The human papillomavirus (HPV) vaccine plays an important role in preventing a series of diseases caused by HPV. Recent studies have shown that as a primary prevention measure, it can considerably prevent HPV infection and HPV-associated cervical cancer. However, studies on the safety, efficacy, and coverage of the HPV vaccine remain insufficient, especially in developing countries. Therefore, in this review, we outlined the recent studies of the HPV vaccine in terms of immunogenicity, safety, efficacy, latest vaccination concepts, and strategies. This review may provide a theoretical basis for use of the HPV vaccine. One of the malignant tumors with the highest prevalence among women includes cervical cancer. According to the World Health Organization (WHO), there are 570,000 cases and 313,000 deaths added yearly worldwide . ProphylSince 2006, the prophylactic HPV vaccine has been licensed in over 100 countries . It is cHPV is an epitheliophilic virus belonging to the papillomavirus family and has a variety of hosts of animals and humans . On the HPV may cause cervical, vulvar, vaginal, penile, anal, rectal, and oropharyngeal cancers, which account for more than 80% of HPV-related cancers in the cervix . The higThe HPV infection is limited to basal epithelial cells, which are infected by micro-scratches on the epithelial surface, which enter the basal cells of the cells with wound healing . ThereafNormal cells transform into cancer cells, due to regulation of the cell cycle by HPV, or due to immune evasion behavior of HPV, which renders the virus undetectable for a long time . E6 reduThe cervical location of infection lacks secondary lymphoid tissues. Many memory B cells can reside, prepare antibodies to neutralize the virus . HoweverThe discovery of the pathogenic mechanism of HPV has led to the exploration of its prevention. The prophylactic HPV vaccine is the first one that has been clinically proven to prevent cancer, with landmark significance. In the 1990s, Romanowski et al. found virus-like particles (VLPs) were similar to natural virus particles and did not have the oncovirus genome . StudiesSeveral VLP-based vaccines have been approved by many countries around the world. 2vHPV was licensed in 2007 for use and consists of recombinant VLPs from L1 protein of the viral capsid of both HPV types 16 and 18 formulated in AS04. 4vHPV is composed of recombinant VLPs self-assembled from major capsid protein L1 of HPV types 6, 11, 16, 18 adjuvanted with neutral salt aluminum hydroxy phosphate sulfate . Merck hThree vaccines have different immune components . 2vHPV aE. coli. Adeno associated virus (AAV)  , bacterius (AAV) , or thosus (AAV)  can imprus (AAV) .Vaccine-mediated protection is not type-specific, and cross-protection exists after vaccination against a closely related type of the same species. Although 2vHPV is only related to HPV-16 and HPV-18, it has shown 93% effectiveness in preventing CIN3, regardless of HPV type , 39. AltFurther, 2vHPV can produce antibodies related to HPV-31,−33,−35,−45,−52, and −58 through cross-protection, namely HPVα-7 (related to HPV-18) or α-9 (related to HPV-16) species . RegardiConcerns about vaccine safety in some European countries have led to a decline in the acceptance of vaccines. The safety of vaccines has been controversial and has become one of the main obstacles to public vaccination. Vaccination is not completely risk free, and it can also cause short term adverse reactions (AEs). The most common AE found currently are local injection site symptoms, including fatigue, headache, and muscle pain. Compared to 4vHPV vaccine, injection site reactions are more likely to occur in 2vHPV and 9vHPV vaccine , 46. StuOver 15 years of active monitoring and investigation of any safety signals detected by the HPV vaccine, from pre-licensing active and passive monitoring were conducted. Therefore, the HPV vaccine is one of the most well-studied vaccines to date. The Global Vaccine Safety Advisory Committee has been studying safety-related issues of HPV vaccination and has publicly announced the continued safety and benefits of vaccines seven times . MoreovePregnancy tests were not required before vaccination, and no adverse outcomes occurred among vaccinated pregnant women. However, HPV vaccination during pregnancy is still not recommended. If pregnancy is confirmed after vaccination, the remaining dose should be postponed to the end of pregnancy , 55. TheIn the US, the cost of receiving a three-dose 2vHPV or 4vHPV vaccine is between $350 and $500 , 58. RedSince April 2016, the European Medicines Agency has approved a two-dose regimen for 9vHPV for teenagers between the ages of 9 and 14, and those who started using the 9vHPV vaccine after the age of 15 or people with immunodeficiency diseases nevertheless recommend a three-dosage regimen .For these three vaccines, people who have received the first vaccine are advised to use the same one to complete the immunization process , 64. WitAs a public health issue, cervical cancer can be eliminated by boosting HPV vaccination, cervical cancer screening and related treatments. WHO called for global action to reach this goal in May 2018 . A systeThe predominant factor making vaccines failing to achieve the desired results is insufficient population coverage . HoweverSince women are the high-risk group of HPV-related diseases, the focus of vaccination programs has always been on women, although in some developed areas vaccination of adolescent men is recommended. Across Europe, HPV vaccination has been implemented in all 28 European Union countries, with vaccination rates as low as 10% in Poland  and 43% In China, cervical cancer is an important social health issue: there are about 140,000 added cases and more than 34,000 deaths every year . This isPublic surveillance can promote the effectiveness and safety of HPV vaccines. Furthermore, there are many ways to obtain vaccination information (such as the media) and the information has been misled by misinformation, speculation, and suspicion. This has led to public distrust of the pharmaceutical industry and biomedical technology , 88. MorDeaths from oropharyngeal cancer (HPV-related cancers) are projected to increase in 2020, particularly in developed countries . TherefoXZ, YW, and GL were involved in the study conception and design. LS and XY participated in data acquisition, analysis, and interpretation. XZ and YL wrote the manuscript. All authors have read and approved the manuscript for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


In an effort to reduce the high rate of suicide among post-9/11 veterans, a collaborative team within the Department of Veterans Affairs (VA) has developed a holistic community-based health promotion program designed to facilitate social and self-connectedness. The purpose of this study was to elicit veteran and stakeholder feedback to prepare the program for piloting and implementation.Focus groups and interviews were conducted with post-9/11 veterans and veteran stakeholders  to elicit feedback regarding the health promotion program. Focus groups and interviews were audio-recorded and transcribed. Qualitative thematic analysis identified key themes emerging from the focus groups and interviews.Seven focus groups  and 3 interviews  were conducted with 41 participants . Overall, participants had a positive perception of the program. Thematic analysis revealed shared perspectives that provided insight into 1) enhancing program recruitment and retention, 2) the perceived ability of a health promotion program to provide more holistic, veteran-centered care, and 3) using health promotion programs to help veterans establish structure in their daily lives.Findings indicated an overall acceptance of the program, and participants’ perspectives on how to reduce barriers and enhance facilitators can inform the development of a larger-scale health promotion program that can be tested through future research. While discussion questions were specifically focused on the program in this study, findings can be considered more broadly for the design and implementation of related programs to effectively improve the health and wellness of post-9/11 veterans. Veterans frequently face a sense of disconnectedness in their social lives  and personal lives  when they leave the military –4. This While efforts have been made to prevent and reduce veteran suicide, the rate of suicide among post-9/11 veterans ages 18–34) remains the highest of all veteran cohorts and has increased by 76% from 2005 to 2017 –34 remai (p.17). The interpersonal psychological theory of suicide (IPT) is a prominent theory of suicidal thoughts and behaviors . The IPTREconnecting to Civilian Life using Activities that Incorporate Mindfulness), focuses on the broad range of factors impacting veterans’ health and address the whole person  to facilitate overall connectedness and reduce the risk of suicidal behaviors among post-9/11 veterans. As RECLAIM was being prepared for piloting, it was important that post-9/11 veterans, who may be future participants in the program, and veteran stakeholders, who would have the ability to recommend or refer veterans to the program, were involved in the design of the program. The purpose of this study was to elicit feedback from veterans and stakeholders regarding initial perceptions of the RECLAIM program and considerations for future implementation.In alignment with the recommendation from the VA to address protective factors and to address the gap in understanding how to strengthen protective factors to prevent suicidal behaviors, a collaborative team within the VA has developed a holistic health promotion program theoretically founded in the IPT and SDT. This program, known as RECLAIM  and is theoretically grounded in the IPT and the SDT. RECLAIM is designed to facilitate veterans’ social and self-connectedness as they reintegrate back into civilian life and, ultimately, reduce veterans’ risk of engaging in suicidal behaviors. RECLAIM is comprised of 8 face-to-face group sessions and self-guided home assignments. Social connectedness will be facilitated through group discussion and recommended community resources and activities, while engaging and developing competence in mindfulness activities and self-guided work will enable veterans’ self-connectedness. The second author (JB), who is trained in mindfulness activities and techniques, will facilitate the program sessions.RECLAIM will be conducted within the VA Wellness Clinic, which is located inside a Midwest YMCA (Young Men’s Christian Association) facility. This is currently the only VA clinic in the country to be housed within a YMCA. This clinic offers physical and operational therapy, pain management, and other counseling services. Majority of the focus groups and interviews were conducted in private offices within the VA Wellness Clinic. One focus group and one interview took place at the nearby VA medical center.Focus groups were conducted to elicit veteran and stakeholder feedback on the RECLAIM program. Focus group questions were designed to encourage discussion of barriers and facilitators to participation, program design preferences , and suggestions for improvement. Participants interested in providing feedback but unable to participate in a focus group time slot were invited to engage in an individual interview using the same questions as the focus groups. This study’s procedures received exempt approval from the local institutional review board  and the Richard L Roudebush VA Medical Center’s Research and Development committee. Veterans and stakeholders verbally consented to study participation prior to beginning audio recording of discussions. To protect participant identity, each participant was assigned a participant ID, which indicated whether the participant was a veteran or a stakeholder.We used purposive sampling  to recruit veteran