat
The White House Idiot has already helped Putin in the devaluation of his Ruble...
Ya think??!!
United States
National Debt $17,895, 836,780,152.52
Newsmax, Moneynews, Newsmax Health, and Independent. American. are registered trademarks of Newsmax Media, Inc. Newsmax TV, and Newsmax World are trademarks of Newsmax Media, Inc.


text:
Narrow your search
Grab your tech passport and travel to Berlin for the massive IFA consumer-electronics trade show.
HTC's new program could help lure new customers, especially now that HTC is offering new phones.
According to a survey of consumers upgrading to the HTC One M8, most are loyal HTC owners, but plenty are trading up from an iPhone or Samsung device as well.
It may not have all of the Galaxy S5's hardware gizmos, but HTC's new Android heavy-hitter scores big where it counts.
The smartphone, built by Motorola Mobility, will feature a battery that can last up to 48 hours and a Turbo Charger that can provide 8 hours of use on a 15-minute charge.
The Japanese electronics giant brings its flagship phone line to the biggest wireless carrier in the US.
The latest "iPhone 6" shell from China, this time in silver, looks an awful lot like another flagship phone already out.
While Blackphone sales are off to a lukewarm start, our hands-on with the privacy-obsessed smartphone finds that it simplifies staying secure on the go.
The big-screen Note line gets updated with two new designs, including one smartphone with a curved display. Samsung also shows off its virtual-reality headset, called the Gear VR.
For the first time since Sony took full control of its mobile business, it will launch a flagship smartphone in the US through T-Mobile, at the same time as everywhere else.
In an interview, Synaptics CEO Rick Bergman talks about the opportunities that stem from the Internet of Things and describes his idea of the holy grail of biometric sensors.


text:
Smock discusses the "new American family" on NPR
Pfeffer and colleagues re-examine impacts of community college attendance
Frey explains the minority-majority remapping of America
Apply for 2-year NICHD Postdoctoral Fellowships that begin September 2015
PSC Fall 2014 Newsletter now available
Martha Bailey and Nicolas Duquette win Cole Prize for article on War on Poverty
Michigan's graduate sociology program tied for 4th with Stanford in USN&WR rankings
Monday, Dec 1
Linda Waite, Health & Well-Being of Adults over 60
Axinn, William, Dirgha Ghimire, and Nathalie Williams. 2011. "Collecting Survey Data during Armed Conflict." PSC Research Report No. 11-730. February 2011.
Surveys provide crucial information about the social consequences of armed conflict, but armed conflict can shape surveys in ways that limit their value. We use longitudinal survey data from throughout the recent armed conflict in Nepal to investigate the relationship between armed conflict events and response rates. The Chitwan Valley Family Study (CVFS) provides a rare window into survey data collection through intense armed conflict. The CVFS data reveal that different dimensions of armed conflict can affect survey response in opposing directions, with bombings in the local area reducing response rates but nationwide political events increasing response rates. This important finding demonstrates that survey data quality may be affected differently by various dimensions of armed conflict. Overall CVFS response rates remained exceptionally high throughout the conflict – we use the CVFS experience to identify principles likely to produce higher quality surveys during periods of generalized violence and instability.
Country of focus: Nepal.
Browse | Search : All Pubs | Next


text:
Other stores
- Alabama
- Arizona
- California
- Colorado
- Connecticut
- Delaware
- Florida
- Georgia
- Hawaii
- Illinois
- Indiana
- Iowa
- Kansas
- Massachusetts
- Michigan
- Minnesota
- Mississippi
- Missouri
- Nevada
- New Jersey
- New Mexico
- New York
- North Carolina
- Oregon
- South Carolina
- Tennessee
- Texas
- Vermont
- Virginia
- Washington
- Wisconsin
Ecco - Williamsburg
5715-62A Richmond Rd. VA 23188 - Williamsburg
(757) 565-6100
Prime Outlets Williamsburg
Founded in Denmark in 1963, ECCO is a global leader in innovative comfort footwear for men, ladies and kids.
Shopping times:
Monday to saturday: 10 am - 9 pm
Sunday: 10 am - 7 pm
Prime Outlets Williamsburg is closed: Easter, Thanksgiving, Christmas
keywords : ecco outlet denmark - ecco outlet danmark - ecco williamsburg outlet - ecco outlet - ecco outlet williamsburg - ecco danmark - ecco williamsburg - more
ecco factory outlet denmark - ecco factory outlet danmark - ecco shoes williamsburg va - ecco outlet dänemark - ecco outlet in denmark - ecco shoe outlet williamsburg va - ecco factory outlet - williamsburg outlet ecco - ecco shoes williamsburg - ecco outlet williamsburg va - ecco williamsburg va - ecco factory outlet stores,willamsburg,va. - ecco outlet stores -
more infos on Ecco
Moultrie News This year the organization hopes to present more than 400 families with a turkey, sides, stuffing, dessert and all items for a complete Thanksgiving meal. Clients started registering in October for pick-up appointments this month. Due to the high ...
GTA 5: ecco la lista delle nuove canzoni presenti su PS4, PC e Xbox One - Videogiochi.com | Tutti i giochi per PC, console, smartphone e tablet
Videogiochi.com | Tutti i giochi per PC, console, smartphone e tablet Durante un recente livestream in cui si è parlato delle nuove versioni di GTA 5, i giocatori sono venuti a sapere quali saranno molte delle nuove canzoni che si potranno ascoltare sulle stazioni radio in-game. Di seguito vi riportiamo la lunga lista ...
ECCO unveil 2015 styles - bunkered
bunkered Alongside the Biom Hybrid 2, ECCO launched the new BIOM G2 shoes, which are nearly 20% lighter than previous ECCO offerings. Available in waterproof GORE-TEX and weather-resistant HYDROMAX options, each pair is made using premium yak leather ...
Ecco Domani launches new lighter style prosecco - Drinks Business Review
Drinks Business Review Ecco Domani Prosecco is made with grapes from Treviso, in northern Italy's renowned Prosecco region. The fruit for this vintage was primarily selected from historic hillside vineyards. Well drained chalk and clay soils and mild, stable temperatures ...
Ecco Domani® Launches Lighter-Style Prosecco For A Stylish Twist On ... - PR Newswire (press release)
PR Newswire (press release) MODESTO, Calif., Nov. 12, 2014 /PRNewswire/ -- Ecco Domani® — the iconic Italian wine brand— is launching Ecco Domani Prosecco, a lightly effervescent Prosecco with a contemporary screw cap closure that gives a fun twist to everyday occasions.
Lastest news
- Memorial Day Week end Sale
- Clarksburg outlets could open in 2015
- Coach Factory Store in Phoenix
- Factory Outlet: Bargain shopping tips
- More factory outlets Ann Taylor
- Coach at Liberty Village Premium Outlets - Flemington
- Tanger Factory Outlets offers notes to repay debt
- Aeon to Open First Outlet Mall in Saitama
- Simon plans to acquire Prime Outlets
- Sales & Events at Chelsea Premium Outlets
Last added
- 2b bebe
- Brighton Collectibles
- Burberry
- Hanna Andersson Outlet
- Papaya Sunwear Outlet
- Jockey
- Cole Haan
- Ecco
- Zales Fine Jewelry Outlet
- L'Occitane en Provence


text:
Added Jan 9, 2014
by iewa
Riga, Latvia
Woolen jacket based on Burda 11/2010 pattern # 104.
Jan 11, 2014, 05.45 PMby yenny lee
Love it!
Jan 10, 2014, 11.55 AMby sarahsdaughter
Jan 10, 2014, 11.27 AMby leokadia
Eine wunderschöne Jacke, mein Kompliment! Und viel Freude beim Tragen!
Jan 10, 2014, 09.13 AMby Mary Athey
This is so timeless and classy, love it x
Jan 10, 2014, 08.40 AMby Ellen Hatteland
Lovely jacket! what a Great job! ;)
Jan 10, 2014, 12.55 AMby cchristie
Gosh, that is just perfection. I hope you are delighted with the result. Enjoy wearing it and the compliments you receive
Jan 10, 2014, 12.05 AMby Deanna31
Wow great insight. It looks so much nicer then the orig. The smaller edging looks a lot more classier and I think it would be easier to match with other garments. Hmmm having ideas…
Jan 9, 2014, 11.44 PMby rita61
Add to Favorites 4 people added it
Sewing & Techniques
See how Meg made this edgy dress using the Janome Artistic Edge Digital Cutter!
