Griesser et al., AJCP 2009: Time interval until clinical remission or progression to CIN3 in month (range)
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More than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\\n\\nOur breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\\n\\n“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\\n\\nAdditionally, each book published by IntechOpen contains original content and research findings.
\\n\\nWe are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
\\n\\n\\n\\n
\\n"}]',published:!0,mainMedia:null},components:[{type:"htmlEditorComponent",content:'
Simba Information has released its Open Access Book Publishing 2020 - 2024 report and has again identified IntechOpen as the world’s largest Open Access book publisher by title count.
\n\nSimba Information is a leading provider for market intelligence and forecasts in the media and publishing industry. The report, published every year, provides an overview and financial outlook for the global professional e-book publishing market.
\n\nIntechOpen, De Gruyter, and Frontiers are the largest OA book publishers by title count, with IntechOpen coming in at first place with 5,101 OA books published, a good 1,782 titles ahead of the nearest competitor.
\n\nSince the first Open Access Book Publishing report published in 2016, IntechOpen has held the top stop each year.
\n\n\n\nMore than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\n\nOur breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\n\n“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\n\nAdditionally, each book published by IntechOpen contains original content and research findings.
\n\nWe are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
\n\n\n\n
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3.0",editedByType:"Edited by",editors:[{id:"259466",title:"Prof.",name:"He",middleName:null,surname:"Tian",slug:"he-tian",fullName:"He Tian"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}}},ofsBook:{item:{type:"book",id:"8804",leadTitle:null,title:"Water and Wastewater Treatment",subtitle:null,reviewType:"peer-reviewed",abstract:"The use of water, one of the most valuable and vital resources in the world, should respond to growing needs, and used water should not have negative effects on the environment. Research on the reduction of used water and wastewater quantities, post-use treatment, or reuse/recovery methods is increasing day by day. These studies focus on finding the most appropriate method from both technical and economic perspectives. In this book, emerging technologies and materials used in the treatment, reuse, or recovery of various kinds of water and wastewaters are examined. The book consists of valuable scientific research specifically including desalination and use of renewable energy, nanomaterials, biosorbents, photocatalytic treatment, as well as riverbank filtration and wetlands. The editor would like to record his sincere thanks to the authors for their contributions.",isbn:"978-1-78923-930-0",printIsbn:"978-1-78923-929-4",pdfIsbn:"978-1-78984-688-1",doi:"10.5772/intechopen.80313",price:119,priceEur:129,priceUsd:155,slug:"water-and-wastewater-treatment",numberOfPages:160,isOpenForSubmission:!1,hash:"ccb46d6518786712b3184b2498fb0cab",bookSignature:"Murat Eyvaz",publishedDate:"July 24th 2019",coverURL:"https://cdn.intechopen.com/books/images_new/8804.jpg",keywords:null,numberOfDownloads:4305,numberOfWosCitations:0,numberOfCrossrefCitations:2,numberOfDimensionsCitations:15,numberOfTotalCitations:17,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"September 5th 2018",dateEndSecondStepPublish:"September 26th 2018",dateEndThirdStepPublish:"November 25th 2018",dateEndFourthStepPublish:"February 13th 2019",dateEndFifthStepPublish:"April 14th 2019",remainingDaysToSecondStep:"2 years",secondStepPassed:!0,currentStepOfPublishingProcess:5,editedByType:"Edited by",kuFlag:!1,biosketch:null,coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"170083",title:"Associate Prof.",name:"Murat",middleName:null,surname:"Eyvaz",slug:"murat-eyvaz",fullName:"Murat Eyvaz",profilePictureURL:"https://mts.intechopen.com/storage/users/170083/images/system/170083.jpeg",biography:"Dr. Eyvaz is an Associate Professor of the Environmental Engineering Department (ENVE) at Gebze Technical University (GTU). He received his bachelor’s degree in environmental engineering from Kocaeli University in Turkey in 2004. He completed his graduate work (M.Sc., 2006 and Ph.D., 2013) at Gebze Institute of Technology (former name of GTU) in Environmental Engineering under the supervision of Dr. Mehmet KOBYA, Prof. in ENVE-GTU (for M.Sc.), and of Dr. Ebubekir YÜKSEL, Prof. in ENVE-GTU and Dr. Ömer AKGİRAY, Professor and Chair of ENVE at Marmara University, (for Ph. D.). He completed his post-doctoral research in the National Research Center on Membrane Technologies (in Istanbul Technical University) under the mentorship of Dr. İsmail KOYUNCU, Professor and Manager of the center, between March 2014-March 2015.\n\nDr. Eyvaz has been in the Environmental Engineering Department of GTU as a Faculty Member (2017-present). His research interests are applications in water and wastewater treatment facilities, electrochemical treatment process, and filtration systems at the lab. and pilot scale, membrane processes (forward osmosis, reverse osmosis, membrane bioreactors), membrane manufacturing methods (polymeric membranes, nanofiber membranes, electrospinning), spectrophotometric analyses (UV, atomic absorption spectrophotometry), chromatographic analyses (gas chromatography, high-pressure liquid chromatography). He has published his findings in the premier journals of his field, Journal of Hazardous Materials, Separation and Purification Technology, Journal of Membrane Science, and Chemical Engineering Journal. He has produced more than 20 peer-reviewed publications (cited over 1000 times) with an h index of 12. He serves as an editor for over 45 various journals and a reviewer in 140 different various journals and conferences indexed in SCI, SCI-E, and other indexes.\n\nDr. Eyvaz and his co-authors’ peer-reviewed publications have continuously and increasingly been cited. By January 2021, the totals of citations to Dr. Eyvaz’s journal publications are 555, 599, and 1055 for Web of Science, Scopus, and Google Scholars databases, respectively, and his h-indexes are 10, 10, and 12, respectively.",institutionString:"Gebze Technical University",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"5",totalChapterViews:"0",totalEditedBooks:"6",institution:{name:"Gebze Technical University",institutionURL:null,country:{name:"Turkey"}}}],coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"1354",title:"Wastewater Engineering",slug:"technology-environmental-engineering-wastewater-engineering"}],chapters:[{id:"66885",title:"Treatment of Water and Wastewater for Reuse and Energy Generation-Emerging Technologies",slug:"treatment-of-water-and-wastewater-for-reuse-and-energy-generation-emerging-technologies",totalDownloads:1291,totalCrossrefCites:1,authors:[{id:"199957",title:"Dr.",name:"Sudesh",surname:"Rathilal",slug:"sudesh-rathilal",fullName:"Sudesh Rathilal"},{id:"262983",title:"Dr.",name:"Emmanuel",surname:"Kweinor Tetteh",slug:"emmanuel-kweinor-tetteh",fullName:"Emmanuel Kweinor Tetteh"},{id:"281613",title:"Dr.",name:"Maggie",surname:"Chetty",slug:"maggie-chetty",fullName:"Maggie Chetty"},{id:"281614",title:"Mr.",name:"Edward Kwaku",surname:"Armah",slug:"edward-kwaku-armah",fullName:"Edward Kwaku Armah"},{id:"281615",title:"Dr.",name:"Dennis",surname:"Asante-Sackey",slug:"dennis-asante-sackey",fullName:"Dennis Asante-Sackey"}]},{id:"66331",title:"Desalination with Renewable Energy: A 24 Hours Operation Solution",slug:"desalination-with-renewable-energy-a-24-hours-operation-solution",totalDownloads:632,totalCrossrefCites:0,authors:[{id:"174208",title:"Dr.",name:"Muhammad Wakil",surname:"Shahzad",slug:"muhammad-wakil-shahzad",fullName:"Muhammad Wakil Shahzad"}]},{id:"65548",title:"Nonconventional Wastewater Treatment for the Degradation of Fuel Oxygenated (MTBE, ETBE, and TAME)",slug:"nonconventional-wastewater-treatment-for-the-degradation-of-fuel-oxygenated-mtbe-etbe-and-tame-",totalDownloads:355,totalCrossrefCites:1,authors:[{id:"228497",title:"Dr.",name:"Hermicenda",surname:"Perez Vidal",slug:"hermicenda-perez-vidal",fullName:"Hermicenda Perez Vidal"},{id:"229146",title:"Dr.",name:"Zenaida",surname:"Guerra Que",slug:"zenaida-guerra-que",fullName:"Zenaida Guerra Que"},{id:"240565",title:"Dr.",name:"Jose Gilberto",surname:"Torres Torres",slug:"jose-gilberto-torres-torres",fullName:"Jose Gilberto Torres Torres"},{id:"240661",title:"Dr.",name:"María A.",surname:"Lunagómez Rocha",slug:"maria-a.-lunagomez-rocha",fullName:"María A. 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This requires extensive analysis of developing trends in scientific research in order to offer our readers relevant content. Creating the book catalogue is also based on keeping track of the most read, downloaded and highly cited chapters and books and relaunching similar topics. I am also responsible for consulting with our Scientific Advisors on which book topics to add to our catalogue and sending possible book proposal topics to them for evaluation. Once the catalogue is complete, I contact leading researchers in their respective fields and ask them to become possible Academic Editors for each book project. Once an editor is appointed, I prepare all necessary information required for them to begin their work, as well as guide them through the editorship process. I also assist editors in inviting suitable authors to contribute to a specific book project and each year, I identify and invite exceptional editors to join IntechOpen as Scientific Advisors. 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Smears",doi:"10.5772/55902",slug:"hpv-l1-detection-as-a-prognostic-marker-for-management-of-hpv-high-risk-positive-abnormal-pap-smears",body:'\n
Cervical cancer is still the 2nd most common cancer in women worldwide, and especially women in developing countries are suffering from the disease [1].
\nIf detected at an early stage Cervical Cancer is preventable. In almost all places around the world the traditional Pap smear is used as primary screening tool and even from being far away to be a perfect test, the benefits of Papanicolaou based cervical cancer screening programs in reducing morbidity and mortality are well accepted.
\nAbout 50 years after Papanicolaou has started his initial work, Meisels & Fortin published in 1976 a report in which they showed that the “halo cell” in pap smears, was a koilocyte - the pathognomic cell of an HPV infection [2] and that low grade or mild dysplasia of the cervix had the histological features of a papillomavirus infection [3].
\nShortly thereafter Lutz Gissmann in the zur Hausen laboratory in Erlangen cloned from genital warts ‘condyloma acuminata’, a novel HPV DNA classified as HPV6 [4].
\nThe idea that Cervical Cancer and cancers at other sides could be caused by a viral infection developed afterwards step by step.