and stakeholder participants . For vetFocus groups and interviews took place in a private conference room in either the community-based VA Wellness Clinic at the YMCA or at the nearby VA medical center. Participants were given a study information sheet prior to conducting the focus group. Each participant completed a demographics form . Veteran participants also completed outcome measures  to assess feasibility  for future studies regarding the developing program.Participants were provided a verbal overview of the planned program and a handout to facilitate discussion. Once participants verbally consented to participation, the audio recording of the discussion began. To achieve the objectives of this study, a semi-structured interview guide was developed using a grounded theory approach . The intFocus groups were recorded, transcribed, and de-identified. Transcripts were reviewed while listening to the audio to ensure accuracy. All data were analyzed using inductive coding and a thematic analysis approach . In aligSeven focus groups with 38 participants (12 veterans and 26 stakeholders) were conducted between August and October 2019. Focus groups lasted approximately 60 min. Three veteran focus groups were held and ranged from 2 to 5 participants. Four stakeholder focus groups were held and ranged from 4 to 10 participants. Three participants (two veterans and one stakeholder) were unable to make a focus group and, instead, engaged in a one-on-one interview. All interviews lasted approximately 30 min. This provided a total of 41 participants. Participants’ age ranged from 24 to 65 years old and the average age of all participants was 39.6 (SD = 10.1). Additional participant demographics are provided in Table The average age of veteran participants was 38.5 (SD = 11.2). Most participants had served in the Army (71.4%) and had seen combat (78.6%). Most veterans indicated they were employed (64.3%), several were retired (28.6%), and a few were unable to work due to disability (21.4%). All veteran participants were receiving VA care at the time of study participation.The average age of stakeholder participants was 40.2 (SD = 9.7). Most stakeholder participants were YMCA employees (51.9%). Five stakeholder participants (18.5%) indicated being military veterans.Analysis revealed three main themes: 1) enhancing program recruitment and retention, 2) the perceived ability of a health promotion program to provide more holistic, veteran-centered care, and 3) using health promotion programs to help veterans establish structure in their daily lives. These themes reflect the perspectives of both veterans and stakeholders. Significantly differing perspectives between veterans and stakeholders are highlighted within the theme discussions below. This section, in alignment with rigorous thematic analysis, provides detailed descriptions and quotes to aid the understanding of how the themes emerged . The parFocus group participants frequently discussed how to get veterans interested in a health promotion program, what would be necessary for buy-in, and how to keep veterans engaged in program activities, even after the program concludes.Participants discussed how veterans would be reluctant to participate if the program’s purpose and activities were vague. It was frequently suggested that peer-to-peer outreach  should be used to promote the program and create immediate buy-in.“If you could have a [veteran] that [others] respected and could sit down with everybody, all of the guys that are getting out or whatever and you talk about these things and be like look, y’all are about to get out. The transition is difficult. Like if you have a respected [veteran] talk about this…the [veterans] would listen.” – Veteran (V12)previous experience practicing mindfulness techniques suggested being clear on the level of difficulty involved in learning the proposed activities.“These things are not very easy either, right? They are something that require discipline and daily practice. It took me some time to accept that in order to live a normal life again or anything resembling that, that it was going to take effort, constant effort every single day to get from where I was to where I wanted to be.” – Veteran (V2)“I know how difficult it is to immerse yourself in [mindfulness] work and how brutal, and it requires a lot of like self-accountability and finding the right community support. I love this stuff, but I love being honest about the work that goes into this.” – YMCA stakeholder (S20)Participants with invasive” and “vague” and the lack of clarity would not appeal to a broad veteran audience and could leave veterans wondering “what [they] would share with you.”“I think that [lifestyle] is kind of a scary word. Because it’s kind of vague. Do you know what I mean? Like it’s a little vague. It might mean different things.” – Veteran (V7)CVeteran participants also felt that some of the proposed terminology, such as ‘lifestyle program,’ was “why isn’t my lifestyle right now [legitimate]?” or state that “there is nothing wrong with my lifestyle.”Use of the term ‘lifestyle’ also made veteran participants question, “piggybacking” onto existing military or VA programs to “prime” service members for participation in RECLAIM. Participants also suggested reaching out to individuals before they exit the military to establish a sense of familiarity with RECLAIM prior to transitioning back into civilian life.Participants repeatedly suggested that RECLAIM promoters needed to find ways to make the program stand out considering veterans receive a lot of information when they exit the military. Veterans suggested ““…before people get out of [the military] introducing them to some of these things and programs that are paired up. [Letting them know that] the VA has something that’s similar so that when they get out, it looks and feels like home to them. Because the military was home.” – Veteran (V13)may reject it immediately” . Even with these challenges, most participants strongly recommended recruiting veterans in the early stage of their career transition.“Transitioning out of the military, like this would have been perfect. Because, even us younger folks, like, I’m out and I’ve never done anything else. I don’t know how to be an adult.” – Veteran (V8)“They send out a bunch of stuff, but it’s never anything that pertains to anybody especially like when you first get out of the military. So getting [RECLAIM] to those [veterans] is probably one of the bigger things.” – Veteran (V2)Participants were also considerate of the fact that many veterans may not be in the frame of mind to consider this type of program upon exit from the service and ““I wish I would’ve had an opportunity like this when I came back from Afghanistan. I think it would’ve made a huge difference for me in my reintegration process. You know, I’ve been home for 7 years and it still feels like yesterday to me. I mean it literally feels like yesterday.” – Veteran (V1)However, some veterans talked about still needing this type of program even though they had transitioned out several years ago.“We always talked about it in the military, being able to build a resilient warrior, right? … Most people that have been around the military would be like, okay, I’m identifying and understanding that context.” – YMCA stakeholder/veteran (S2)In addition to providing clarity, terminology was discussed by participants to create a sense of familiarity regarding RECLAIM and its concepts. Participants repeatedly suggested use of the term “resilience” because it is frequently used in the military.tech savvy”  veterans, enhance RECLAIM’s appeal, and increase the likelihood of recruitment and retention of these veterans. This would also allow veterans to access program-related independently, which would support long-term engagement. Apps where veterans could check in were frequently suggested for establishing a sense of accountability and improve program retention.Participants encouraged the inclusion of technology, such as apps or podcasts, which would be familiar to younger “more like wellness than health care” because it moves beyond the typical medical model  and considered the whole person.“So having a program like this kind of gets past that first layer of oh, we’re just going to treat your symptom. [This program] is thinking past that. You’re not just treating a symptom. – Veteran (V11)“If your body is not doing well, then your mind doesn’t do well. And a lot of doctors, they’ll just throw some meds at mental health to try to make you feel better and they don’t take into consideration the exercise, the eating, the environment that you’re in, or the social aspects.” – Veteran (V14)Participants expressed how the RECLAIM program centered around wellness and how it might encourage veterans to pursue healthcare outside of illness. One veteran participant (V2) described RECLAIM as “preemptive”  and “[liking] the idea of being proactive instead of reactive” (YMCA stakeholder). A VA clinician (S5) also expressed how programs like RECLAIM are “a good way to start that paradigm shift for more preventative help.”Several stakeholder participants discussed how RECLAIM was ““The VA’s system is kind of set to react. And this is the first time we are shifting our model to prevention, which I think it’s a good time to do it with the [younger veterans]. So I think [RECLAIM] is a neat way to get it started.” – VA clinician (S10)“I think you would have to say it’s something connected with the VA, because I don’t think a lot of people, a lot of soldiers, don’t know how to get into the VA. …But I think saying something like this is VA, like associated with the hospital would be big because then veterans are going [to understand] like this is the information you need for whatever [benefits]. – Veteran (V1)Several participants suggested that veterans may engage with RECLAIM and acquire information that encourages them to seek additional care and may positively impact their health long-term. As such, the RECLAIM program was considered a valuable opportunity to help connect veterans to their VA benefits.[they’re] in control of all of these things” .“You know mindfulness is huge for everybody. But being self-aware is, sometimes we don’t realize our problems until we see ourselves more clearly. And I think that that’s a really great benefit to the program if they can be more mindful of – oh I didn’t realize I was feeling this way, or I didn’t realize how my behaviors or habits were shaping my mind state or you know my health. – VA clinician (S8)“Like it’s just the world that we live in, how busy we are, and how much we put on our plates that we…. It’s very easy to be unmindful, which makes us feel more disconnected.” – Veteran (V9)Some participants expressed how the mindfulness component of the RECLAIM program could help veterans 1) be more attuned to what was going on with their health, 2) understand why they feel the way they do, and 3) recognize that “feels less clinical”  than a hospital setting and would provide a “quiet space”  for veterans to focus on things like meditation and breathing.Participants indicated that the space for conducting the program ““So I think if we you know do more community partners and take things out of the stigma of the VA … I think getting out into the clinic is a wonderful way to think outside the box.” – VA clinician (S10)“I mean I love my country but flags and military logos and the president and all that I mean it’s not going to feel like a relaxing environment to me, you know? …if you really want me to relax, that’s probably not the best way.” – Veteran (V2)it’s very stressful to go to the VA” and “it is depressing [and] very sad” . Another veteran (V4) didn’t think the setting would make a drastic difference for most veterans and some veterans may positively view the VA environment “because everybody’s there.”Some veteran participants also discussed how the environment of a VA medical center may cause unpleasant feelings and that for some veterans “how everything was provided” and that “when [veterans] get out, [they] go through a loss period and [they’re] trying to find a connection.”