Editors' Pick
No need to go outside… spend the morning in dolled up in this collection of vintage style pajamas.
BurdaStyle Magazine US
Get an inside look at the patterns from the first 4 issues of BurdaStyle US
As an early special Black Friday promotion you can now enroll in the course ($80 value) for $49.99!
Register for Meg's new course, space is limited!
Sewing & Techniques
Learn how to use your bodice sloper to draft this popular collar style
Get the Piped Trench Coat pattern
You must allow our "request for permission" request to login to Burdastyle with Facebook.


text:
Man arrested after struggle with police
On Sunday morning at 3:04 a.m. the Storm Lake Police Department was called to 116 Irving St. after a report of an assault in progress.
Police met with a 23-year-old female who reported to police that Domonick Tribble, 26, of Laurens had allegedly engaged in an argument with the female victim outside of her residence.
Storm Lake Police were called to Storm Lake Middle School Friday afternoon at 3:30 p.m. after a report of a fight.
Police were told that a 14-year-old boy and a 13-year-old boy, both from Storm Lake, engaged in a physical altercation outside the middle school. Both sustained minor injuries.
Israel Barron-Gomez was arrested Saturday night and
charged with Delivery of Marijuana and Possession of
Drug Paraphernalia.
Israel Barron-Gomez was arrested Saturday night and
charged with Delivery of Marijuana and Possession of
Drug Paraphernalia.
Police arrest one person in drug bust
The Storm Lake Narcotics Team and K9 Unit executed a search warrant on a residence Saturday night at 6:30 p.m. at a residence located at 711 Highview Drive in connection with the sale of illegal drugs.
Police located and seized a digital scale, packaging materials and drug paraphernalia.
Peterson man charged with possession of a controlled substance
Ryan Holder, 29, of Peterson was arrested and charged with possession of a controlled substance on Friday at 9:52 p.m.
A Clay County deputy pulled Holder over in the 1700 mile of Highway 10 for an equipment violation.
Storm Lake Police report that on Friday evening the department conducted compliance checks to ascertain if appropriate measures were being taken in connection with the sale of alcohol.
Police checked 18 establishments licensed to sell alcohol in Storm Lake by sending an underage patron into the business to purchase alcohol.
The Storm Lake Police Department is warning the community of a telephone scam that presented itself in the area where residents are being asked for personal banking information.
Police learned that citizens and businesses in the Storm Lake area are receiving automated phone calls from an unknown number.
On Monday, Jan. 13 Storm Lake Police took a report of theft of a wallet and unauthorized use of a credit card.
Police were told by the reporting party that on Sunday at 11 p.m. he misplaced his wallet at the Storm Lake McDonalds.
The victim reported the incident to McDonalds staff but they were unable to locate the wallet Sunday night.
Police were conducting a bar check at 1:23 a.m. Sunday morning at Malarky's Night Club when they saw two men fighting inside the club.
Police took both men into custody.
Edwin Rios, 21, of Storm Lake and Viradet Bourommavong, 32, of Grimes were arrested and charged with disorderly conduct and public intoxication.
They were booked on a $600 bond each.
$1K reportedly stolen from SL Taco John's
Storm Lake Police reported an investigation into a series of thefts at the Storm Lake Taco John's store where cash shortages appeared between June and November 2013.
Police were told that on multiple occasions the cash registers were short of funds totaling $1,000.
SL residents should notify police if they get a call
The Storm Lake Police Department is warning the community of a telephone scam that presented itself in the area illegally using the MidAmerican Energy Company name.
Copyright 2013-2014 | The Storm Lake Times | All Rights Reserved
220 W Railroad St
PO Box 487
Storm Lake, IA 50588
712.732.4991 | 1.800.732.4992
SSL Certificate


text:
Arizona Cardinals franchise player Larry Fitzgerald, who recently conducted the Phoenix Symphony, kept busy over the weekend by judging Sunday's Miss USA pageant. Fitzgerald was one of nine finals judges for the event, which was broadcast on NBC. Miss Connecticut walked away with the crown — Fitzgerald is the only reason to keep watching the Cardinals. We'll see if he and Carson Palmer can figure it out this season.
2013 Pre Season WR Rankings
Fitz Doesn't Need A Golf Cart When He Hits The Greens
Juan – has written 5299 posts on this site.
Juan Elway is an enthusiast of Fantasy Football, Movies, and Combat Sports, but don't call him an expert. He once shook Adrian Peterson's hand and AP winced in pain. Follow him on Twitter where you can partake in all sorts of shenanigans.


text:
Diego Sanchez's loss could be Josh Koscheck's gain.
Koscheck, who hasn't fought since a December title loss to welterweight champion Georges St-Pierre due to a broken orbital bone, tweeted that he's accepted Sanchez's spot on this month's UFC 135 card.
Sanchez recently pulled out of a fight with Matt Hughes due a broken hand. Koscheck now awaits word from Hughes on whether he'll accept the bout.
read news >>
It's a busy day at the Zuffa offices.
On the heels of a few massive announcements already made today, UFC
president Dana White just announced that Josh Koscheck and Matt Hughes have agreed to meet in the
co-feature of this month's UFC 135 event.
Koscheck is a late replacement for Diego Sanchez, who was forced to withdraw from the matchup with a broken hand.
read news >>
After a bit of deliberation, Matt Hughes and Josh Koscheck are now set to face off in the co-main event for UFC 135 coming up on Sept 24 in Denver.
Read More >> read news >>
It didn't take UFC matchmaker Joe Silva long to find a replacement to fight Matt Hughes at UFC 135. Read More >> read news >>
Josh Koscheck is the final obligation on the current contract of Matt Hughes.
Consequently, the former UFC welterweight champ is playing his future by
ear after he fights the onetime title challenger Saturday at UFC 135.
"The outcome of this fight won't really matter, to be honest," he said
today. "After this fight, win or lose, doesn't matter, I'll talk to the
UFC and we'll figure out what we want to do."
read news >>
A rumored UFC 135 clash between Matt Hughes and Josh Koscheck was confirmed late Tuesday when UFC president Dana White announced the matchup via Twitter. read news >>
It's been a rough stretch for Josh Koscheck the past 18 months. But things were great in September 2011 when he stopped Matt Hughes with one second left in the first round at UFC 135. Relive that fight inside. read news >>
Josh Koscheck was given the opportunity of a lifetime when he got the chance to fight UFC legend Matt Hughes at UFC 135. Check out the full fight courtesy of Fuel TV.
Retweet this Share on Facebook
• Email &bu read news >>
An expected welterweight clash between Matt Hughes and Diego Sanchez is now official for UFC 135, promotion officials announced Friday read news >>
The Ultimate Fighting Championship hasn't promoted a pay-per-view event in Denver since "Ultimate Ultimate" in 1995. That will change with the first Zuffa-owned UFC pay-per-view event in the Mile High City, UFC 135: Jones vs. Rampage. Read More >> read news >>
As expected, Diego Sanchez and fellow welterweight Matt Hughes will meet in a UFC 135 main-card bout.
UFC executives recently made the long-rumored bout official.
UFC 135 takes place Sept. 24 at Denver's Pepsi Center. A title fight between light-heavyweight champion Jon Jones and Quinton "Rampage" Jackson headlines the pay-per-view main card.
read news >>


text:
Antwan Space downs the Vols again, this time in overtime, 68-65
Antwan Space did it again.
The Texas A&M forward who broke the Tennessee men's basketball team's back with a game-winning 3-pointer in Knoxville earlier this season once again hit a game-deciding 3-pointer in Saturday's rematch between the Aggies and the Vols at Reed Arena.
Texas A&M 68, Tennessee 65.
Space's shot fell through the net with four seconds left in overtime. The Vols called a timeout, but failed to create a shot attempt at the other end once play resumed.
Twice at the end of regulation, UT thought it had won the game. The Vols stormed back from an eight-point deficit with 1:46 left in regulation and appeared to take a 60-59 lead when Antonio Barton hit a 3-pointer. But that shot was negated by a UT time out taken before the shot.
Out of the Vols' time out, Stokes scored a layup and drew a fifth foul on A&M's leading scorer, Alex Caruso. But Stokes' potentially game winning free throw bounced off the front rim and the Vols fell in overtime.
