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: 129 real Questions

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LPI LPIC-2 Exam 201 (Part

LPIC-2 201-450 apply assessments | killexams.com real Questions and Pass4sure dumps

enhance your LPIC-2 201-450 readiness with this app in accordance with bestselling Sybex examine lead with the aid of Steve Suehring. apply tests cowl a hundred% of exam aims.

apply exams QUESTIONS: 300+ useful result questions with in-depth explanations.multiple practice and mock tests to check your examination readiness. exams are randomly generated every time you Take the examine. Take regularly to be stronger prepared for the proper peek at various.

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The apply examine questions fully verify:1. ability Planning2. Linux Kernel3. system Startup4. Filesystem and Devices5. advanced Storage device Administration6. Networking Configuration7. materiel maintenance

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LPIC-2 ( exam codes 201-450 and 202-450 ) is the second certification in LPI’s multi-degree expert certification program. The LPIC-2 will validate the candidate's ability to administer wee to medium–sized blended networks. The candidate necessity to acquire an dynamic LPIC-1 certification to obtain LPIC-2 certification, but the LPIC-1 and LPIC-2 checks may well be taken in any order.

prerequisites: The candidate acquire to acquire an energetic LPIC-1 certification to obtain LPIC-2 certification, however the LPIC-1 and LPIC-2 tests could be taken in any order

about the AuthorSteve Suehring is an second Professor of Computing and novel Media applied sciences at university of Wisconsin – Stevens point. Steve has labored as an editor for LinuxWorld journal, and has written several books on a total lot of applied sciences, together with JavaScript, Linux protection, windows Server certifications, Perl, and others. Steve has worked at a expansive information superhighway issuer in each techniques engineering and protection roles, and has additionally worked at a Fortune a thousand commerce assisting to featuring architectural direction on a lot of initiatives.


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Following the depart well with of their events mission, they acquire updated their DumpsKey preparatory module for LPIC-2 (201) examination in line with the recent syllabus alterations made through 201-450. because the revised syllabus is focused on expanding your key capabilities, capabilities and advantage LPIC-2 (201) and capability planning and automation and logging systems, so is their exam Simulation. DumpsKey has organized an in depth record of issues that are introduced currently and which acquire been eliminated altogether from the older edition of the syllabus to be able to assist you to reside focused on the experience of your 201-450 certifications.

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Our skilled pool of specialists, researchers and instructors acquire cataloged and build collectively the checklist of questions that are without doubt asked within the examination of the novel syllabus. different essential tips just dote the prerequisite certification for the 201-450 LPIC-2 (201) the alterations within the query patterns and the rationalization of every query allows you to verify your electricity and education growth has been lined in the preparatory PDF. The PDF includes the newly collected examination dumps according to the up to date syllabus. together with the PDF version, DumpsKey preparatory simulator peek at various application has additionally been changed to accommodate the revision made with the aid of 201-450. It includes novel and updates shows, video clips, demonstration situations and straightforward illustration of network pastime in an pains to facilitate now not only your researching process however will additionally hone your backup & healing and LPIC-2 (201) advantage. together with the PDF version, their examination simulation has additionally been changed to accommodate the revision made via 201-450. It carries novel and updates displays, video clips; demonstration situations and simple illustration of system architecture.

 

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DumpsKey tremendously encourages its customers to test free visitation application earlier than deciding to buy them. only after being convinced, that you can resolve to purchase their exam fabric. DumpsKey additionally gives the money back guarantee if its test preparatory substances don’t champion you to be 201-450 certified professional in your very first effort. DumpsKey is immensely haughty to be one of the most oldest and most trusted service suppliers in this box. as a result of its relentless efforts for the previous 10 years, their proper exam Simulation cloth has gathered a foundation of more than 70,000+ convinced consumers, and its acceptance is flawless in helping their customer of their experience of acquiring the 201-450 LPIC-2 (201) certification. DumpsKey offers an introductory slice charge of 10% on its novel preparatory materials for a limited amount of time.

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Linux expert Institute examination Labs with FOSSFA/ict@innovation in South Africa | killexams.com real Questions and Pass4sure dumps

Sacramento, CA, united states: February 17, 2011) – The Linux skilled Institute (LPI), the world’s premier Linux certification corporation (http://www.lpi.org), introduced promotional exam labs for his or her Linux skilled Institute Certification (LPIC) with the Free and Open supply application foundation for Africa (FOSSFA: http://www.fossfa.web/) on the adolescence Chamber of Commerce and trade’s Technopreneurship Centre, Johannesburg, South Africa on March 5, 2011 at 10 a.m. This examination lab is a component of a bigger “teach-the-trainers” application, ict@innovation,jointly sponsored with the aid of FOSSFA and Deutsche Gesellschaft für Internationale Zusammenarbeit GmbH (GIZ: http://www.giz.de) and is undertaken with the cooperation of LPI-South Africa.

