human
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Background Mapping from health status measures onto generic preference-based measures is becoming a common solution when health state utility values are not directly available for economic evaluation . However the accuracy and reliability of the models employed is largely untested , and there is little evidence of their suitability in patient data sets . This paper examines whether mapping approaches are reliable and accurate in terms of their predictions for a large and varied UK patient data set . Methods SF-36 dimension scores are mapped onto the EQ-5D index using a number of different model specifications . The predicted EQ-5D scores for subsets of the sample are compared across inpatient and outpatient setting s and medical conditions . This paper compares the results to those obtained from existing mapping functions . Results The model including SF-36 dimensions , squared and interaction terms estimated using r and om effects GLS has the most accurate predictions of all models estimated here and existing mapping functions as indicated by MAE ( 0.127 ) and MSE ( 0.030 ) . Mean absolute error in predictions by EQ-5D utility range increases with severity for our models ( 0.085 to 0.34 ) and for existing mapping functions ( 0.123 to 0.272 ) . Conclusion Our results suggest that models mapping the SF-36 onto the EQ-5D have similar predictions across inpatient and outpatient setting and medical conditions . However , the models overpredict for more severe EQ-5D states ; this problem is also present in the existing mapping functions Background Patient-reported outcome ( PROs ) measures are being used more frequently in investigational studies of treatments for moderate to severe plaque psoriasis . The objective of this study was to examine the relationships among the Dermatology Life Quality Index ( DLQI ) , the Short Form 36 ( SF-36 ) , and the EuroQOL 5D ( EQ-5D ) and to assess their validity , responsiveness , and estimates of minimum important differences . Methods A Phase II , r and omized , double-blind , parallel group , placebo-controlled , multi-center clinical trial assessed the clinical efficacy and safety of two doses of subcutaneously administered adalimumab vs. placebo for 12 weeks in the treatment of 147 patients with moderate to severe plaque psoriasis . This study provided the opportunity to evaluate the validity and responsiveness to change in clinical status of PROs instruments . Patients completed the DLQI , SF-36 , and EQ-5D question naires at baseline and at 12 weeks . Blinded investigators assessed the Psoriasis Area and Severity Index ( PASI ) scores and the Physician 's Global Assessment ( PGA ) scores of enrolled patients . The responsiveness of the measures to changes in the clinical endpoints from baseline to Week 12 was assessed . Estimates of minimum important differences ( MID ) were derived . All analyses were performed with blinded data ; findings and conclusions were not biased based on treatment condition . Results The dermatology-specific DLQI was highly correlated to clinical endpoints at baseline and at Week 12 , and was the most responsive PRO to changes in endpoints . Compared with the SF-36 , the EQ-5D index score and VAS scores were generally more highly correlated with clinical endpoints , but displayed about the same degree of responsiveness . The most responsive SF-36 scales were the Bodily Pain and Social Functioning scales . Estimates of the MID for the DLQI ranged from 2.3–5.7 and for the SF-36 Physical Component Summary ( PCS ) score ranged from 2.5–3.9 . Conclusion This study provides support for the continued use of the DLQI and SF-36 PCS in the assessment of treatments for psoriasis . On the basis of the results from this trial , the EQ-5D should be considered as a general PRO measure in future clinical trials of patients with moderate to severe plaque psoriasis Patients with breast cancer treated with adjuvant chemotherapy  experience not only fatigue and menopausal symptoms but also documented cognitive dysfunction and reduced capacity to carry out activities of daily living . The role of epoetin alfa in improving cognition and functional capacity was assessed in a large r and omized trial through patient self-reported outcomes . Patients with breast cancer ( N = 354 , adjuvant and metastatic ) undergoing chemotherapy  were r and omized in a 1:1 ratio to receive epoetin alfa ( 40,000 IU once weekly ) or the st and ard of care ( SOC ) . Change in patient-reported Health Utilities Index Mark 3 ( HUI3 ) from baseline to week 12 was compared between the epoetin alfa and SOC groups . In addition , correlations between the disease-nonspecific HUI3 utility scale and the cancer-specific quality of life instrument Functional Assessment of Cancer Therapy-Anemia ( FACT-An ) and Fatigue subscales were assessed . Epoetin alfa treatment significantly improved HUI3 