UT fell to 16-11, 7-7 SEC with the loss. The Aggies improved to 16-11, 7-7.
Jordan McRae led the Vols with 20 points. Stokes scored 16 and pulled down 16 rebounds. Jeronne Maymon finished with 16 points and 13 rebounds.
Caruso and Jamal Jones paced the Aggies with 14 a piece. Space scored six, none more important than his final three.


text:
Editing of Bulbapedia is currently restricted. Please see this message for more details.
Pokémon Omega Ruby and Alpha Sapphire have arrived!
Check BNN and Bulbanews for up-to-date Pokémon news and discuss it on the forums or in our IRC channel.
Category:Pocket Monsters Diamond & Pearl (Sakai Takayuki)
From Bulbapedia, the community-driven Pokémon encyclopedia.
This category is for articles pertaining to the Pocket Monsters Diamond & Pearl manga series created by 坂井 孝行 Sakai Takayuki.
This category has the following 3 subcategories, out of 3 total.
Pages in category "Pocket Monsters Diamond & Pearl (Sakai Takayuki)"
This category contains only the following page.


text:
Movistar Argentina: Get Additional Mobile Bonus on Top Ups from October, 20 2014 to December, 31 2014 (GMT -0300)
Claro Colombia: Get Double Online Bonus on Top Ups November, 26 2014 (GMT -0500)
Tigo Colombia: Get Additional Bonus on Top Ups from November, 07 2014 to November, 28 2014 (GMT -0500)
Viva Dominican Republic: Get Double Balance on Mobile Recharges from October, 17 2014 to December, 10 2014 (GMT -0400)
Tigo Guatemala: Get 200% Online Bonus on Mobile Recharges November, 26 2014 (GMT -0600)
Digicel Haiti: Get 8x Mobile Bonus on Recharges from November, 25 2014 to November, 30 2014 (GMT -0500)
Tigo Honduras: Receive Triple Balance on Mobile Recharges from November, 01 2014 to November, 30 2014 (GMT -0600)
Telcel Mexico: Get Online Bonus on Top Ups from September, 01 2014 to January, 01 2015 (GMT -0500)
|CY.SEND® Mobile Top UP Blog
|Telecoms, Mobile, Travel
China's state media have warned the US against "flexing its muscles" after Washington unveiled a defence review switching focus to the Asia-Pacific.
In an editorial, official news agency Xinhua said President Barack Obama's move to increase US presence in the region could come as a welcome boost to stability and prosperity.
But it said any US militarism could create ill will and "endanger peace".
Mr Obama also plans $450bn (£290bn) in cuts to create a "leaner" military.
Thousands of troops are expected to be axed over the next decade under the far-reaching defence review.
The defence budget could also lose another $500bn at the end of this year after Congress failed to agree on deficit reduction following a debt-ceiling deal in August 2011.
Mr Obama said the "tide of war was receding" in Afghanistan and that the US must renew its economic power.
Regional disputes
However, he told reporters at the Pentagon: "We'll be strengthening our presence in the Asia-Pacific, and budget reductions will not come at the expense of this critical region."
Xinhua said the US role could be good for China in helping to secure the "peaceful environment" it needed to continue its economic development.
But it added: "While boosting its military presence in the Asia-Pacific, the United States should abstain from flexing its muscles, as this won't help solve regional disputes.
"If the United States indiscreetly applies militarism in the region, it will be like a bull in a china shop, and endanger peace instead of enhancing regional stability."
BBC Asia analyst Charles Scanlon said the US decision to focus on Asia would have come as no surprise to China's leaders. However, to some in Beijing, it would look like a containment strategy designed to curtail China's growing power.
Beijing officials have yet to comment.
However, the Communist Party's Global Times newspaper said Washington could not stop the rise of China and called on Beijing to develop more long-range strike weapons to deter the US navy.
'Flexible and ready'
The US strategy shifts the Pentagon away from its long-standing doctrine of being able to wage two wars simultaneously.
However, Defence Secretary Leon Panetta emphasised the military would retain its ability to confront more than one threat at a time, and would be more flexible and adaptable than in the past.
Mr Obama said: "The world must know - the United States is going to maintain our military superiority with armed forces that are agile, flexible and ready for the full range of contingencies and threats."
No specific cuts to troop numbers or weapons programmes were announced on Thursday - those are to be presented as part of the federal budget next month.
But a 10-15% reduction to the US Army and the Marine Corps is being considered over the next decade - amounting to tens of thousands of troops, Obama administration officials have told US media.
Initial Republican reaction to the review was negative. Chairman of the House Armed Services Committee, California Representative Howard McKeon, said the new policy was a "retreat from the world in the guise of a new strategy".
"This is a lead-from-behind strategy for a left-behind America," he said in a statement.
(BBC news)


text:
Determinants of VIA (Visual Inspection of the Cervix After Acetic Acid Application) positivity in cervical cancer screening of women in a peri-urban area in Andhra Pradesh, India.
ABSTRACT Visual inspection of the cervix after acetic acid application (VIA) is widely recommended as the method of choice in cervical cancer screening programs in resource-limited settings because of its simplicity and ability to link with immediate treatment. In testing the effectiveness of VIA, human papillomavirus DNA testing, and Pap cytology in a population-based study in a peri-urban area in Andhra Pradesh, India, we found the sensitivity of VIA for detection of cervical intraepithelial neoplasia grade 2 and worse (CIN2+) to be 26.3%, much lower than the 60% to 90% reported in the literature. We therefore investigated the determinants of VIA positivity in our study population.
We evaluated VIA positivity by demographics and reproductive history, results of clinical examination, and results from the other screening methods.
Of the 19 women diagnosed with CIN2+, only 5 were positive by VIA (positive predictive value, 3.1%). In multivariate analysis, VIA positivity (12.74%) was associated with older age, positive Pap smear, visually apparent cervical inflammation, and interobserver variation. Cervical inflammation of unknown cause was present in 21.62% of women. In disease-negative women, cervical inflammation was associated with an increase in VIA positivity from 6.1% to 15.5% (P<0.001). Among the six gynecologists who performed VIA, the positivity rate varied from 4% to 31%.
The interpretation of VIA is subjective and its performance cannot be readily evaluated against objective standards.
VIA is not a robust screening test and we caution against its use as the primary screening test in resource-limited regions.