All LPIC assessments might be available (LPI-one zero one, 102, 201, 202, 301, 302, 303 and 304) by using registration and charge in develop (Paypal or credit card) at routine@lpi.org.  All assessments can be create at an boost promotional rate of US $ninety five each and every other than the LPI-301 examination (LPIC-3 certification). For details on charge on web site in Rand (ZAR) and pricing of the LPI-301 examination delight contact operations@south-africa.lpi.org

each and every exam takes approximately 90 minutes to complete. Candidates must carry their LPI id and a executive issued image identification to the exam lab.  To Take fraction in the exam labs you should obtain an LPI identity at LPI’s registration enviornment: http://www.lpi.org/eng/certification/register_now

“We absolutely champion FOSSFA efforts to promote the boom of Linux experts flawless over Africa. Their program is peculiarly useful as it provides each LPI and FOSS working towards and, as smartly, advantage building in entrepreneurship. this may obtain unavoidable that there are conceivable IT carrier suppliers who can recommend in your charge scope and at ease solutions in Linux and Open supply application to their potential clients,” talked about Jim Lacey, president and CEO of the Linux knowledgeable Institute.

¨during this 2nd LPI coach-the-trainer workshop, they hope to construct on the momentum that they began in Nairobi flawless over the primary workshop. within the first workshop, 12 members were licensed in LPIC-1. With this training and certification, these individuals are now able to convey LPI training in their personal associations as a commerce initiative. With this they are able to construct a community of shoes across Africa to be able to make a contribution to the wider deployment of Open source options, with the intent to in flip obtain a auspicious contribution to economic construction in Africa, pointed out Evans Ikua, FOSS Certification supervisor, ict@innovation.

The joint FOSSFA/GIZ Linux practicing project is a fraction of the ict@innovation application which aims at constructing capacities for African small and medium ICT firms to Do commerce with Free and Open source application. The ict@innovation application is additionally funded through the German Federal Ministry for economic Cooperation and development (BMZ) and the Open Society Initiative for Southern Africa (OSISA).

The software offers online practicing modules for LPIC-1 certification and is purchasable athttp://www.ict-innovation.fossfa.net/e-studying/index.Hypertext Preprocessor?class=LC

FOSSFA is additionally setting up the primary “made in Africa” training manual for LPIC-1 which may be released under a artistic Commons license.  For further suggestions on this LPIC-1 practicing manual initiative delight see: http://www.ict-innovation.fossfa.web/weblog/%5Buser-rawpercent5D/ictnnovation-lpic-1-practicing-guide-coming-quickly

The Linux skilled Institute is globally supported by means of the IT trade, enterprise purchasers, group authorities, govt entities and the tutorial neighborhood. LPI’s certification program is supported by an affiliate network spanning 5 continents and is disbursed international in numerous languages in additional than 7,000 testing areas. because 1999, LPI has delivered over 270,000 exams and 90,000 LPIC certifications flawless over the world.

concerning the Linux skilled Institute:

The Linux expert Institute promotes and certifies fundamental competencies on Linux and Open source applied sciences through the international birth of finished, most effective, vendor-independent checks. based as an international non-profit organization in September 1999 with the aid of the Linux community, the Linux expert Institute continues to reveal recognized world management within the certification of Linux experts. LPI advances the Linux and Open supply stream through strategic partners, sponsorships, inventive courses and group construction actions. LPI’s foremost fiscal sponsors are Platinum Sponsors IBM, Linux Journal, Linux magazine, Novell, SGI, and TurboLinux in addition to Gold Sponsors, HP and IDG.

About ict@innovation:

The ict@innovation programme focuses on Free and Open supply utility (FOSS) as a key know-how to drive innovation, add autochthonous value and create sustainable and budget friendly ICT-solutions. ict@innovation is a partnership of the Free utility and Open supply basis for Africa (FOSSFA:http://www.fossfa.net/) and Deutsche Gesellschaft für Internationale Zusammenarbeit GmbH (GIZ: http://www.giz.de) which goals to raise regional networking and to obtain stronger consulting capacities of regional and national ICT associations and training institutions as neatly as of other exchange agents. Funding partners are the German Federal Ministry for monetary Cooperation and construction(BMZ:http://www.bmz.de/en/index.html) and the Open Society Initiative for Southern Africa (OSISA: http://www.osisa.org/).




