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Папилломавирусная инфекция и заболевания шейки матки у беременных женщин. Факторы риска социального статуса, репродуктивного и контрацептивного поведения
Папилломавирусная инфекция и заболевания шейки матки у беременных женщин. Факторы риска социального статуса, репродуктивного и контрацептивного поведения
Бебнева Т.Н., Дикке Г.Б. Папилломавирусная инфекция и заболевания шейки матки у беременных женщин. Факторы риска социального статуса, репродуктивного и контрацептивного поведения. Гинекология. 2020; 22 (6): 74–79. DOI: 10.26442/20795696.2020.6.200460
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Аннотация
Цель. Определить факторы риска инфицирования вирусом папилломы человека (ВПЧ) высокого канцерогенного риска (ВКР) и заболеваний шейки матки (ЗШМ) у беременных женщин, связанные с особенностями социального статуса, репродуктивного и контрацептивного поведения.
Материалы и методы. Дизайн: открытое сравнительное неинтервенционное когортное исследование в параллельных группах. Число пациенток – 330, из них 148 человек без ВПЧ и с ВПЧ – 182. Они разделены на 4 группы в зависимости от наличия или отсутствия ЗШМ. Методы: анализ анамнестических данных, общеклинические, тест «Квант-21» для определения ВПЧ, цитологическое исследование, расширенная кольпоскопия.
Результаты. Выявлены наиболее значимые факторы риска инфицирования ВПЧ ВКР: микоплазменная инфекция (отношение шансов – ОШ 5,9) и бактериальный вагиноз в анамнезе (ОШ 5,3), употребление алкоголя (ОШ 4,0). Значимыми также являются инфекции, передаваемые половым путем, в анамнезе (трихомониаз и хламидийная инфекция), а также более 3 половых партнеров (ОШ 2,7). Наиболее значимыми факторами риска ЗШМ у ВПЧ-инфицированных женщин оказались: возраст старше 35 лет (ОШ 3,8), бактериальный вагиноз в анамнезе (ОШ 3,0) и отсутствие регулярного скрининга (ОШ 2,4). Кроме того, имело значение коитархе ранее 16 лет (ОШ 2,2). Обнаружены также факторы, указывающие на низкий риск инфицирования ВПЧ ВКР, – использование презервативов (ОШ 0,3), а о низком риске ЗШМ свидетельствовали возраст моложе 25 лет (ОШ 0,2) и регулярный скрининг (ОШ 0,3).
Заключение. Инфицированность ВПЧ ВКР и распространенность ЗШМ у беременных на фоне ВПЧ-инфекции связаны преимущественно с социальными факторами риска, в меньшей степени – с факторами репродуктивного и контрацептивного поведения.
Ключевые слова: беременность, вирус папилломы человека, заболевания шейки матки, факторы риска.
Materials and methods. Design: open-label comparative non-interventional cohort study in parallel groups. The total number of patients – 330 people, of whom 148 women were negative for HPV and 182 women were positive. They were divided into 4 groups depending on the presence or absence of CD. Methods: analysis of anamnesis data, general clinical, test “Kvant-21” to determine HPV, cytological examination, extended colposcopy.
Results. The most significant risk factors for HPV HRS infection were identified: history of mycoplasma infection (OR 5.9) and BV (OR 5.3), alcohol consumption (OR 4.0).
A history of STIs (trichomoniasis and chlamydial infection), as well as more than 3 sexual partners (OR 2.7) were also significant. The most significant risk factors for CD in HPV-infected women were: age over 35 years (OR 3.8), a history of bacterial vaginosis (OR 3.0), and lack of regular screening (OR 2.4). The coitarche earlier than 16 years old (OR 2.2) also mattered. There were also found factors indicating a low risk of HPV infection – the use of condoms (OR 0.3), and a low risk of CD was indicated by age under 25 years (OR 0.2) and regular screening (OR 0.3).
Conclusion. HPV infection with HRS and the prevalence of CMC in pregnant women against the background of HPV infection is associated mainly with social risk factors, to a lesser extent – with factors of reproductive and contraceptive behavior.
Key words: pregnancy, human papillomavirus, cervical diseases, risk factors.
Материалы и методы. Дизайн: открытое сравнительное неинтервенционное когортное исследование в параллельных группах. Число пациенток – 330, из них 148 человек без ВПЧ и с ВПЧ – 182. Они разделены на 4 группы в зависимости от наличия или отсутствия ЗШМ. Методы: анализ анамнестических данных, общеклинические, тест «Квант-21» для определения ВПЧ, цитологическое исследование, расширенная кольпоскопия.