\nIn the meantime both concepts are merged and it is accepted that a persisting infection caused by the sexual transmitted human papillomavirus (HPV), is almost always the trigger for the occurrence of cervical cancer and the main agent for cervical epithelial dysplasias.
\nOf the more than 120 HPV subtypes known today, the anogenital ones are further divided into low risk (LR-HPV) and currently at least 15 high risk types (HR-HPV; HPV 16, 18, 45, 31, 33, 52, 58 are most frequent). While the former are only in rare cases cancerogenic, HR-HPV are detected virtually regularly in high-grade intraepithelial neoplasias and invasive cervical cancers, of which more than 70% are HPV 16 and HPV 18 [5].
\nThe negative predictive value of the highly sensitive DNA determination of HR-HPV in the cervical smear cell material is with more than 99% very high, i.e. women not infected with these HPV subtypes very probably have no high-grade intraepithelial lesion and no cervical cancer.
\nOn the other hand the use as primary screening tool for cervical cancer is limited because the positive predictive value of a HPV DNA test is low.
\nThe majority of HR-HPV infections remain morphologically undetected and even in mild dysplasias with persisting infections the probability for the development of high grade intraepithelial lesions is only about 20% focusing on young women.
\nTherefore even if thinking about the possibility to replace cytology as primary screening tool, the Pap-test will remain to verify a positive HPV DNA test, to confirm the presence of abnormal cells and most important to determine the severity or grade of disease, a unique feature of the morphological methods.
\nSince the early days of cervical cytology it is known that the morphologically identified lesions of different grades are mixtures of distinct biological stages resulting in different clinical outcomes, remission or progression [6].
\nToday with the knowledge that HPV is a necessary but not sufficient cause for the development of most cervical cancers, transient HPV infection and precancer are often used synonymous for these biologically different conditions.
\nTraditionally cervical cancer prevention programs rely on the repeated application of a 3-step strategy:
\nScreening by cervical cytology with the Pap - Test;
Follow up of the cytology positive women with HPV DNA testing colposcopic evaluation and directed biopsy of abnormal-looking cervical tissue for diagnosis; and if necessary
Excisional or ablative treatment of the cervical tissue in women diagnosed with CIN2+ or precancer.
For Pap smear diagnosis different reporting systems are in use worldwide. Besides the original WHO classification [7], The Bethesda System (TBS) [8] is internationally accepted, while the Munich Nomenclature II is being recommended in Germany [9].
\nBased on Ostors meta-analysis it’s common sense that treatment isn’t warranted for early dysplastic lesions as for atypical squamous cells of undetermined significance (ASCUS) and mild dysplasia (LSIL) since only 10% of the mild dysplastic lesions will progress to CIN3+ [10].
\nA cytological follow up with colposcopic evaluation is recommended for these women and if necessary directed biopsies of abnormal-looking cervical tissue for diagnosis are taken.
\nThe cervical histopathologic diagnoses of these samples are graded according to the cervical intraepithelial neoplasia (CIN) system as normal, CIN1, CIN2, CIN3, and cervical cancer [11].
\nSo far diagnosis of CIN2 or worse is the clinical threshold leading to ablative or excisional therapy in the United States and Europe.
\nIn the meantime a discussion started if moderate dysplasias, the cytological CIN2 equivalent, should be called low grade or high grade lesion. Ostor reported that only 20% of the moderate dysplasitic lesions progressed to CIN3+, typically a threshhold that should not warrant invasive procedures.
\nAs a consequence of the current situation conisations are being performed frequently, with potentially negative impact on reproductive outcomes for fertile women, including preterm delivery and low-birth-weight infants [12] with possible life long fatal disabilities.
\nDespite the conservative recommendation in the Munich Nomenclature II, not to treat CIN2, conisation was one of the most common surgical procedures performed in women of fertile age in Germany during 2010, accounting for more than 50.000 cases [13].
\nThe dilemma is that neither cytological follow up, colposcopy nor HPV DNA testing could indicate whether a remission or progression of the precursor lesion to invasive cancer will occur. Therefore more specific tools like prognostic markers would be of great value, allowing an individualized management of cervical lesions depending on their risk profil.
\nOver the last couples of years cytological samples as well as colposcopically guided punch biospsies, have been used to determine if Cytoactiv HPV L1 detection is able to predict the clinical outcome of HPV high risk positive early dysplastic lesions.
\nModerate dysplastic lesions, being part of HSIL, have been investigated as well since the Munich nomenclature II, in contrast to TBS, groups moderate dysplastic lesions, together with mild dysplasias, in the category IIID, with recommendation for cytological follow up and colposcopy.
\nThis different risk assesement offered the unique possibility to follow up these women with moderate dysplasias as well.
\nL1 or the major capsid protein is one of eight known HPV specific proteins (E1, E2, E4, E5, E6, E7, L1 and L2).
\nIt is produced within the cytoplasm and translocated into the nucleus, clearly visible by strong nuclear immunochemical staining reaction in intermediate and superficial squamous epithelial cells.
\nThe L1 protein forms an icosahedral capsid with a T=7 symmetry and a 50 nm diameter. The capsid is composed of 72 L1 pentamers, linked to each other by disulfide bonds, and associated with the minor capsid protein L2, which encapsulates the viral DNA to build new infectious viral particles that are released in the upper epithelial layer. [14]
\nAt the same time, L1 is a ligand for a still not reliably identified surface receptor, a heparan sulfate proteoglycan, on the basal cell layer of the epithelium to provide initial virion attachment to target cells. As a general rule, the HPV gains access to the basal epithelial layers as a result of epithelial erosions or mucosal ulcerations in the transformation zone susceptible to inflammation at the cervical/endocervical junction.
\nOnce attached, the virion enters the host cell via a L2 dependant, clathrin-mediated endocytosis, the capsid becomes decraded, the virus DNA is released and routed into the nucleus of the cell [15].
\nThe virus genome then separately lies outside the chromosomal DNA of the host cell as a ring-shaped, episomal DNA molecule.
\nThese initial steps are not associated with cellular changes that can be detected by morphological methods. This individually variably long so called latent or silent virus infection can only be detected with molecular biological methods.
\nThe signals to leave the latent virus infection and to initiate the productive or permissive phase of the viral life cycle, leading to a L1 synthesis, are not identified yet. Once differentiation of the immature squamous epithelial host cells begins, the viral DNA starts to replicate to high copy numbers. In the further course and dependent on the host cell differentiation the late proteins are synthesized, and encapsidates the viral DNA. Thus, mature, infectious viruses emerge, which are released from the perishing superficial squamous epithelia [16].
\nWithin the scope of this productive phase, morphological epithelial changes mostly occur after several weeks or months post infection, which allow the cytological diagnosis of dysplasia in the smear. The typical morphological changes like nuclear enlargement, multinucleosis, changes in the chromatin structure and cytoplasm composition as well as koilocytes or ´halo cells´ have already been described by Papanicolaou.
\nUpon termination of the productive phase, the viral life cycle from primary infection to the release of the virus is completed without any malignant neoplasia having occurred (Figure 1). The L1 capsid protein is detectable at that stage of the life cycle, only.
\nHPV life cycle, as described in the text.
A particular methodical advantage of the L1 capsid protein detection is that the protein is synthesized in the cells of the superficial layer of the epithelium that are easy to obtain by taking a smear (see Figure 2).
\nThe typical L1 staining is a strong, homogenous nuclear stain (Figure 3-7), in contrast to other markers, leading to a very good interobserver reproducibility. Using histological sections Galgano et al. [17] reported for Cytoactiv a raw agreement and k of 96.9% and 0.88, respectively. With 98% raw agreement and 0.96 for kappa Mehlhorn et al. [26] reported similar results for the use of Cytoactiv in cytological samples.
\nL1+ CIN1 -A particular methodical advantage of the L1 capsid protein detection is that the protein is synthesized in the cells of the superficial layer of the epithelium that are easy to obtain by taking a smear
L1 staining intensity correlates with the amount of L1 capsid protein producedand it becomes more intense towards the surface of the epithelium
L1 positive LSIL
L1 + Koilocytes
L1 + Koilocyte with 2 nuclei
L1+ HSIL, Mehlhorn et al. [26]
Initial L1 studies faced the problem that the sensitivity of randomly choosen L1 antibodies was unacceptable low. One major problem was the well known high frequency of point mutations leading to a loss of the relevant epitopes, and false negative results as a viral strategy to escape immune recognition. This high variability is in clear contrast to the stability of epitopes recognized by antibodies detecting cellular proteins, like p16 or ki67.
\nDuring the product development of Cytoactiv it was possible to increase the sensitivity significantly by extensive selection processes generating an optimized antibody detecting a specific epitope.
\nNevertheless there were a small number of cases where it was impossible to detect the L1 capsid protein. The reason for this finding was not clear in the beginning.
\nIn 2003 Melsheimer et al. [18] have published that most of the HPV high risk associated LSIL expressed HPV L1 capsid protein, but in most of the HSIL cases the HPV L1 capsid protein was not synthesized (see Figure 3-6).
\nThey suggested that a loss of viral L1 capsid protein, as a major target of the immune response in HPV infected SIL, could function as a prognostic marker for the development of CIN lesions.
\nLater on Griesser et al. [19] were able to confirm this suggestion in a retrospective study with 84 routinely performed conventional Pap smears. During a follow up time of 23 month they showed that the HPV high risk associated mild to moderate dysplastic squamous lesions without immunochemically detectable HPV L1 capsid protein progressed significantly more likely to CIN3+ (76,4%) than the L1 positive cases (23,6%).
\nSimilar results were reported by Rauber et al. [20] in 2008 in a retrospective study of 279 HPV High risk positive conventional Pap smears with mild and moderate severe morphological changes. The progression rate to CIN3+ of L1 capsid protein positive cases was found to be only 12,3% (p-value <0,001).
\nIn the same year Scheidemantel et al. [21] tested the Cytoactiv – Kit on 111 HPV High risk positive ThinPrep – slides. They reported that none of the L1 positive patients showed a progression towards cervical cancer and on the other hand all progredient cases were found to be L1 negative.
\nAn additional advantage of choosing the ThinPrep system emerged in the meantime. The ThinPrep Imager allows the automated evaluation of the L1 stained slides, to speed up the reading process [22]. The benefit of computer based automatisation can be extended to conventional Pap smears and SurePath slides as well if choosing BD´s focal point system.