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201-400 exam Dumps Source : LPIC-2 Exam 201 (Part 1 of 2) version 4.0

Test Code : 201-400
Test cognomen : LPIC-2 Exam 201 (Part 1 of 2) version 4.0
Vendor cognomen : LPI
: 129 real Questions

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The Study of the Prevention of Anal Cancer (SPANC): design and methods of a three-year prospective cohort study | killexams.com real questions and Pass4sure dumps

Overview of design

SPANC is an ongoing, prospective, cohort study based in Sydney, Australia. The study follows HIV-negative and HIV-positive homosexual men aged 35 years and older at six visits over a epoch of three years, including a baseline enrollment visit, four follow-up screening visits and final visit to argue flawless study results. The main objective of the study is to investigate the epidemiology of anal HPV infection and related cytological and histological anal abnormalities in this population. Specifically, the study aims to 1) determine the prevalence, incidence and risk factors for anal HPV genotype detection and associated lesions, 2) investigate rates of clearance and persistence of anal HPV infection, 3) investigate rates of progression and regression of intraepithelial anal lesions and 4) assess the psychosocial/QoL impact of screening in homosexual men. In addition to the objectives described above, a number of sub-studies are nested within the main study. These embrace sub-studies on molecular biomarkers, lesion-specific HPV genotyping using laser capture microdissection (LCM), HPV serology, immunology, health economics and qualitative studies. Details of these sub-studies will not be covered in this paper.

The baseline data collection commenced in September 2010 and will conclude when the plenary study sample of 600 men is enrolled (approximately July 2015). Data from the baseline facet of the study will be used to investigate the prevalence of type-specific anal HPV infection and prevalence of anal squamous intraepithelial lesions. Results from the baseline questionnaire will be used to investigate the demographic, behavioural and clinical determinants and risk factors for type-specific HPV infection and low and high-grade anal squamous intraepithelial lesions (LSIL and HSIL). Additionally, the baseline cytology and HPV genotyping results will be compared with the final histological diagnosis to evaluate the value of anal cytology and HPV genotyping as potential screening tools in a setting where the prevalence of anal HPV and HSIL is very tall [13]. Baseline psychosocial factors will be compared with post-test questionnaire findings.

Follow-up of participants will continue to 2018. Incidence, persistence, clearance and regression rates of type-specific HPV infection and associated HSIL will be calculated and compared between groups with different behavioural, biological and clinical risk factors. Additionally, the impact of screening on men’s physical and psychological well-being and QoL will be measured and used to assess the benefits and potential harms of the screening test.

The study will recruit a total of 600 men with an approximate 3:2 ratio of HIV-negative to HIV-positive participants. Interim baseline data will be published on the first 350 participants recruited to the finish of July 2013.

Ethics

Ethics approval for the study was first granted on 21 April 2010 by the St Vincent’s Hospital (SVH, Sydney, Australia) Human Research Ethics Committee (File Number 09/203). The study is conducted in accordance with the National Health and Medical Research Council (NHMRC) National Statement of Ethical Conduct in Human Research 2007 (http://www.nhmrc.gov.au/book/national-statement-ethical-conduct-human-research), the World Medical Association Declaration of Helsinki (October 2000) and the International Conference on Harmonisation Note for Guidance on top-notch Clinical practice (ICH-GCP) (http://www.tga.gov.au/industry/clinical-trials-note-ich13595.htm). Written informed consent is obtained from flawless individuals before any study-specific procedures are performed.

Study population and recruitment

Obtaining a representative sample of homosexual men is challenging, as there is no defined population from which to draw a sample. Therefore, recruitment strategies used in SPANC are based on previous community-based studies conducted by the Kirby Institute and are centered on a number of community-based settings in Sydney. These embrace gay community companionable events and organizations, referrals from other participants and participants from previous community-based studies involving homosexual men at the Kirby Institute. Information regarding the study is distributed through leaflets and advertisements on gay community websites and SPANC information nights. To ensure a diverse population of men is reached, advertisements are moreover placed in the local gay press and the companionable networking site Facebook.

Eligible participants are men aged 35 years or over who report sex with another man in their lifetime (any homosexual contact). Participants are excluded if they are unable to understand English, unable to attend scheduled follow-up visits or are unwilling to undergo HRA, acquire a bleeding disorder or are on anti-coagulation medications (except aspirin and other non-steroidal anti-inflammatory drugs). Men who acquire previously had an HRA or who acquire a history of anal cancer are moreover excluded from the study.

Once enrolled, contact with the participants is maintained though regular reminder emails, text messages and telephone calls from SPANC study staff. To maximize retention and maintain tryst with the cohort, participants receive regular SPANC newsletters containing information on the progress of the study as well as generic information pertinent to the field. The newsletters are moreover used to address issues and concerns raised by the participants at their study visits or in the feedback section of the follow-up questionnaires.

Study procedures

At each screening visit men undergo a digital ano-rectal exam (DARE), an anal Pap test for HPV genotyping and anal cytology, HRA and biopsy of any visible abnormalities. Testing for sexually transmitted infections is performed on blood, urine, throat and rectal samples at flawless visits other than the six month visit. flawless participants complete audio, computer-assisted, self-administered interviews (ACASI, QDS, Bethesda, MD) at each visit. Additionally, two home-based self-administered questionnaires are scheduled two weeks and three months after the provision of cytology and histology results. The study flux and visit schedule are outlined in Figure 

1

and Table 

1

. The final home based self-administered questionnaire takes region six months after Visit 5, to assess any longer term cancer worry and psychological distress that may be related to anal cancer screening. Two months after Visit 5, participants undergo a 30–60 minute consultation with a research clinician (visit #6). At this study visit, the results of each study visit (#1 - #5), including cytological and histological assessments and HPV testing, are summarised and explained to participants. In addition, individualised evaluation of anal cancer risk based on their test results, and information about future potential anal cancer screening options are provided.