Результаты. Выявлены наиболее значимые факторы риска инфицирования ВПЧ ВКР: микоплазменная инфекция (отношение шансов – ОШ 5,9) и бактериальный вагиноз в анамнезе (ОШ 5,3), употребление алкоголя (ОШ 4,0). Значимыми также являются инфекции, передаваемые половым путем, в анамнезе (трихомониаз и хламидийная инфекция), а также более 3 половых партнеров (ОШ 2,7). Наиболее значимыми факторами риска ЗШМ у ВПЧ-инфицированных женщин оказались: возраст старше 35 лет (ОШ 3,8), бактериальный вагиноз в анамнезе (ОШ 3,0) и отсутствие регулярного скрининга (ОШ 2,4). Кроме того, имело значение коитархе ранее 16 лет (ОШ 2,2). Обнаружены также факторы, указывающие на низкий риск инфицирования ВПЧ ВКР, – использование презервативов (ОШ 0,3), а о низком риске ЗШМ свидетельствовали возраст моложе 25 лет (ОШ 0,2) и регулярный скрининг (ОШ 0,3).
Заключение. Инфицированность ВПЧ ВКР и распространенность ЗШМ у беременных на фоне ВПЧ-инфекции связаны преимущественно с социальными факторами риска, в меньшей степени – с факторами репродуктивного и контрацептивного поведения.
Ключевые слова: беременность, вирус папилломы человека, заболевания шейки матки, факторы риска.
________________________________________________
Materials and methods. Design: open-label comparative non-interventional cohort study in parallel groups. The total number of patients – 330 people, of whom 148 women were negative for HPV and 182 women were positive. They were divided into 4 groups depending on the presence or absence of CD. Methods: analysis of anamnesis data, general clinical, test “Kvant-21” to determine HPV, cytological examination, extended colposcopy.
Results. The most significant risk factors for HPV HRS infection were identified: history of mycoplasma infection (OR 5.9) and BV (OR 5.3), alcohol consumption (OR 4.0).
A history of STIs (trichomoniasis and chlamydial infection), as well as more than 3 sexual partners (OR 2.7) were also significant. The most significant risk factors for CD in HPV-infected women were: age over 35 years (OR 3.8), a history of bacterial vaginosis (OR 3.0), and lack of regular screening (OR 2.4). The coitarche earlier than 16 years old (OR 2.2) also mattered. There were also found factors indicating a low risk of HPV infection – the use of condoms (OR 0.3), and a low risk of CD was indicated by age under 25 years (OR 0.2) and regular screening (OR 0.3).
Conclusion. HPV infection with HRS and the prevalence of CMC in pregnant women against the background of HPV infection is associated mainly with social risk factors, to a lesser extent – with factors of reproductive and contraceptive behavior.
Key words: pregnancy, human papillomavirus, cervical diseases, risk factors.
Полный текст
Список литературы
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[Zarochentseva N.V. Zabolevaniia sheiki matki pri beremennosti (sovremennye aspekty diagnostiki i taktika vedeniia). Avtoref. dis. … d-ra med. nauk. Moscow, 2009 (in Russian).]
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8. Winer RL, Hughes JP, Feng Q et al. Prevalence and risk factors for oncogenic human papillomavirus infections in high-risk mid-adult women. Sex Transm Dis 2012; 39 (11): 848–56. DOI: 10.1097/OLQ.0b013e3182641f1c
9. Ciavattini A, Sopracordevole F, Di Giuseppe J et al. Cervical intraepithelial neoplasia in pregnancy: Interference of pregnancy status with p16 and Ki-67 protein expression. Oncol Lett 2017; 13 (1): 301–6. DOI: 10.3892/ol.2016.5441
10. Liu P, Xu L, Sun Y, Wang Z. The prevalence and risk of human papillomavirus infection in pregnant women. Epidemiol Infect 2014; 142 (8): 1567–78. DOI: 10.1017/S0950268814000636
11. Braaten KP, Laufer MR. Human Papillomavirus (HPV), HPV-Related Disease, and the HPV Vaccine. Rev Obstet Gynecol 2008; 1 (1): 2–10.