\nThe first prospective randomized study was published in 2009 by Griesser and colleagues [23]. The study included 211 HPV High risk-positive mild and moderate dysplasias (LSIL and HSIL) with a follow-up of the patients up to 48 months. The results of all former retrospective studies were confirmed and strengthened. Depending on patients age (<30 / >30) and the classification of the precancerous lesion (LSIL or HSIL) only 20 % of all L1 positive cases showed a progression to CIN3+. In contrast to this finding up to 97% of the L1 negative cases showed a progression.
\nIn this study the mean duration from the initial L1 positively / negatively stained smears to the recognition of disease progression or remission were reported as well.
\nFor L1 negative cases the time interval until progression was 6 months (range, 1-29) and 6.4 months (range 2-12) for clinical remission, whereas for the L1 positive cases it took 8.5 months (range, 1-13) until progression, and 7 months (range, 3-35) for clinical remission respectively.
\n\n | \n L1-\n | \n\n L1- LSIL\n | \n\n L1- HSIL\n | \n\n L1+\n | \n\n L1+ LSIL\n | \n\n L1+ HSIL\n | \n
Remission | \n6.4 (2-12) | \n7.5 (3-12) | \n2 | \n7 (3-35) | \n6.5 (3-18) | \n9 (3-35) | \n
Progression | \n6 (1-29) | \n6 (1-29) | \n6 (1-20) | \n8.5 (1-13) | \n9 (6-13) | \n8 (1-13) | \n
Griesser et al., AJCP 2009: Time interval until clinical remission or progression to CIN3 in month (range)
Stemberger – Papic et al. [24] reported similar results for Croatian women and concluded that immunostaining for HPV L1 capsid protein could offer prognostic information about mild and moderate intraepithelial cervical squamous lesions.
\nIn 2010 and 2011 two Korean studies reported that the prognostic significance of the L1 detection with Cytoactiv for the clinical outcome of early dysplastic lesions can be confirmed for East Asian women as well.
\nLee et al [25] confirmed 2011 in a prospective trial of 318 women the benefit for Cytoactiv for the management of HPV high risk positive LSIL women. The positive predictive value of HPV L1-positive cases for no progression was 91.7%, and the negative predictive value of HPV L1-negative cases for progression to high-grade lesions was 27.7.
\nThe results of the largest study so far, a prospective international multicenter study of 809 HPV High risk positive LSIL and HSIL was performed by Mehlhorn et al. [26].
\nDuring the follow up of 54 month 83,5% of the HPV-L1 negative progressed to CIN3+, as compared to only 19,8% of the HPV-L1 positive cases. The difference of the clinical outcome of HPV-L1 negative and HPV-L1 positive cases was statistically highly significant (p-value <0.0001) and independent of the classification as mild dysplasia (LSIL) and moderate dysplasia (HSIL).
\nThe authors concluded that HPV-L1 detection allows identifying transient HPV infections and precancerous lesions within the group of HPV high-risk positive early dysplastic lesions.
\nThe high progression rate of HPV-L1 negative mild and moderate dysplasia emphasizes the precancerous nature of these lesions.
\nAs a clinical recommendation they suggested that a close follow-up with colposcopy and histological evaluation and removal of these lesions should be considered.
\nThe low malignant potential of HPV-L1 positive cases, however, indicates transient HPV infection, justifying a watch and wait strategy with cytological follow-up thus preventing overtreatment especially for women in their reproductive age.
\n\n Author\n | \n\n classification\n | \n\n No.cases\n | \n\n L1 negative\n | \n\n L1 positive\n | \n\n Mean age\n | \n\n Follow up\n | \n
Mehlhorn | \nLSIL | \n479 | \n72,9 | \n11,8 | \n33,6 | \n54 month | \n
Griesser | \nLSIL | \n68 | \n84 | \n25 | \n33,6 | \n48 month | \n
in total | \n\n | 547 | \n75 | \n13,1 | \n33,6 | \n\n |
Risk profil LSIL - Progression to CIN3+ for L1+ and L1- cases
\n Author\n | \n\n classification\n | \n\n No.cases\n | \n\n L1 negative\n | \n\n L1 positive\n | \n\n Mean age\n | \n\n Follow up\n | \n
Mehlhorn | \nHSIL | \n322 | \n92,7 | \n37,4 | \n33,6 | \n54 month | \n
Griesser | \nHSIL | \n119 | \n96,9 | \n33 | \n33,6 | \n48 month | \n
in total | \n\n | 441 | \n94,2 | \n34,6 | \n33,6 | \n\n |
Risk profil HSIL - Progression to CIN3+ for L1+ and L1- cases
As already mentioned earlier colposcopically guided punch biopsies are taken during the follow up of women with abnormal Pap smears as step 2 of the 3 step strategy of cervical cancer prevention.
\nNegri and colleagues [27] pointed out in their study that the possibility of predicting the behavior of low-grade cervical lesions could be of high value in clinical practice, potentially allowing an individualized management of cervical lesions depending on their progression risk.
\nHilfrich and Hariri [28] have discribed first, the prognostic relevance of HPV L1 capsid protein detection on paraffin embedded histological sections, initially reported on routinely performed Papanicolaou stained cervical smears and on liquid based cytology (LBC) [18], [19] (see Figure 9).
\nIn contrast to these cytology reports, the association of the cervical intraepithelial lesions with HPV high risk types was not confirmed by highly sophistic DNA methods like PCR [18] or Hybrid capture II [19], but the use of a second biomarker, p16, which together with L1, can be easily integrated in any histopathology lab.
\nOverall only 16.1% of the 87 L1 negative, p16 positive CIN lesions showed a remission of the lesion, compared to 72.4% of the double positive cases. None of the L1/p16 double negative CIN lesions progressed. Hariri found similar results for the combination of ProExC and Cytoactiv.
\nNegri and colleagues [27] included in their approach 38 conization specimens with coexisting cervical intraepithelial neoplasia grade 1 (CIN1) and 3 (CIN3) (group A) and 28 punch biopsies from women with CIN1 and proven spontaneous regression in the follow-up (group B). In group A, all CIN3 were p16 positive (p16+) and L1 negative (L1-). The CIN1 of this group were p16+ L1- and p16+ L1+ in 68.42% and 31.57%, respectively. No other expression pattern was found in this group. In group B, the p16+ L1-, p16+ L1+, p16- L1+, and p16- L1- patterns were found in 3.57%, 25%, 14.29%, and 57.14%, respectively. Overall, 96.29% p16+ L1- CIN1 were found in group A, whereas all the p16- L1+ and p16- L1- CIN1 were found in group B.
\nThey found that no cases with both L1 and p16 negativity were found in group A, and proposed that this pattern might be classified as ‘‘low risk’’ or, unless the original section shows obvious dysplastic features, as ‘‘no evidence of CIN.’
\nThe results of the study showed that p16 and L1 immunohistochemistry can be helpful for estimating the biologic potentiality of low-grade squamous cervical lesions. Particularly in cases in which the grade of the lesion is morphologically difficult to assess, the p16/L1 expression pattern could be useful for planning the clinical management of these women.
\n\n Staining pattern\n | \n\n Risk profileNegri et al.\n | \n\n Risk profileHilfrich / Hariri\n | \n
P16+ / L1 - | \n‘‘high-risk’’, 3,6% remission | \n High risk 16.1% remission | \n
P16+ / L1+ | \nindeterminate’’ risk | \n72,4% remission not distinguished in p16+/- | \n
P16- / L1+ | \n‘‘low-risk’’ | \n\n |
P16- / L1- | \n‘‘low risk’’, or ‘‘no evidence of CIN.’ | \n No potential to progress | \n
Risk profils according to Negri et al./ Hilfrich, Hariri
Using 101 HPV High risk positive CIN1 Choi et al [29] published 2010 that the HPV L1 protein expression is closely related to spontaneous disease regression. Not using p16, but a type-specific HPV-DNA Chip, it was possible for the first time to correlate the HPV type with the regression of the L1 positive CIN1 lesions. 50% of the HPV16 positive CIN1, 72,7% of the HPV58, 76.9% of the HPV18, 77.8% of the HPV33, 83,3% of the HPV53 and 100% of the HPV31 positive cases regressed during the follow up period of 1 year (see Figure 8).
\n\n HPV 16\n | \n\n HPV 58\n | \n\n HPV 18\n | \n\n HPV 33\n | \n\n HPV 53\n | \n\n HPV 31\n | \n
50% | \n72,7% | \n76,9% | \n77,8% | \n83,3% | \n100% | \n
Choi et al, Remission of Cytoactiv L1 positive cases within 1 year in relation to the HPV type
HPV16 / L1+CIN1 – according to Choi et al. regress in 50% of the cases within 12 month.
In contrast to all other studies Galgano et al. [17] asked if HPV L1 detection, as a stand alone marker, could be a useful diagnostic, but not prognostic, tool.
\nAs HPV specific protein L1 is only detectable in HPV positive lesions. HPV negative CIN lesions have to be L1 negative, because the virus is absent.
\nAccording to Hilfrich/Hariri and Negri et al L1 negativ cases are mixtures of HPV associated and non HPV associated CIN lesions, especially analysing CIN1.
\nHPV positive (p16 positive) but L1 negative lesions are high risk lesions whereas on the other hand HPV negative (p16 negative) and L1 negative lesions are ´no risk´ lesion or as Negri mentioned could be classified as ´no evidence of CIN´.
\nL1+ CIN2
Not surprisingly mixing and not differentiating the L1 negative ´high risk´ and the L1 negative ´no risk´ entities have to result in ´disappointing´ results because remission and progression of the lesions are observed equally.
\nIn the meantime the combination of L1 and p16 has been investigated on cytological samples by Ungureanu and colleagues [30] as well. As expressed in different phases of cervical carcinogenesis, the authors expected that p16 and L1 are potentially promising markers of progression risk of LSIL. The combination of p16 and L1 capsid protein immunostaining in LBC appears to be useful for an early diagnosis of precancerous lesions and for an appropriate clinical attitude.
\nConsistent with the previous data they found that expression of L1 capsid protein could be observed in 33.33% of ASC-US cases, 50% of LSILs, 18.51% of HSILs. No positive cases were found in the group of SCC, thus indicating that L1 capsid protein expression tends to decline with increasing severity of the lesions.
\nAs already described a tight communication between the virus and the host cell is of critical importance for the viral life cycle. On the one hand it is strictly linked to the epithelial cell differentiation, on the other hand HPV need to modulate the proliferation / differentiation status of the host cells to allow replication in ´non dividing cells´ and the maturation of new infectious virus particles.
