Importantly, HPV infection is known to cause cancer (Human papillomavirus (HPV) is a common infection, affecting up to 75% of sexually active people.e cancer . The incidence rate for oropharyngeal cancers has been steadily increasing since the mid-1990s, particularly in men. It has been increasing at a rate of 4.5 times faster in males than in females.We often think of HPV mainly as a major cause of cervical cancer. In fact, oropharyngeal cancers outnumber cases of cervical cancer due to HPV.preventable with vaccination, but already low vaccination rates have been made worse by the pandemic. For example, Ontario school-based HPV vaccination rates have dropped to as low as 5.2% and 0.8% for the 2019-2020 and 2020-2021 school years.These cancers are Human Papillomavirus Vaccine: Canadian Immunization Guide indicates the vaccine should be used for anyone over the age of 9, immunocompromised or with multiple sexual partners that increase virus exposure. The National Advisory Committee on Immunization and the Canadian Immunization Guide have a table indicating the “Recommended Immunization Schedule and HPV Vaccine, by Group.” If there is any doubt about who to include for vaccination, this reference can help answer questions.Identify patients who would benefit from HPV vaccination. The Government of Canada’s You can set up case-finding strategies to proactively identify patients meeting these criteria. Set up an HPV campaign in your pharmacy. This could also include establishing collaborative relationships with dental professionals—they are already screening for oral cancers and will be writing prescriptions for HPV vaccination. Expect prescriptions for vaccines and questions for further education from dental offices.Incorporate a vaccination history into your regular activities, such as every medication history, new patient assessment and all medication reviews that you do.Inform patients of the benefits of HPV vaccination. Ask “Are you aware of your risk of certain cancers from HPV infection?” Mention other preventive measures: vaccines, smoking cessation, reducing alcohol consumption, physical barriers such as condoms and limiting the number of sexual partners.https://www.gardasil9.ca).Have handouts on HPV for distribution to your patients . ■While the COVID-19 pandemic has highlighted pharmacists as immunization superheroes, it has also caused a major reduction in other kinds of vaccination. By proactively case-finding for HPV vaccine candidates, incorporating vaccination histories into your assessments/medication reviews and partnering with dental professionals, pharmacists can also become cancer prevention superheroes. Please see the accompanying infographic on HPV and the pharmacists' role, packaged with this journal (also available at


The aim of this review was to describe the association and related mechanisms between HPV, EBV, and the development of oral and oropharyngeal cancer. A search for scientific evidence was carried out in electronic databases . It was found that, among the carcinogenic mechanisms of HPV, E6 and E7 proteins are responsible for the malignization process, inhibiting tumor suppressors p53 and pRb. As to EBV, it was noted that its “hit and run” phenomenon manipulates the host epigenetic mechanism, triggering the tumor process without the virus being currently present; a “cellular reprogramming” is essentially generated, causing heritable changes in gene expression without DNA mutation. In conclusion, there is an association between oropharyngeal carcinogenesis and HPV and also between the former and EBV. Further studies are required to clarify the causal mechanisms and impact of both viruses on cancer development and to obtain biomarkers of greater specificity in the case of EBV. Cancer is one of the leading causes of death, and it has become the first or second cause of death before reaching the age of 70 in several countries. According to the World Health Organization (WHO), cancer has led to a sharp decline in mortality rates from heart disease and stroke .Head and neck cancer (HNC) is a worldwide public health problem that includes different types of cancer. HNC constitutes approximately 7% of all existing malignancies, being the fourth leading cause of cancer death in men .Oral cancer (OC) accounts for 2% of all cancers affecting the body, and it is considered the 15th leading cause of cancer mortality in the world –5.Oral cancer is very common in South Central Asia, India, and Melanesia, with Papua New Guinea having the highest incidence rate in both sexes worldwide, which might be associated with betel nut chewing in these countries. Incidence is also high in Eastern Europe, Western Europe, Australia, and New Zealand .Tobacco and alcohol consumption are among the risk factors for SCC and they account for 75% of all cases, while the remaining 25% include infection by Human Papillomavirus (HPV) . It has In recent studies, it has been reported that approximately 20% of all carcinogenic processes that afflict humans are caused by viruses with oncogenic potential, called oncoviruses. This is due to the chronic inflammation caused by a viral infection, which leads to cell death, cell cycles with uncontrolled proliferation, and modulation of the expression of specific regulatory proteins of the host cell. These oncoviruses manage to decode genes that interfere with the genetic machinery of the infected cells, causing viral replication and the synthesis of viral proteins. The role of viral infection in the tumor process is extensive because it requires the interaction of various factors, such as the compromise of the immune system, certain specific mutations, and exposure to cancerous agents . In receThe aim of this review was to describe how HPV and EBV are associated with the development of oral and oropharyngeal cancer based on the best available evidence.Two genetically distinct types of head and neck squamous cell cancer (HNSCC) have been determined, the first one is related to alcohol, tobacco, and oral trauma, and the other is associated with HPV infection . The latHPV infection has been established as an etiologic factor for oral and oropharyngeal cancers , 13. TheHPV types affecting the mucosa can be divided into high-risk and low-risk groups, with about 15 high-risk HPV types. About 90% of HNSCC are caused by HPV 16 and 18, having a 2.8 times higher probability of causing this type of cancer when compared to other less risky types , 15. HPVBoth mortality and incidence of HPV-related HNSCC have increased significantly in recent decades. Concerning the incidence rate, it rose from 16.3% to 71.7% between 1984 and 2004 in the United States, specifically in the case of the oropharyngeal type, which can be related to the increasing incidence of tumor-related HPV –17. AccoSome of the factors that could explain the causal association between HPV and oral cancer are the affinity of HPV for epithelial cells, its oncogenic role, and some morphological similarities between the genital and oropharyngeal epithelium .In addition, oral and oropharyngeal HPV(+) cancers share some characteristics, such as their diagnosis in young people aged under 39 years, high-risk sexual behaviors, and a better prognosis in comparison with their HPV(−) counterparts .HPV infection is the most common sexually transmitted infection, and approximately 75% of sexually active adults acquire at least one genital HPV infection in their lifetime . It is uSpecific sexual practices such as oral sex and oral-anal contact and having multiple sexual partners may favor the occurrence and pathogenesis of HPV in the oral cavity , 21. FurAdditionally, there are sites in the oropharynx associated with HPV as they are exposed to the virus, including the base of the tongue, tonsils, soft palate, uvula, and Waldeyer's ring . The incHaving multiple sexual partners is also a risk factor for Human Immunodeficiency Virus (HIV) infection. The direct role of HIV in HPV-associated neoplasms is not fully resolved yet. However, HIV infection depresses the immune system against HPV since lower CD4+ lymphocyte levels increase the prevalence of oral, anal, and cervical HPV infection and the incidence of high-grade intraepithelial neoplasia .The overall incidence of HNC in the US has decreased in recent years due to lower tobacco use. However, the incidence of HPV-related oropharyngeal cancer appears to be increasing, which is also the case in European countries .Several studies have shown an association between alcohol and tobacco consumption and oral HPV(+) infection in certain types of HNC , 13, 14.Several studies have reported that there is a higher prevalence of oral HPV infection and its high-risk types in men as compared to women, in both HPV-related subsites and all anatomical sites studied. This prevalence has increased from 3 to 5 times, being this information consistent with the higher incidence of HNC in the male gender compared to the female. The tendency to affect the male sex could be explained by biological differences or behaviors associated with sexual practices , 13. A 2HPV infection initiates in the basal stratum of the epithelium, where capsid proteins (L1) come into contact with cell surface receptors. For the HPV to access, it needs a disruption or trauma in the tissue; otherwise, if the epithelium remains undamaged, the virus will be unable to reach its site of action . The oraOnce the virus encounters a target cell, the viral DNA reaches the nucleus, where it can remain in an episomal state or enter a state of active transcription . HPV doeOne of the mechanisms by which HPV causes cancer is the oncoproteins E6 and E7 of the virus, which inhibit tumor suppressor proteins p53 and retinoblastoma proteins (pRb). In particular, the E6 