Figure 1

Study flux at each study visit.

Table 1

Study visit schedule outlining procedures and assessments performed at each visit

Visit number

1

2

3

4

5

6

Study months

0

6

12

24

36

38

Interview process

           

 Informed consent

X

         

 Baseline interview

X

         

 Follow up Interview

 

X

X

X

X

 

 Psychological interview

X

X

X

X

X

 

Clinical process

           

 Venepuncture

X

 

X

X

X

 

 Digital ano-rectal exam

X

X

X

X

X

 

 Anal swab

X

X

X

X

X

 

 Urine sample & throat swab1

X

 

 

 High resolution anoscopy & biopsy

X

X

X

X

X

 

 Discussion of flawless study results and anal cancer risk

         

x

Laboratory process

           

 HIV testing2

X

 

 

 Syphilis testing 1

X

 

 

 HPV PCR

X

X

X

X

X

 

 Anal cytology

X

X

X

X

X

 

 Histology3

X

X

X

X

X

 

 Gonorrhoea and chlamydia testing1

X

 

  Questionnaires

Data collected in the baseline questionnaire (visit #1) includes data on socio-demographics, predictors of gay companionable tryst and community involvement, lifetime and recent (previous six months) sexual practices, generic health, lifestyle and anal health. At follow-up visits (#2 - #5) the questions focus on sexual experiences, generic health, lifestyle and anal health issues in the previous six months. Additional information is sought from HIV-positive participants at flawless study visits on clinical measures such as CD4 T-lymphocyte count, HIV viral load and AIDS-defining illnesses. Measures of the potential psychosocial impact of anal screening are collected at the baseline visit and in the two-week and three-month (post-visit) questionnaires. The two-week questionnaire moreover contains questions on discomfort experienced during the procedure and post-procedure symptoms, including smart and bleeding.

An overview of the components of the questionnaire, including examples of variables and the measures and scales utilized are provided in Table 

2

.

Table 2

Summary of the main sections of the baseline and result up questionnaires

Socio-demographics

Age, country of birth, ethnicity, relationship status, accommodation status, employment status, income

Adapted from the Health in Men [15] and Positive Health [16] studies

Sexual practices

Sexual identity

Adapted from Health in Men and Positive Health studies [15, 16]

Age at first receptive anal intercourse:

Gay community fitful surveys [17, 18]

Number of lifetime insertive and receptive anal partners (with and without a condom)

Lifetime number of female partners

Preferred position during anal sex (receptive or insertive)

Number of insertive and receptive anal partners (with and without a condom) in the previous six months

Frequency of fingering, fisting and insertion of toys and other objects in the previous six months

Gay companionable engagement

Time spent with gay/homosexual friends

Gay community fitful surveys [19]

Disclosure of sexuality to friends/family

Number of gay friends

Involvement with gay community

Health and lifestyle

Smoking status

45 and Up study [20]

Alcohol and drug use

History of health problems (lifetime and in the terminal month)

History of depression and anxiety

Physical activity

General health

Section

Examples of Variables

Measures and Standardized Scales

Anal health

History and frequency of anal douching

Adapted from the Blokes with Anal Squamous Intraepithelial Lesions (BASIL) study [21]

History of STIs

Anal symptoms

HPV knowledge

Psychosocial evaluation

Generic measure of health related attribute of life

SF36 v2 (Australian) [22]

Disease specific distress associated with diagnosis of SIL

Cervical Dysplasia Distress and Screening questionnaires (modified) [23, 24]

Generic measures of distress

Distress thermometer [24]

Worry about developing anal cancer Perception of risk of anal cancer

Cancer worry [24]

Frequency of thinking about the tests

Perceived risk of cancer Intrusive thoughts [25]

Psychosexual health

HIV-positive status specific

Length of HIV infection

Positive Health study [16]

Viral load

Most recent CD4-Tcell count

Nadir CD4-Tcell count

Type of antiretroviral medication

Length of time on antiretroviral medication

History of AIDS associated illness

Procedure related feedback

Post procedure smart and bleeding

 

Length of smart and bleeding

Discomfort associated with the procedures

Other

Reason for joining study

Adapted from Health In Men and positive Health studies [15, 16]

Source of recruitment

Clinic procedures Venepuncture

Blood samples are drawn for HIV and syphilis testing. Participants provide additional, optional consent to acquire their blood stored (as serum and cell pellets). HPV genotype specific serology may be performed and specimens may be tested for other potential determinants of anal cancer risk at a later stage.

Urine and throat swab

Swabs from the tonsillar arch and posterior nasopharynx are collected for gonorrhoea testing. For urethral gonorrhoea and chlamydia testing participants are asked to void the first 10 ml of urine into the infertile container provided.