Article: Spectroscopic studies of the complexes trans-[PtX2(CH2CH2)(pyrazine)] and trans-[Pt2X4(CH2CH2)2-(pyrazine)][Show abstract] [Hide abstract]
ABSTRACT: Pyrazine (pz) reacts with Zeise's salt and its bromo and iodo analogues, K[PtX3-(CH2CH2)] (X Cl, Br, I) to form two series of complexes: trans-[PtX2(CH2CH2)(pz)] (I) and trans-[Pt2X4(CH2CH2)2(pz)] (II). The 1H NMR spectra reveal that the pyrazine in type (I) complexes is fluxional since the aromatic proton resonance is a singlet. The value of JPtH is consistent with trans-coordination. IR bands are assigned by deuteration of the ethylene and pyrazine and by varying the coordinated halide. The antisymmetric νPtC2 band occurs near 470 cm−1 while νPtN is near 200 cm−1. In type (II) complexes the infrared-forbidden symmetric νPtC2 band is observed near 400 cm−1 while νPtN is strongly halogen-dependent. The electronic spectra reveal a X− → Pt2+ charge transfer band at 240 nm and a combined π → π∗ (pyrazine) and π → π∗ (ethylene) band near 270 nm. The 5d → π∗ (pz) and 5d → π∗ (ethylene) transitions yield a broad envelope in the spectra of type (I) complexes near 320 nm. This becomes resolved into two components in type (II) spectra.Journal of Molecular Structure 01/1983; · 1.40 Impact Factor
Article: The feasibilities of TruScreen for primary cervical cancer screening: a self-controlled study.[Show abstract] [Hide abstract]
ABSTRACT: OBJECTIVE: Screening programs based on cytology testing led to the incidence reduction of cervical cancer mortality of about 70-80 % in industrialized countries. However, these favorable results have not been replicated in developing areas. Thus, we aim to evaluate the efficacy of TruScreen (Polartechnics, Sydney, Australia) in detecting of precancerous lesions in comparison with cervical cytology test. METHODS: A total of 181 outpatients were screened by TruScreen using the pathological results as the gold standard. The medical records of cytological smear within 6 weeks were obtained from 169 of these participants. The reliability and yield of TruScreen and cytological smear were assessed. The screening results of TruScreen were compared with those obtained from the conventional smear. RESULTS: The sensitivities for histologically confirmed cervical intraepithelial neoplasia (CIN) lesions by TruScreen and Pap, were 67.4 % (95 % CI 53.4-81.5) and 87.9 % (95 % CI 76.7-99.0), respectively. The specificities for histologically confirmed CIN lesions by TruScreen and Pap, were 68.1 % (95 % CI 60.3-75.9) and 74.3 % (95 % CI 70.0-81.4), respectively. In contrast to Pap smear, TruScreen was comparatively efficacious in screening of cervical cancer (χ (2) = 0.0133, P = 0.9081). CONCLUSION: TruScreen is a potential test for initial cervical screening in developing world regions.Archives of Gynecology 01/2013; · 0.91 Impact Factor
Article: Prevalence of cervical intraepithelial neoplasia (CIN) in patients attending Minia Maternity University Hospital.[Show abstract] [Hide abstract]
ABSTRACT: Cervical cancer is the second most common cancer of the genital tract. Wide use of screening programs can help in prevention of cervical cancer. To screen and evaluate the prevalence of cervical intraepithelial neoplasia (CIN) by visualization of the cervix after application of 5 % acetic acid (VIA) in Minia Maternity University Hospital. The study included 3,600 women from outpatient clinics of Minia Maternity University Hospital. They were screened for cervical cancer with the use of visual inspection of the cervix after application of 5 % acetic acid (VIA). Positive cases were subjected to colposcopy after referral to the colposcopy unit in the same hospital. Colposcopy-guided biopsies were done for colposcopic positive patients. One hundred and twenty women with negative VIA as control were randomly examined with colposcopy to evaluate the effectiveness of the test used, and no cases experienced cervical lesion. The prevalence was 5.8 % for cervical lesions, 1.4 % for HPV infection alone, 3.3, 0.84 and 0.27 % for CIN I, CIN II and CIN III, respectively. The prevalence of CIN II or higher was 1.11 % (40/3,600). Prevalence of CIN in the study population was 138 out of 1,800 cases (7.7 %). Pre-invasive high-grade lesions represent 1.3 % in participant women. VIA can be used in national programs for cervical cancer screening.Archives of Gynecology 12/2013; · 0.91 Impact Factor
Page 1
Determinants of VIA (Visual Inspection of the Cervix After Acetic
Acid Application) Positivity in Cervical Cancer Screening of
Women in a Peri-Urban Area in Andhra Pradesh, India
Haripriya Vedantham1, Michelle I. Silver2, B. Kalpana1, C. Rekha1, B.P. Karuna1, K.
Vidyadhari1, S. Mrudula1, Brigitte M. Ronnett4, K. Vijayaraghavan1, Gayatri Ramakrishna5,
Pavani Sowjanya5, Shantha Laxmi5, Keerti V. Shah3, and Patti E. Gravitt2,3 for the CATCH
Study Team
1SHARE INDIA, Mediciti Institute for Medical Sciences, Ghanpur, India 2Department of
Epidemiology, Johns Hopkins Bloomberg School of Public Health 3Department of Molecular
Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health 4Departments of
Pathology and Gynecology and Obstetrics, Johns Hopkins University School of Medicine and
Hospital, Baltimore, Maryland 5Center for DNA Fingerprinting and Diagnostics, Hyderabad, India
Objectives—Visual inspection of the cervix after acetic acid application (VIA) is widely
recommended as the method of choice in cervical cancer screening programs in resource-limited
settings because of its simplicity and ability to link with immediate treatment. In testing the
effectiveness of VIA, human papillomavirus DNA testing, and Pap cytology in a population-based
study in a peri-urban area in Andhra Pradesh, India, we found the sensitivity of VIA for detection of
cervical intraepithelial neoplasia grade 2 and worse (CIN2+) to be 26.3%, much lower than the 60%
to 90% reported in the literature. We therefore investigated the determinants of VIA positivity in our
study population.
Methods—We evaluated VIA positivity by demographics and reproductive history, results of
clinical examination, and results from the other screening methods.
Results—Of the 19 women diagnosed with CIN2+, only 5 were positive by VIA (positive predictive
value, 3.1%). In multivariate analysis, VIA positivity (12.74%) was associated with older age,
positive Pap smear, visually apparent cervical inflammation, and interobserver variation. Cervical
inflammation of unknown cause was present in 21.62% of women. In disease-negative women,
cervical inflammation was associated with an increase in VIA positivity from 6.1% to 15.5% (P <
0.001). Among the six gynecologists who performed VIA, the positivity rate varied from 4% to 31%.
Conclusions—The interpretation of VIA is subjective and its performance cannot be readily
evaluated against objective standards.
© 2010 American Association for Cancer Research.
Corresponding Author: Patti E. Gravitt, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 North
Wolfe Street, E6148, Baltimore, MD 21205. Phone: 443-287-6179; Fax: 410-955-1383. email@example.com.
Note: Members of the CATCH Study Team are listed in Supplementary, data, available at Cancer Epidemiology, Biomarkers &
Prevention Online (http://cebp.aacrjournals.org/).
Disclosure of Potential Conflicts of Interest
Patti E. Gravitt, member of the Women's Health Scientific Advisory Board, Quiagen, Inc. No other potential conflicts of interest were
NIH Public Access
Author Manuscript
Cancer Epidemiol Biomarkers Prev. Author manuscript; available in PMC 2011 May 1.
Published in final edited form as:
Cancer Epidemiol Biomarkers Prev. 2010 May ; 19(5): 1373–1380. doi:10.1158/1055-9965.EPI-09-1282.
NIH-PA Author Manuscript
NIH-PA Author Manuscript
NIH-PA Author Manuscript
Page 2
Impact—VIA is not a robust screening test and we caution against its use as the primary screening
test in resource-limited regions.
The much higher incidence of cervical cancer in developing nations, as compared with that in
developed nations, has been ascribed to the fact that it has been possible to maintain effective
Pap smear screening programs in the developed world but not in the developing world (1). An
effective Pap smear screening program requires many consecutive steps, including (a) the
collection in the clinic of cells from the transformation zone of the cervix and the endocervix,
(b) smearing the cells on a slide and fixing them, (c) staining and reading the slide by a
cytopathologist, (d) transmitting the cytology results to the health care provider, (e)
communicating the cytology results to the woman and arranging for a second visit if the smear
is abnormal, and (f) a second visit by the woman for additional tests (e.g., colposcopy and
cervical biopsy) or for treatment. The infrastructure required for all these steps has not been
available in the developing world and there has been a strong need for a screening test that is
simpler and can be interpreted immediately and combined with treatment, if necessary, at the
initial screening visit.
Visual inspection of the cervix after acetic acid application (VIA) has long been regarded as
the most promising method for screening in resource-limited settings (2,3). VIA is performed
by a trained health care provider who applies a 3% to 5% acetic acid solution to the cervix and
then observes the transformation zone of the cervix for 1 to 2 minutes for acetowhite epithelium,
which is thought to be indicative of abnormal cellular changes (4). In most instances, the VIA-
positive woman can be treated at the same visit with cryotherapy to ablate the transformation
zone. Both VIA and cryotherapy can be conducted in the field, thus eliminating the need for a
clinic visit altogether. This procedure has many advantages: it can be performed by a trained
paramedical worker; it needs simple equipment; the results are immediately available; and
treatment, if needed, can be provided at the same visit.
We conducted a population-based study of human papillomavirus (HPV) infections and
cervical cancer in Medchal Mandal, a peri-urban area near Hyderabad, in Andhra Pradesh,
India.6 A major goal of the study was to examine which screening methods are most effective
when applied in a typical peri-urban Indian setting. We compared VIA, cervical cytology, and
an HPV DNA assay [Qiagen's Digene hybrid capture 2 (hc2) test] for detection of cervical
intraepithelial neoplasia grades 2 and 3 and cervical cancer (CIN2+). The sensitivity of VIA
for detection of CIN2+ in our study, based on women who were fully evaluated, was 26.3%,
a value much lower than those reported in the literature. In contrast, performances of cervical
cytology (sensitivity, 63.2%) and HPV DNA screening (sensitivity, 84.2%) were comparable
to previous reports (5,6). The sensitivity estimates were lower for all three assays when they
were adjusted for verification bias.