\nAs long as the L1 capsid protein can be detected within the nucleus of dysplastic cells the virus was successful in this ´walk on the edge´. Despite of all viral activities the cells are still in the condition to allow the normal, productive life cycle of the Human Papilloma Viruses.
\nL1 capsid protein negative dysplasias, however, are due to this virally induced cellular deregulation processes no longer capable to produce virions.
\nA shift from a productive HPV infection towards a non-productive or precancerous lesion has occurred.
\nThe reasons for this event are multifarious since the differentiation dependent expression of L1 is controlled at multiple levels. A block at any of the following steps, such as transcription (integration and / or methylation of the DNA), post-transcriptional processing and translation, could be responsible for the loss of L1 capsid protein.
\nIntegration of the viral DNA is considered to be of critical importance for the progression from CIN to cancer, since the frequency of HPV-16 viral integration increase in parallel with the severity of cervical lesions.
\nDuring the integration process of the HPV genome into the host chromosome a linearization of the ring – shaped, episomal viral DNA is required. It’s easy to imagine, that this non directed event is regularly associated with a deregulation of the strictly controlled episomal DNA. As a consequence of the integration process alterations of the control region and loss or disruption of HPV specific proteins like the early and late proteins can be observed [31].
\nEven if the L1 gene is not affected directly, the integration of the virus with loss of transcriptional control by E2 results in over expression of E6 and E7 leading to immortalization and transformation of the cells [32].
\nAs a result, the epithelial host cell remains in the cell cycle and increasingly becomes genetically instable without being able to run its differentiating program.
\nL1 genes can functionally be inactivated afterwards too, as a result of mutation, gene deletion and insertion as well as DNA methylation so that no capsid protein will be produced anymore (discussed later).
\nA dysmaturational autonomous tumor emerges in the host epithelium; a ´point of no return´ is crossed.
\nBut for the background that many of the HPV-associated cancers do not even carry any integrated viral genome [31], [33] additional mechanisms have to exist to block L1 expression. In the meantime a discussion started if integration is the initial step towards cervical cancer, or maybe only the consequence of the E6/E7 induced genetic instability of the host cells.
\nControl of gene expression by epigenetic modification of distinct DNA sequences is a fundamental biological process, which affects for example embryonic development, cellular differentiation and others.
\nOne important mechanism, affecting the chromatin conformation, is the methylation of DNA, specifically at cystidine-guanidine (CpG) dinucleotides. Methylated CpG dinucleotides bind repressors, which alter the conformation of nucleosomes through their interaction with histone deacetylases in a manner unfavourable to transcription [34].
\nIn the meantime it’s known that epigenetic mechanisms play a major role in the transcription of the HPV genome as well [35], [36].
\nSeveral reports showed that the HPV genome is differentially methylated during progression from simple infected to transformed cells.
\nAlterations were observed particularly in the control region, and the L1 and L2 gene in high grade precancer and invasive cancer. These observations lead to the suggestion that the lack of expression of these genes may be attributed at least in part to increasing methylation of the respective parts of the viral genomes.
\nKalantari et al. for example reported that methylation exceeds 50% in the case of some CpG dinucleotides within the L1 gene [37].
\nIn addition E2 expression seems to be strictly linked to the differentiation process from normal to malignant cells, indirectly affecting L1 expression as well. Vinokurova showed that E2 binding sites are highly methylated in undifferentiated cells, inhibiting E2-binding, and demethylation at the E2 binding sites occurs in association with the cell differentiation only [38].
\nThat means different mechanisms are existing to prevent L1 mRNA transcription.
\nOnce the transcription of the late mRNA was successful, additional mechanisms have been reported that are able to control or block the L1 capsid protein expression.
\nMori et al. [39] showed that RNA instability elements are within the L1 and L2 coding mRNAs of HPV16, which function in undifferentiated cells. Although the mechanism for RNA destabilization are still subject of further investigations this mechanism could be important for L1 expression.
\nKoffa et al. [40] reported that the L1 mRNA of HPV16 was retained in the nucleus in undifferentiated W12 epithelial cells, suggesting that the nuclear export of late mRNAs was inhibited in the dividing cells, thus preventing translation of the L1 protein in the cytoplasm. The factor(s) mediating the nuclear export of late mRNAs has not been identified yet [41].
\nLast but not least the rare codon usages found in L1 and L2 might also contribute to the inhibition of late gene translation [42]. In terminally differentiated cells, the altered expression ratios of tRNA species could compensate for the inhibitory effect of the rare codon usages [43].
\nAll these steps could be of critical importance for L1 capsid protein expression. As indicated a lot of questions are still remaining and need to be answered in the future. Most probably not only a single control mechanism is responsible for the oberserved loss of L1 capsid proteins.
\nThe immune system developed special innate and adaptive immune mechanisms to recognize and fight against foreign agents that invade our body.
\nSometimes these methods are ineffective especially when the agent uses mechanisms to evade the immune system, like HPV is doing.
\nSince the HPV infection remains located in the epithelium, mucosal ulceration is a prerequisite for antigen contact with the immune cells in the stroma and in addition to a sufficiently high antigen dose, an efficient immune response, against HPV, also requires supporting mediators.
\nHowever, HPV itself has own characteristics also due to its route of infection that protect it from access of the immune system.
\nThe HPV infection does not cause a systemic spreading of the infection by means of a viraemia and the infected epithelia are not destroyed. Thus, any inflammatory tissue reaction supporting the immune response is suppressed, and the virus material is only released on the epithelial surface which is poor in immune defence cells and distant from immune centers.
\nFinally, the virus itself express only very low levels of viral protein, suppresses the release of cytokines from epithelia and intraepithelial antigen-presenting Langerhans\' cells and can suppress the expression of histocompatibility antigens required for the interaction of epithelial cells and immune cells. The E7 and E6 proteins are involved in this inhibition [44], [45].
\nConsequently, one could envision that in this setting an efficient transfer of antigen from HPV infected keratinocytes to the antigen presenting cells (APC) is not triggered.
\nNevertheless a successful immune response to genital HPV infection is established in almost all cases. But the time required for clearance of high risk types, particulary HPV16, averages 8-14 month, which is considerably longer than 5-6 months needed for clearance of low risk types [44].
\nThe only fully accessible antigen sources in the earlier stage of virally induced SIL to promote an activation of the immune system are free viral particles consisting of 360 L1 capsid proteins.
\nTherefore it seems not to be surprising, that a clinical remission of the lesion is observed regularly if the L1 capsid protein is detectable in the dysplastic cells.
\nTo generate an effective virus specific immune response the virus particles have to be detected by the antigen presenting cells (APC) of squamous epithelium, the Langerhans cells (LC) or Dendritic cells (DC), and armed effector cells, has to migrate back to the infected site, and destroy the infected keratinocytes leading to a spontaneous clinical remission of the lesion.
\nIf such immunologic activation mechanisms are functional, they are quite effective since with about 20% the malignant potential for these L1-positive lesions, irrespective of the dysplasia being cytologically mild or moderate, is low.
\nOn the other hand it is still not clear how L1 specific cytotoxic T-cells could be able to destroy the HPV reservoir in the basal cell layer to cause clinical remission, since the L1 capsid protein is only detectable in terminally differentiated cells.
\nIn analogy to the basal cells it was shown for the L1 capsid protein negative C3 cell line, that these cells are sensitive to L1 specific cytotoxic T-cells [46]. The only explanation seems to be a L1 expression level in these cells (as well as the basal cells), lower than the detection limit used for analysis. As described earlier L1 mRNA is detectable in the nucleus of undifferentiated cells.
\nA second explanation for the clinical remission of L1 capsid protein positive dysplasias could be, that the viral capsids work as a kind of abjuvance, only triggering the cell mediated response to the early proteins, principally E2 and E6, which are thought to be important for lesion regression [47].
\nNevertheless it was shown recently by Mehlhorn et al. [48] that the detection of antibodies against HPV16 L1 in the serum is always associated with clinical remission, if the L1 capsid protein is detectable in the smear of HPV high risk positive mild and moderate dysplasias. These L1 specific serum antibodies shouldn’t be able to fight against the HPV infected cells, but it shows that a L1 specific activation of the immune system is of critical importance for the clearance of the HPV infection.
\nAn ineffective immune response maybe promoted by HLA incompatibilities, factors contributing to cervical cancer like tobacco smoking or the coexistence of dysplasias of different grade in the transformation zone, possibly reflecting a mixture of L1-positive and L1-negative lesions with different progressive potentials may be the reasons for a progression of some L1-positive intraepithelial lesions.
\nIn addition Yang et al [49] identified several mutant HPV16 L1 isolates carrying genes encoding proteins that neither assemble nor activate VLP-dependent innate and adaptive immune responses. They concluded that this may represent an additional mechanism of the evasion of innate immune recognition during cervical carcinogenesis.
\nAbsence of L1 capsid protein, as the only fully accessible antigen sources in the earlier stage of virally induced SIL, leads to the situation that the viral immune escape mechanisms are maintained and the dysplastic cells, unnoticed by the immune system, proceed in the process of malignant transformation.
\nWith more than 80% in cytology and more than 90% for CIN1/2 the malignant potential of the L1-negative dysplasias is exceedingly high, similar to what is expected for a true precancerous lesion.
\nThe differentiation dependent loss of the L1 stimulus may lead to a local ´lack of immunity´ further supporting the virally induced alterations.
\nThese may lead to additional disorders of cell cycle regulation at transcriptional, translational and genomic levels thus resulting in a progression of the early precursor lesions to CIN3+. [49]- [51].
\nReasons for the extremely rare cases of clinical remission of L1-negative cases (~5-10%) are most likely due to sampling errors with absence of L1 expressing cells in the sample or expression levels below the detection limit of the highly sensitive immunochemical assay, as reported for the C3 cell line [46].
\nTo treat or not to treat that remains the last question, that has to be answered for women with abnormal Pap smears at the end of the cervical cancer prevention program.
\nAs step 3 of the traditional programs it is common sense that excisional or ablative treatment of the cervical tissue is needed in women diagnosed with precancer.
\nA statement that is easy to agree on, but difficult to follow since mild, moderate and severe dysplasias or the histological equivalents CIN1, CIN2, CIN3 are mixtures of distinct biological stages resulting in different clinical outcomes and neither cytological follow up, colposcopy nor HPV DNA testing could indicate whether a remission or progression of the precursor lesion to invasive cancer will occur.