“I’m out and I’ve never done anything else. I don’t know how to be an adult. Because the military told me what to wear, when to be there. They provided me a nice check…gave me clothes, food, and everything. So for me to get out, I have to do it all by myself, everything.” – Veteran (V8)“I know that a lot of military members struggle to assimilate to civilian life because they have such a structured lifestyle while they’re in the military that when they’re out on their own, they have nobody to help hold them accountable besides themselves.” – YMCA stakeholder (S24)Veterans discussed how they had grown accustomed to the structure of the military and “don’t have that experience and don’t know the questions to ask”  when they get out of the military.“[The military] is a high stress job. But then even when you get out it’s different because now, you’re [experiencing] a very different stress. The stress they’re used to is military stress. That is something you can handle because you’re going to do it every day.” – Veteran (V10)Participants agreed that providing structure would be especially beneficial for younger veterans who entered the service prior to acquiring a sense of independence and “don’t have purpose in life, [they’re] not going to be driven to take care of yourself because there’s nothing that you’re striving for” .Participants expressed that it was important for veterans to have a sense of purpose and passion because, if they ““It’s easy for people to push past some of these barriers and start reclaiming their life if they have that mission or purpose.” – YMCA Stakeholder (S26)you know what’s expected of you”  in the service and this creates a “very strong purpose, drive, [and] mission” . However, this purpose, drive, and mission becomes lost in translation when veterans exit the service. Participants expressed how RECLAIM could help veterans establish a “new normal”  within the civilian world, while also acquiring additional skills and resources.“If you’re out of the military and that was your mission, like taking some time over those 8 weeks to maybe develop what that is and then reinforce it with health care skills that help them to build off of it.” – VA clinician (S4)“If you don’t have a sense of purpose, like you’re starting to fall into some [stuff], you know, this [program] is a tool that you can use if you start feeling that you’re falling by the wayside.” – Veteran (V14)Veterans discussed how “isolate yourself when you get out,” which “creates so many downstream effects” .Participants discussed how RECLAIM could help veterans rebuild a support system. Social support was considered an important aspect of the program because there is a tendency to ““You had that brother and sisterhood [in the service] and I think that [RECLAIM] would be a great thing to have, especially to include into tools for new veterans.” – Veteran (V13)didn’t think there was much of a veteran community around.” Participants expressed that the RECLAIM program could help strengthen the veteran community by actively connecting veterans and their families with community resources. Some stakeholders echoed these considerations about helping veterans “understanding the resources that are available to them” . Stakeholders also viewed RECLAIM and its positioning within a community-based organization as an “opportunity to create partnerships”  in the community.One veteran (V11) indicated he “connect [veterans] with [family],” while others thought some veterans may “[not] want [family] knowing what [they’re] struggling with” .Inclusion of family, especially spouses or significant others, was frequently discussed and suggested for consideration within RECLAIM to help veterans re-establish their support system. However, there was some inconsistency about whether inclusion of family was always a positive and necessary aspect of the program; one veteran (V2) shared that the program could help “As presented earlier, the Interpersonal Psychological Theory of Suicide (IPT)  and the Participants frequently discussed the importance of using familiar language when promoting RECLAIM and presenting program content. Additionally, peer-to-peer outreach (another way to create familiarity) was often suggested. These suggestions are consistent with the theoretical constructs of belonging (IPT) and relatedness (SDT); program materials and content familiar to veterans can provide them with the sense of being connected to the program and its content which, as participants indicated, can increase the likelihood of buy-in and continued engagement.Participants were drawn to the idea that RECLAIM is proactive and focuses on aspects of the whole person to improve well-being. Some participants also expressed how the mindfulness component of RECLAIM will help veterans be more attuned to and understanding of their health needs and recognize that they are in control. These aspects support the needs of autonomy (SDT) and competence (SDT). The proposed mindfulness activities also aim to improve veterans’ resiliency and coping skills, allowing them to independently address difficult situations or emotions, and prevent the perception that they are a burden on others (IPT). Finally, some participants discussed the benefits of the community-based setting, which can improve veterans’ sense of belonging (IPT) and relatedness (SDT) by connecting them with other veterans in their community.When veterans transition out of the military, the structure  they had become accustomed to is not readily apparent when they leave the service. Therefore, participants perceived RECLAIM as an opportunity to assist veterans’ efforts to replicate the structure of the military into their civilian lives. Providing veterans with structure addresses all five theoretical constructs of both the IPT and the SDT. First, by establishing a new purpose or mission, and related goals, veterans will be able to feel more autonomous (SDT) and competent (SDT) and, therefore, can perceive themselves as less burdensome (IPT) to others. In addition, RECLAIM can facilitate veterans’ sense of belonging (IPT) and relatedness (SDT) by connecting them with other veterans who will be able to identify with their experiences, concerns, struggles, etc. The inclusion of family members, as suggested by some participants, can also increase veterans’ sense of belonging.The RECLAIM health promotion program was designed to facilitate post-9/11 veterans’ social and self-connectedness to reduce the risk of engaging in suicidal behaviors. The purpose of this study was to elicit veteran and stakeholder feedback to provide an in-depth understanding of participants’ perceptions of RECLAIM, which would be considered for the program design and implementation. In addition to overall positive perceptions of RECLAIM, findings revealed three overarching themes: 1) enhancing program recruitment and retention, 2) the perceived ability of a health promotion program to provide more holistic, veteran-centered care, and 3) using health promotion programs to help veterans establish structure in their daily lives. While the findings from this study specifically inform the ongoing development and future implementation of RECLAIM, many of the principles discussed are relevant for the design and implementation of other programs focused on health and wellness for post-9/11 veterans, including those aimed at reducing the risk of suicidal behaviors in this population.Veterans expressed concern over some of the proposed terminology presented in the focus group discussions. In particular, the proposed concept of a ‘lifestyle’ program was not generally well-received; participants indicated that term was “invasive,” “vague,” and created a perception that there was something wrong with veterans’ current lifestyles. Similarly, veterans in previous studies have indicated a general distrust with the VA healthcare system and add that vague language can fuel this distrust and is off-putting , 24. TheMindfulness-based interventions are among the most commonly used complementary and integrated health (CIH) approaches within the VA . HoweverSeveral participants considered RECLAIM to be an opportunity to help veterans connect to and understand available services at the VA. Some veteran participants indicated being unaware of VA benefits prior to exiting the military and having limited knowledge regarding the processes to obtain benefits. This is critical to address considering VA services, such as nutrition and weight loss, can help facilitate proactive behaviors by helping veterans make healthy decisions that will positively impact their overall and long-term health. Similarly, these challenges were expressed by veterans in previous studies who reported difficulty navigating the VA system due to a lack of understanding or misunderstanding available services and benefits , 30. UnfWhen individuals enter into military service, they adopt military norms, values, and language through basic training , 32. WhiParticipants in this study have not actually participated in the RECLAIM program but were responding to and providing their perceptions of a description of the program. Perceptions of RECLAIM could change based on a veteran’s actual experience engaging in the program and its proposed activities. All veteran participants indicated they were receiving VA care at the time of study participation, which limits the understanding of how veterans not enrolled in VA care may perceive RECLAIM. Additionally, veteran and VA clinician participants in this study were from a single VA facility and perspectives may be limited based on the experiences at this specific location. Some focus group participants may not have felt comfortable sharing their opinions and, therefore, their perspective may not be represented in the findings. Finally, the overall positive response to the RECLAIM program may have been due to selection bias introduced in the convenience sampling method.The purpose of this study was to elicit feedback from veterans and stakeholders regarding initial perceptions of the RECLAIM program and considerations for future implementation. Formative research in the RECLAIM program design protocol ensures the program is contextually appropriate to the needs of post-9/11 veterans. Discussions in this study were specifically directed at the RECLAIM program and the feedback acquired in this study will be considered in further refinement and future implementation of the RECLAIM program. However, the findings from this study can be considered for the development and implementation of other related programs designed to improve the health and wellness of post-9/11 veterans and/or reduce their risk for engaging in suicidal behaviors. Initial feedback from participants in this study indicate that RECLAIM is an acceptable and veteran-centric program. Future research may consider incorporating the aspects of RECLAIM that participants indicated were appealing into other programs for post-9/11 veterans. In addition, findings from this study also highlighted barriers and facilitators to program implementation, along with strategies for recruiting and retaining participants. These are barriers and facilitators that future work should consider and proactively address to increase veterans’ ability to successfully engage with veteran-directed programs and interventions. Finally, future research should continue to evaluate how the interpersonal psychological theory of suicide and the self-determination theory inform each other to enhance our understanding of how to effectively address and improve protective factors among veterans to reduce their risk of suicidal behaviors.Additional file 1.