To better understand the causes for the poor performance characteristics observed for VIA, we
have conducted an analysis to identify possible determinants of VIA positivity in our
6Gravitt et al., manuscript in preparation.
Vedantham et al. Page 2
Cancer Epidemiol Biomarkers Prev. Author manuscript; available in PMC 2011 May 1.
NIH-PA Author Manuscript
NIH-PA Author Manuscript
NIH-PA Author Manuscript
Page 3
Materials and Methods
Study design and participants
Community Access to Cervical Health, or CATCH, is a population-based screening study in
Medchal Mandal, a peri-urban area near Hyderabad, in the state of Andhra Pradesh, India. The
study aimed to enroll all eligible women, 25 years and older, who were not pregnant and had
not had a hysterectomy (7). Details of the study are presented elsewhere (manuscript
submitted). In brief, a total of 2,331/5,603 (41.6%) eligible women were enrolled between
January 2005 and July 2007. Participants consented to an interviewer-administered
questionnaire and also provided biological specimens. The participants were screened by Pap
smear and HPV DNA testing of a physician-collected cervical swab, as well as by VIA. Twenty
percent of the women enrolled were randomly selected to receive colposcopy on the day of
enrollment regardless of test results to allow adjustment for verification bias. All women found
to have one or more positive tests (n = 582) were invited back for a second visit for colposcopic
examination and biopsy where indicated. Compliance with colposcopic follow-up was 66%.
The study protocol was approved by the Institutional Review Boards in India (SHARE
Research/Mediciti Institute of Medical Sciences, Ghanpur, Andhra Pradesh) and in Baltimore
(Johns Hopkins Bloomberg School of Public Health).
Using interviewer-administered standardized questionnaires, we collected basic demographic
information including age, educational attainment, occupation, religion, family income, and
other socioeconomic status markers including total members of household, number of rooms
in household, inside toilet/running water, type of cooking fuel, and whether cooking was done
indoors or out. We also assessed prior cervical cancer screening history and presence of
gynecologic symptoms, a detailed reproductive and contraceptive use history, and current and
past tobacco use and exposure to passive smoke.
In keeping with our aim to evaluate the performance of the screening tests in a typical peri-
urban Indian setting, we sought only readily available resources for training. Master's level
technicians were trained for 3 to 5 days to perform the hc2 test by the digene representative
for India. Three experienced cytologists reviewed all Pap smears, and equivocal results were
arbitrated by consensus. A 1-week refresher training on the Bethesda System was provided to
the senior pathologist at Johns Hopkins Medical Institutions. A total of seven gynecologists
performed VIA over the study period. All of these had prior GYN clinical experience with
varying degrees of postgraduate training as well. Initially, two of the study gynecologists
(gynecologists 1 and 5) received hands-on training at the Tata Memorial Centre Rural Cancer
Project in Barshi, Maharastra State, India, which has conducted extensive VIA screening
programs in collaboration with the IARC (8,9). These gynecologists trained the remaining four
study gynecologists using the complementary JHPIEGO training handbook "Cervical Cancer
Prevention Guidelines for Low-Resource Settings" with accompanying CD-ROM of cervical
images (10).
Vaginal and cervical swabs for HPV DNA testing were collected as described (7). The hc2
assay was done according to the manufacturer's instructions. Any sample with ≥1.0 relative
light unit per control sample was considered positive for HPV DNA.
Pap smears were collected by spatula and endocervical brush, smeared onto a glass slide, and
fixed in ethanol. A standardized data collection form was used to document results of the
cervical cytology, including the final cytologic diagnosis based on the Bethesda System (11).
A cytologic abnormality of atypical squamous cells-undetermined significance (ASC-US) or
Vedantham et al.Page 3
Cancer Epidemiol Biomarkers Prev. Author manuscript; available in PMC 2011 May 1.
NIH-PA Author Manuscript
NIH-PA Author Manuscript
NIH-PA Author Manuscript
Page 4
more severe diagnosis was considered to be a positive Pap screening result. Inflammatory
changes were frequently present in Pap smears and were noted in the data form. The presence
of inflammation in the Pap smears was evaluated as a risk factor for VIA positivity.
Using standard interpretation guides, a positive VIA outcome was defined as "sharp, distinct,
well-defined, dense (opaque, dull, or, oyster white) acetowhite areas with or without raised
margins, abutting the squamocolumnar junction in the transformation zone" or "strikingly
dense acetowhite areas in the columnar epithelium" or "condyloma and leukoplakia occurring
close to the squamocolumnar junction turning intensely white" 1 minute after the application
of a 5% acetic acid solution.
A separate standardized data collection form was used by the gynecologist who performed the
screening to document any visible abnormalities of the external genitalia, vagina, and cervix.
We defined cervical inflammation as visibly apparent erythema, edema, and/or bleeding on
contact. All women with a positive test result on any one or more of the screening tests were
invited back for a second visit for colposcopy (and directed biopsy where indicated). Biopsies
were reviewed by the local pathologists, with a final review by an experienced gynecologic
pathologist at Johns Hopkins Medical Institutions (JHMI). A histologic diagnosis of CIN2+
was required to classify the woman as a case. The JHMI diagnosis was used as a final case
definition for this analysis.
Data analysis
Sensitivity and specificity estimates for each screening assay were calculated. Crude estimates
excluded any woman who did not have the opportunity for full diagnostic verification (i.e.,
women who screened negative and were not randomized to immediate colposcopy, as well as
referred women who refused colposcopy and/or biopsy). We also calculated verification bias–
adjusted estimates using inverse-probability weighting, applying observed disease prevalence
among women with colpo-biopsy results to the full cohort. Specifically, we estimated a
sampling weight for each of 16 sampling strata defined by the eight combinations of Pap, VIA,
and HPV test results (e.g., +++, ++−,…, −+, −), combined with the two strata of whether a
colposcopy was done, and a biopsy was done when indicated. Univariate analyses to assess
the distribution of VIA results with demographic and clinical exam variables were conducted
using χ2 tests. We used logistic regression to estimate odds ratios and 95% confidence intervals.
Multivariate logistic regression was used to estimate the independent association of each
covariate with the outcome by adjusting for potential confounding variables. Final variable
selection was done using a backward stepwise elimination process. A P value of ≤0.05 was
considered significant. All analyses were conducted using STATA version 10.0.
We did not set an upper age eligibility for participation in our study because we felt that all
women over age 25 may benefit from the comprehensive screening using three different
strategies. However, we recognize that programs designed around visual strategies were not
intended for women over age 50 to 55 years. When we restricted our analysis to women age
25 to 50 years, our results did not change; therefore, the unrestricted analyses are presented.
The population characteristics are summarized in Table 1. The women ranged in age from 25
to 85 years; about 64% were <40 years old. Almost 70% of the women reported not having
any formal education. A large majority (87%) was currently married. Few women (a little more
than 1%) reported having had a previous Pap smear.
Almost 32% of women had an abnormal result in at least one of the three screening tests, but
less than 1% had an abnormal result in all three tests (Table 2). The distribution of the women
Vedantham et al. Page 4
Cancer Epidemiol Biomarkers Prev. Author manuscript; available in PMC 2011 May 1.
NIH-PA Author Manuscript
NIH-PA Author Manuscript
NIH-PA Author Manuscript
Page 5
by the results of all three assays and the distribution of the 19 women who were identified as
having CIN2+ by their test results are shown in Table 3. Only 5 of the 19 women with CIN2
+ were VIA positive (26.3%), as compared with 12 women who were Pap smear positive
(63.2%) and 16 women who were HPV positive (84.2%).
Correlates of VIA positivity
The demographic and clinical correlates of VIA positivity in a univariate analysis are shown
in Table 1. Exposures that were collected but not represented in the table were explored and
found to have no association with VIA results. Univariately, VIA positivity was significantly
correlated with age over 60 years; Christian or Hindu religion; less education; being divorced,
widowed, or separated; visually apparent cervical inflammation; positive Pap smear; the
gynecologist conducting the VIA test; microscopically evident inflammation in the Pap smear;
and diagnosis of CIN2+. In multivariate analysis (Table 4), age over 60 years, positive Pap
smear, visually apparent cervical inflammation, and variation in positivity rates between
gynecologists remained significantly correlated with VIA positivity.