Digital Ano-Rectal Examination (DARE)

DARE is performed on flawless participants at each study visit by a study physician using lubricant mixed with 1% lignocaine. viable abnormalities and their positions in the anal canal or perineum are recorded on the HRA report form (See Additional file 1).

Anal pap test collection

Two anal canal samples are collected from flawless participants at each study visit. The first is an anal Pap test, wherein a Dacron swab moistened with tap water is inserted (3-5 cm) into the anal canal by the study clinician, pressed firmly against the wall of the anal canal and slowly withdrawn in a spiral style over approximately one minute. Immediately after sampling, the swab is inserted into a vial containing 20 ml of PreservCyt (Hologic, Inc., Marlborough, MA, United States) fixative medium and mixed vigorously. Specimens are sent to Douglas Hanly Moir Pathology (DHM, Sydney, Australia) for processing. Before cytological processing, one fifth (4 mL) of the PreservCyt sample is transferred into a second vial for HPV DNA detection and genotyping to avoid cross-contamination [26]. The remaining sample is used for cytological analysis. If the anal Pap test is unsatisfactory for cytological evaluation, a restate anal collection is performed no less than two weeks from the first. This minimum time requirement is to allow adequate time for the anal mucosal cells to regenerate after the initial Pap test.

A second swab (BD ProbeTec sample collection kit, BD Diagnostics, Sparks, MD, United States) is inserted (3-5 cm) into the anal canal by the study clinician and gently rotated, then placed into the infertile transport tube for testing for gonorrhoea and chlamydia.

High Resolution Anoscopy (HRA)

HRA is performed at each study visit following collection of the anal canal samples. After a visual examination of the perianal region and perineum, a plastic anoscope coated with lignocaine-containing lubricant is inserted into the anal canal and the introducer removed. A gauze swab soaked in 3% acetic acid is then inserted through the anoscope and left in the anal canal for one minute, to blot the anal mucosa. The gauze is then removed and the anoscope re-inserted. The anal canal is visualised under tall magnification using a colposcope with real-time video image capturing software (Second opinion Version 7.0, Second opinion Telemedicine Solutions, Inc. Torrance, California, USA). Further acetic acid is repeatedly applied, followed by Lugol’s iodine to blot for any macroscopic abnormality [27, 28]. Biopsies of visual abnormalities suspicious of HPV-related lesions are taken with mini Tischler forceps and placed into a formalin/saline solution and sent to DHM for processing and histopathological assessment. divorce forceps are used for each lesion, in order to obviate cross contamination.

Following removal of the anoscope, 3% acetic acid is applied to the perianal skin and the belt examined using the colposcope. If both intra-anal and peri-anal biopsies are to be taken, the anoscopist may schedule the participant to recur for peri-anal biopsies at a later visit (within two weeks of study visit). flawless peri-anal abnormalities are biopsied under lignocaine local anaesthesia.

Clinical impressions of intra-anal and peri-anal abnormalities and their anatomical positions are recorded on the HRA report form (See Additional file 1). Quantification of the total belt of intra-anal and/or peri-anal tissue affected by HSIL is recorded retrospectively once the histology results are known using a seven point scale; 1) single wee lesion, 2) < half of one quadrant, 3) ≥ half of one quadrant but < one quadrant, 4) ≥ one quadrant but < two quadrants, 5) ≥ two quadrants but < three quadrants, 6) ≥ three quadrants, 7) circumferential disease. Additionally, annotations of suspected HSIL lesions are taken at the time of the procedure. flawless reporting is performed with the lore of the participant’s HIV status. The clinicians are moreover sensible of the participant’s cytology, and HRA +/− biopsy results from any previous study visits.

All study anoscopists are required to undergo a formal training program prior to their involvement with the study. This training program was adapted from the British Society for Colposcopy and Cervical Pathology Training Program [27]. Anoscopists are required to keep at least 25 HRA procedures and then execute at least 50 HRAs under the direct supervision of an experienced anoscopist. flawless cases are recorded in a log reserve and the results of anal Pap tests and biopsies reviewed, when they become available. Once the anoscopist is deemed competent, they start performing HRA on their own. If required, they are able to access advice and clinical champion from an experienced anoscopist on an ongoing basis and the log reserve of flawless procedures is maintained.

A attribute assurance program for anoscopists is moreover in place. First, each anoscopist’s cytology/histology correlation and number of unsatisfactory Pap tests are summarised quarterly and a meeting of anoscopists is held at which the data are discussed and any significant differences between anoscopists are addressed. Second, a SPANC multidisciplinary team meeting is held quarterly involving the study investigators, anoscopists and pathologists. Six to eight cases are covered at each meeting including review of HRA images, cytology and histology slides and results, and HPV results. Each anoscopist presents their cases and any discordant results are discussed by the team. detailed minutes are kept and action plans determined.