scores compared with patients receiving SOC ( P = 0.036 ) . Three subscales within HUI3 were also significantly better for epoetin alfa-treated patients ( emotion , P = 0.048 ; ambulation , P = 0.048 ; and cognition , P = 0.02 ) . Moreover , a strong correlation ( P = 0.0001 ) exists between the disease-nonspecific utility scale HUI3 and the disease-specific FACT-An and FACT-Fatigue scales in terms of overall scores and score changes . The findings of the study demonstrate for the first time in patients with breast cancer that epoetin alfa significantly enhances functional well-being , which translates into significantly better utility scores . In addition , epoetin alfa also significantly improved cognitive function of women undergoing chemotherapy , and this could have an important impact on their lives from a societal perspective OBJECTIVES The authors compare two generic measures of health status with disease-specific measures in a r and omized controlled trial of  transurethral resection of the prostate with laser vaporization prostatectomy for benign prostatic hypertrophy . METHODS Patients entered into the trial completed the following question naires prior to treatment and at follow-up at 3 months and 1 year . The Medical Outcomes Study 36-Item Short Form Health Survey ( SF-36 ) is a generic measure that produces an eight-dimension profile as well as two summary measures of health status ( the physical component score and the mental component score ) . The EuroQol provides two single index measures of health status ; one intended to convey the utility ( or lack of ) that an individual derives from his or her own health state compared with alternative states and a second simple visual analog scale " thermometer " of health status . The American Urological Association symptom score and the Bothersome index are disease-specific indices of health status for use specifically with benign prostatic hypertrophy patients . RESULTS The EuroQol indicates no statistically significant improvements with time for either arm of the trial . The SF-36 physical and general health perceptions domains indicates statistically significant improvements for the transurethral resection of the prostate arm alone at 3 months and 1 year , as do the physical summary score at the 3-month follow-up visit . The effect sizes of these improvements , however , are small , using st and ard criteria . In contrast , statistically significant differences are found with time for both  transurethral resection of the prostate and laser prostatectomy  on both disease-specific measures , which also indicate statistically significant superior outcome for the transurethral resection of the prostate arm compared with the laser arm . CONCLUSIONS The results indicate that the disease-specific measures are more sensitive to change than the generic measures of outcome . Possible explanations for this are discussed Abstract Introduction Transanal endoscopic microsurgery ( TEM ) is a minimal invasive technique for local excision of rectal tumours . The procedure is performed via a rectoscope with a diametre of 4 cm . The aim of this prospect i ve study was to assess both functional outcome and quality of life after TEM . Patients and methods Between 2004 and 2006 , 47 patients were studied prior to and at least 6 months after TEM .  Demographics , operative details and post-operative complications were recorded . Functional outcome was determined using the Faecal Incontinence Severity Index ( FISI ) . Quality of life was measured using the EuroQol EQ-5D question naire and the Faecal Incontinence Quality of Life ( FIQL ) score . Results Six months after surgery , median FISI score was found to be decreased ( p < 0.01 ) , depicting an improvement in faecal continence . This improvement was most significant in tumours within 7 cm from the dentate line ( p = 0.01 ) . From the patients ’ perspective , post-operative quality of life was found to be higher ( p < 0.02 ) . A significant improvement was observed in two of the four FIQLS domains ( embarrassment , p = 0.03 ; lifestyle , p = 0.05 ) . The domains of lifestyle , coping and behaviour and embarrassment were correlated with the FISI ( all p < 0.05 ) . Conclusion This study indicates TEM has no deteriorating effect on faecal continence . Moreover , once the tumour has been excised using TEM , quality of life is improved We evaluated 4 different health‐related quality of life ( HRQL ) measures prospect ively to determine their ability to detect change over time : the Health Utilities Index Mark 2 and Mark 3 , the Pediatric Quality of Life Inventory ( PedsQL ) 4.0 Generic Core and Cancer Module , the EuroQol EQ‐5D visual analogue scale ( EuroQol ) , and the Lansky Play‐Performance Scale Background R and omized controlled trials ( RCTs ) have reported improved or unchanged three-year survival following  laparoscopic colon resection ( LCR ) for colon cancer compared with that following open resection ( OCR ) . The aim of this study was to determine health-related quality of life ( HRQL ) in patients r and omized to laparoscopic or open resection for colon cancer . Methods In total , 285 patients ( 130 LCR , 155 OCR ) from seven Swedish centers were included .  