Self-sampling for HPV testing may be a method to increase overall cervical cancer screening rates among Black women, who are underscreened for cervical cancer in parts of the US. The purpose of this study was to assess preferred characteristics for delivery of HPV self-sampling kits, return of HPV self-sampling kits, and communication of HPV test results and explore sociodemographic factors  associated with acceptability of self-sampling for HPV testing.Survey data were gathered at an Indiana minority health fair. Participants evaluated 9 scenarios that varied along 3 dimensions: HPV self-sampling kit delivery , HPV self-sampling kit return , and HPV test results . The 9 scenarios were produced from a fractional factorial design and rated on a 0 to 100 scale. Ratings-based conjoint analysis (RBCA) determined how each dimension influenced ratings. A measure for acceptability of self-sampling was obtained from the ratings of all 9 scenarios. The acceptability measure was regressed on sociodemographics.The 98 participants ranged in age from 21 to 65 (M = 45). Across the 9 scenarios, overall acceptability to self-sample had a mean of 60.9 (SD = 31.3). RBCA indicated that HPV self-sampling kit return had the most influence on ratings, followed by HPV self-sampling kit delivery, and finally, HPV test result communication. Thirty-six percent of participants rated all self-sampling scenarios the same. Sociodemographic characteristics were not associated with acceptability of self-sampling.Self-sampling for HPV testing was found to be generally acceptable to Black women in this pilot survey study. This information could be used by researchers developing self-sampling interventions and the implementation of self-sampling among providers. Black women in the United States (US) continue to bear an unequal burden of cervical cancer, which is a salient problem in Indiana where Black women have a 23% higher cervical cancer incidence  and 25% Self-sampling for HPV testing has been integrated into screening programs in other countries , return of the HPV self-sampling kit , and how women would like the results delivered . Ratings-based conjoint analysis (RBCA), a methodological and analytic technique, is uniquely suited to this research focus, as it evaluates how a product’s characteristics  influence product preferences. A secondary aim was to explore sociodemographic characteristics that could be related to self-sampling for HPV testing acceptability. Although studies have begun to examine acceptability related to self-sampling for HPV testing in the US, it is important to understand these preferences along multiple dimensions (delivery and return of HPV self-sampling kits and HPV results delivery) especially among Black women who have higher incidence and mortality from cervical cancer. Results of this pilot survey study could inform future interventions or implementation of self-sampling for HPV testing by determining which factors are most important to women’s willingness to use this technology.This study was submitted to and approved as exempt research by the Indiana University IRB. Participants gave verbal consent as signed consent is not required for exempt research according to Indiana University IRB. The participants were provided a verbal and written description of the study. The written description included the following information: that subjects were being asked to participate in research; a description of the study procedures; a statement regarding any potential risks or benefits of participation; a statement that participation is voluntary; and the name, affiliation, and contact information of the researchers.n = 58) or paper surveys (n = 40) after determining eligibility and explanation of the study. Participants were compensated with a $20 gift card after completing the survey.The data were collected from women who attended the health fair portion of the Annual Indiana Black Expo, a large cultural event that draws an estimated 40,000 attendees. Eligibility inclusion criteria included women who were 1.) Black, 2.) between the ages of 21–65 , and 3.) could read and write English. Exclusion criteria included women with a hysterectomy. A sample of 98 women were included in analysis. The sample size was limited by the inclusion criteria, the availability of research personnel, and the many health vendors with displays at the health fair . Participants were given the choice between a computer survey administered on REDCap , education, and marital status of participants. Then, participants were given a description of self-sampling for HPV testing and asked to evaluate hypothetical self-sampling scenarios that varied along 3 dimensions: delivery of an HPV self-sampling kit , return of the HPV self-sampling kit , and HPV result delivery . A full factorial design would have required women to rate 27 scenarios, which would have imposed undue burden on the respondents. Therefore, we generated a fractional factorial design using the conjoint analysis procedure available in SPSS version 24  to create nine representative, independent scenarios that allowed us to evaluate the main effects of the dimensions. An example of a scenario presented to participants was “An HPV self-sampling kit delivered by mail that could be returned by mail with results delivered by text message. If self-sampling were available today, and you had time, how likely would you be to complete self-sampling in the given scenario?”. Participants rated the scenarios on an 11-point scale in intervals of 10 points (1–100) where 0 represented that they would never complete self-sampling for HPV testing and 100 meant that they would definitely complete self-sampling for HPV testing. Acceptability for HPV self-sampling in general was evaluated by creating a scale score based on the mean value across the 9 items illustrating hypothetical self-sampling scenarios .n = 63) who did not assign the same ratings to all scenarios. Participants who assigned the same ratings to all scenarios were not included in analyses. Nine hypothetical self-sampling scenarios were each defined along 3 dimensions: delivery of HPV self-sampling kit , return of HPV self-sampling kit , and delivery of HPV results . Income, education, and marital status were regressed on the HPV testing acceptability measure  in a linear regression model.We used SPSS 24 to describe sociodemographic characteristics for all 98 participants and the 63 participants who did not assign the same ratings to all scenarios. Then, RBCA was used to examine how HPV self-sample kit characteristics influenced ratings for participants  and were therefore included in the conjoint analysis and the total sample (n = 98) were examined (Table n = 35) rated all the scenarios the same. Sixty percent (n = 21) of the sample who rated the scenarios the same held strongly positive views of self-sampling (Table n = 8) had strongly negative views. Seventeen percent (n = 6) held midpoint views. The 35 participants who demonstrated no variability across the vaccine scenarios were necessarily eliminated from the conjoint analysis. The overall conjoint analysis was based on the 63 participants who did not rate all the vaccine scenarios the same and provided responses for all nine scenarios.Sociodemographics  of the women who rated the scenarios differently (ed Table . Of the cent n = 1 of the p = .723) found an R2 of .014.Across the 9 scenarios, overall willingness to self-sample ranged from 0 to 100 with a mean of 60.9 SD = 31.3). The least acceptable self-sample scenario, “An HPV self-sampling kit picked up at the clinic that could be returned by mail with results delivered by mail”, received a mean score of 60.4 (SD = 36.5). The most acceptable self-sample scenario was “An HPV self-sampling kit picked up at the clinic, returned to the pharmacy, and results delivered by phone” . Table 1.3. The For the 63 participants in the conjoint analysis, the part-worth utilities in Fig. The current study evaluated factors related to the willingness of participants to engage in HPV testing for self-sampling. Previous studies that have examined HPV self-sampling acceptability have not used RBCA to allow examination of multiple dimensions of HPV self-sampling that could be important in implementation of the technology. The factors measured in the current study included: delivery of an HPV self-sampling kit , return of the HPV self-sampling kit , and how women would like the results delivered . Overall acceptability appeared to be mostly positive with a mean score of 60.9 and the lowest mean score 60.4. A previous study using clinic-based delivery and return of self-sampling found an acceptability rate of 100% , howevern = 63) did discriminate between the different self-sampling for HPV testing scenarios. The most important self-sampling for HPV testing characteristic was kit return with a preference for return to a pharmacy. Although some aspects of HPV self-sampling kit return have been measured before, studies have not examined if other methods of return (pharmacy or clinic) would be preferred to mailed return. A previous study found that a majority of participants (82%) reported being comfortable sending the kit through the mail [The current study found that most participants . Further research with a larger, more representative population is necessary to more fully understand characteristics related to acceptability of self-sampling for HPV testing and potential sociodemographic, health belief, and knowledge predictors of acceptability. Third, other self-sampling characteristics not measured, such as device type or invitation method, could be more important than those measured in the current study. For example, a recent study found that most participants responded to an invitation to opt into a self-sampling for HPV testing study by mail (61%) or online (37%) rather than by phone (1%) or email (< 1%) [This study has several limitations. First, the participants were all from a minority health fair and Black, which may limit generalizability. Other populations may find self-sampling for HPV testing more or less acceptable and/or have different preferences than this specific subgroup. For example, a study of British women found that HPV testing was more acceptable among White women . The higl (< 1%) . Due to In summary, self-sampling was found to be generally acceptable to Black women in this pilot survey study. The most important characteristic among the women related to self-sampling was the return of the HPV self-sampling kit, second, delivery of the kit, and finally the HPV results delivery method. Sociodemographic characteristics including income, education, and marital status were not related to self-sampling for HPV testing acceptability. If these findings can be replicated among the general population or underscreeners, the information could be used by researchers developing interventions related to self-sampling for HPV testing and the implementation of self-sampling among providers.