12. Mbulawa ZZA, van Schalkwyk C, Hu N-C et al. High human papillomavirus (HPV) prevalence in South African adolescents and young women encourages expanded HPV vaccination campaigns. PLoS ONE 2018; 13 (1): e0190166. DOI: 10.1371/journal.pone.0190166
13. Petry KU, Wörmann B, Schneider A. Benefits and Risks of Cervical Cancer Screening. Oncol Res Treat 2014; 37 (Suppl. 3): 48–57. DOI: 10.1159/000365059
14. Arbyn M, Ronco G, Anttila A et al. Evidence regarding human papillomavirus testing in secondary prevention of cervical cancer. Vaccine 2012; 30 (Suppl. 5): F88–99. DOI: 10.1016/j.vaccine.2012.06.095
15. López-Hernández D, Beltrán-Lagunes L, Brito-Aranda L, López-Hernández M de L. Human papillomavirus infection and it correlates with clinically relevant gynecological and obstetric conditions: A cross-sectional study. Med Clin (Barc) 2016; 147 (3): 101–8. DOI: 10.1016/j.medcli.2016.04.018
16. Samkange-Zeeb FN, Spallek L, Zeeb H. Awareness and knowledge of sexually transmitted diseases (STDs) among school-going adolescents in Europe: a systematic review of published literature. BMC Public Health 2011; 11: 727. DOI: 10.1186/1471-2458-11-727
17. Panatto D, Amicizia D, Trucchi C et al. Sexual behaviour and risk factors for the acquisition of human papillomavirus infections in young people in Italy: suggestions for future vaccination policies. BMC Public Health 2012; 12: 623. DOI: 10.1186/1471-2458-12-623
18. Bassuk SS, Manson JE. Oral contraceptives and menopausal hormone therapy: relative and attributable risks of cardiovascular disease, cancer, and other health outcomes. Ann Epidemiol 2015; 25 (3): 193–200. DOI: 10.1016/j.annepidem.2014.11.004
19. Makuza JD, Nsanzimana S, Muhimpundu MA et al. Prevalence and risk factors for cervical cancer and pre-cancerous lesions in Rwanda. Pan Afr Med J 2015; 22: 26. DOI: 10.11604/pamj.2015.22.26.7116
2. Salcedo MM, Damin AP, Agnes G et al. Prevalence of human papillomavirus infection in pregnant versus non-pregnant women in Brazil. Arch Gynecol Obstet 2015; 292 (6): 1273–8.
3. Chen J, Gopala K, Puthatta A et al. Prevalence and Incidence of Human Papillomavirus (HPV) Infection Before and After Pregnancy: Pooled Analysis of the Control Arms of Efficacy Trials of HPV-16/18 AS04-Adjuvanted Vaccine. Open Forum Infect Dis 2019; 6 (12): ofz486. DOI: 10.1093/ofid/ofz486
4. Mitra A, MacIntyre D, Lee Y et al. Cervical intraepithelial neoplasia disease progression is associated with increased vaginal microbiome diversity. Sci Rep 2015; 5: 16865. DOI: 10.1038/srep16865
5. Beharee N, Shi Z, Wu D, Wang J. Diagnosis and treatment of cervical cancer in pregnant women. Cancer Med 2019; 8 (12): 5425–30. DOI: 10.1002/cam4.2435
6. Zarochentseva N.V. Zabolevaniia sheiki matki pri beremennosti (sovremennye aspekty diagnostiki i taktika vedeniia). Avtoref. dis. … d-ra med. nauk. Moscow, 2009 (in Russian).
7. Nejo YT, Olaleye DO, Odaibo GN. Prevalence and Risk Factors for Genital Human Papillomavirus Infections Among Women in Southwest Nigeria. Arch Basic Appl Med 2018; 6 (1): 105–12.
8. Winer RL, Hughes JP, Feng Q et al. Prevalence and risk factors for oncogenic human papillomavirus infections in high-risk mid-adult women. Sex Transm Dis 2012; 39 (11): 848–56. DOI: 10.1097/OLQ.0b013e3182641f1c
9. Ciavattini A, Sopracordevole F, Di Giuseppe J et al. Cervical intraepithelial neoplasia in pregnancy: Interference of pregnancy status with p16 and Ki-67 protein expression. Oncol Lett 2017; 13 (1): 301–6. DOI: 10.3892/ol.2016.5441
10. Liu P, Xu L, Sun Y, Wang Z. The prevalence and risk of human papillomavirus infection in pregnant women. Epidemiol Infect 2014; 142 (8): 1567–78. DOI: 10.1017/S0950268814000636
11. Braaten KP, Laufer MR. Human Papillomavirus (HPV), HPV-Related Disease, and the HPV Vaccine. Rev Obstet Gynecol 2008; 1 (1): 2–10.