\nThe good news is that the ratio of remission or transient HPV infection of the one hand, and progression or precancer on the other hand is moving to precancer with the severity of the lesion.
\nBut even CIN3 is not uniform in being precancer. Ostor reported that 30% of these cases will show a spontaneous remission if untreated. Nevertheless we agree that a treatment is warranted.
\nAccepting CIN2 as the clinical threshold for treatment moves us towards a higher degree of overtreatment, increasing in parallel the potential harms on reproductive outcomes for fertile women, including preterm delivery and low-birth-weight infants with life long fatal disabilities.
\nAs shown HPV L1 detection with Cytoactiv is an objective standard to optimize the clinical management of women with abnormal Pap smears.
\nThe data published over the last decade shows uniform that HPV-L1 detection allows identifying transient HPV infections and precancerous lesions within the group of HPV high-risk positive early dysplastic lesions (mild and moderate dysplasia) see Figure 10.
\nHistologically, CIN grading is based upon the proportion of the surface epithelium composed of undifferentiated cells characteristic of the basal layer. Increasing grade is associated with a progressive loss of epithelial maturation. L1 detection allows to identify the different progressive potentials of transient HPV infection (red) and precancer (yellow).
As summarized in Tables 2-4, 75% of the L1 negative LSIL and 94,2% of the L1 negative HSIL progressed to CIN3. Using CIN1 and CIN2 lesions with 83,9 – 96,4% the results are compareable.
\nThese high progression rates of HPV-L1 negative mild and moderate dysplasia emphasizes the precancerous nature of these lesions. Only 5-25% of these lesions regress spontaneously a rate even better than what is accepted for treatment of CIN3, but years before the severe dysplasia arise.
\nAs stated by different authors a close follow-up with colposcopy and histological evaluation is advisable and removal of these lesions should be considered.
\nOn the other hand the low malignant potential of HPV-L1 positive cases indicates transient HPV infection, or true ´low grade lesions´.
\nOnly 13,1% of the L1 positive LSIL, and 34,6% of the L1 positive HSIL progressed to CIN3, typically thresholds justifying ´a watch and wait strategy´ with cytological follow-up.
\nIntegrating the promising serological HPV L1 antibody rapid test into this procedure seems to be able to improve this data further, thus preventing overtreatment especially for women in their reproductive age.
\nOnly in case of persistence of the L1 positive lesion a colposcopy should be performed.
\nAt the end of the day a combination of cytology, colposcopy, HPV DNA determination and HPV L1 detection offers a unique possibility to increase the benfits of cervical cancer screening programs, by reducing the potentials harms.
\nSolid waste is the byproducts of human activities such as production, consumption and distribution of various goods in the society. There are a number research has been investigated in the various aspects such as technology, innovation, recycling of solid waste management in the developing and developed countries. There are a lack of studies on economic analysis of solid waste management particularly in the developing countries, for example cost and revenue aspects [1, 2]. Most of the municipal corporation has not been maintained proper data on solid waste generation, collection, transportation and final disposal. Therefore economists are confused economic estimation of solid waste management [3]. Moreover, economic analysis of solid waste management is the most helpful to local policy makers on various aspects for instance, designing waste management tax/charges or subsidies at the municipal level [4]; cost and benefits of waste to energy [5] and determining of urban property through the better environmental amenities [6, 7]. There are various economics estimation of per ton of solid waste management in India, For example, National Institute of Urban Affairs [8] had estimated at Rs 135 for per ton of solid waste collection and disposal and another study by National Solid Waste Association [9] had calculated at Rs 417 per ton of solid waste management [3, 10]. Therefore, this chapter has discussed the economics of solid waste management and public policy at the municipal level in various developing and developed countries.
Harisch [11] was the first author who had made an important methodology contribution to study the methods of Solid Waste Management. Attention had then been shifted to the second generation of research, particularly to the work of Stevens [12] who had made substantial improvements in the Model of Hirsch [11] and those of Dubin and Navarro [13] whose papers had included some methodological innovations also. Don Fullerton and Thomas Kinnaman [14] and Beede and Bloom [15] had made generation reforms and had introduced new methods of making an econometric analysis of Solid Waste Management. Finally, a few Indian studies had made use of new methodological approaches and innovations which had used more of the statistical methods. So, more recent studies had been considered in greater detail in this section.
The First empirical study to use econometric analysis for determining, among other things, as to which form of service delivery (public or private) had an effect on the municipal cost, was that of Hirsch [11], who had studied a sample of 24 Municipalities in St. Louis country (Missouri). However, this study had used econometric model in terms of the explanatory variables were limited to the data that was an available in 1960s, the year for which he had collected the information. Therefore, the variables that were finally used to explain cost (the average costs per service) were the number of waste collection locations, the weekly collection frequency, whether the collection point was an alone or a collective agencies, the residential area, sources of finance and the form of service management, and the distinction between the municipal and the private delivery. The Article had concluded that there were significant differences in the service cost between the municipal and the private delivery. This study did not find any economies of scale with respect to the output in the service. Hardy and Greission [16] had analysed the possibility of saving costs through cooperative efforts in the collection and the disposal of the solid waste material. Heuristic algorithms had been used to determine the best locations for landfills and the best routes for the collection trucks to follow in the study area in five countries. They had discussed about the rural public service delivery problems, and had designed a method to determine the least cost solid waste management system for the selected areas. According to them the economies of scale to be realised in the disposal phase of a solid waste management system and the costs of collection were dependent on the population density and the size of the service area. The combined collection and disposal costs had indicated that the regional system could be justified for the selected study areas. The least cost system for the five countries have two regional landfills. The annual costs associated with this system of $ 447.275, was found to be substantially lesser than the amount of $ 519,815 estimated for the system with each county operating the system independently. The results of the economic analysis had indicated that a regional system for the solid waste collection and disposal could be justified from the standpoint of view of costs.
Kumar et al. [17] had applied the fuzzy regression approached of forecasting for the years 2007 to 2024. The Study had emphasised the importance of forecasting the waste composition and the significance of the waste segregation for the efficient operation of the various reuse-recycle treatment and for producing efficient disposal facilities. The fuzzy regression coefficient was estimated based on the historical data of socioeconomic conditions (in this study, per capita income, GDP, persons per household, Total Population and Density) and the respective solid waste compositions (in this study; paper waste, plastics, food items, metals, glass pieces and other wastes). The fuzzy regression analysis had estimated the variations in the composition of the wastes: the percentages of wastes paper and food wastes were expected to decrease from 29.50 to 24.58 per cent and from 36.37 to 27.55 per cent, respectively, between the years 2007 and 2024. On the other hand, the waste of plastic contents was expected to increase from 2.74 to 3.55 per cent. The most significant changes were expected in respect of the percentage changes in the case of metals and glass, which had been estimated to increase by three times and two times, respectively, as compared to the present percentage levels. Maria Eugenia Ibarraran Viniegra [18] had attempted to examine the people’s willingness to pay for making improvements in the quality of the environment that could be brought about by a proper garbage collection system. The Study had carried out an econometric estimation of the determinants of Willingness to pay for environmental quality in San Pedro Cholula and was focused on the Municipality of San Pedro Cholula, located to the North of the city of Atlixco and to the West of the city of Pueble. Its area was 712 square kilometres and its population was approximately 150,000 inhabitants. The majority (36.5 per cent) of them was agricultural engaged in activities, and next in important were people engaged in arts and crafts and workers (14.5 per cent); and businessmen (8.3 per cent). An average Willingness to pay for the Project was $ 1.85 dollar her month per household. Age was a factor of significance and it was having an inverse relationship with to Willingness to Pay. The relationship between environmental ethics and that of Willingness to pay had shown a contradiction between people’s willingness to pay and their interest for environmental quality. This might be due to the fact that they did not express their true Willingness to pay because they feared that the garbage collection fees might increase. Finally, they had suggested a step towards valuation of the environmental quality and had allowed for making investment decisions with more and better information in Developing Countries.
Sarkhel and Banerjee [19] had calculated the economic value of municipal solid waste management in West Bengal. This study had interviewed 570 individual households and the mean Willingness to pay from the responses to the open-ended questions was calculated to be Rs. 12. with a median at Rs. 5.00 and a 75 per cent of the respondents expressing their willingness to pay at less than Rs.10.00, the distribution appeared to be skewed to the left with a very few extreme observations in the right-tail, pulling the mean substantially to a higher had level than that of the median. The Authors had also estimated the benefits that could derive by adopting the improved system of municipal waste management in Bally the Municipality in West Bengal. Altaf and Deshazp [20] had studied about the problem of the “Household Demand for Improved Solid Waste Management in: Pakistan” and the objectives of the study focused on integrating the demand side information into the planning process. Most of the attempts at improving the performance had been focused on the supply-side issues such as the collection, disposal and the capacity but had not yielded significant results. The sampling frame was provided by the Federal Bureau of Statistics (FBS). This census sampling frame work divided Gujranwala into 436 enumeration Blocks which represented the neighbor hoods containing 200 to 250 households. The Blocks were stratified according to income by the FBS. This stratification was retained for the study as the municipal solid waste services were provided at the block level and not at the household level. This study had followed stratified random sampling method for 1000 households. The distribution of the wastes from both the houses and the streets were tabulated at the disposal sites. About 20 per cent of the households had reported that their wastes were collected directly by the municipal disposal collectors using handcarts. The remaining households had disposed of the wastes outside their in houses with only 2 per cent of them doing so in bins provided by the municipal corporation. The most common disposal site, reported by 30 per cent of households, was an empty plot in the neighbourhood.
Economic instruments are the major role in the effective solid waste management sectors of many developed and developing countries. There are a number of instruments available in the literature. The economic instruments have been used for the different aspects, for instance, reducing waste generation, improving environmental quality and human well-being [21]. Economic instruments are listed revenue generating instruments, revenue providing instruments and non-revenue instruments. First, Revenue generating instruments such as Charges taxes and subsides. Second, revenue providing instruments are includes charges and tax reductions, fiscal incentives, development rights, funds. Finally, non-revenue instruments are trade off arrangements, deposit refund system, and take back systems. Table 1 highlights various type of economic instruments of solid waste management have adapted many developing and developed countries. Economic instruments have also help for cost-effectiveness, economic efficiency of solid waste management sector Nahman and Godfry [22]. However, the implementations of the economic instruments are especially in the developing countries very difficult due to involvement of institution and governance. For instance, in India has been generated more tones of solid waste from several years, therefore, economists they want to estimate cost of waste disposal, but there is lack of economic analysis of solid waste management [3].