We investigated human papillomavirus (HPV) infection and detected anal squamous intraepithelial lesions by modified liquid-based cytology (LBC) and p16/Ki67 dual-staining. Anal swabs (n=393) were collected from patients with HIV infection. Anal cells were kept in 95% ethyl alcohol for modified LBC. DNA was extracted from cells for HPV detection and genotyping using real-time PCR and reverse line blot hybridization. Results: Nine samples (2.3%) were unsatisfactory specimens, 74.8% (294/393) were negative for intraepithelial malignancies (NILM) and 22.9% (90/393) exhibited squamous intraepithelial lesions (SIL). In the latter category, 13.7% of samples (54/393) contained atypical squamous cells of undetermined significance (ASCUS), 6.9% (27/393) were classified as low-grade SIL (LSIL) and 2.3% (9/393) as high-grade SIL (HSIL). A total of 331 from 393 swab samples were suitable for detection of HPV infection. Among these, 34.1% (113/331) were positive. HPV 58 (15.9%) was the most common genotype, followed by HPV 18 (14.2%) and HPV 16 (11.5%). The severity of abnormal cells was significantly associated with HPV infection. Dual staining with p16/Ki-67 was performed on 130 samples: in 30.8% (40/130) of samples positive staining was significantly associated with severity of abnormal cells. Agreement between cytology, p16/Ki67 dual-staining and high-risk HPV detection was 100% in HSIL samples. Interestingly, eight apparently NIML cases might have contained abnormal cells, since they were positive by both p16/Ki67 dual-staining and high-risk HPV detection. Anal specimens screened using modified LBC with 95% ethyl alcohol solution as the fixative are suitable for screening anal precancerous lesions by cytology, HPV testing and p16/Ki-67 dual staining. Co-expression of p16 and Ki-67 in the same anal cells is an indicator of a deregulated cell cycle caused by HPV oncoproteins and is typical of precancerous cells . There is limited information on the prevalence of anal HPV on the best strategy of screening for anal cancer. In this study, we investigated the correlation between results from cytology, HPV DNA and p16/Ki-67 dual staining in HIV-infected patients.Anal cancer has striking similarities with cervical cancer in terms of etiology and pathogenesis. Both are associated with persistent infection by human papillomavirus (HPV) . Immunosuppressed state with decreased numbers of CD4+ cells, HIV infection and sexual practices, such as receptive anal intercourse and high lifetime number of sexual partners, are all risk factors for anal HPV infection leading to anal cancer . Over the past decade, the incidence rate of anal cancer has increased, particularly in HIV-infected individuals among whom incidence is about 30-fold higher than in the general population . The weakening immune system of HIV-infected individuals is an additional risk factor for HPV infection that leads to anal intraepithelial neoplasia (AIN) and anal cancer . Screening for cervical cancer by cytology is widely accepted as the best strategy to reduce incidence and mortality rate: anal cytology can perhaps do the same for anal cancer . Anal cytology screening is recommended for all at-risk populations, including HIV-infected individuals . Anal cytology for detection of AIN is moderately sensitive (60-70%) and specific (32-59%). Additional tests need to be developed cytological technique for increase sensitive and specific to improve these results . Testing for HPV DNA is an adjunct to cytology, or can be used alone to screen for anal cancer: it has greater sensitivity (75-100%) than cytology . However, HPV is very common in the general population and need not be associated with anal cancer. Hence this test is not very specific. In recent years, several biomarkers have been proposed for immunocytochemistry to detect expression of cellular products affected by HPV infection. Observed deregulation of the cell cycle identifies those infections at risk of progression toward dysplasia and carcinoma. Such tests should be more specific than HPV DNA testing. One of the most widely studied markers is the cyclin-dependent kinase inhibitor p16 INK4a (p16) . Recently, a kit has been developed by CINtecSpecimen collection and preparationThe study protocol was reviewed and approved by the Ethics Committee of Khon Kaen University, Thailand (HE 551148). This study was a cross-sectional analysis of 393 HIV-infected individuals at Srinagarind Hospital and Sirindhorn Hospital in Thailand. Included were all such patients who underwent anal cancer screening between January 2014 and February 2016. Exclusion criteria were; presence of gastrointestinal hemorrhage, intestinal obstruction or anal wound. Anal specimens were collected with Rayon swabs that were gently inserted approximately 5-6 cm into the anal canal while rotating the swab to contact all sides of the anal canal. The anal swab was quickly placed in 95% ethyl alcohol prior to modified-liquid based cytology .Anal cytologyAnal cytology specimens in 95% ethyl alcohol were centrifuged at 1500 rpm for 10 minutes at room temperature. The sediment (approximately 200 µl) was transferred to positively charged slides. The slides were air-dried at room temperature then fixed in 95% alcohol for at least 15 min, and Papanicolaou stains were used to assess cellularity and morphology. All slides were evaluated independently by 2 cytologists. The cytology results were categorized following the Bethesda system (2014) as unsatisfactory specimen contains nucleated squamous cells less than 1-2 per high power field, many anucleated squamous epithelial cells, obscuring bacterial, fecal material and cellular debris, negative for intraepithelial lesion or malignancy (NILM), atypical squamous cells of undetermined significance (ASCUS), low-grade squamous intraepithelial lesion (LSIL), atypical squamous cells cannot rule out high-grade squamous intraepithelial lesion (ASC-H), High-grade squamous intraepithelial lesion (HSIL), and squamous cells carcinoma (SCC) .HPV DNA extraction and genotypingAnal cells were washed with phosphate buffered saline by centrifugation at 13,500 rpm, 4°C for 5 minutes and DNA was extracted using the AllPrep DNA mini kit  according to the manufacturer instruction. Quality of the extracted DNA was evaluated by amplification of the ß-globin gene as an internal control. Samples positive by PCR for the ß-globin gene were subjected to HPV DNA detection by real-time PCR on a LightCycler 480 instrument (Roche Diagnostics). A 142-bp fragment from the L1 region of HPV DNA was amplified using the consensus primers GP5+/GP6+ . The HPV DNA positive samples were used for HPV DNA genotyping by reverse line blot hybridization (RLBH), assaying 37 HPV types including HPV 6, 11,16, 18, 26, 31, 33, 34, 35, 39, 40, 42, 43, 44, 45b, 51, 52, 53, 54, 55, 56, 57, 58, 59, 61, 66, 68, 70, 71 CP8106, 72, 73, 81 CP3804, 82 MM4, 82 IS39, 83 MM7, 84 MM8, CP 6108.Immunocytochemistry® PLUS Cytology Kit reagent. The kit designed were used a primary monoclonal mouse antibody directed to human p16 protein and a primary monoclonal rabbit antibody directed against Ki-67 protein. After counterstaining, a two-step mounting protocol must be applied: in the first step an aqueous mounting of the specimens using an aqueous mounting medium. Subsequently, the slides may be cover-slipped using a permanent mounting medium. The result can be evaluated by light microscopy inspection. The positive result of p16/Ki-67 was defined as one or more of anal epithelial cells stained with both a brown cytoplasmic stain (p16) and red nuclear (Ki-67) irrespective of interpretation of morphological abnormalities slides without any double-stained cells were called negative for p16/Ki-67 dual stain.The residual specimens were centrifuged at 1,500 rpm for 10 minutes at room temperature, the sediment was aspirated approximately 200 µl and then transferred to positively-charged slides. The slides were air-dried at room temperature after that fixed in 95% alcohol for at least 15 minutes and dried the slide on a flat horizontal surface for 60 min at room temperature, before performing p16/Ki-67 dual stain. The p16/Ki-67 dual stain study was performed automatically, using VENTANA BenchMark XT equipment and CINtecStatistical analysisStatistical analysis was carried out using SPSS program, version 19.0 for Windows . The chi-square test was used to quantify any correlation between anal cytology and HPV DNA testing. A value of p <0.05 was considered statistically significant. Cytological diagnosisIn total, 393 anal specimens were collected including 64.6% 254/393) from males and 35.4% (139/393) from