As expected, VIA positivity was associated with positivity in the other two screening tests,
although the association was stronger for Pap than for hc2 (Table 1). Specifically, VIA
positivity was seen in 16.3% of the 240 HPV-positive women as compared with 12.4% of the
HPV-negative women (P = 0.085), and in 17.7% of the 344 Pap-positive women as compared
with 11.9% of the Pap-negative women (P = 0.003). VIA was also more likely to be positive
in the 19 women with CIN2+ (26.3%) as compared with women without CIN2+ (8%; P =
Visually apparent cervical inflammation was seen in 504 (21.6%) women. We inquired if
cervical inflammation increased the rate of VIA positivity in disease-negative women. Of the
2,331 women in the study, 19 were diagnosed with CIN2+, and 362 test-positive women either
did not undergo colposcopy or refused a biopsy at colposcopy. After exclusion of these women,
the remaining 1,950 women were considered disease negative. In this group, VIA positivity
was 15.5% in women with inflammation and 6.1% in women without inflammation (P < 0.001;
Table 5). In contrast, neither Pap nor HPV test positivity was significantly increased among
women with clinical evidence of cervical inflammation compared with uninflamed women
(9.8% versus 7.5% and 8.3% versus 5.8% for Pap and HPV tests, respectively). Thus, cervical
inflammation seems to have contributed to the increase in false-positive VIA test results
observed in our study, likely a result of acetowhite staining of metaplastic cells, which are
common during the healing that follows robust inflammatory responses. Among the 19 disease-
positive women, cervical inflammation was present in 11 (57.9%). VIA was positive in 3 of
11 (27.3%) women with cervical inflammation and in 2 of 8 (25.0%) women without cervical
inflammation. These numbers were too small to determine the effect of inflammation on the
diagnostic accuracy of VIA in disease-positive women.
Finally, there was a marked variation in the rates of VIA positivity among the six gynecologists
who conducted the examinations (Table 4). VIA positivity ranged from a low of 4% for two
gynecologists to a high of 18% for one gynecologist and 31% for another gynecologist. The
greatest variation was between providers 1 and 5, the two providers who had received the most
training. Among women who were satisfactorily colposcoped, only five VIA-positive women
were identified as disease positive. For quality assurance for a VIA provider in our study, we
would have liked to know how well her VIA results matched the final microscopic diagnosis
of CIN2+. However, it was not possible to examine in a timely manner how the VIA results
of an individual observer matched the final diagnosis of CIN2+ made many weeks after the
initial visit.
Vedantham et al. Page 5
Cancer Epidemiol Biomarkers Prev. Author manuscript; available in PMC 2011 May 1.
NIH-PA Author Manuscript
NIH-PA Author Manuscript
NIH-PA Author Manuscript
Page 6
The results of the VIA screening in our population were disappointing. If we had followed the
frequently proposed guidelines (10,12) of using VIA as the primary and sole screening test and
offered cryotherapy to VIA-positive women, we would have performed more than 200
cryotherapies for possible benefit to only five of these women. Furthermore, if VIA had been
used as the only screening assay in our population, we would have missed 14 of the 19 women
(73.7%) who had cervical cancer precursor lesions. We have therefore closely examined why
the test was so ineffective in our population and have also evaluated our results in the context
of performance of VIA screening in previous investigations.
In univariate analyses of the determinants of VIA positivity, we found that, as expected, VIA
positivity was associated with Pap smear abnormality, the diagnosis of CIN2+, and HPV
positivity, confirming that the test results were related to HPV-caused disease. However, we
also found two other variables unrelated to CIN2+ diagnosis that were strongly associated with
VIA positivity in both univariate and final multivariate analyses. One was variation in positivity
rates between observers and the other was visually apparent clinical inflammation of the cervix.
The marked observer variation raises the question of whether the test providers were adequately
trained. Many previous reports have stressed the importance of training the test providers (5,
8,13). As described in Materials and Methods, the test providers in our study were all
gynecologists with significant clinical experience and they had closely followed the Cervical
Cancer Prevention Guidelines for Low-Resource Settings competency-based training tool
prepared by JHPIEGO (10). Specifically, two health providers were trained at a centralized
expert facility and served as local "master trainers" for the rest of the gynecologic study staff.
Yearly refreshers by an expert gynecologist from New Delhi were provided. Recommendations
suggest that these refresher visits use indicators to assess program performance and also
incorporate performance standards to assess individual performance through on-site
observation. Programmatic indicators cannot be assessed until a substantial proportion of
women are screened. The key areas of the on-site assessment of the provider's performance
are (a) the ability to correctly delineate the extent of the acetowhite lesions and (b) to make
appropriate case management recommendations. We used the provided CD-ROM images to
assess step a; however, proper assessment of step b is not feasible in real time, and with low
disease prevalence would require screening of our entire population size before sufficient
numbers of cases are available to make this assessment. Specifically, tissue specimens of
suspect lesions are not collected before cryotherapy, and thus it would not be possible to
monitor how well an individual provider's VIA diagnosis matches the pathologic diagnosis in
a time frame that would allow immediate intervention including retraining. Thus, although the
steps for quality assurance proposed by JHPIEGO (e.g., conducting image review exercises
and co-assessments between the health provider and the quality control monitor) may decrease
interobserver variation, it is hard to see how they would improve the diagnostic accuracy of
the assay. In any case, it is unlikely that community-based programs in resource-poor settings
will have health providers for VIA-based screening who are better trained than those in our
Clinical inflammation of the cervix (erythma, edema, bleeds easily) was present in 21.6% of
the women. In these women, VIA positivity was recorded in 23.6%, compared with 9.7% of
women without cervical inflammation. An examination of VIA in disease-negative women
showed that inflammation led to more than twice the rate of false-positive VIA. Our results
were similar to those in a recent study of women in rural El Salvador. Inflammation graded by
microscopic examination of cervical biopsy was present in 74% of these women, and among
women who had no cervical neoplasia, inflammation was associated with twice the rate of VIA
positivity (14).
Vedantham et al. Page 6
Cancer Epidemiol Biomarkers Prev. Author manuscript; available in PMC 2011 May 1.
NIH-PA Author Manuscript
NIH-PA Author Manuscript
NIH-PA Author Manuscript
Page 7
A previous study that examined whether "false positive" VIA results were associated with
specific genital tract infections other than HPV (e.g., Chlamydia trachomatis and
Trichomonas) found no evidence for such an association (3). We inquired if more ubiquitous
latent herpesvirus infections commonly detected in the cervical epithelium (15–17) might be
a plausible cause of the relative nonspecificity of the VIA results.7 Although we detected EBV
and cytomegalovirus DNA at the cervix of the patients (20.4% and 25.7%, respectively), these
infections were not correlated with VIA reactivity. The high geographic variability in the
prevalence of cervical inflammation and the inability to identify a responsible infectious agent
could be expected to contribute to poor reproducibility of VIA performance across broad
Our estimate of 26.3% sensitivity for detection of CIN2+ is among the lowest recorded for
VIA. However, previous reports typically show a wide range of sensitivities for the assay. In
the 11 studies conducted in Africa and India by the IARC with a common training protocol
and test definition, one would have expected a narrow range in estimates of sensitivity.
However, the sensitivity of VIA for the detection of CIN2+ in these studies varied widely,
from a high of 91% to a low of 61% (6). Variability in VIA sensitivity is even more extreme
when comparing across study protocols. For example, in the multicenter Latin American
Screening study (18), the sensitivity of VIA for CIN2+ was 50%. In the TATI study in Peru,
the sensitivity of VIA for severe dysplasia was 48% (19). In an early study in the United States,
the sensitivity of VIA for CIN2+ was 29% (20). In a review of 17 cross-sectional studies, VIA
positivity rates varied from 3% to 53% (21). In their discussion about the validity of screening
tests, Mahe and Gaffikin (21) list a number of reasons for the observed heterogeneity in VIA
sensitivity estimates. These include lack of a standardized test definition, differences in training
and skills of the test providers, underlying prevalence of other sexually transmitted infections,
lack of uniformity in application of gold standard for disease definition, and absence of
blinding. The results of the analyses presented here are consistent with the multifactorial causes
of variability in VIA test performance and suggest that a large part of the observed variation
was due to factors other than disease prevalence.