Revenue generation | Revenue provide | Non-revenue |
---|---|---|
Disposal Taxes | Tax credits | Deposit refund system |
Pollution Taxes | Environmental improvement fund | Tradable permit |
Eco-taxes | Development rights | Eco-labeling |
Pollution charges | Research grants | Product stewardship |
Waste generation taxes | Host community compensation | Liability insurance |
Producer charges | Tax rebates | Take-back system |
Waste tipping charges | Charge reduction | Disclosure requirements |
Product charges | Carbon sequestration fund | Bonds and sureties |
Callan and Thomas [23] in their study on “Adopting a Unit Pricing System for Municipal Solid Waste: Policy and Socio-Economic Determinants” had carried out a detailed analysis by adopting a unit pricing system for municipal solid waste in USA. 351 Towns are included in the estimation, with 79 of these communities employing the MSW unit pricing approach and they had used the logistic regression equation for their estimation. The estimated parameters and their asymptotic standard error and each parameter gave the estimated change in the log of the odds of adopting unit pricing associated with a unit change in the corresponding independent variable. This study had empirically estimated the influence of the various theorised determinants of unit pricing adoption. From a broad perspective, this study had found that certain socio-economic and demographic characteristics appeared to have influenced the adoption decision. Although such factors were not controllable by the policy makers, an awareness of these determinants could correct false expectations and hence diminish the risk of costly failure. This Study had suggested that a community’s decision to adopt unit pricing was explainable and therefore predictable to some extent. In certain instances, the decision may be directly or indirectly controllable through policy initiatives. The relevance of these findings to MSW policy initiatives development should motivate further empirical investigations of unit pricing adaptation and the associated implications for policy makers and for the society at large.
Kinnaman [24] had used a skeletal model to develop and to frame a discussion of optimal policy design. This Model employed the virgin and the recycled materials so that the ratio of input prices was equal to that the ratio of marginal products. The Households might choose between the garbage and the recycling in a similar manner. Since agents in this simple model internalized all of the costs and benefits of their choices, resources were allocated efficiently and the optimal quantities of garbage and recycling were produced. The household utility would have an impact due to by these effects. So assume now that u = u (c,g), where ug < 0. Under this assumption, households failed to internalise the fuel social costs of their disposal decisions. Too much garbage and too little recycling could be adopted by a decentralized economy. The majority of the households are paid traditional ways such as garbage removal fee or local property tax to the municipalities. Miranda [25] in the study on “Unit based Pricing in The United States: A Tally of Communities” had highlighted 21 communities with unit-pricing programmes and had compared the quantity of garbage and that of recycling over the year preceding the implementation of the unit-pricing system with the year following it. Results had indicated that these towns had reduced garbage by 17 per cent and had increased recycling by 128 per cent. These large estimates could not be attributed directly to pricing garbage, since in every programme curbside recycling programsme were implemented during the same year as that of the adoption of the unit-pricing programme. Callan and Thomas [26] had predicted that the implementation of a user fee had increased the portion of the wastes recycled by 6.6 percentage points. This impact increased to the level of percentage 12.1 points when the user fee was accompanied by a curbside recycling program.
Kinnaman and Fullerton [27] had demonstrated that the disposals of household wastes were constrained by two disposals an option that is garbage disposal at landfill and recycling, and then marginal cost pricing which would tend to substitute recycling for garbage disposal. But if illegal disposal or burning features was a third alternative in the household disposal choice set, then unit pricing would encourage illicit dumping. If marginal cost pricing resulted in an increase in illegal dumping, and if the externality costs are high, the efficiency losses from under- pricing services might be smaller to bear with. In fact, the initial introduction of the unit pricing system resulted only in a modest reduction in waste disposal through dumping [28]. Fullerton and Kinnaman [29] had estimated that 28 per cent of the reduction in garbage resulting from pricing garbage disposal at the curb might be due to of illegal dumping. Jenkins [30], Blume [31] and Miranda and Aldy [32] had also come out with similar findings. The unit pricing model was used in a household production framework Morris and Holthausen [33] had shown that a price increase on the conventional disposal method did not affect recycling. In the system of unit pricing, the households found it more convenient to increase the total waste reduction efforts. The resources like Time and the prices of the purchased inputs devoted to the recycling process were high but they became less effective because of the reduction of wastes. Maraco Runkel [34] had attempted to develop a partial equilibrium vintage model of a durable good in which the producers determined the output and the product durability either under perfect or under imperfect competition. The Model differed from the previous durable goods Models in explicitly accounting for the consumption waste and for the disposal costs. This Paper had investigated as to how the Extended Producer Responsibility (EPR) in waste management had influenced the product durability and welfare. At the end of the products’ life the households had to pay a unit-based waste tax that coved the marginal disposal costs also. When purchasing consumption goods, rational households anticipate the tax, adjust their demand such that less waste was generated and rendered the resource allocation very efficient. The analysis derived the first-best and the second-best regulatory schemes and, on the basis of these schemes and had, investigated as to how EPR had influenced durability and welfare. All considered EPR instruments had exerted a positive effect on durability. Under perfect competition, the first-best outcome was attained provided the EPR had assigned a few marginal disposal costs to producers at the end of the products’ life; for example, through a take-back requirement combined with a regulated private disposal by the firms.
Marcello Basili et al. [35] had analysed and evaluated the costs and benefits of the New Garbage Plan (NGP), and had used hypothesis that Willingness To Pay (WTP) should reflect the value of the community of having a better environmental quality according to the contingent valuation literature. The study sample was divided into two subsets: firms and households, through the information gathered with the help of a detailed questionnaire and the, parametric and the non-parametric estimates were elaborated to analyse the willingness to pay of the population for the benefits flowing from increased SWC, increased incineration and through the cutting down of the landfills. The non-parametric from (using the double-bounded format) had produced an estimation of the minimum willingness to pay for the households and the firms, without the need to make any assumption about the true probability distribution of the values in the population. The mean willingness to pay for an increasing SWC was € 15.89 for households and € 20.89 for firms. The mean willingness to pay was easy to calculate but did not convey enough information for the policy makers. This was because of the fact that it was not possible to know the possibility of the willingness to pay to the socio-economic characteristics which could be obtained through parametric estimation producers. The Non – parametric estimates were robust, whereas the parametric estimates gave more information, and the authors had combined the non-parametric with the parametric estimates.
There are some recent literature have focused on economics of solid waste management at the national level. For example, cost and revenue aspects of municipal solid waste management, Al-Salem et al. (2014) had estimated the cost and revenue aspects of municipal solid waste management in the Great London. This study had found material resource recovery is more favorable in the context of economic in the city. Another study, Nahman [4] estimated the external cost of solid waste landfill in Cape Town, South Africa. The external costs are includes environmental as well as social cost in the estimation methodology. This study had estimated at the US$ 16 per tons of waste which has energy generation process from the municipal solid waste in the Cape Town. Aleluia and Ferrão [1] calculated the costs of solid waste management in the Asian Countries. The cost have included such as capital and operational expenditure for the municipal solid waste management. This study had estimated the average capital expenditure cost per ton US$ 21,493 for the Asian cities. Casado et al. [6] had calculated that the cost of municipal waste incineration through the Hedonic Pricing Method in England. This study had found that the impact of effective incineration the house prices range between 0.4 % to 1.3% in the study area. Sun et al. [7] had estimated the value of real estate price due to municipal solid waste landfill in Shenzhen, China through the hedonic price method. This study has found that the property value has been increased by 1.30% if the landfill away from houses.
There is lack of primary investigation on economics of solid waste management at the various municipalities in the many developing countries. The present chapter has discussed the various aspects on economics of solid waste management such as economic instrument, policy issues etc. However, the implementations of economic instruments are the major problems. Therefore, need to strengthen local institution and governance. In many developing countries like India, economists are facing many difficulties for estimating economics of solid waste management due to lack of data on waste generation, disposal and recycling [3, 36, 37, 38]. Economic estimate of solid waste is better understanding for local policy makers for designing healthy urban planning towards achieving sustainable cities. Most of the developing countries are in lack of finance and technology for effective solid waste management. Economics of solid waste management could provide a good framework for solid waste management especially cost and benefit aspects at the local and regional level [39]. Further, economics estimation of solid waste is more helpful to decision makers for designing tax/charges or other economic instrument for efficient allocation of financial and technological resources at the city level [24]. A number of Asian countries are difficult to design better solid waste management due to lack of studies on economic estimation in terms of cost of collection, transportation, segregation and final disposal [1]. Although, there are other economic problems raised due to lack of economic estimation of solid waste, for example negative externality [2]. Therefore, need to support economics of solid waste related studies at the regional, local and national level through the grants, support and guidance for better solid waste management for achieving environmental sustainability.
As an Open Access publisher, IntechOpen is dedicated to maintaining the highest ethical standards and principles in publishing. In addition, IntechOpen promotes the highest standards of integrity and ethical behavior in scientific research and peer-review. To maintain these principles IntechOpen has developed basic guidelines to facilitate the avoidance of Conflicts of Interest.
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\n\nA Conflict of Interest is a situation in which a person's professional judgment may be influenced by a range of factors, including financial gain, material interest, or some other personal or professional interest. For IntechOpen as a publisher, it is essential that all possible Conflicts of Interest are avoided. Each contributor, whether an Author, Editor, or Reviewer, who suspects they may have a Conflict of Interest, is obliged to declare that concern in order to make the publisher and the readership aware of any potential influence on the work being undertaken.