gene induces the degradation of the p53 protein by interacting with its associated protein (E6AP). On the other hand, E7 binds to pRb and disrupts its binding to genes that encode a group of transcription factors E2F). Therefore, if E7 inactivates pRb, the latter will not be able to perform its function and prevent the excessive cell growth that takes place in tumors, consequently increasing the susceptibility of the individual to develop cancer. Cell cycle dysregulation caused by HPV infection can lead to the accumulation of DNA damage, thus promoting carcinogenesis F. Theref.In the mechanism mentioned above, the infected daughter cell abandons the basement membrane where it would leave the cell cycle and cease its DNA replication, but the E6 and E7 proteins play their role, thus preventing the cell from entering a state of genetic nonreplication. Both proteins combine their activities to create a phase of the cell cycle, called pseudo-S, in which the synthesis of genetic material occurs . By inacIn parallel, E7 binds to pRb through the specific sequence LXCXE, which allows its degradation. E2F is again not properly regulated, favoring the transcription to the synthesis stage of the cell cycle. E7 binds to other pocket proteins that are related to pRb, p107, and p130 as well. This results in increased cellular DNA replication and increased cell division, causing the number of HPV-infected cells to rise .In addition to the mechanism of E6 and E7 oncoproteins, there is a variety of molecular mechanisms for HPV-induced carcinogenesis in the head and neck, including immune evasion, facilitation of genomic instability, virus DNA integration, and changes in global DNA methylation and gene expression .Further studies are, nevertheless, needed to reveal the underlying molecular mechanisms of HPV in oropharyngeal cancer and in turn to develop new preventive and optimal treatment strategies for patients with HPV-related HNSCC .To date, there is no method that is considered the gold standard for HPV detection in the oropharynx. Among the known methods, microbiopsy and brush cytology stand out. The former is a minimally invasive technique that consists of making a cytological smear on the lesion, using a brush or a swab. To be analyzed by a pathologist, the sample collection is placed in a sterile polypropylene cup. Microbiopsy, on the other hand, consists of an excisional process of the lesion, in which the sample obtained is analyzed by a pathologist, along with a second smaller sample subjected to a molecular virological analysis. In the latter, the detection of the virus's DNA is carried out by means of a Polymerase Chain Reaction (PCR), which allows DNA extraction, identification of different HPV genotypes, and data analysis .According to a prospective study, published in 2020, that analyzed these two HPV detection methods and was carried out in sixty-five patients with oral leukoplakia, microbiopsy is more reliable and accurate for detecting HPV and its genotypes than brush cytology. This is in part because it allows access to the most basal layer of the epithelium, where HPV DNA is often located episomally. Despite its advantage, this method is not used as a screening tool since it follows an invasive procedure .Another more recent method was evaluated in a study carried out in 2021. It was based on HPV sequencing (HPV-seq) through the identification of a tumor DNA marker of malignant lesions associated with this virus (ctDNA). The results demonstrated that HPV-seq outperformed digital PCR (dPCR) in detecting ctDNA and by providing quantitative and qualitative information. Therefore, HPV-seq represents a promising and sensitive method for ctDNA detection and analysis in HPV-associated malignancies . As to oHPV(+) oropharyngeal SCC has a better prognosis compared with nonvirus-related SCC , 16, 27.HPV(+) HNSCC has a better long-term prognosis, a lower mutational burden and cell differentiation, and a higher 5-year survival rate. Its overexpression of the p16 biomarker, with functional inactivation of p5, rarely generates metastases and is highly radio- and chemosensitive, as compared to its HPV(−) counterpart see  28, 29], 2928, 2Furthermore, overexpression of the p16 biomarker is used to detect poorly differentiated and locally more advanced  HPV(+) oropharyngeal carcinomas. Therefore, in HPV(+) malignant lesions, an increased expression of this protein could be used as a favorable prognostic marker. On the other hand, loss of p16 expression by deletion, hypermethylation, or mutation is common in alcohol and tobacco-induced OSCC, producing lesions with a worse prognosis as they do not respond in the same way to chemo and radiotherapy .As mentioned above, the HPV E6 oncoprotein can inactivate p53 although in these cases it would be a functional inactivation, not a mutation as it occurs in OSCC associated with tobacco and