12. Mbulawa ZZA, van Schalkwyk C, Hu N-C et al. High human papillomavirus (HPV) prevalence in South African adolescents and young women encourages expanded HPV vaccination campaigns. PLoS ONE 2018; 13 (1): e0190166. DOI: 10.1371/journal.pone.0190166
13. Petry KU, Wörmann B, Schneider A. Benefits and Risks of Cervical Cancer Screening. Oncol Res Treat 2014; 37 (Suppl. 3): 48–57. DOI: 10.1159/000365059
14. Arbyn M, Ronco G, Anttila A et al. Evidence regarding human papillomavirus testing in secondary prevention of cervical cancer. Vaccine 2012; 30 (Suppl. 5): F88–99. DOI: 10.1016/j.vaccine.2012.06.095
15. López-Hernández D, Beltrán-Lagunes L, Brito-Aranda L, López-Hernández M de L. Human papillomavirus infection and it correlates with clinically relevant gynecological and obstetric conditions: A cross-sectional study. Med Clin (Barc) 2016; 147 (3): 101–8. DOI: 10.1016/j.medcli.2016.04.018
16. Samkange-Zeeb FN, Spallek L, Zeeb H. Awareness and knowledge of sexually transmitted diseases (STDs) among school-going adolescents in Europe: a systematic review of published literature. BMC Public Health 2011; 11: 727. DOI: 10.1186/1471-2458-11-727
17. Panatto D, Amicizia D, Trucchi C et al. Sexual behaviour and risk factors for the acquisition of human papillomavirus infections in young people in Italy: suggestions for future vaccination policies. BMC Public Health 2012; 12: 623. DOI: 10.1186/1471-2458-12-623
18. Bassuk SS, Manson JE. Oral contraceptives and menopausal hormone therapy: relative and attributable risks of cardiovascular disease, cancer, and other health outcomes. Ann Epidemiol 2015; 25 (3): 193–200. DOI: 10.1016/j.annepidem.2014.11.004
19. Makuza JD, Nsanzimana S, Muhimpundu MA et al. Prevalence and risk factors for cervical cancer and pre-cancerous lesions in Rwanda. Pan Afr Med J 2015; 22: 26. DOI: 10.11604/pamj.2015.22.26.7116
2. Salcedo MM, Damin AP, Agnes G et al. Prevalence of human papillomavirus infection in pregnant versus non-pregnant women in Brazil. Arch Gynecol Obstet 2015; 292 (6): 1273–8.
3. Chen J, Gopala K, Puthatta A et al. Prevalence and Incidence of Human Papillomavirus (HPV) Infection Before and After Pregnancy: Pooled Analysis of the Control Arms of Efficacy Trials of HPV-16/18 AS04-Adjuvanted Vaccine. Open Forum Infect Dis 2019; 6 (12): ofz486. DOI: 10.1093/ofid/ofz486
4. Mitra A, MacIntyre D, Lee Y et al. Cervical intraepithelial neoplasia disease progression is associated with increased vaginal microbiome diversity. Sci Rep 2015; 5: 16865. DOI: 10.1038/srep16865
5. Beharee N, Shi Z, Wu D, Wang J. Diagnosis and treatment of cervical cancer in pregnant women. Cancer Med 2019; 8 (12): 5425–30. DOI: 10.1002/cam4.2435
6. Зароченцева Н.В. Заболевания шейки матки при беременности (современные аспекты диагностики и тактика ведения). Автореф. дис. … д-ра мед. наук. М., 2009.
[Zarochentseva N.V. Zabolevaniia sheiki matki pri beremennosti (sovremennye aspekty diagnostiki i taktika vedeniia). Avtoref. dis. … d-ra med. nauk. Moscow, 2009 (in Russian).]
7. Nejo YT, Olaleye DO, Odaibo GN. Prevalence and Risk Factors for Genital Human Papillomavirus Infections Among Women in Southwest Nigeria. Arch Basic Appl Med 2018; 6 (1): 105–12.