HRQL was assessed preoperatively and at 2 , 4 , and 12 weeks postoperatively with the EQ-5D and EORTC QLQ-C30 instruments . Results The LCR patients did significantly better on the social function component of the EORTC QLQ-C30 at two and four weeks and on the role function component at two weeks . Conclusion Laparoscopic resection for colon cancer improved quality of life during the first postoperative month Background Although cancer-specific Health-Related Quality of Life ( HRQOL ) are commonly included in r and omized clinical trials or other prospect i ve non-r and omized clinical studies , it is rare that preference-based instruments are used that allow the calculation of a utility weight suitable for estimating quality -adjusted life-years gained . Objective To develop a mapping algorithm to transform the EORTC QLQ-C30 question naire responses into EQ-5D derived utilities . Study design Retrospective data analysis of a multicentre , multicountry prospect i ve clinical trial in breast cancer patients . Methods Regression analysis of individual pairs of EQ-5D and QLQ-C30 scores . Results A model that explained 80 % of the variance was developed to estimate EQ-5D Utilities from QLQ-C30 scores at individual level . From this reliable group level means and deviations can be derived . Conclusions Mapping from QLQ-C30 scores to EQ-5D-derived utilities when only QLQ-C30 data are available has been shown to be possible with good accuracy . Validation of the proposed algorithm in other external clinical data sets should be encouraged Goals of workAlthough the EuroQol ( EQ-5D ) is widely used for economic evaluation , it remains unclear whether it can be combined with medical data to predict survival in patients with terminal cancer . Patients and methods We carried out this prospect i ve study on 142 terminal cancer patients in four hospice-palliative care units . Association was sought between survival time and a range of variables such as cancer site , performance , previous treatment , age , sex , pain , and EuroQol . The EQ-5D was transformed into the corresponding EQ-5D utility . For univariate analysis , we estimated differences in survival with the Gehan generalized Wilcoxon test . For those variables that were significant , we performed multivariate analysis using the Cox proportional hazard model . Main results Univariate analysis showed that sex , age , performance , previous use of chemotherapy , and the EQ-5D utility provided statistically significant prognostic survival information . The median survival time was 13.0 days for the group with an EQ-5D utility score lower than −0.5 and 21.0 days for the group with an EQ-5D utility score above −0.5 . In multivariate analysis with the Cox proportional hazard model , an EQ-5D utility score ≤0.5 ( RR 1.57 , 95 % confidence interval 1.06–2.33 ) was an independent negative predictor of survival . Conclusions The EQ-5D quality -of-life assessment tool might be useful for predicting survival time for terminal cancer patients State anxiety ( S-STAI-6 ) , distress ( GHQ-12 ) , concern and quality of life ( EuroQoL-EQ-5D ) 6 months after human papillomavirus ( HPV ) testing in women with borderline or mildly dyskaryotic smear test results were assessed based on a prospect i ve question naire study , with 6-month follow-up after the smear test result . Two centres participated in an English pilot study of HPV testing . Participants included two groups of women receiving abnormal smear test results : ( tested for HPV and found to be ( a ) HPV positive ( n=369 ) or ( b ) HPV negative ( n=252 ) ) and two groups not tested for HPV ( those receiving ( c ) abnormal smear test results ( n=102 ) or ( d ) normal smear test results ( n=288 ) ) . There were no differences in anxiety , distress or health-related quality of life between the four study groups at 6 months . Levels of concern about the smear test result remained elevated in all groups receiving an abnormal smear test result , and were highest in the group untested for HPV . 
    Output:
    
agent
RESULTS ( 1 ) EQ-5D was valid and responsive for skin conditions and most cancers ; in vision , its performance varied according to aetiology ; and performance was poor for hearing impairments .
The HUI3 performed well for hearing and vision disorders .
It also performed well in cancers although evidence was limited and there was no evidence in skin conditions .
Response mapping using all the domain scores was the best performing model for the EORTC QLQ-C30 .
In an exploratory analysis , a limited dependent variable mixture model performed better than an equivalent linear model .