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She performed (inter)national tasks as vice-president of the Concilium Anaesthesia and related committees. \nShe performed research in several fields, with over 100 publications in (inter)national journals and numerous papers on scientific conferences. \nShe received several awards and is a member of Honour of the Dutch Society of Anaesthesia.",institutionString:null,institution:{name:"Albert Schweitzer Hospital",country:{name:"Gabon"}}},{id:"83089",title:"Prof.",name:"Aaron",middleName:null,surname:"Ojule",slug:"aaron-ojule",fullName:"Aaron Ojule",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Port Harcourt",country:{name:"Nigeria"}}},{id:"295748",title:"Mr.",name:"Abayomi",middleName:null,surname:"Modupe",slug:"abayomi-modupe",fullName:"Abayomi Modupe",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/no_image.jpg",biography:null,institutionString:null,institution:{name:"Landmark University",country:{name:"Nigeria"}}},{id:"94191",title:"Prof.",name:"Abbas",middleName:null,surname:"Moustafa",slug:"abbas-moustafa",fullName:"Abbas Moustafa",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/94191/images/96_n.jpg",biography:"Prof. Moustafa got his doctoral degree in earthquake engineering and structural safety from Indian Institute of Science in 2002. He is currently an associate professor at Department of Civil Engineering, Minia University, Egypt and the chairman of Department of Civil Engineering, High Institute of Engineering and Technology, Giza, Egypt. He is also a consultant engineer and head of structural group at Hamza Associates, Giza, Egypt. Dr. Moustafa was a senior research associate at Vanderbilt University and a JSPS fellow at Kyoto and Nagasaki Universities. He has more than 40 research papers published in international journals and conferences. He acts as an editorial board member and a reviewer for several regional and international journals. His research interest includes earthquake engineering, seismic design, nonlinear dynamics, random vibration, structural reliability, structural health monitoring and uncertainty modeling.",institutionString:null,institution:{name:"Minia University",country:{name:"Egypt"}}},{id:"84562",title:"Dr.",name:"Abbyssinia",middleName:null,surname:"Mushunje",slug:"abbyssinia-mushunje",fullName:"Abbyssinia Mushunje",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Fort Hare",country:{name:"South Africa"}}},{id:"202206",title:"Associate Prof.",name:"Abd Elmoniem",middleName:"Ahmed",surname:"Elzain",slug:"abd-elmoniem-elzain",fullName:"Abd Elmoniem Elzain",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Kassala University",country:{name:"Sudan"}}},{id:"98127",title:"Dr.",name:"Abdallah",middleName:null,surname:"Handoura",slug:"abdallah-handoura",fullName:"Abdallah Handoura",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"École Supérieure des Télécommunications",country:{name:"Morocco"}}},{id:"91404",title:"Prof.",name:"Abdecharif",middleName:null,surname:"Boumaza",slug:"abdecharif-boumaza",fullName:"Abdecharif Boumaza",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Abbès Laghrour University of Khenchela",country:{name:"Algeria"}}},{id:"105795",title:"Prof.",name:"Abdel Ghani",middleName:null,surname:"Aissaoui",slug:"abdel-ghani-aissaoui",fullName:"Abdel Ghani Aissaoui",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/105795/images/system/105795.jpeg",biography:"Abdel Ghani AISSAOUI is a Full Professor of electrical engineering at University of Bechar (ALGERIA). He was born in 1969 in Naama, Algeria. He received his BS degree in 1993, the MS degree in 1997, the PhD degree in 2007 from the Electrical Engineering Institute of Djilali Liabes University of Sidi Bel Abbes (ALGERIA). He is an active member of IRECOM (Interaction Réseaux Electriques - COnvertisseurs Machines) Laboratory and IEEE senior member. He is an editor member for many international journals (IJET, RSE, MER, IJECE, etc.), he serves as a reviewer in international journals (IJAC, ECPS, COMPEL, etc.). He serves as member in technical committee (TPC) and reviewer in international conferences (CHUSER 2011, SHUSER 2012, PECON 2012, SAI 2013, SCSE2013, SDM2014, SEB2014, PEMC2014, PEAM2014, SEB (2014, 2015), ICRERA (2015, 2016, 2017, 2018,-2019), etc.). His current research interest includes power electronics, control of electrical machines, artificial intelligence and Renewable energies.",institutionString:"University of Béchar",institution:{name:"University of Béchar",country:{name:"Algeria"}}},{id:"99749",title:"Dr.",name:"Abdel Hafid",middleName:null,surname:"Essadki",slug:"abdel-hafid-essadki",fullName:"Abdel Hafid Essadki",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"École Nationale Supérieure de Technologie",country:{name:"Algeria"}}},{id:"101208",title:"Prof.",name:"Abdel Karim",middleName:"Mohamad",surname:"El Hemaly",slug:"abdel-karim-el-hemaly",fullName:"Abdel Karim El Hemaly",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/101208/images/733_n.jpg",biography:"OBGYN.net Editorial Advisor Urogynecology.\nAbdel Karim M. A. El-Hemaly, MRCOG, FRCS � Egypt.\n \nAbdel Karim M. A. El-Hemaly\nProfessor OB/GYN & Urogynecology\nFaculty of medicine, Al-Azhar University \nPersonal Information: \nMarried with two children\nWife: Professor Laila A. Moussa MD.\nSons: Mohamad A. M. El-Hemaly Jr. MD. Died March 25-2007\nMostafa A. M. El-Hemaly, Computer Scientist working at Microsoft Seatle, USA. \nQualifications: \n1.\tM.B.-Bch Cairo Univ. June 1963. \n2.\tDiploma Ob./Gyn. Cairo Univ. April 1966. \n3.\tDiploma Surgery Cairo Univ. Oct. 1966. \n4.\tMRCOG London Feb. 1975. \n5.\tF.R.C.S. Glasgow June 1976. \n6.\tPopulation Study Johns Hopkins 1981. \n7.\tGyn. Oncology Johns Hopkins 1983. \n8.\tAdvanced Laparoscopic Surgery, with Prof. Paulson, Alexandria, Virginia USA 1993. \nSocieties & Associations: \n1.\t Member of the Royal College of Ob./Gyn. London. \n2.\tFellow of the Royal College of Surgeons Glasgow UK. \n3.\tMember of the advisory board on urogyn. FIGO. \n4.\tMember of the New York Academy of Sciences. \n5.\tMember of the American Association for the Advancement of Science. \n6.\tFeatured in �Who is Who in the World� from the 16th edition to the 20th edition. \n7.\tFeatured in �Who is Who in Science and Engineering� in the 7th edition. \n8.\tMember of the Egyptian Fertility & Sterility Society. \n9.\tMember of the Egyptian Society of Ob./Gyn. \n10.\tMember of the Egyptian Society of Urogyn. \n\nScientific Publications & Communications:\n1- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Asim Kurjak, Ahmad G. Serour, Laila A. S. Mousa, Amr M. Zaied, Khalid Z. El Sheikha. \nImaging the Internal Urethral Sphincter and the Vagina in Normal Women and Women Suffering from Stress Urinary Incontinence and Vaginal Prolapse. Gynaecologia Et Perinatologia, Vol18, No 4; 169-286 October-December 2009.\n2- Abdel Karim M. El Hemaly*, Laila A. S. Mousa Ibrahim M. Kandil, Fatma S. El Sokkary, Ahmad G. Serour, Hossam Hussein.\nFecal Incontinence, A Novel Concept: The Role of the internal Anal sphincter (IAS) in defecation and fecal incontinence. Gynaecologia Et Perinatologia, Vol19, No 2; 79-85 April -June 2010.\n3- Abdel Karim M. El Hemaly*, Laila A. S. Mousa Ibrahim M. Kandil, Fatma S. El Sokkary, Ahmad G. Serour, Hossam Hussein.\nSurgical Treatment of Stress Urinary Incontinence, Fecal Incontinence and Vaginal Prolapse By A Novel Operation \n"Urethro-Ano-Vaginoplasty"\n Gynaecologia Et Perinatologia, Vol19, No 3; 129-188 July-September 2010.\n4- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Laila A. S. Mousa and Mohamad A.K.M.El Hemaly.\nUrethro-vaginoplasty, an innovated operation for the treatment of: Stress Urinary Incontinence (SUI), Detursor Overactivity (DO), Mixed Urinary Incontinence and Anterior Vaginal Wall Descent. \nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/ urethro-vaginoplasty_01\n\n5- Abdel Karim M. El Hemaly, Ibrahim M Kandil, Mohamed M. Radwan.\n Urethro-raphy a new technique for surgical management of Stress Urinary Incontinence.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/\nnew-tech-urethro\n\n6- Abdel Karim M. El Hemaly, Ibrahim M Kandil, Mohamad A. Rizk, Nabil Abdel Maksoud H., Mohamad M. Radwan, Khalid Z. El Shieka, Mohamad A. K. M. El Hemaly, and Ahmad T. El Saban.\nUrethro-raphy The New Operation for the treatment of stress urinary incontinence, SUI, detrusor instability, DI, and mixed-type of urinary incontinence; short and long term results. \nhttp://www.obgyn.net/urogyn/urogyn.asp?page=urogyn/articles/\nurethroraphy-09280\n\n7-Abdel Karim M. El Hemaly, Ibrahim M Kandil, and Bahaa E. El Mohamady. Menopause, and Voiding troubles. \nhttp://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly03/el-hemaly03-ss\n\n8-El Hemaly AKMA, Mousa L.A. Micturition and Urinary\tContinence. Int J Gynecol Obstet 1996; 42: 291-2. \n\n9-Abdel Karim M. El Hemaly.\n Urinary incontinence in gynecology, a review article.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/abs-urinary_incotinence_gyn_ehemaly \n\n10-El Hemaly AKMA. Nocturnal Enuresis: Pathogenesis and Treatment. \nInt Urogynecol J Pelvic Floor Dysfunct 1998;9: 129-31.\n \n11-El Hemaly AKMA, Mousa L.A.E. Stress Urinary Incontinence, a New Concept. Eur J Obstet Gynecol Reprod Biol 1996; 68: 129-35. \n\n12- El Hemaly AKMA, Kandil I. M. Stress Urinary Incontinence SUI facts and fiction. Is SUI a puzzle?! http://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly/el-hemaly-ss\n\n13-Abdel Karim El Hemaly, Nabil Abdel Maksoud, Laila A. Mousa, Ibrahim M. Kandil, Asem Anwar, M.A.K El Hemaly and Bahaa E. El Mohamady. \nEvidence based Facts on the Pathogenesis and Management of SUI. http://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly02/el-hemaly02-ss\n\n14- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Mohamad A. Rizk and Mohamad A.K.M.El Hemaly.