females. Nine of 393 specimens (2.3%) were regarded as unsatisfactory in modified LBC: fewer than 6 nucleated squamous cells were present per high-power field. Among remaining samples, 74.8% (294/393) were classified as negative for intraepithelial lesion or malignancy (NILM) and 22.9% (90/393) as atypical squamous cells of undetermined significance (ASCUS) following the Bethesda system 2014. The most common categories within abnormal squamous intraepithelial lesion (ASIL) were ASCUS  followed by low-grade squamous intraepithelial lesion (LSIL)  and high-grade squamous intraepithelial lesion (HSIL)  , 2.54/393 frThe prevalence of HPV DNA Of the 393 anal specimens, valid HPV DNA results were obtained from 331: 62 samples lacking adequate material for DNA extraction were excluded. HPV DNA was not detected in 65.9% (248/331) of samples: 34.1% (113/331) were positive. The most common high-risk HPV genotypes in single-genotype infections were HPV 58 , HPV 18  and HPV 16 . Other HPV high-risk genotypes present as single infections were HPV 33 , HPV 45 , HPV 53 , HPV 56 , HPV 70  and HPV 73 . Low-risk HPV genotypes detected were HPV 11 , HPV 6 , HPV 42 , HPV 72  and HPV 43 . The top three multiple-genotype HPV infections were HPV 11 & 52 , HPV 6 & 16 , HPV 11 & 16  and HPV 18 & 58 . HPV DNA was found in 55.8% (63/113) of specimens classed as NILM and in 44.2% (50/113) of those classed as ASIL. In the latter category, HPV DNA was found in 22.1% (25/113) of ASCUS samples, 15.9% (18/113) of LSIL samples and 6.2% (7/113) of HSIL samples . The prop16/Ki-67 dual stain testing in cytological categoriesAnal epithelial cells positive for Ki-67 showed red-stained nuclei while those positive for p16 had brown staining in the cytoplasm. The negative results of p16/Ki-67 dual stain were not stained or both of brown staining in the nuclear and cytoplasm of p16 . A totalScreening for anal cancer is recommended for all HIV-infected patients, although no standard guidelines exist. Following the cervical cancer screening model, anal cytology has been proposed for anal cancer screening . In this regard, the conventional smear is often air-dry artifact. Liquid-based cytology preparations such as ThinPrep, Liqui-PREP and modified liquid-base cytology yield low background smears due to reduction in fecal material and bacteria, facilitating easier visualization of abnormal cells . We found abnormal anal cytology in 22.9% of HIV-infected patients. Another study in Thailand reported the prevalence of ASIL among HIV-infected men who have sex with men (MSM) to be 43.0% . Among samples in the ASIL category, 13.7% were in the ASCUS subcategory, a lower proportion than reported in another study on HIV-infected MSM (between 16.7% and 25.7%) . We classified 2.3% of samples as HSIL, which is considered the real precursor of anal carcinoma. LSIL, at 6.9%, was a more frequent diagnosis than HSIL. It is worth noting that LSIL might be clinically important. In one study, about 62% of HIV-positive MSM and 36% of HIV-negative MSM who had a diagnosis of LSIL at baseline progressed to HSIL within 2-4 years . A diagnosis of ASCUS may also hide squamous intraepithelial lesions . The presence of any abnormal anal cytological finding indicates a potential association with high-grade anal intraepithelial neoplasia (AIN) on pathological examination . These data underline that all patients with a cytological report of ASCUS or worse need a follow-up for accurate diagnostic investigation. Importantly, HPV is the most common sexually transmitted viral disease implicated in progression of anal intraepithelial lesion into squamous cell carcinoma. HPV has a particularly high prevalence among HIV-infected patients. HPV DNA testing is recommended an alternative or an adjunct to cytology . In our anal samples collected for modified LBC, the prevalence of HPV infection was 34.14%, which lies within the range noted in previous publications . It should be noted that the prevalence of ASIL and HPV infection varies according to sexual behavior and geography. Furthermore, infection by any HPV is associated with a 4-fold increased risk of having abnormal anal cytology . In our study, the prevalence of HPV infection seems to rise with grade of cytological abnormality. We found HPV infection, both with single and multiple genotypes, in all ASIL samples. Infections with two or more HPV genotypes is common in anal specimens . The prevalence of high-risk HPV single infection was 47.8%. Corresponding values for women and for HIV-infected men who have sex with men range from 37.5% . Among high-risk HPV types, we found HPV 58 to be the most common, followed by HPV 18, HPV 16 and HPV 33. The most common high-risk HPV types in HIV patients worldwide are HPV 16 followed by HPV 18 . Among Spanish MSM, the most prevalent high-risk HPV was HPV 31 and in China, HPV 58 were the most frequently detected . As for low-risk HPV types, HPV 11, HPV 6 and HPV 42 were the most frequently detected. Abnormal anal cytology can be associated with low-risk HPV types HPV6, HPV 11, HPV 40 and HPV 42 . The frequency of HPV genotypes varies by geographic region. The high-risk HPV infections were detected in cases with each cytological diagnosis including negative, ASCUS, LSIL and HSIL. However, it should be noted that HPV DNA testing has high sensitivity but low specificity as a screening tool for cancer . The presence of high-risk HPV infection in cases classed as ASCUS may reflect the fact that a diagnosis of ASCUS is consistent with benign reactive changes other than malignancy. Similarly, in cases classed as LSIL by cytology, we found infection with high-risk HPV. LSIL may be a consequence of low-risk HPV infection and other causes. HSIL cases were positive for HPV DNA including high-risk HPV, low-risk HPV and multiple infections with both. We found HSIL to be strongly associated with high-risk HPV infection, as also reported by others . In the immunocytochemistry study, we conducted p16/Ki-67 dual staining on a selected series of anal specimens with all grades of abnormal cytology and/or HPV DNA-positive. We investigated the correlation between p16/Ki-67 dual staining and the cytological diagnosis and high-risk HPV infection. There was a significant increase in samples positive for p16/Ki-67 with increasing severity of the cytological lesion, especially in HISL with high-risk HPV infection. Nevertheless, we found 8 cases (29.63%) of cytologically normal samples with high-risk HPV infection and positive for p16/Ki-67 staining. It may be that these 8 cases are also precancerous despite their normal appearance. Similarly, Lee and Lee (2016) demonstrated that 5 of 6 cervical samples of ASCUS and LSIL with p16 methylation progressed to HSIL . It is worth noting that 8 of 17 cases (47.06 %) of ASIL that were positive for low-risk HPV were also positive for p16/Ki-67. One follow-up study on cervical cases classified as ASCUS and negative for high-risk HPV found that, one year later, 23% had progressed to LSIL and 4% to HSIL . Furthermore, Balmagambetova et al., (2019), in a review of the literature, noted the reported presence of low-risk HPV types 6 and 11 in invasive anal cancer cases  and Serrano et al., (2015) reported low-risk HPV associated with cancers of the anus, cervix, vagina and vulva . Several previous studies have reported p16/Ki-67 positivity is independent of HPV genotypes and achieved a sensitivity equal to HPV testing with significantly higher specificity . Consequently, the presence of p16/Ki-67 staining in normal cells or dysplastic cells should not be ignored and may indicate deregulation of the cell cycle. In this study, we detected p16/Ki-67 dual stain in anal specimens positive for HPV or cytological diagnosis as ASIL including ASCUS, LSIL and HSIL. Such staining was not detected in NILM samples positive for low-risk HPV or without HPV. Therefore, the screening of anal samples with p16/Ki-67 dual stain should be done when the patient has a cytological diagnosis of ASCUS or LSIL, with or without HPV infection. Limitations of our study were that a small number of cases were analyzed by p16/Ki-67 dual staining and no biopsy was taken to confirm specificity. In conclusion, anal specimens screened using modified LBC with 95% ethyl alcohol solution as the fixative are suitable for screening anal precancerous lesions by cytology, HPV testing and p16/Ki-67 dual staining. This study should contribute to management guidelines for anal cancer screening. If the results of cytology were ASCUS and LSIL, with or without the presence of HPV DNA, further investigation by p16/Ki-67 dual staining is worthwhile.