alcohol intake. In fact, the rate of p53 mutations due to HPV is very low. All this supports the existing evidence that HPV-associated oral and oropharyngeal SCC has longer survival and better prognosis, as compared to its HPV(−) counterpart .Clinicians recommend that individuals are vaccinated against HPV, regardless of gender, for the prevention of cancers, such as oropharyngeal cancer . Two vacWorldwide, the estimated number of people infected with EBV exceeds 5.5 billion . EBV is EBV has been frequently identified in carcinomas located in the oropharyngeal region, whose main risk factors are tobacco and alcohol. However, tumors located at the nasopharyngeal site have been associated with environmental cofactors such as nutritional components, oral hygiene, and host factors. The latter include genetic predisposition, family history, and male gender . An apprEBV belongs to the oncogenic human herpesvirus family, and it is composed of linear double-stranded DNA enveloped in a capsid . The rouThe oral cavity is the primary site of infection and reservoir of the virus, mainly in the tonsils and Waldeyer's ring. Replication occurs in the upper differentiated layers of epithelial cells, and when the virus is transferred to the saliva, it becomes a form of transmission, with even asymptomatic patients being carriers of the virus. Additionally, the virus can be transmitted through transplants and transfusions , 27.Although the virus was originally isolated in Burkitt's lymphoma, recent findings have clarified its oncogenic role, due to its association with various neoplastic processes. Among these are Hodgkin's lymphoma, non-Hodgkin's lymphoma, natural killer T-cell lymphoma, nasopharyngeal carcinoma (NPC), gastric carcinoma, and SCC , 27, 31.In all malignant lesions, the virus is in a latent phase, a state that evades the host immune system while allowing sustained expression of viral oncogenes . In addiThe EBV genome can exist as episomes or extrachromosomal copies of the genetic material. These express latent genes during different stages of B-cell differentiation in vivo. In the case of EBV, it expresses the latency III program or one of the two alternative forms of virus latency (known as latency I and latency II), expressing different products depending on its latency state .In recent years, a phenomenon has been observed in which EBV generates an epigenetic “cellular reprogramming” in lymphoid and epithelial cells. In these cells, heritable changes in gene expression occur, not involving a mutation in the DNA sequence itself. This malfunction of epigenetic machinery can have a direct impact on the expression of tumor suppressor genes and oncogenes, which could lead to tumor generation. Some of these epigenetic alterations associated with tumor generation include DNA methylation, histone modification, and chromatin conformation alterations. In fact, the impact of EBV on epigenetic regulation is evident and it takes part in the development of different cancers; for example, EBNA1, which is the protein that maintains the EBV episome, is detectable in every type of EBV-associated neoplastic process. It can bind to some promoter regions of oncogenes and tumor suppressor genes, regulating their expression in B lymphocytes and epithelial cells .It has been shown that malignancies involving EBV have altered states of DNA methylation in tissues that are EBV(−). Specific viral factors manage to manipulate the epigenetic mechanism of the host, triggering the progression of the tumor process; it does not necessarily require the current presence of the virus for this to occur . This meConcerning the cell cycles of EBV(+) cells, in the first cycle, about 8% of the viral genome is lost, and after eight cycles, 50% of its DNA has been lost. After fifty cycles, only 1% of the viral genetic information remains in the cell lines, being undetectable by conventional methods, such as the use of the EBER biomarker . This waSeveral primary studies and systematic reviews have established EBV as a risk factor for OSCC. Also, it is described that the location of EBV is common in the tonsils and base of the tongue, sites considered EBV reservoirs . HoweverOver the years, studies have recognized an association between EBV infection and HNC. Despite this, the evidence on the incidence of EBV-derived cancers is contradictory . For insThese disparate results may be explained by the role of the virus in tumor development and progression mainly. The emergence of new markers has clarified this contradiction in the studies, recognizing the role of EBV in the development of the neoplastic process even though its genome is no longer present .Among the markers for detecting the presence of the virus are the genes of viral proteins involved in cell proliferation, immune response, and apoptosis. These genes regulate these processes and produce cellular