\n Urethro-plasty, a Novel Operation based on a New Concept, for the Treatment of Stress Urinary Incontinence, S.U.I., Detrusor Instability, D.I., and Mixed-type of Urinary Incontinence.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/urethro-plasty_01\n\n15-Ibrahim M. Kandil, Abdel Karim M. El Hemaly, Mohamad M. Radwan: Ultrasonic Assessment of the Internal Urethral Sphincter in Stress Urinary Incontinence. The Internet Journal of Gynecology and Obstetrics. 2003. Volume 2 Number 1. \n\n\n16-Abdel Karim M. El Hemaly. Nocturnal Enureses: A Novel Concept on its pathogenesis and Treatment.\nhttp://www.obgyn.net/urogynecolgy/?page=articles/nocturnal_enuresis\n\n17- Abdel Karim M. El Hemaly. Nocturnal Enureses: An Update on the pathogenesis and Treatment.\nhttp://www.obgyn.net/urogynecology/?page=/ENHLIDH/PUBD/FEATURES/\nPresentations/ Nocturnal_Enuresis/nocturnal_enuresis\n\n18-Maternal Mortality in Egypt, a cry for help and attention. The Second International Conference of the African Society of Organization & Gestosis, 1998, 3rd Annual International Conference of Ob/Gyn Department � Sohag Faculty of Medicine University. Feb. 11-13. Luxor, Egypt. \n19-Postmenopausal Osteprosis. The 2nd annual conference of Health Insurance Organization on Family Planning and its role in primary health care. Zagaziz, Egypt, February 26-27, 1997, Center of Complementary Services for Maternity and childhood care. \n20-Laparoscopic Assisted vaginal hysterectomy. 10th International Annual Congress Modern Trends in Reproductive Techniques 23-24 March 1995. Alexandria, Egypt. \n21-Immunological Studies in Pre-eclamptic Toxaemia. Proceedings of 10th Annual Ain Shams Medical Congress. Cairo, Egypt, March 6-10, 1987. \n22-Socio-demographic factorse affecting acceptability of the long-acting contraceptive injections in a rural Egyptian community. Journal of Biosocial Science 29:305, 1987. \n23-Plasma fibronectin levels hypertension during pregnancy. The Journal of the Egypt. Soc. of Ob./Gyn. 13:1, 17-21, Jan. 1987. \n24-Effect of smoking on pregnancy. Journal of Egypt. Soc. of Ob./Gyn. 12:3, 111-121, Sept 1986. \n25-Socio-demographic aspects of nausea and vomiting in early pregnancy. Journal of the Egypt. Soc. of Ob./Gyn. 12:3, 35-42, Sept. 1986. \n26-Effect of intrapartum oxygen inhalation on maternofetal blood gases and pH. Journal of the Egypt. Soc. of Ob./Gyn. 12:3, 57-64, Sept. 1986. \n27-The effect of severe pre-eclampsia on serum transaminases. The Egypt. J. Med. Sci. 7(2): 479-485, 1986. \n28-A study of placental immunoreceptors in pre-eclampsia. The Egypt. J. Med. Sci. 7(2): 211-216, 1986. \n29-Serum human placental lactogen (hpl) in normal, toxaemic and diabetic pregnant women, during pregnancy and its relation to the outcome of pregnancy. Journal of the Egypt. Soc. of Ob./Gyn. 12:2, 11-23, May 1986. \n30-Pregnancy specific B1 Glycoprotein and free estriol in the serum of normal, toxaemic and diabetic pregnant women during pregnancy and after delivery. Journal of the Egypt. Soc. of Ob./Gyn. 12:1, 63-70, Jan. 1986. Also was accepted and presented at Xith World Congress of Gynecology and Obstetrics, Berlin (West), September 15-20, 1985. \n31-Pregnancy and labor in women over the age of forty years. Accepted and presented at Al-Azhar International Medical Conference, Cairo 28-31 Dec. 1985. \n32-Effect of Copper T intra-uterine device on cervico-vaginal flora. Int. J. Gynaecol. Obstet. 23:2, 153-156, April 1985. \n33-Factors affecting the occurrence of post-Caesarean section febrile morbidity. Population Sciences, 6, 139-149, 1985. \n34-Pre-eclamptic toxaemia and its relation to H.L.A. system. Population Sciences, 6, 131-139, 1985. \n35-The menstrual pattern and occurrence of pregnancy one year after discontinuation of Depo-medroxy progesterone acetate as a postpartum contraceptive. Population Sciences, 6, 105-111, 1985. \n36-The menstrual pattern and side effects of Depo-medroxy progesterone acetate as postpartum contraceptive. Population Sciences, 6, 97-105, 1985. \n37-Actinomyces in the vaginas of women with and without intrauterine contraceptive devices. Population Sciences, 6, 77-85, 1985. \n38-Comparative efficacy of ibuprofen and etamsylate in the treatment of I.U.D. menorrhagia. Population Sciences, 6, 63-77, 1985. \n39-Changes in cervical mucus copper and zinc in women using I.U.D.�s. Population Sciences, 6, 35-41, 1985. \n40-Histochemical study of the endometrium of infertile women. Egypt. J. Histol. 8(1) 63-66, 1985. \n41-Genital flora in pre- and post-menopausal women. Egypt. J. Med. Sci. 4(2), 165-172, 1983. \n42-Evaluation of the vaginal rugae and thickness in 8 different groups. Journal of the Egypt. Soc. of Ob./Gyn. 9:2, 101-114, May 1983. \n43-The effect of menopausal status and conjugated oestrogen therapy on serum cholesterol, triglycerides and electrophoretic lipoprotein patterns. Al-Azhar Medical Journal, 12:2, 113-119, April 1983. \n44-Laparoscopic ventrosuspension: A New Technique. Int. J. Gynaecol. Obstet., 20, 129-31, 1982. \n45-The laparoscope: A useful diagnostic tool in general surgery. Al-Azhar Medical Journal, 11:4, 397-401, Oct. 1982. \n46-The value of the laparoscope in the diagnosis of polycystic ovary. Al-Azhar Medical Journal, 11:2, 153-159, April 1982. \n47-An anaesthetic approach to the management of eclampsia. Ain Shams Medical Journal, accepted for publication 1981. \n48-Laparoscopy on patients with previous lower abdominal surgery. Fertility management edited by E. Osman and M. Wahba 1981. \n49-Heart diseases with pregnancy. Population Sciences, 11, 121-130, 1981. \n50-A study of the biosocial factors affecting perinatal mortality in an Egyptian maternity hospital. Population Sciences, 6, 71-90, 1981. \n51-Pregnancy Wastage. Journal of the Egypt. Soc. of Ob./Gyn. 11:3, 57-67, Sept. 1980. \n52-Analysis of maternal deaths in Egyptian maternity hospitals. Population Sciences, 1, 59-65, 1979. \nArticles published on OBGYN.net: \n1- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Laila A. S. Mousa and Mohamad A.K.M.El Hemaly.\nUrethro-vaginoplasty, an innovated operation for the treatment of: Stress Urinary Incontinence (SUI), Detursor Overactivity (DO), Mixed Urinary Incontinence and Anterior Vaginal Wall Descent. \nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/ urethro-vaginoplasty_01\n\n2- Abdel Karim M. El Hemaly, Ibrahim M Kandil, Mohamed M. Radwan.\n Urethro-raphy a new technique for surgical management of Stress Urinary Incontinence.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/\nnew-tech-urethro\n\n3- Abdel Karim M. El Hemaly, Ibrahim M Kandil, Mohamad A. Rizk, Nabil Abdel Maksoud H., Mohamad M. Radwan, Khalid Z. El Shieka, Mohamad A. K. M. El Hemaly, and Ahmad T. El Saban.\nUrethro-raphy The New Operation for the treatment of stress urinary incontinence, SUI, detrusor instability, DI, and mixed-type of urinary incontinence; short and long term results. \nhttp://www.obgyn.net/urogyn/urogyn.asp?page=urogyn/articles/\nurethroraphy-09280\n\n4-Abdel Karim M. El Hemaly, Ibrahim M Kandil, and Bahaa E. El Mohamady. Menopause, and Voiding troubles. \nhttp://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly03/el-hemaly03-ss\n\n5-El Hemaly AKMA, Mousa L.A. Micturition and Urinary\tContinence. Int J Gynecol Obstet 1996; 42: 291-2. \n\n6-Abdel Karim M. El Hemaly.\n Urinary incontinence in gynecology, a review article.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/abs-urinary_incotinence_gyn_ehemaly \n\n7-El Hemaly AKMA. Nocturnal Enuresis: Pathogenesis and Treatment. \nInt Urogynecol J Pelvic Floor Dysfunct 1998;9: 129-31.\n \n8-El Hemaly AKMA, Mousa L.A.E. Stress Urinary Incontinence, a New Concept. Eur J Obstet Gynecol Reprod Biol 1996; 68: 129-35. \n\n9- El Hemaly AKMA, Kandil I. M. Stress Urinary Incontinence SUI facts and fiction. Is SUI a puzzle?! http://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly/el-hemaly-ss\n\n10-Abdel Karim El Hemaly, Nabil Abdel Maksoud, Laila A. Mousa, Ibrahim M. Kandil, Asem Anwar, M.A.K El Hemaly and Bahaa E. El Mohamady. \nEvidence based Facts on the Pathogenesis and Management of SUI. http://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly02/el-hemaly02-ss\n\n11- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Mohamad A. Rizk and Mohamad A.K.M.El Hemaly.\n Urethro-plasty, a Novel Operation based on a New Concept, for the Treatment of Stress Urinary Incontinence, S.U.I., Detrusor Instability, D.I., and Mixed-type of Urinary Incontinence.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/urethro-plasty_01\n\n12-Ibrahim M. Kandil, Abdel Karim M. El Hemaly, Mohamad M. Radwan: Ultrasonic Assessment of the Internal Urethral Sphincter in Stress Urinary Incontinence. The Internet Journal of Gynecology and Obstetrics. 2003. Volume 2 Number 1. \n\n13-Abdel Karim M. El Hemaly. Nocturnal Enureses: A Novel Concept on its pathogenesis and Treatment.\nhttp://www.obgyn.net/urogynecolgy/?page=articles/nocturnal_enuresis\n\n14- Abdel Karim M. El Hemaly. Nocturnal Enureses: An Update on the pathogenesis and Treatment.\nhttp://www.obgyn.net/urogynecology/?page=/ENHLIDH/PUBD/FEATURES/\nPresentations/ Nocturnal_Enuresis/nocturnal_enuresis",institutionString:null,institution:{name:"Al Azhar University",country:{name:"Egypt"}}},{id:"113313",title:"Dr.",name:"Abdel-Aal",middleName:null,surname:"Mantawy",slug:"abdel-aal-mantawy",fullName:"Abdel-Aal Mantawy",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Ain Shams University",country:{name:"Egypt"}}}],filtersByRegion:[{group:"region",caption:"North America",value:1,count:5681},{group:"region",caption:"Middle and South America",value:2,count:5161},{group:"region",caption:"Africa",value:3,count:1683},{group:"region",caption:"Asia",value:4,count:10200},{group:"region",caption:"Australia and 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