Purpose: Mexico’s public hospitals are experiencing major operational problems which seriously affect the care of Mexican citizens. Some hospitals have initiated efforts to apply the Kaizen philosophy to improve this situation. Therefore, the purpose of this article is to analyze the methodological impact of Kaizen–Kata implementation in Mexican public hospitals that have tried to solve operational problems using this improvement approach. Design/Methodology/Approach: The service organization implemented Kaizen–Kata methodology in order to improve one operational problem-process in health care. A case-study approach was used in this research in order to understand the effects of the Kaizen–Kata methodology in solving problems in their operational procedures. Findings: Six specific drivers were identified when applying the Kaizen–Kata methodology. Furthermore, the impact on the levels of implementation of the Kaizen–Kata methodology in each of the improvement teams studied was also identified. Research Limitations: The main limitation of the research is that only three case-studies are presented thus it is not possible to generalize its results. Practical Implications (Where Possible): Other public hospitals can use this specific example as a working guide to solve the operational problems of health systems. Originality/Value: A methodology of continuous improvement in manufacturing was imported from the industry sector for application in an operational health care process. The Kaizen–Kata methodology contributed significantly to improving issues involving delays, customer complaints, process reworks and extra-cost, among other effects of operational problems. Following the change of government in 2018, Mexico’s health system began to bring to light several operational and service problems that had been dragging on before, and that have increased in these years of the new government of Mexico ), confirming the work of Bortolotti [Disciplined implementation of Kaizen–Kata methodology, applied strictly step-by-step for the resolution of public hospital problems in the “action trench” .It is verifiable that all Kaizen–Kata teams in public hospitals experienced a form of systematic and continuous improvement which gave them a guiding light in the “sea” of operational problems that these hospitals in Mexico experience. The successful application in solving operational problems in public hospitals of techniques and tools focused on Kaizen philosophy is also corroborated in the literature in different countries such as the USA, Sweden, the UK, Germany and Egypt, among others ,32,41,42The literature confirms the presence of several of these critical drivers indicated; however, as a vital contribution of our research it was contrasted that in a work culture such as that of the Mexican public health sector, the improvement teams integrated in Kaizen–Kata methodology worked more as mechanisms to promote change and improvement, compared to other workers , without realizing that they themselves were generating the change. In addition, having a simple, clear and easy to apply improvement methodology  clarified the path of change of old management practices.On the other hand, to answer the second research question regarding the level of application of the different steps of Kaizen–Kata methodology in its implementation when solving operational problems, we rely on the specific questionnaire pertaining thereto. Each of the teams studied presents differences in the implementation of the methodology according to the working environment of each hospital and the level of understanding of the methodology by each team in each hospital. As can be seen in the hospital of Case A, of medium-large size, it had the capacity to implement more Kaizen–Kata equipment; in total, there were five teams in different areas of the hospital, able to apply the Kaizen–Kata methodology in varied ways. There were Kaizen–Kata teams such as the “A&E a” and “Cystic Fibrosis” teams which achieved 4 or 5 points (high effective application) in most steps of the methodology. In this type of successful team, the most difficult step to achieve once implemented was the standardization of improvement activities; this is probably due to the resistance to change of bureaucratic structures in public hospitals.gemba allows for a deeper application of the Ishikawa diagram; for this reason, some teams were delayed in the progress of the application of the methodology. These teams had some areas of opportunity at the conclusion of some of the steps of the methodology which delayed the implementation process; for example, the cardiology team skipped the prioritization step (construction of the Pareto diagram) due to an oversight, which caused delays in implementation.The other three Kaizen–Kata teams shown in the graph had problems from the early stages or when developing the tools in the Ishikawa diagram that look for root causes of the problem. This tool requires a lot of quantitative data (carried over from the previous steps of the methodology) to be able to establish the qualitative cause–effect relationships at the time of construction. A quantitative data collection in the Case B, being smaller in size, only had two Kaizen–Kata teams. The “patient care” team performed well and many of its members were staff, motivated to improve the service provided to patients, for example, by trying to improve waiting times in the pre-consultation room. Therefore, the application of the methodology was successful (mostly five points). The other team , with a greater workload due to being in the emergency department, had more areas of opportunity when applying Kaizen–Kata methodology. The step where the process got stuck was the Improvement Action Plan, because several of its actions required some technical investment from the hospital, such as new stretchers, ambulances and medical-support equipment in A&E. The improvement project was left at a point of “work in progress”, with the Kaizen–Kata team trained and motivated.Case C, the smallest of the public hospitals, implemented a single Kaizen–Kata unit. The team of cystic-fibrosis doctors and nurses worked in a disciplined way to eliminate the problem of “drug shortages” for treating cystic fibrosis, including improving and optimizing their warehouse inventory model—a small, but highly motivated team, as can be seen from their scores of 4–5 on the entire methodology.Finally, it is important to point out that the literature on the application of Kaizen–Kata is practically non-existent when it comes to describing the operational discipline in application of each step of the methodology by the KTs, that is, how each team applies each step or the “improvement routine”. A poorly applied or “not applied” (skipped) step will result in “failures” or unobserved areas of opportunity in the resolution of operational problems posed ,43,44. Agemba; and (6) a shift towards proactive vision and continuous improvement routines for all the employees. We also observed that, of the eight teams studied, at least three produced a “successful application” of four or five points, while others ran up against barriers or inhibitors that hindered the implementation of Kaizen. Thus, according to the results found using the qualitative methodology of the case study, there was no attempt to conclude that Kaizen–Kata methodology is the “total solution” to “all” operational problems of public hospitals. However, the progress in the application of the Kaizen–Kata methodology up to the final levels exhibited by practically all the teams demonstrates that work routines of these public employees, who are used to work related bureaucracy, have changed radically; this is due to having the opportunity of and space for dialog (the Kaizen team) to improve their own operational problems in their daily work.This research examines the application of the Kaizen–Kata methodology to solve operational problems in public hospitals in Mexico. Our findings detected six critical drivers in the application: (1) leadership of senior management; (2) operational discipline in the application of the methodology; (3) network of Kaizen–Kata teams; (4) the team of support staff; (5) on-the-job training in the In fact, as an additional observation, without being able to be empirically contrasted at the time of closing this article, public hospitals that applied Kaizen–Kata methodology seem to be responding better to the coronavirus crisis by having teams prepared with previous learning of a particular methodology. As a proposal to extend the work, a study of this in the future would be interesting. The Kaizen–Kata methodology also explores the possibility of innovating and redesigning processes using other approaches and information technologies such as the implementation of ERP . This toFinally, a limitation of the work is that results and conclusions of the study cannot be generalized because only three public hospitals were studied; however, this work may represent an implementation guide for other public hospitals in Mexico and other countries that have similar problems in becoming more efficient.


The concentrations of CD39 and CD73 in PFP increased with disease progression . The PFP of patients with HSILs or CC showed the highest concentrations of CD39  and CD73 , which were associated with a high capacity to generate Ado from the hydrolysis of adenosine diphosphate (ADP) and adenosine monophosphate (AMP). The addition of POM-1 and APCP, specific inhibitors of CD39 and CD73, respectively, inhibited the ADPase and AMPase activity of PFP by more than 90%. A high level of the 90 kD isoform of CD73 was detected in the PFP of patients with HSILs or CC. Digestion with endoglycosidase H and N-glycanase generated CD73 with weights of approximately 90 kD, 85 kD, 80 kD, and 70 kD. In addition, the levels of transforming grow factor-β (TGF-β) in the PFPs of patients with LSIL, HSIL and CC positively correlated with those of CD39  and CD73 . These results suggest that persistent infection by HR-HPV and the concomitant production of TGF-β promote the expression of CD39 and CD73 to favor CC progression through Ado generation.Persistent infection with high-risk human papillomavirus (HR-HPV) is the main factor in the development of cervical cancer (CC). The presence of immunosuppressive factors plays an important role in the development of this type of cancer. To determine whether CD39 and CD73, which participate in the production of immunosuppressive adenosine (Ado), are involved in the progression of CC, we compared the concentrations and hydrolytic activity of these ectonucleotidases in platelet-free plasma (PFP) samples between patients with low-grade squamous intraepithelial lesions (LSILs) ( Persist3.1.3.5) , 11. In ity A2AR . In addiity A2AR . Upregulity A2AR , 15. In ity A2AR , prostatity A2AR , neuroblity A2AR , and othity A2AR , 20 can ity A2AR –24, suggRecently, we provided evidence that cells obtained from cervical samples of patients with low-grade intraepithelial neoplasms (CINI) positive for HPV-16 showed higher concentrations of CD39 and CD73 than cells from samples of patients with CINI negative for HPV-16 and from