Sensitivity for detection of precancers at colposcopy and reassurance provided by a negative colposcopy are in need of systematic study and improvement. We sought to evaluate whether selecting the appropriate women for multiple targeted cervical biopsies based on screening cytology, human papillomavirus testing, and colposcopic impression could improve accuracy and efficiency of cervical precancer detection. In all, 690 women aged 18-67 years referred to colposcopy subsequent to abnormal cervical cancer screening results were included in the study (ClinicalTrials.gov: NCT00339989). Up to 4 cervical biopsies were taken during colposcopy to evaluate the incremental benefit of multiple biopsies. Cervical cytology, human papillomavirus genotyping, and colposcopy impression were used to establish up to 24 different risk strata. Outcomes for the primary analysis were cervical precancers, which included p16⁺ cervical intraepithelial neoplasia 2 and all cervical intraepithelial neoplasia 3 that were detected by colposcopy-guided biopsy during the colposcopy visit. Later outcomes in women without cervical intraepithelial neoplasia 2⁺ at baseline were abstracted from electronic medical records. The risk of detecting precancer ranged from 2-82% across 24 strata based on colposcopy impression, cytology, and human papillomavirus genotyping. The risk of precancer in the lowest stratum increased only marginally with multiple biopsies. Women in the highest-risk strata had risks of precancer consistent with immediate treatment. In other risk strata, multiple biopsies substantially improved detection of cervical precancer. Among 361 women with cervical intraepithelial neoplasia <2 at baseline, 195 (54%) had follow-up cytology or histology data with a median follow-up time of 508 days. Lack of detection of precancer at initial colposcopy that included multiple biopsies predicted low risk of precancer during follow-up. Risk assessment at the colposcopy visit makes identification of cervical precancers more effective and efficient. Not finding precancer after a multiple-biopsy protocol provides high reassurance and allows releasing women back to regular screening.

Shiitake mushrooms ( Lentinus edodes ) have many nutritional and medicinal benefits. The cultivation of log-grown shiitake mushrooms encourages forest farming and can be an opportunity for farmers interested in developing an additional enterprise. In 2006, the University of Missouri Center for Agroforestry conducted a nationwide survey of shiitake mushroom producers to analyze the U.S. shiitake mushroom industry by taking into consideration the forces that influence competition based on Porter's five forces model. Shiitake mushrooms are grown primarily as a side business, especially those produced exclusively outdoors. Indoor production on sawdust generates higher income than outdoor production on logs, but log production is more suitable for a small-scale operation in an agroforestry setting. Barriers to entry are created by relationships in the market, economies of scale, and the learning curve effect. Although there are a limited number of spawn suppliers in the market, they produce quality inoculum and maintain good relationships with shiitake mushroom producers. The majority of respondents sell their shiitake mushrooms locally. Gourmet restaurants, farmers markets, and on-farm outlets are the main markets for shiitake mushrooms. Trends in demand are increasing and prices are high. Shiitake mushrooms can be replaced with other common or gourmet mushroom types, but also have their own identity for numerous nutritional and medicinal properties. Competition for log-grown shiitake mushrooms arises from shiitake mushrooms produced on sawdust and from imports. To successfully survive in the market, firms create competitive advantages through quality, customer service, and consistent supply. Barriers to success in the shiitake mushroom business include demanding work requirements, the need for a serious commitment to produce and market shiitake mushrooms, a 1-year time lag between investment and a return on investment, and insufficient production and marketing information. Grower associations, universities, and state and federal agencies must join their efforts to fund and support shiitake mushroom research and industry development.