Laboratory procedures HPV genotyping

All anal swabs placed in PreservCyt specimens are tested for HPV DNA using the Roche LINEAR ARRAY (LA) HPV genotyping test (Roche Molecular Systems, Alameda, CA, United States). DNA is extracted with the automated MagNA absolute isolation and purification system (Roche Molecular Systems) by a modified protocol using 1 ml aliquots of PreservCyt specimens as described previously [29]. The LA HPV genotyping test involves PCR amplification of a 450 bp region of the HPV L1 gene and allows for the identification of 37 HPV genotypes (6, 11, 16, 18, 26, 31, 33, 35, 39, 40, 42, 45, 51, 52, 53, 54, 55, 56, 58, 59, 61, 62, 64, 66, 67, 68, 69, 70, 71, 72, 73, 81, 82, 83, 84, IS39 (HPV 82v subtype), and CP6108 (HPV 89) as well as amplification of 265 bp region of the human ß-globin gene, serving as an internal control. As an in-house modification, samples that produced a negative internal control are retested with ½ the volume of eluted DNA in order to reduce the inhibition due to tall bacterial DNA content in those samples. In addition, due to viable cross-reactivity of the HPV-52 probe with types 33, 35, and 58 amplicons, samples positive for one or more of HPV-33, 35, and 58 probes are further tested using a real-time PCR assay with an HPV-52 specific hydrolysis probe to rule out presence of HPV 52 in addition to those types [30].

Syphilis testing

A screening enzyme immunoassay (EIA; ICE syphilis, Murex Biotech Ltd, Dartford, United Kingdom) is used to test for syphilis. Positive screening results are confirmed with the Treponema pallidum particle agglutination assay and/or the fluorescent treponemal antibody absorption test. The rapid plasma reagin (RPR) test is used on those with confirmed syphilis to assist clinical staging and to detect re-infection. flawless participants are tested for syphilis at the baseline visit. At visits 3, 4 and 5, serology is performed on those participants who acquire previously tested negative for syphilis and report sexual activity since the terminal visit. In participants with confirmed syphilis at any prior visit, only RPR is performed.

HIV testing

HIV testing is performed at baseline on flawless participants who report their HIV status to be negative, using the AxSYM HIV antigen/antibody Combo (Abbott Diagnostics, Abbott Park, IL, United States). Positive results are confirmed by a western blot assay. HIV testing is performed at visits 3, 4 and 5, on those HIV-negative participants who report sexual activity since the terminal visit.

Gonorrhoea and chlamydia testing

All baseline samples are tested for gonorrhoea and chlamydia by strand displacement amplification (SDA) using the BD ProbeTec assay (BD Diagnostics, Sparks MD). Positive samples undergo a supplementary nucleic acid amplification assay to validate the diagnosis. result up testing is performed at visit 3, 4, and 5 on those participants who report sexual activity since the terminal visit.

Cytology and histopathology

The laboratory reporting cytological and histopathological results is a specialist gynaecological unit operating within a big private generic pathology laboratory in Sydney, Australia. The gynaecological unit reports more than 250 000 cervical cytology specimens (conventional and liquid-based slides) per year and more than 12 000 gynaecological surgical specimens per year. Three anatomical pathologists, each with more than 15 years’ experience in gynaecological pathology, are involved in the study. The number of cytologists and pathologists involved were limited in order to enhance reproducibility of reporting. Prior to commencement of the study, a pathologist and a cytologist prepared a teaching manual based on available literature and assembled a set of teaching slides, drawn from previous smaller studies of anal canal lesions. flawless participating staff undertook training based on these materials.

Cytopathology

Prior to processing for cytology, a 4 ml aliquot is removed from the ThinPrep vial (total sample volume 20 ml) under infertile conditions. This aliquot is forwarded to Royal Women’s Hospital Molecular Microbiology laboratory (Melbourne, Australia) for HPV testing. The balance of the sample is processed using a ThinPrep 2000 processor (Hologic Inc.,Marlborough, MA, United States) to produce a TP slide (Hologic Inc., Marlborough, MA, United States), which is then stained with the ThinPrep proprietary blot (Hologic Inc., Marlborough, MA, United States). The slide is manually screened by a study cytologist on a gauge light microscope. The cytologist completes a checklist, and creates a provisional report, which is forwarded with the slide to one of the three study pathologists for assessment and final reporting. A ‘satisfactory’ slide is defined as having at least 2000 nucleated squamous cells. The presence or absence of a transformation zone component (at least 10 colorectal glandular cells and/or squamous metaplastic cells) is recorded but does not impress determination of satisfactory status. The Bethesda System (TBS) [31] criteria and terms are used for cytology reporting. Both the cytologist and pathologist view the slide blind to any lore of previous or current cytology or histology. Participant date of birth and study code was available, but no other demographic or clinical information accompanied the specimen.