immortalization, which is important for the appearance of neoplasia . NoncodiLately, new methods in molecular biology that are much more sensitive and specific have been developed and are being studied. In neoplastic cells of Burkitt's lymphoma EBER(−), the presence of microRNA coding for the virus has been demonstrated. However, studies are still needed to implement these tools, which would clarify the role of the virus in the neoplastic process, the loss of viral genomes in some tumors studied, and the difficulty of analyzing the spontaneous occurrence of cancers. Finally, the use of coding microRNA markers could be the missing piece in the “hit-and-run” theory of tumor progression .It is estimated that globally between 15% and 20% of carcinomas affecting the oropharynx are coinfected with EBV and HPV. However, in the case of SCC in the tonsils and base of the tongue, coinfection rates have been seen to vary from 25% to 70% .One study showed that EBV/HPV coinfection increases the replication of both viruses when cultured together in vitro. During coinfection, HPV may alter the viral cycle of EBV, favoring its latency. On the other hand, EBV delays epithelial differentiation and promotes an invasive phenotype, further enhancing the invasiveness of epithelial cells expressing the E6 and E7 oncogenes of HPV-16 .p value 0.03). This suggests that both viruses interact in the progression of these cancers [In a study published in 2020, EBV and high-risk HPV coinfection was analyzed in HNSCC tissues from Bosnian patients. A 34.7% coinfection rate was observed in the samples, being strongly associated with advanced-stage HNSCC ( cancers .Although evidence is still lacking to define how EBV might contribute to the pathogenesis of HPV(+) oropharyngeal cancers, this could be explained by the influence of HPV and EBV on each other's viral cycles .There is an association between oropharyngeal carcinogenesis, HPV, and EBV, independently and also when both of the viruses are present. The main carcinogenic mechanism of HPV is through E6 and E7 proteins, which inhibit tumor suppressors p53 and pRb. As to EBV, the tumor process is triggered without the virus necessarily being present; this phenomenon was called “hit and run.”Further studies are required to clarify the causal mechanisms and contribution of both viruses to cancer development. Regarding HPV, future research should focus on analyzing the effectiveness of new preventive strategies, including HPV immunization for oral and oropharyngeal cancer. In the case of EBV, the introduction of new detection techniques and biomarkers of greater specificity is needed.


Data on depression and anxiety were collected from the results of the questionnaire in the CEPS for the adolescent mental health test. Compliance with the 24-HMG was defined as: physical activity time (PA) ≥ 60 min/day was defined as meeting the PA. Screen time (ST) ≤ 120 min/day was defined as meeting the ST. Adolescents aged 13 years achieved 9–11 h of sleep per night and adolescents aged 14–17 years achieved 8–10 h of sleep per night, defined as meeting sleep. Logistic regression models were used to examine the association between meeting and not meeting the recommendations and the risk of depression and anxiety in adolescents. (3) Results: Of the sample studied, 0.71% of adolescents met all three recommendations, 13.54% met two recommendations and 57.05% met one recommendation. Meeting sleep, meeting PA+ sleep, meeting ST + sleep, and meeting PA + ST + sleep were associated with a significantly lower risk of anxiety and depression in adolescents. Logistic regression results showed that differences in the effects of gender on the odds ratio (ORs) for depression and anxiety in adolescents were not significant. (4) Conclusions: This study determined the risk of developing depression and anxiety in adolescents who met the recommendations for 24-HMG alone and in combination. Overall, meeting more of the recommendations in the 24-HMGs was associated with lower anxiety and depression risk outcomes in adolescents. For boys, reducing the risk of depression and anxiety can be prioritised by meeting PA + ST + sleep, meeting ST + sleep and meeting sleep in the 24-HMGs. For girls, reducing the risk of depression and anxiety may be preferred by meeting PA + ST + sleep or meeting PA+ sleep and meeting sleep in 24-HMGs. However, only a small proportion of adolescents met all recommendations, highlighting the need to promote and support adherence to these behaviours. Previous studies have extensively investigated the relationship between adequate physical activity, limited screen time and adequate sleep time, as well as the physical and mental health of adolescents ,2,3,4,5.n = 481) who achieved PA ≥ 60 min/day had 30% lower odds of depression and 46% lower odds of anxiety compared to adolescents with PA < 60 min/day (insufficient time