The large recently completed intervention trial in Osmanabad India, in which screenings by
VIA, cytology, and HPV were compared for their ability to reduce the incidence of advanced
cervical cancer and associated mortality, provides a possible example of the difficulties in
interpreting VIA results even when VIA is used in the best possible circumstances. In the initial
report of this investigation (8), the three assays were judged to be functioning equally well in
detecting cervical cancers and precancers. However, in the final evaluation, screening with
VIA (or with Pap smear) was reported to be ineffective in reducing the incidence of advanced
cervical cancer and associated mortality (9). In contrast, HPV screening reduced the incidence
of advanced cervical cancers and associated mortality by about 50%. Women positive in any
of the three tests were managed in the same way. Therefore, it is very likely that the poor
performance of VIA (and of cytology) in the final analysis was due to their lower sensitivity
in identifying women with cervical cancer precursors or cervical cancer, and that the earlier
interpretation of equivalent sensitivity of VIA and the HPV assay was incorrect. This collective
evidence thus confirms the high degree of variability in diagnostic accuracy for the subjective
VIA test, which is not substantially reduced even when using common protocols and training
The positive predictive value (PPV) for VIA in our study was 3.1%, implying that if we were
performing cryotherapy for all VIA-positive women, we would be conducting 32 unnecessary
cryotherapies for each necessary cryotherapy. This estimate for PPV is one of the lowest
reported, but low estimates are not uncommon in previous studies. In the 11 IARC-guided
7Gravitt and Silver, unpublished data.
Vedantham et al. Page 7
Cancer Epidemiol Biomarkers Prev. Author manuscript; available in PMC 2011 May 1.
NIH-PA Author Manuscript
NIH-PA Author Manuscript
NIH-PA Author Manuscript
Page 8
studies (6), the PPVs ranged from 3.8% to 22.5%. The PPV estimate in LAMS study was 6.6%
(18), and in the TATI study, 6.5% (19). In the Osmanabad study the PPV was 7.4% (9),
implying 13 unnecessary cryotherapies for each necessary cryotherapy, assuming that all VIA-
positive women were treated with cryotherapy. It should be noted that under all of the above
scenarios, a large majority of the women given cryotherapy will not have disease and that this
is contrary to what is implied in the ACCP fact sheet (12) that under this scheme, only an
"occasional" screen-positive disease-negative woman would be treated by cryotherapy.
We conclude that VIA screening is not robust enough for primary screening in under-resourced
regions. Modified or more intensive training efforts are unlikely to result in substantial
improvements and are impractical to implement on a broad scale. The 2009 ACCP fact sheet
(22), released in response to the data from the Osmanabad Study (9), recommends that until
HPV testing becomes feasible and affordable, programs should consider introducing or
expanding VIA plus cryotherapy as a cervical cancer prevention strategy. We caution against
the adoption of this approach, which may result in a large number of unnecessary cryotherapies
with minimal clinical benefit. Although we recognize that more effective alternative strategies
such as affordable HPV DNA testing (23) are not likely to be available for another 2 to 3 years,
adopting a "something is better than nothing" approach in the interim risks entrenchment of
an ineffective program and possible loss of public confidence.
Grant Support
INDO-US collaborative program of Department of Biotechnology, Ministry of Science and Technology, Government
of India and the NIH, United States (BT/IN/US/CRHR/PP/2002), and the NIH Specialized Programs of Research
Excellence (P50 CA98252).
1. Denny L, Quinn M, Sankaranarayanan R. Chapter 8: Screening for cervical cancer in developing
countries. Vaccine 2006;24:S71–S77.
2. Visual inspection with acetic acid for cervical-cancer screening: test qualities in a primary-care setting.
Lancet 1999;353:869–873. [PubMed: 10093978]
3. Denny L, Kuhn L, Pollack A, Wright TCJR. Direct visual inspection for cervical cancer screening: an
analysis of factors influencing test performance. Cancer 2002;94:1699–1707. [PubMed: 11920531]
4. Sankaranarayanan, R.; Wesley, R. A practical manual on visual screening for cervical neoplasia.
France: IARC; 2003.
5. Wright TC Jr. Chapter 10: Cervical cancer screening using visualization techniques. J Natl Cancer Inst
Monogr 2003;2003:66–71. [PubMed: 12807948]
6. Arbyn M, Sankaranarayanan R, Muwonge R, et al. Pooled analysis of the accuracy of five cervical
cancer screening tests assessed in eleven studies in Africa and India. Int J Cancer 2008;123:153–160.
[PubMed: 18404671]
7. Sowjanya AP, Paul P, Vedantham H, et al. Suitability of self-collected vaginal samples for cervical
cancer screening in periurban villages in Andhra Pradesh, India. Cancer Epidemiol Biomarkers Prev
2009;18:1373–1378. [PubMed: 19423518]
8. Sankaranarayanan R, Nene BM, Dinshaw KA, et al. A cluster randomized controlled trial of visual,
cytology and human papillomavirus screening for cancer of the cervix in rural India. Int J Cancer
2005;116:617–623. [PubMed: 15818610]
9. Sankaranarayanan R, Nene BM, Shastri SS, et al. HPV screening for cervical cancer in rural India. N
Engl J Med 2009;360:1385–1394. [PubMed: 19339719]
10. Blumenthal, PD.; McIntosh, N. Cervical cancer prevention guidelines for low-resource settings.
Baltimore: JHPIEGO; 2005.
Vedantham et al.Page 8
Cancer Epidemiol Biomarkers Prev. Author manuscript; available in PMC 2011 May 1.
NIH-PA Author Manuscript
NIH-PA Author Manuscript
NIH-PA Author Manuscript
Page 9
11. Solomon, D.; Nayar, R. The Bethesda System for reporting cervical cytology: definitions, criteria,
and explanatory notes. 2nd ed.. New York: Springer; 2004.
12. ACCP. Cervical cancer prevention fact sheet. 2007;Vol. 2009
13. Blumenthal PD, Lauterbach M, Sellors JW, Sankaranarayanan R. Training for cervical cancer
prevention programs in low-resource settings: focus on visual inspection with acetic acid and
cryotherapy. Int J Gynecol Obstet 2005;89:S30–S37.
14. Davis-Dao CAMS, Cremer MMDMPH, Felix JMD, Cortessis VKP. Effect of cervicitis on visual
inspection with acetic acid [article]. J Lower Genital Tract Dis 2008;12:282–286.
15. Taylor Y, Melvin WT, Sewell HF, Flannelly G, Walker F. Prevalence of Epstein-Barr virus in the
cervix. J Clin Pathol 1994;47:92–93. [PubMed: 8132820]
16. Gradilone A, Vercillo R, Napolitano M, et al. Prevalence of human papillomavirus, cytomegalovirus,
and Epstein-Barr virus in the cervix of healthy women. J Med Virol 1996;50:1–4. [PubMed: 8890032]
17. Broccolo F, Cassina G, Chiari S, et al. Frequency and clinical significance of human β-herpesviruses
in cervical samples from Italian women. J Med Virol 2008;80:147–153. [PubMed: 18041029]
18. Sarian LO, Derchain SF, Naud P, et al. Evaluation of visual inspection with acetic acid (VIA), Lugol's
iodine (VILI), cervical cytology and HPV testing as cervical screening tools in Latin America. This
report refers to partial results from the LAMS (Latin AMerican Screening) study. J Med Screen
2005;12:142–149. [PubMed: 16156945]
19. Almonte M, Ferreccio C, Winkler JL, et al. Cervical screening by visual inspection, HPV testing,
liquid-based and conventional cytology in Amazonian Peru. Int J Cancer 2007;121:796–802.
[PubMed: 17437272]
20. Slawson DC, Bennett JH, Herman JM. Harrisburg Area Research Network. Are Papanicolaou smears
enough? Acetic acid washes of the cervix as adjunctive therapy: a HARNET study. J Fam Pract
1992;35:271–277. [PubMed: 1517723]
21. Mahe C, Gaffikin L. Screening test accuracy studies: how valid are our conclusions? Application to
visual inspection methods for cervical screening. Cancer Causes Control 2005;16:657–666.