normal donors (NDs). The solubilized cervical mucus of these patients also showed higher concentrations of soluble CD39 and CD73, which was associated with a greater capacity to produce Ado through the hydrolysis of ATP and AMP .To determine whether CD39 and CD73 are involved in the development of CC, we analyzed the concentrations and hydrolytic activity of these ectonucleotidases in plasma samples from patients with LSILs, HSILs, or CC. For comparison, ND plasma samples were also analyzed.Instituto Mexicano del Seguro Social (IMSS)), the gynecology service of the Oncology Hospital of CMN SXXI of the IMSS, Mexico City, Mexico, and the Western National Medical Center (CMNO-IMSS) in Guadalajara, Jalisco, Mexico, between April 2016 and May 2018 after signing the informed consent form endorsed by the local bioethics committee. Women without cervical lesions were diagnosed by conventional cytology (Papanicolaou stain) and colposcopy. In cases of precancerous lesions or CC, the diagnosis was confirmed by histopathology. The cytologies and biopsies were analyzed by the pathologists of each clinic and were classified according to the Bethesda System 2001 [Biological samples were obtained from women who attended early detection programs at the Gynecology and Obstetrics Hospital No. 4 of the Mexican Social Security Institute (tem 2001  as follo+) was used as previously reported [Cervical samples from women diagnosed with NILM were collected during gynecological examinations with a cytobrush  and then placed in transport medium  to be stored at 4°C until DNA extraction. The samples were analyzed by conventional single-round polymerase chain reaction (PCR) to rule out the presence of HPV using the MY09/MY11 primers ; women wreported .The cervical samples of women diagnosed with SILs or CC were subjected to molecular analysis by PCR using the LINEAR ARRAY® HPV kit  for genotyping of the 37 main types of HPV that infect the anogenital region , HPV-56, HPV-58, HPV-59, HPV-61, HPV-62, HPV-64 (HPV-34 subtype), HPV-66, HPV-67, HPV-68, HPV-69, HPV-70, HPV-71, HPV-72, HPV-73 (MM9), HPV-81, HPV-82 (MM4), HPV-83 (MM7), HPV-84 (MM8), IS39 (HPV-84 variant), and HPV-89 (CP6108)). In each sample, the human beta-globin gene was amplified as an internal control. After the hybridization reaction, the strips were visually read against a reference guide. All procedures followed the manufacturer's instructions.g for 10 min to isolate the plasma. The blood plasma was centrifuged at 2422 × g for 10 min at 4°C to separate platelets as previously reported [The peripheral blood samples used in this study were obtained from 15 NDs, 18 patients with LSILs, 12 patients with HSILs, and 19 patients with CC . The plates were incubated for 1 h at 37°C and then overnight at 4°C. The plates were washed with a washing solution (PBS 0.1% Tween-20) and then incubated with a blocking solution (2% BSA w/v in PBS 0.1% Tween-20) for 2 h at 37°C. After washing, an anti-CD39 or anti-CD73 antibody  was added at a 1 : 1000 dilution in blocking solution and incubated for 2 h at 37°C. The plates were washed six times and incubated with the secondary goat anti-mouse or anti-rabbit IgG bound to alkaline phosphatase  in a 1 : 500 dilution in blocking solution and incubated for 2 h at 37°C. After eight washes, the substrate for alkaline phosphatase  diluted in diethanolamine  was added to 10% (pH 9.8). Finally, the reading was performed at a wavelength of 405 nm in an ELISA plate reader.CD39 and CD73 were detected in PFP by the enzyme-linked immunosorbent assay (ELISA). The data were interpolated in type curves using different concentrations (1-35 ng/ml) of human recombinant enzymes  diluted in phosphate-buffered saline (PBS). PFP was diluted with PBS, and CD39 was detected in PFP diluted to 1 : 40,000 and CD73 to 1 : 25,000. Samples of 100 μl of each PFP sample was incubated in the presence of ADP or AMP at a final concentration of 5 mM. After 72 h of incubation, Ado production was evaluated. To inhibit the enzymatic activity of CD39 and CD73, the specific inhibitors polyoxotungstate sodium  and adenosine 5′- diphosphate , respectively, were used at a final concentration of 5 mM, as previously described [μl. The amount of Ado produced by each sample incubated with ATP or AMP was evaluated through ultra-high-performance liquid chromatography (UPLC) after applying 25 μl of each reaction to a chromatograph  using a mobile phase composed of 0.5% acetonitrile, 5% methanol, and 94.5% sodium acetate (0.25 M and pH 6.3). Before reading, the samples were filtered through 3000 D Amicon filters . A standard Ado curve was prepared in Empower 3  to evaluate the Ado concentrations in the different samples.To determine the hydrolytic activity of CD39 and CD73 ectonucleotidases contained in the PFP, 5 escribed . The totβ1 in PFP samples, the Quantikine human TGF-β1 ELISA kit (R&D Systems) was used according to the manufacturer's protocol.To quantify the TGF-μl of each PFP or 20 ng of CD73 contained in the PFP (based on the rhCD73 type curve) were treated with Laemmli buffer and analyzed by 10% sodium dodecyl sulfate- (SDS-) polyacrylamide gel electrophoresis. Proteins were transferred to a nitrocellulose membrane , which was incubated with blocking solution (TBS 0.1% Tween-20 and 5% BSA) for 60 min at room temperature. The membrane was washed twice with washing solution (TBS 0.1% Tween-20) and then incubated with anti-CD73  at a 1 : 1000 dilution in blocking solution overnight at 5°C. After five washes, the membrane was incubated with the secondary antibody (HRP goat anti-rabbit) at a 1 : 1500 dilution with blocking solution for 1 h. After five washes, the presence of CD73 in the membrane was revealed in ChemiDoc  using the Chemiluminescent Peroxidase Substrate .To analyze the presence of CD73, samples of 3 μl of a denaturing solution (1 M β-mercaptoethanol and 2% SDS). Next, the endoglycanase H  and N-glycanase  enzymes were added to a final concentration of 0.05 U/ml and incubated for 18 h at 37°C. Last, the products of enzymatic digestion were analyzed by Western blot using the anti-CD73 antibody as described above.To deglycosylate CD73 contained in PFP samples, these samples were incubated for 5 min at 37°C in the presence of 1.5 All numerical data are presented as the mean value ± standard error of the mean (SEM) of three independent experiments. The comparisons and correlations were evaluated by multivariate statistical analysis with GraphPad Prism version 7 .The present study was carried out with 64 cervical and peripheral blood samples from women who attended early cancer detection programs at the Gynecology and Obstetrics Hospital No. 4 of the IMSS and the gynecology service of the Oncology Hospital of CMN SXXI of the IMSS, Mexico City, Mexico, and the Western National Medical Center (CMNO-IMSS) in Guadalajara, Jalisco, Mexico. According to the cytological and histopathological analysis, 15 samples came from ND women , 18 LSIL+) was used    , the LSI< 0.001) .μl of each PFP were incubated in the presence of 5 mM ADP or AMP  and in the presence or absence of POM-1 or APCP, specific inhibitors of CD39 and CD73, respectively. Aliquots of each reaction were taken at the beginning and after 72 h of incubation to evaluate Ado production through UPLC. Using different concentrations (0.1-10 μM) of synthetic Ado as reference standards , respectively  (r = 0.2502 (p < 0.001)   and r = < 0.001) , respectIn the last 10 years, cancer research has especially focused on the role played by Ado-, CD39-, and CD73-producing ectoenzymes in immunomodulation and evasion of the antitumor immune response. In fact, inhibition of the adenosinergic pathway in the tumor microenvironment has been proposed as an indispensable alternative in oncological therapy , 37. HowOur working group recently reported higher expression levels of CD39 and CD73 in cells obtained from cervical samples of patients with CINI positive for HPV-16 than in cells from HPV-16-negative samples and ND samples, which correlated with the presence of higher levels of CD39 and soluble CD73 in cervical mucus with the capacity to produce Ado through hydrolysis of ATP and AMP . However53NAS, 311NSS, 333NYS, and 403NGT, and changes in glycosylation in one or more of these sites can alter the hydrolytic activity of CD73 because the three of them  are found in the C-terminal catalytic domain of the molecule [β increases the levels of CD39 and CD73 in activated T cells and myeloid suppressor cells [β1 in CC has been directly correlated with the degree of disease progression [β1 promoter by recognizing the Sp1 sequence [β, which is important for inducing and maintaining CD73 expression. We also demonstrated that Ado generated by the enzymatic activity of CD73 induced the production of TGF-β in tumor cells by interacting with A2AR and A2BR, suggesting an important connection between the adenosinergic pathway and the production of TGF-β in cells infected with HPV [β in the PFP of patients with LSILs, HSILs, or CC than in that of NDs. In fact, a positive correlation was observed between the TGF-β concentration of these patients and the CD39 and CD73 concentrations detected in PFP. In addition, we observed that patients with HSILs or CC, who presented the highest plasma concentrations of TGF-β, CD39, and CD73, showed the highest numbers of sexual partners  and pregnancies  in contrast to numbers of 2.2 and 1.1, respectively, in the ND group. A strong correlation was also observed between the number of sexual partners and CD39, as well as between the number of pregnancies and the expression of CD39 and CD73, in patients with LSILs, HSILs, or CC (The increase in soluble CD73 found in PFP samples from patients with HSILs or CC in our study is consistent with reports of increased hydrolytic activity of AMP in the plasma of patients with advanced cancer , 42. Intmolecule . On the molecule , 45. We molecule , 42. TGFor cells . The expgression  and withsequence . We prevwith HPV . In thiss, or CC , which iβ associated with persistent infection by HR-HPV may be an important factor inducing and maintaining the expression of the CD39 and CD73 ectonucleotidases during the development of CC. Considering the important role of the adenosinergic pathway in the suppression of the antitumor immune response through Ado generation [Therefore, the results obtained in this study suggest that the production of TGF-neration  and thatneration , the conβ in the PFP of patients with LSILs, HSILs, or CC was significantly higher than that of NDs and showed positive correlations with the levels of CD39 and CD73. These results suggest that the production of TGF-β associated with persistent infection by HR-HPV, which is present in more than 99% of CC cases [This study provides the first evidence that the concentrations of the PFP-soluble CD39 and CD73 ectonucleotidases in patients in different stages of CC development positively correlated with disease progression and the capacity to generate Ado from the hydrolysis of ADP and AMP. The greater AMPase activity found in the PFP of patients with HSILs or CC was associated with a high concentration of a highly glycosylated 90 kD CD73 isoform. The level of TGF-CC cases , 50, is