or insufficient days) [n = 942) [Depression and anxiety are common mental health problems among adolescents, and depression is often accompanied by anxiety. From 2001 to 2020, the global prevalence of depression among adolescents increased by 34%, with the highest prevalence of depression in the Middle East, Africa and Asia . In a sunt days) . A meta-nt days) . A studynt days) . Ojio etn = 942) . Thus, an = 942) . HoweverWith the release of the 24-HMG, more researchers have begun to examine adolescent mental health from the perspective of integrating physical activity time, screen time and sleep time, rather than examining multiple determinants in isolation. For example, a systematic evaluation by Sampasa-Kanyinga et al. (2020) of 115,540 adolescents aged 5–17 years in 12 countries, including the USA and the UK, found that meeting the three recommendations in the 24-HMG held a good association with better mental health indicators  . The stuhttp://ceps.ruc.edu.cn/, accessed on 19 January 2023.This study analysed primary data from the China Education Tracking Survey (CEPS), a national cohort study designed to document the attributes of developmental and educational experiences of Chinese adolescents. The CEPS study adopted a multi-stage stratified design with county , school and class as primary, secondary and tertiary sampling units, respectively. Primary sampling units were stratified by region and size of the migrant population, with counties in Shanghai or other regions with high migrant populations being oversampled. Within each sampled county, four schools were sampled using the probability proportion method. the CEPS team developed survey weights to address the probability of inequality of choice . This stThis study used the Canadian 24-HMG as a reference standard. The contents of the Canadian 24-HMG are shown in The CEPS investigated the frequency of physical activity per week and the duration of a single session of physical activity in adolescents, and we referenced the Canadian 24-HMG, where PA ≥ 60 min/day was defined as meeting physical activity guidelines (meeting PA).The CEPS investigated the daily screen time of adolescents from Monday to the weekend. The amount of time adolescents spent watching television, surfing the internet and playing computer games each day was aggregated to obtain the amount of screen time adolescents spent each day. Referring to the Canadian 24-HMG, screen time ≤ 120 min/day was defined as meeting sedentary guidelines (meeting ST).The CEPS surveyed adolescents’ self-reported daily sleep duration. Referring to the Canadian 24-HMG, satisfying sleep was defined as sleeping at least 9–11 h per night for 13 year olds and 8–10 h per night for 14–17 year olds.75 as the critical score. A total anxiety score exceeding the sample P75 score was defined as having anxiety symptoms. A total depression score exceeding the sampleP75 score was defined as having depressive symptoms [The CEPS measures anxiety and depression in adolescents with a total of nine items. The scale was designed with reference to the generalized anxiety scale (GAD-7) ,32 and tsymptoms .Study participants were asked to self-report demographic data, including sex, age, ethnicity, single child, residence, father’s highest education, mother’s highest education, body mass index (BMI) and perceived household economic status. BMI was calculated by dividing weight (kg) by the square of height (m) . In thisp < 0.05.All data analyses were carried out using Stata 17.0 software. Descriptive statistics were used to characterise the sample. Frequency percentages were used to describe the categorical variables. Continuous variables were tested with the Shapiro–Wilk test, satisfying the normality distribution, and the variables were described by the mean ± SD. Gender differences between variables were performed using chi-square tests or t-tests. Logistic regression analysis was used to test the relationship between physical activity time (PA ≥ 60 min/day), screen time (ST ≤ 120 min/day) and sleep time  in meeting the 24-HMG and the occurrence of anxiety and depression. Adolescents were divided into eight groups based on their meeting of the 24-HMG recommendations: meeting none, only meeting PA, only meeting ST, only meeting sleep, meeting PA + ST, meeting PA + sleep, meeting ST + sleep, meeting PA + ST + sleep. All logistic regression models were adjusted for covariates and analysed extraordinarily to see if this association was affected by gender. Statistical significance was defined as The final study sample size for this study was 9420 Chinese adolescents in grade K8. The mean age was 14.53 ± 0.69 years. The overall sample consisted of 54.81% boys and 44.86% single children . ParticiThe prevalence of depression and anxiety in different groups of adolescents is shown in Among boys, the three groups with the lowest prevalence of