8. Winer RL, Hughes JP, Feng Q et al. Prevalence and risk factors for oncogenic human papillomavirus infections in high-risk mid-adult women. Sex Transm Dis 2012; 39 (11): 848–56. DOI: 10.1097/OLQ.0b013e3182641f1c
9. Ciavattini A, Sopracordevole F, Di Giuseppe J et al. Cervical intraepithelial neoplasia in pregnancy: Interference of pregnancy status with p16 and Ki-67 protein expression. Oncol Lett 2017; 13 (1): 301–6. DOI: 10.3892/ol.2016.5441
10. Liu P, Xu L, Sun Y, Wang Z. The prevalence and risk of human papillomavirus infection in pregnant women. Epidemiol Infect 2014; 142 (8): 1567–78. DOI: 10.1017/S0950268814000636
11. Braaten KP, Laufer MR. Human Papillomavirus (HPV), HPV-Related Disease, and the HPV Vaccine. Rev Obstet Gynecol 2008; 1 (1): 2–10.
12. Mbulawa ZZA, van Schalkwyk C, Hu N-C et al. High human papillomavirus (HPV) prevalence in South African adolescents and young women encourages expanded HPV vaccination campaigns. PLoS ONE 2018; 13 (1): e0190166. DOI: 10.1371/journal.pone.0190166
13. Petry KU, Wörmann B, Schneider A. Benefits and Risks of Cervical Cancer Screening. Oncol Res Treat 2014; 37 (Suppl. 3): 48–57. DOI: 10.1159/000365059
14. Arbyn M, Ronco G, Anttila A et al. Evidence regarding human papillomavirus testing in secondary prevention of cervical cancer. Vaccine 2012; 30 (Suppl. 5): F88–99. DOI: 10.1016/j.vaccine.2012.06.095
15. López-Hernández D, Beltrán-Lagunes L, Brito-Aranda L, López-Hernández M de L. Human papillomavirus infection and it correlates with clinically relevant gynecological and obstetric conditions: A cross-sectional study. Med Clin (Barc) 2016; 147 (3): 101–8. DOI: 10.1016/j.medcli.2016.04.018
16. Samkange-Zeeb FN, Spallek L, Zeeb H. Awareness and knowledge of sexually transmitted diseases (STDs) among school-going adolescents in Europe: a systematic review of published literature. BMC Public Health 2011; 11: 727. DOI: 10.1186/1471-2458-11-727
17. Panatto D, Amicizia D, Trucchi C et al. Sexual behaviour and risk factors for the acquisition of human papillomavirus infections in young people in Italy: suggestions for future vaccination policies. BMC Public Health 2012; 12: 623. DOI: 10.1186/1471-2458-12-623
18. Bassuk SS, Manson JE. Oral contraceptives and menopausal hormone therapy: relative and attributable risks of cardiovascular disease, cancer, and other health outcomes. Ann Epidemiol 2015; 25 (3): 193–200. DOI: 10.1016/j.annepidem.2014.11.004
19. Makuza JD, Nsanzimana S, Muhimpundu MA et al. Prevalence and risk factors for cervical cancer and pre-cancerous lesions in Rwanda. Pan Afr Med J 2015; 22: 26. DOI: 10.11604/pamj.2015.22.26.7116
________________________________________________
2. Salcedo MM, Damin AP, Agnes G et al. Prevalence of human papillomavirus infection in pregnant versus non-pregnant women in Brazil. Arch Gynecol Obstet 2015; 292 (6): 1273–8.
3. Chen J, Gopala K, Puthatta A et al. Prevalence and Incidence of Human Papillomavirus (HPV) Infection Before and After Pregnancy: Pooled Analysis of the Control Arms of Efficacy Trials of HPV-16/18 AS04-Adjuvanted Vaccine. Open Forum Infect Dis 2019; 6 (12): ofz486. DOI: 10.1093/ofid/ofz486
4. Mitra A, MacIntyre D, Lee Y et al. Cervical intraepithelial neoplasia disease progression is associated with increased vaginal microbiome diversity. Sci Rep 2015; 5: 16865. DOI: 10.1038/srep16865
5. Beharee N, Shi Z, Wu D, Wang J. Diagnosis and treatment of cervical cancer in pregnant women. Cancer Med 2019; 8 (12): 5425–30. DOI: 10.1002/cam4.2435
6. Zarochentseva N.V. Zabolevaniia sheiki matki pri beremennosti (sovremennye aspekty diagnostiki i taktika vedeniia). Avtoref. dis. … d-ra med. nauk. Moscow, 2009 (in Russian).
7. Nejo YT, Olaleye DO, Odaibo GN. Prevalence and Risk Factors for Genital Human Papillomavirus Infections Among Women in Southwest Nigeria. Arch Basic Appl Med 2018; 6 (1): 105–12.