[PubMed: 16049804]
22. ACCP. Cervical cancer prevention fact sheet. 2009;Vol. 2009
23. Sellors JW, Eder PS, et al. A new HPV-DNA test for cervical-cancer screening in developing regions:
a cross-sectional study of clinical accuracy in rural China. Lancet Oncol 2008;9:929–936. [PubMed:
Vedantham et al. Page 9
Cancer Epidemiol Biomarkers Prev. Author manuscript; available in PMC 2011 May 1.
NIH-PA Author Manuscript
NIH-PA Author Manuscript
NIH-PA Author Manuscript
Page 10
NIH-PA Author Manuscript
NIH-PA Author Manuscript
NIH-PA Author Manuscript
Vedantham et al.Page 10
Table 1
Demographic characteristics, summary of screening results, and association with VIA positivity (χ2)
n (%)*
VIA pos,
n (%)
Age (y)
25–29 659 (28.7)67 (10.17)0.002
30–34460 (20.0) 63 (13.70)
35–39 351 (15.3)45 (12.82)
40–44256 (11.2) 30 (11.72)
45–49 199 (8.7) 28 (14.07)
50–54 131 (5.7) 18 (13.74)
55–60 106 (4.6)13 (12.26)
60+133 (5.8)33 (24.81)
Hindu2,023 (86.8)251 (12.41)0.046
Muslim99 (4.3) 8 (8.08)
Christian 208 (8.9)38 (18.27)
Other1 (0.04) 0 (0.00)
Education (y)
None1,606 (69.4) 221 (13.76)0.048
1–8 435 (18.8) 53 (12.18)
9+272 (11.8) 23 (8.46)
Marital status
Married 2,003 (86.7)242 (12.08) 0.028
308 (13.3)51 (16.56)
Cervical inflammation†
Absent1,827 (78.4)178 (9.74)<0.001
Present 504 (21.6)119 (23.61)
Had previous
Pap smear
No 2,233 (95.5)286 (12.87)0.654
Yes27 (1.2)2 (7.41)
Don't know79 (3.4)9 (11.39)
Gynecologist seen‡
1 624 (26.8)24 (3.85) <0.001
36 (0.3)0 (0.00)
4 734 (31.5) 98 (13.35)
5313 (13.4) 97 (30.99)
6277 (11.9)49 (17.69)
7253 (10.9)24 (9.49)
8 123 (5.3)5 (4.07)
Cancer Epidemiol Biomarkers Prev. Author manuscript; available in PMC 2011 May 1.
Page 11
NIH-PA Author Manuscript
NIH-PA Author Manuscript
NIH-PA Author Manuscript
Vedantham et al.Page 11
n (%)*
VIA pos,
n (%)
Absent 1,471 (63.1) 170 (11.56)0.025
Present860 (36.9)127 (14.77)
Pap smear║
Negative1,987 (85.2) 236 (11.88)0.003
Positive344 (14.8) 61 (17.73)
Hybrid capture 2
Negative2,091 (89.7) 258 (12.43)0.085
Positive 240 (10.3)39 (16.25)
Negative1,950 (99.0)155 (7.95) 0.004
Positive 19 (0.96)5 (26.32)
*Total numbers do not add to 2,331 because of missing data. Specifically, 36 women missing age, 18 women missing education, 20 women missing
marital status, 2 women missing Pap history, 1 woman missing gynecologist seen.
†Cervical inflammation indicates erythema, edema, or bleeds on contact.
‡Gynecologist no. 2 saw patients only during the pilot phase of the project, which is not reported here.
§Inflammation recorded as present if Pap report noted partially or totally obscuring inflammation.
║Pap smear negative, normal/reactive atypia; positive, ASC-US or more severe diagnosis.
¶Women who were referred but did not attend colpo and women who refused biopsy were excluded (n = 362).
Cancer Epidemiol Biomarkers Prev. Author manuscript; available in PMC 2011 May 1.
Page 12
NIH-PA Author Manuscript
NIH-PA Author Manuscript
NIH-PA Author Manuscript
Vedantham et al. Page 12
Table 2
Screening test positive prevalence and combination of test results
Screening test or test
Test prevalence,
n (%)
Pap344 (14.76)
Any test positive 733 (31.45)
All tests positive16 (0.69)
All tests negative1,598 (65.55)
Cancer Epidemiol Biomarkers Prev. Author manuscript; available in PMC 2011 May 1.
Page 13
NIH-PA Author Manuscript
NIH-PA Author Manuscript
NIH-PA Author Manuscript
Vedantham et al. Page 13
Table 3
Distribution of the women by screening test results and disease status [n (%)]
297 (12.7)
2,043 (87.3)
61 (2.6)
236 (10.1)
283 (12.1)
1,751 (75.1)
16 (0.7)
45 (1.9)
23 (1.0)
213 (9.1)
48 (2.1)
235 (10.1)
153 (6.6)
1,598 (68.6)
No. of CIN2+ detected in each diagnostic test category among women receiving colposcopic examination: n/N (%)
4/11 (36.4)
1/16 (6.3)
6/29 (20.7)
2/131 (1.5)
5/106 (4.7)
1/304 (0.3)
Cancer Epidemiol Biomarkers Prev. Author manuscript; available in PMC 2011 May 1.
Page 14
NIH-PA Author Manuscript
NIH-PA Author Manuscript
NIH-PA Author Manuscript
Vedantham et al. Page 14
Table 4
Multivariate association of risk factors for VIA positivity (n = 2,288)
Variable OR (95% CI)Adj. OR (95% CI)
Age (y)
30–591.33 (0.99–1.79) 1.13 (0.83–1.55)
60+2.92 (1.83–4.65) 2.08 (1.25–3.47)
Pap outcome*
Positive1.32 (1.04–1.70)1.41 (1.00–1.98)
Cervical inflammation†
Present 2.86 (2.21–3.70)4.3 (3.16–5.86)
43.85 (2.43–6.10) 2.59 (1.61–4.16)
511.23 (6.99–18.02)13.79 (8.43–22.57)
65.37 (3.22–8.96) 6.13 (3.62–10.38)
7 2.62 (1.46–4.71)2.13 (1.17–3.89)
81.06 (0.40–2.83)1.04 (0.39–2.83)
NOTE: Data were mutually adjusted for all the variables in the model; 43 dropped due to missing data.
Abbreviations: OR, odds ratio; 95% CI, 95% confidence interval.
*Pap smear negative, normal/reactive atypia; positive, ASC-US or more severe diagnosis.
†Cervical inflammation indicates erythema, edema, or bleeds on contact.
‡Gynecologist no. 3 saw <10 patients, none of whom were VIA positive, and was therefore excluded from this analysis.
Cancer Epidemiol Biomarkers Prev. Author manuscript; available in PMC 2011 May 1.
Page 15
NIH-PA Author Manuscript
NIH-PA Author Manuscript
NIH-PA Author Manuscript
Vedantham et al. Page 15
Table 5
Distribution of positive test results among disease-negative women with and without inflammation (n = 1,950)
With inflammation (n = 386), n (%)*
Without inflammation (n = 1,564), n (%)
Pap+ 38 (9.8)118 (7.5) 0.136
*The percentage represents the proportion in each inflammation category with a positive screening test result (i.e., column percentages).
Cancer Epidemiol Biomarkers Prev. Author manuscript; available in PMC 2011 May 1.


text:
Monday. OK, we can get through this. I just need some coffee, and then I'll be on my way. I'll be OK. Everything is… Read more
Vienna has always been a city talented in turning the old into new. On its outskirts are gas silos that were reinvented… Read more
British artist Damien Hirst has just unveiled his latest exhibition at the White Cube Gallery in São Paulo. Titled… Read more
Whether you live in London or plan to visit over November and December, here are four things to do that are worthy of… Read more
Paris seems to have the answer to everything these days. Need a gourmet burger on the fly? Head on over to a food truck… Read more
While you'd be forgiven for thinking that the only thing noteworthy that happened this week was the world losing their… Read more
The holidays are fast approaching and so are the impending dinner parties for friends and family you're bound to host at… Read more
Lately I've been finding myself yearning to go back to Japan — partly because of the recent Tokyo Designers Week, and… Read more
A lot was happening in the world of design this week — here are some of our favorites: … Read more
It's around this time each year — as the occurrence of rain shifts from the occasional shower to a regularity — that I… Read more