3 ) The exploratory valuation study found that bolt-on items for vision , hearing and tiredness had a significant impact on values of the health states , but the direction and magnitude of differences depended on the severity of the health state .
The vision bolt-on item had a statistically significant impact on EQ-5D health state values and a full valuation model was estimated .
EQ-5D performs well in studies of cancer and skin conditions .
Mapping techniques provide a solution to predict EQ-5D values where EQ-5D has not been administered .
For conditions where EQ-5D was found to be inappropriate , including some vision disorders and for hearing , bolt-ons provide a promising solution .
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Background Mapping from health status measures onto generic preference-based measures is becoming a common solution when health state utility values are not directly available for economic evaluation . However the accuracy and reliability of the models employed is largely untested , and there is little evidence of their suitability in patient data sets . This paper examines whether mapping approaches are reliable and accurate in terms of their predictions for a large and varied UK patient data set . Methods SF-36 dimension scores are mapped onto the EQ-5D index using a number of different model specifications . The predicted EQ-5D scores for subsets of the sample are compared across inpatient and outpatient setting s and medical conditions . This paper compares the results to those obtained from existing mapping functions . Results The model including SF-36 dimensions , squared and interaction terms estimated using r and om effects GLS has the most accurate predictions of all models estimated here and existing mapping functions as indicated by MAE ( 0.127 ) and MSE ( 0.030 ) . Mean absolute error in predictions by EQ-5D utility range increases with severity for our models ( 0.085 to 0.34 ) and for existing mapping functions ( 0.123 to 0.272 ) . Conclusion Our results suggest that models mapping the SF-36 onto the EQ-5D have similar predictions across inpatient and outpatient setting and medical conditions . However , the models overpredict for more severe EQ-5D states ; this problem is also present in the existing mapping functions Background Patient-reported outcome ( PROs ) measures are being used more frequently in investigational studies of treatments for moderate to severe plaque psoriasis . The objective of this study was to examine the relationships among the Dermatology Life Quality Index ( DLQI ) , the Short Form 36 ( SF-36 ) , and the EuroQOL 5D ( EQ-5D ) and to assess their validity , responsiveness , and estimates of minimum important differences . Methods A Phase II , r and omized , double-blind , parallel group , placebo-controlled , multi-center clinical trial assessed the clinical efficacy and safety of two doses of subcutaneously administered adalimumab vs. placebo for 12 weeks in the treatment of 147 patients with moderate to severe plaque psoriasis . This study provided the opportunity to evaluate the validity and responsiveness to change in clinical status of PROs instruments . Patients completed the DLQI , SF-36 , and EQ-5D question naires at baseline and at 12 weeks . Blinded investigators assessed the Psoriasis Area and Severity Index ( PASI ) scores and the Physician 's Global Assessment ( PGA ) scores of enrolled patients . The responsiveness of the measures to changes in the clinical endpoints from baseline to Week 12 was assessed . Estimates of minimum important differences ( MID ) were derived . All analyses were performed with blinded data ; findings and conclusions were not biased based on treatment condition . Results The dermatology-specific DLQI was highly correlated to clinical endpoints at baseline and at Week 12 , and was the most responsive PRO to changes in endpoints . Compared with the SF-36 , the EQ-5D index score and VAS scores were generally more highly correlated with clinical endpoints , but displayed about the same degree of responsiveness . The most responsive SF-36 scales were the Bodily Pain and Social Functioning scales . Estimates of the MID for the DLQI ranged from 2.3–5.7 and for the SF-36 Physical Component Summary ( PCS ) score ranged from 2.5–3.9 . Conclusion This study provides support for the continued use of the DLQI and SF-36 PCS in the assessment of treatments for psoriasis . On the basis of the results from this trial , the EQ-5D should be considered as a general PRO measure in future clinical trials of patients with moderate to severe plaque psoriasis Patients with breast cancer treated with adjuvant chemotherapy  experience not only fatigue and menopausal symptoms but also documented cognitive dysfunction and reduced capacity to carry out activities of daily living . The role of epoetin alfa in improving cognition and functional capacity was assessed in a large r and omized trial through patient