8. Winer RL, Hughes JP, Feng Q et al. Prevalence and risk factors for oncogenic human papillomavirus infections in high-risk mid-adult women. Sex Transm Dis 2012; 39 (11): 848–56. DOI: 10.1097/OLQ.0b013e3182641f1c
9. Ciavattini A, Sopracordevole F, Di Giuseppe J et al. Cervical intraepithelial neoplasia in pregnancy: Interference of pregnancy status with p16 and Ki-67 protein expression. Oncol Lett 2017; 13 (1): 301–6. DOI: 10.3892/ol.2016.5441
10. Liu P, Xu L, Sun Y, Wang Z. The prevalence and risk of human papillomavirus infection in pregnant women. Epidemiol Infect 2014; 142 (8): 1567–78. DOI: 10.1017/S0950268814000636
11. Braaten KP, Laufer MR. Human Papillomavirus (HPV), HPV-Related Disease, and the HPV Vaccine. Rev Obstet Gynecol 2008; 1 (1): 2–10.
12. Mbulawa ZZA, van Schalkwyk C, Hu N-C et al. High human papillomavirus (HPV) prevalence in South African adolescents and young women encourages expanded HPV vaccination campaigns. PLoS ONE 2018; 13 (1): e0190166. DOI: 10.1371/journal.pone.0190166
13. Petry KU, Wörmann B, Schneider A. Benefits and Risks of Cervical Cancer Screening. Oncol Res Treat 2014; 37 (Suppl. 3): 48–57. DOI: 10.1159/000365059
14. Arbyn M, Ronco G, Anttila A et al. Evidence regarding human papillomavirus testing in secondary prevention of cervical cancer. Vaccine 2012; 30 (Suppl. 5): F88–99. DOI: 10.1016/j.vaccine.2012.06.095
15. López-Hernández D, Beltrán-Lagunes L, Brito-Aranda L, López-Hernández M de L. Human papillomavirus infection and it correlates with clinically relevant gynecological and obstetric conditions: A cross-sectional study. Med Clin (Barc) 2016; 147 (3): 101–8. DOI: 10.1016/j.medcli.2016.04.018
16. Samkange-Zeeb FN, Spallek L, Zeeb H. Awareness and knowledge of sexually transmitted diseases (STDs) among school-going adolescents in Europe: a systematic review of published literature. BMC Public Health 2011; 11: 727. DOI: 10.1186/1471-2458-11-727
17. Panatto D, Amicizia D, Trucchi C et al. Sexual behaviour and risk factors for the acquisition of human papillomavirus infections in young people in Italy: suggestions for future vaccination policies. BMC Public Health 2012; 12: 623. DOI: 10.1186/1471-2458-12-623
18. Bassuk SS, Manson JE. Oral contraceptives and menopausal hormone therapy: relative and attributable risks of cardiovascular disease, cancer, and other health outcomes. Ann Epidemiol 2015; 25 (3): 193–200. DOI: 10.1016/j.annepidem.2014.11.004
19. Makuza JD, Nsanzimana S, Muhimpundu MA et al. Prevalence and risk factors for cervical cancer and pre-cancerous lesions in Rwanda. Pan Afr Med J 2015; 22: 26. DOI: 10.11604/pamj.2015.22.26.7116
Авторы
Т.Н. Бебнева*1, Г.Б. Дикке2
1 ФГАОУ ВО «Российский университет дружбы народов», Москва, Россия
2 ФГБУ «Национальный медицинский исследовательский центр эндокринологии» Минздрава России, Москва, Россия;
3 ЧОУ ДПО «Академия медицинского образования им. Ф.И. Иноземцева», Санкт-Петербург, Россия
*bebn@mail.ru
1 People’s Friendship University of Russia, Moscow, Russia;
2 Endocrinology Research Centre, Moscow, Russia;
3 Inozemtsev Academy of Medical Education, Saint Petersburg, Russia
*bebn@mail.ru
1 ФГАОУ ВО «Российский университет дружбы народов», Москва, Россия
2 ФГБУ «Национальный медицинский исследовательский центр эндокринологии» Минздрава России, Москва, Россия;
3 ЧОУ ДПО «Академия медицинского образования им. Ф.И. Иноземцева», Санкт-Петербург, Россия
*bebn@mail.ru
________________________________________________
1 People’s Friendship University of Russia, Moscow, Russia;
2 Endocrinology Research Centre, Moscow, Russia;
3 Inozemtsev Academy of Medical Education, Saint Petersburg, Russia
*bebn@mail.ru
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