Histopathology

Biopsies are received in 10% formal saline and processed in a routine fashion. Nine levels of each biopsy are prepared. Levels one to three and seven to nine are routinely stained with Haematoxylin and Eosin (H&E) stain. Levels four to six are prepared on a coated slide and left unstained for potential exhaust for histochemical staining or immunostaining. Each case is viewed and reported by one of the three study pathologists. Every attempt is made to ensure that a different pathologist views the concurrent cytology and histology specimens of an individual participant. At times where this is not viable due to logistical issues, the study pathologist reports the cytology and histology at different times. flawless reporting is done blinded to clinical factors (other than age) and previous results.

Reporting of the biopsies is performed in accordance with criteria, terminology and recommendations of the Lower Anogenital Squamous Terminology (LAST) Project [32, 33]. Details pertinent to this study are as follows:

  • Within the category of HSIL, further subdivision is performed, into anal intraepithelial neoplasia (AIN) grade 2 and AIN grade 3. If the biopsy is from perianal skin the terms perianal intraepithelial neoplasia (PAIN) 2 and 3 are used.

  • Immunostaining for p16 INK4A (p16) is performed on the unstained spare slide in the following circumstances:

  • To differentiate HSIL from a benign mimic, in particular, atypical immature metaplasia, but moreover inflammatory/reactive changes, tangential sectioning and partial epithelial denudation.

  • When a diagnosis of AIN 2 is proposed, in order to validate positive p16 reactivity. If the result is negative, the lesion is downgraded to LSIL or negative for SIL.

  • Immunostaining for p16 is not used in formulating diagnoses of straightforward LSIL or straightforward HSIL – AIN 3.

  • Immunostaining for p16 is reported as positive if there is “continuous tough nuclear or nuclear plus cytoplasmic staining of the basal cell layer with extension upwards involving at least one third of the epithelial thickness” [32, 33]. Any other pattern of staining is regarded as negative.

  • Carcinomas are measured in two dimensions and categorized as “Superficially invasive squamous cell carcinoma of the anus” (SISSCA) if they meet the terminal definition.

  • In addition to the terminal categories above, a decision was made to sub-categorise LSIL into ‘exophytic’ and ‘flat’, based on presence or absence respectively of architectural features of condylomata accuminatum. This decision reflected the possibility that the two variations of LSIL may be associated with different HPV types [34, 35].

    If infection with organisms other than HPV is suspected, commandeer stains are used, for instance immunoperoxidase staining for HSV-1 and/or HSV-2 in the presence of ulceration; and Ziehl-Neelsen staining if granulomata are present.

    Characteristics of the enrolled population

    The socio-demographic and lifestyle characteristics of the first 350 participants are presented in Table 

    3

    . Data are presented for the overall cohort, and stratified by HIV status. Details of HIV infection (if positive) are presented in Table 

    4

    . Since the study’s commencement approximately 594 men were contacted by the study team at least once and approximately 404 were screened for eligibility. Fifty-four (54) men were excluded because they did not meet the inclusion criteria. Most common reasons for exclusion were: too puerile (26%); unable to attend scheduled visits due to time/location (26%); acquire previously had a HRA (13%); acquire a history of bleeding disorders or were on anti-coagulant medication (11%); acquire previously been diagnosed with anal cancer (9%), or other intuition (15%). By the finish of July 2013, 350 men of whom 29% (n=101) were HIV-positive were recruited into the study.

    Table 3

    Socio-demographic, health and lifestyle characteristics

     

    n

    %

    n

    %

    n

    %

    Age

               

    Median (IQR)

    49 (42–55)

    49 (43–54)

    49 (42–56)

    Mean (SD)

    49.6 (9.3)

    48.7 (7.4)

    49.9 (9.9)

     35 – 44 years

    110

    31.4

    31

    30.7

    79

    31.7

     45 – 54 years

    143

    40.9

    47

    46.5

    96

    38.6

     55 + years

    97

    27.7

    23

    22.8

    74

    29.7

    Country of birth

               

     Australia

    234

    66.9

    72

    71.3

    162

    65.1

     New Zealand

    21

    6.0

    6

    5.9

    15

    6.0

     Other

    95

    27.1

    23

    22.8

    72

    28.9

    Ethnic background

               

     Anglo- Celtic

    292

    83.4

    80

    79.2

    212

    85.1

     Aboriginal/Torres Strait

    5

    1.4

    2

    2.0

    3

    1.2

     Other

    53

    15.1

    19

    18.8

    34

    13.7

    Highest flush of education

               

     High School

    67

    19.1

    24

    23.8

    43

    17.3

     Tertiary diploma or trade1

    84

    24.0

    28

    27.7

    56

    22.5

     Undergraduate degree

    86

    24.6

    28

    27.7

    58

    23.3

     Postgraduate degree

    113

    32.3

    21

    20.8

    92

    37.0

    Work situation

               

     Full/Part time/self-employed

    254

    72.6

    66

    65.4

    188

    75.5

     Unemployed

    17

    4.9

    4

    4.0

    13

    5.2

     Retired

    57

    16.3

    22

    21.8

    35

    14.1

     Other 2

    22

    6.3

    9

    8.9

    13

    5.2

    Weekly income (AU$)