self-reported outcomes . Patients with breast cancer ( N = 354 , adjuvant and metastatic ) undergoing chemotherapy  were r and omized in a 1:1 ratio to receive epoetin alfa ( 40,000 IU once weekly ) or the st and ard of care ( SOC ) . Change in patient-reported Health Utilities Index Mark 3 ( HUI3 ) from baseline to week 12 was compared between the epoetin alfa and SOC groups . In addition , correlations between the disease-nonspecific HUI3 utility scale and the cancer-specific quality of life instrument Functional Assessment of Cancer Therapy-Anemia ( FACT-An ) and Fatigue subscales were assessed . Epoetin alfa treatment significantly improved HUI3 scores compared with patients receiving SOC ( P = 0.036 ) . Three subscales within HUI3 were also significantly better for epoetin alfa-treated patients ( emotion , P = 0.048 ; ambulation , P = 0.048 ; and cognition , P = 0.02 ) . Moreover , a strong correlation ( P = 0.0001 ) exists between the disease-nonspecific utility scale HUI3 and the disease-specific FACT-An and FACT-Fatigue scales in terms of overall scores and score changes . The findings of the study demonstrate for the first time in patients with breast cancer that epoetin alfa significantly enhances functional well-being , which translates into significantly better utility scores . In addition , epoetin alfa also significantly improved cognitive function of women undergoing chemotherapy , and this could have an important impact on their lives from a societal perspective OBJECTIVES The authors compare two generic measures of health status with disease-specific measures in a r and omized controlled trial of  transurethral resection of the prostate with laser vaporization prostatectomy for benign prostatic hypertrophy . METHODS Patients entered into the trial completed the following question naires prior to treatment and at follow-up at 3 months and 1 year . The Medical Outcomes Study 36-Item Short Form Health Survey ( SF-36 ) is a generic measure that produces an eight-dimension profile as well as two summary measures of health status ( the physical component score and the mental component score ) . The EuroQol provides two single index measures of health status ; one intended to convey the utility ( or lack of ) that an individual derives from his or her own health state compared with alternative states and a second simple visual analog scale " thermometer " of health status . The American Urological Association symptom score and the Bothersome index are disease-specific indices of health status for use specifically with benign prostatic hypertrophy patients . RESULTS The EuroQol indicates no statistically significant improvements with time for either arm of the trial . The SF-36 physical and general health perceptions domains indicates statistically significant improvements for the transurethral resection of the prostate arm alone at 3 months and 1 year , as do the physical summary score at the 3-month follow-up visit . The effect sizes of these improvements , however , are small , using st and ard criteria . In contrast , statistically significant differences are found with time for both  transurethral resection of the prostate and laser prostatectomy  on both disease-specific measures , which also indicate statistically significant superior outcome for the transurethral resection of the prostate arm compared with the laser arm . CONCLUSIONS The results indicate that the disease-specific measures are more sensitive to change than the generic measures of outcome . Possible explanations for this are discussed Abstract Introduction Transanal endoscopic microsurgery ( TEM ) is a minimal invasive technique for local excision of rectal tumours . The procedure is performed via a rectoscope with a diametre of 4 cm . The aim of this prospect i ve study was to assess both functional outcome and quality of life after TEM . Patients and methods Between 2004 and 2006 , 47 patients were studied prior to and at least 6 months after TEM .  Demographics , operative details and post-operative complications were recorded . Functional outcome was determined using the Faecal Incontinence Severity Index ( FISI ) . Quality of life was measured using the EuroQol EQ-5D question naire and the Faecal Incontinence Quality of Life ( FIQL ) score . Results Six months after surgery , median FISI score was found to be decreased ( p < 0.01 ) , depicting an improvement in faecal continence . This improvement was most significant in tumours within 7 cm from the dentate line ( p = 0.01 ) . From the patients ’ perspective , post-operative quality of life was found to be higher ( p < 0.02 ) . A significant improvement was observed in two of the four FIQLS domains ( embarrassment , p = 0.03 ; lifestyle , p = 0.05 ) . The domains of lifestyle , coping and behaviour and embarrassment were correlated with the FISI ( all p < 0.05 ) . Conclusion This study indicates TEM has no deteriorating effect on faecal continence . Moreover , once the tumour has been excised using TEM , quality of life is improved We evaluated 4 different health‐related quality of life ( HRQL ) measures prospect ively to determine their ability to detect change over time : the Health Utilities Index Mark 2 and Mark 3 , the Pediatric Quality of Life Inventory ( PedsQL ) 4.0 Generic Core and Cancer Module , the EuroQol EQ‐5D visual analogue scale ( EuroQol ) , and the Lansky Play‐Performance Scale Background R and omized controlled trials ( RCTs ) have reported improved or unchanged three-year survival following  laparoscopic colon resection ( LCR ) for colon cancer compared with that following open resection ( OCR ) . The aim of this study was to determine health-related quality of life ( HRQL ) in patients r and omized to laparoscopic or open resection for colon cancer . Methods In total , 285 patients ( 130 LCR , 155 OCR ) from seven Swedish centers were included .  HRQL was assessed preoperatively and at 2 , 4 , and 12 weeks postoperatively with the EQ-5D and EORTC QLQ-C30 instruments . Results The LCR patients did significantly better on the social function component of the EORTC QLQ-C30 at two and four weeks and on the role function component at two weeks . Conclusion Laparoscopic resection for colon cancer improved quality of life during the first postoperative month Background Although cancer-specific Health-Related Quality of Life ( HRQOL ) are commonly included in r and omized clinical trials or other prospect i ve non-r and omized clinical studies , it is rare that preference-based instruments are used that allow the calculation of a utility weight suitable for estimating quality -adjusted life-years gained . Objective To develop a mapping algorithm to transform the EORTC QLQ-C30 question naire responses into EQ-5D derived utilities . Study design Retrospective data analysis of a multicentre , multicountry prospect i ve clinical trial in breast cancer patients . Methods Regression analysis of individual pairs of EQ-5D and QLQ-C30 scores . Results A model that explained 80 % of the variance was developed to estimate EQ-5D Utilities from QLQ-C30 scores at individual level . From this reliable group level means and deviations can be derived . Conclusions Mapping from QLQ-C30 scores to EQ-5D-derived utilities when only QLQ-C30 data are available has been shown to be possible with good accuracy . Validation of the proposed algorithm in other external clinical data sets should be encouraged Goals of workAlthough the EuroQol ( EQ-5D ) is widely used for economic evaluation , it remains unclear whether it can be combined with medical data to predict survival in patients with terminal cancer . Patients and methods We carried out this prospect i ve study on 142 terminal cancer patients in four hospice-palliative care units . Association was sought between survival time and a range of variables such as cancer site , performance , previous treatment , age , sex , pain , and EuroQol . The EQ-5D was transformed into the corresponding EQ-5D utility . For univariate analysis , we estimated differences in survival with the Gehan generalized Wilcoxon test . For those variables that were significant , we performed multivariate analysis using the Cox proportional hazard model . Main results Univariate analysis showed that sex , age , performance , previous use of chemotherapy , and the EQ-5D utility provided statistically significant prognostic survival information . The median survival time was 13.0 days for the group with an EQ-5D utility score lower than −0.5 and 21.0 days for the group with an EQ-5D utility score above −0.5 . In multivariate analysis with the Cox proportional hazard model , an EQ-5D utility score ≤0.5 ( RR 1.57 , 95 % confidence interval 1.06–2.33 ) was an independent negative predictor of survival . Conclusions The EQ-5D quality -of-life assessment tool might be useful for predicting survival time for terminal cancer patients State anxiety ( S-STAI-6 ) , distress ( GHQ-12 ) , concern and quality of life ( EuroQoL-EQ-5D ) 6 months after human papillomavirus ( HPV ) testing in women with borderline or mildly dyskaryotic smear test results were assessed based on a prospect i ve question naire study , with 6-month follow-up after the smear test result . Two centres participated in an English pilot study of HPV testing . Participants included two groups of women receiving abnormal smear test results : ( tested for HPV and found to be ( a ) HPV positive ( n=369 ) or ( b ) HPV negative ( n=252 ) ) and two groups not tested for HPV ( those receiving ( c ) abnormal smear test results ( n=102 ) or ( d ) normal smear test results ( n=288 ) ) . There were no differences in anxiety , distress or health-related quality of life between the four study groups at 6 months . Levels of concern about the smear test result remained elevated in all groups receiving an abnormal smear test result , and were highest in the group untested for HPV . 
    Output:
    