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The HPV-related variants of VIN would logically be prevented by targeted strategies such as vaccination. HPV type 16 DNA has been shown to exist in VIN and VAIN specimens more than 70% of the time. No preventative vaccine trials have speci cally targeted prevention of VIN. VIN was postulated to be prevented as a bene cial side effect of ongoing vaccination for CIN and cervical cancer.18, 19 The 5-year follow-up of patients randomized to the quadrivalent HPV vaccine showed no cases of HPV-related CIN or external anogenital or vaginal disease in the treatment population.17 Gardasil (Merck) is a prophylactic vaccine against four strains of HPV (6, 11, 16, and 18). As previously noted, the most common HPV type in VIN is HPV 16. Gardasil is currently recommended for women aged 9 to 26 who are not currently infected with HPV. For women already infected, a therapeutic vaccine would be necessary. Small trials of a therapeutic vaccine have shown promising results, but remain investigational.20 Unfortunately, there is no way to predict the behavior of a single lesion in your patient. Risk factors for progression include age greater than 40 and immunosuppression. The recommendations for observation alone in this subset of women are cautionary and patients must be reliable for followup. Recurrent VIN may occur years after treatment, especially in the immunosuppressed or radiated. Therefore treated patients should be educated that they should be screened for VIN for the long term.

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such analyses). In particular, task-based billing has the beneficial effect of restraining the tendency of law firms to overstaff (a practice formerly known as overmanning) a matter; for example, sending three attorneys to a deposition when only two would suffice. Also, by identifying the various timekeepers who are billing time to a matter, task-based billing highlights the introduction of new players to the team. This is important because new players must be brought up to speed briefed on the facts and the status of the case, a process that is time consuming (both the briefer and the briefee are billing their time) and, hence, costly. The obvious goal is to involve the fewest possible people in the case. A client should be careful not to let lawyers use his or her case as a convenient account to which they can bill otherwise unbillable time (this practice should be familiar to anyone who has worked for a government contractor), nor allow the firm to use his or her case as a training vehicle for interns and new associates. Let them train their employees at someone else s expense. Moreover, law firms that know that they are being monitored simply perform more efficiently. Check on a firm s policy with respect to disbursements. Some firms take a surprisingly narrow view of what is covered by their hourly fees virtually everything is a disbursement. One firm, in the authors experience, charged a fee for the use of the firm s own library. Another firm (more aggressive than creative) simply tacked on a Misc. fee. A surprising number of firms will mark up their disbursements, adding a profit margin. Sometimes this is disguised as an accounting fee or administrative fee. Such a markup is unethical if it is not disclosed to the client, and tacky when it is. Some firms will add an overtime charge to a client s bill, reflecting additional compensation paid to support staff who may have worked late. Such changes may be acceptable when the overtime was necessitated by the demands of the case. They are clearly not acceptable when they result from poor scheduling or understaffing by the firm.