               

     <200

    24

    6.9

    7

    6.9

    17

    6.8

     200-499

    59

    16.9

    29

    28.7

    30

    12.1

     500-999

    61

    17.4

    23

    22.8

    38

    15.3

     1000—1499

    61

    17.4

    12

    11.9

    49

    19.7

     ≥1500

    140

    40.0

    29

    28.7

    111

    44.6

     Missing responses

    5

    1.4

    1

    1.0

    4

    1.6

    Currently in a relationship

               

     No

    155

    44.3

    54

    53.5

    101

    40.6

     Yes, with manly partner

    191

    54.6

    45

    44.6

    146

    58.6

     Yes, with female partner

    4

    1.1

    2

    2.0

    2

    0.80

    Smoking status

               

     Never

    193

    55.1

    44

    43.6

    149

    59.8

     Past

    108

    30.9

    35

    34.7

    73

    29.3

     Current

    49

    14.0

    22

    21.8

    27

    10.8

    Alcohol consumption

               

     Never

    28

    8.0

    9

    8.9

    19

    7.6

     < once a week

    81

    23.1

    33

    32.7

    48

    19.3

     1-2 days a week

    86

    24.6

    17

    16.8

    69

    27.7

     3-4 days a week

    61

    17.4

    21

    20.8

    40

    16.1

     5-6 days a week

    51

    14.6

    12

    11.9

    39

    15.7

     Every day

    43

    12.3

    9

    8.9

    34

    13.7

    Recreational drug exhaust in the past 6 months 3

     No

    95

    27.1

    19

    18.8

    76

    30.5

     Yes

    255

    72.9

    82

    81.2

    173

    69.5

    Table 4

    Characteristics of HIV-positive men

    Years HIV-positive

       

     Median (Range)

    16 (8.3-25.3)

     Mean (SD)

    16.5 (9.0)

    Nadir CD4 T cell/μL

       

     Over 500

    11

    10.9

     201 - 500

    41

    40.6

     51 - 200

    27

    26.7

     < 50

    21

    20.8

     Missing

    1

    1.0

    Last CD4 T cell/μL

       

     Over 750

    29

    28.7

     501-750

    36

    35.6

     351-500

    20

    19.8

     201-350

    9

    8.9

     101-200

    1

    1.0

     50-100

    1

    1.0

     <50

    2

    2.0

     Missing

    3

    3.0

    Last viral load test

       

     Undetectable

    80

    79.2

     Detectable

    14

    13.9

     Missing

    7

    6.9

    History of AIDS defining illness

       

     No

    70

    69.3

     Yes

    31

    30.7

    Currently taking any anti-retroviral medication

       

     No

    11

    10.9

     Yes

    90

    89.1

    The majority of men were recruited from community based sources including from gay community events (32%) or the SPANC website/Facebook (13%). Fifteen percent (15%) were recruited through friends or partners, 14% through gay organizations or HIV/AIDS organisations, 11% through gay press and 6% other. In 9% of cases men were recruited from generic practice or sexual health clinics.

    The median age of participants at the time of baseline interview was 49 years (IQR 42–55). The majority of participants (67%) were born in Australia and most (83%) reported Anglo-Celtic ethnic background. The cohort was highly educated, with 57% of participants having completed university and 40% reporting a weekly income of ≥ $1500. Forty-five percent (45%) of men reported being a past or current cigarette smoker. The majority of men (92%) consumed alcohol at least once a week and 73% acquire used drugs recreationally in the past 6 months (Table 3).

    HIV-negative participants in SPANC were generally more likely to acquire higher levels of education, higher income, having plenary or fraction time employment and higher alcohol consumption. HIV-positive participants were more likely to report past or current cigarette smoking and recreational drug exhaust (Table 3).

    Almost flawless participants self-identified as being homosexual, gay or queer (95.4%) and 4.6% self identified as bisexual, heterosexual or other. The median age of first receptive anal intercourse was 21 years (IQR 17–25). Participants were highly sexually active, with 53% of the men reporting more than 200 lifetime manly sexual partners, and 29% reported having more than 10 manly sexual partners in the previous 6 months. Fifty five percent (55%) of men reported having unprotected receptive anal intercourse (URAI) in the previous 6 months. A lifetime history of anal STIs was moreover common in this group being reported by 26%, 21%, 17% and 19% of men for anal gonorrhea, syphilis, chlamydia and herpes, respectively. Having ever had anal or genital warts was reported by 43% and 29% of men, respectively. Compared with the HIV-negative, HIV-positive participants in SPANC reported more lifetime and recent sexual partners, more frequent URAI, and more past STIs.

    Among HIV-positive participants (n=101), the median time they had been vital with HIV was 16 years (IQR 8–25). The majority (84%) had a self-reported CD4 T cell weigh over 350cells/μL, 79% reported undetectable HIV viral load at their terminal test and 89% were on treatment at the time of the baseline interview (Table 4).



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