depression were, in order, the meeting PA + ST + sleep group (9.43%), the meeting ST + sleep group (21.15%) and the meeting PA + sleep group (22.68%). Among the girls, the three groups with the lowest prevalence of depression, in order, were the meeting PA + ST group (11.11%), the meeting PA + sleep group (212.50%) and the meeting ST + sleep group (19.56%).Among boys, the three groups with the lowest prevalence of anxiety were, in order, the meeting PA + ST + sleep group (7.55%), the meeting ST + sleep group (22.44%) and the meeting PA + sleep group (23.71%). Among the girls, the three groups with the lowest prevalence of anxiety were, in order, the meeting PA + sleep group (9.8%), the meeting ST + sleep group (21.22%) and the meeting PA + ST + sleep group (21.43%).p < 0.01) and 0.68 (p < 0.01), respectively, compared to the not-meeting group. This indicated that the effect of only meeting sleep on depression was more significant than the effect on anxiety. Logistic regression results showed that differences in the effects of gender on the ORs for depression and anxiety in adolescents were not significant. In the boys sample, the ORs for depression and anxiety in the only meeting sleep group were 0.60 (p < 0.01) and 0.64 (p < 0.01), respectively. In the girls sample, the ORs for depression and anxiety in the only meeting sleep group were 0.70 (p < 0.01) and 0.73 (p < 0.01), respectively.p < 0.01). This indicates that the effect of meeting PA and sleep guidelines on depression was more significant than the effect on anxiety. Compared to the meeting none group, the ORs for depression and anxiety in the meeting ST + sleep group were 0.46 and 0.57, respectively (p < 0.01). Logistic regression results showed that differences in the effects of gender on the ORs for depression and anxiety in adolescents were not significant.p < 0.01). This indicates that meeting PA + sleep had a more significant effect on depression than on anxiety. The ORs for depression and anxiety in the meeting ST + sleep group were 0.42 and 0.54, respectively, compared to the meeting none group (p < 0.01). For boys, this indicates that the effect of meeting ST and sleep guidelines on depression was more significant than the effect on anxiety. The effect of meeting ST and sleep guidelines on depression and anxiety was more significant than the effect of meeting PA and sleep guidelines on depression and anxiety.In the boys sample, the ORs for depression and anxiety in the meeting PA + sleep group were 0.55 and 0.64, respectively, compared to the meeting none group (p < 0.01). This indicates that the effect of meeting PA and sleep guidelines on anxiety was more significant than that on depression. Compared to the meeting none group, the ORs for depression and anxiety in the meeting ST + sleep group were 0.42 and 0.59, respectively (p < 0.01). For girls, This indicates that the effect of meeting ST and sleep guidelines on depression was more significant than the effect on anxiety. The effect of meeting PA and sleep guidelines on depression was more significant than the effect of meeting ST and sleep guidelines on depression. The effect of meeting ST and sleep guidelines on anxiety was more significant than the effect of meeting PA and sleep guidelines on anxiety. The effect of meeting PA + and sleep guidelines on depression was more significant than the effect of meeting PA + and sleep guidelines on anxiety. The effect of meeting ST and sleep guidelines on anxiety was more significant than the effect of meeting PA and sleep guidelines on anxiety.In the girls sample, the ORs for depression and anxiety in the meeting PA + sleep group were 0.29 and 0.24, respectively, compared to the meeting none group (p < 0.01). This indicates that meeting PA, ST and sleep guidelines had a more significant effect on anxiety than on depression. In the boys sample, the ORs for depression and anxiety in the meeting PA + ST + sleep group were 0.20 and 0.08, respectively, compared to the meeting none group (p < 0.01). This indicates that meeting PA, ST and sleep guidelines had a more significant effect on anxiety than on depression. In the girls sample, the ORs for depression and anxiety in the meeting PA + ST + sleep group were 0.52 and 0.60, respectively, compared to the meeting none group (p < 0.01). This indicates that the effects of meeting PA, ST and sleep guidelines were more significant for anxiety than for depression. Logistic regression results showed that the differences in the effects of gender on the ORs for depression and anxiety in adolescents were not significant.This study used a K8 grade sample based on the CEPS (2014–2015) to determine the relationship between meeting the 24-HMG and students’ self-rated anxiety and depression. In this study, only 0.71% of the adolescents in the study sample met the three recommendations of the 24-HMG. This indicated a low adherence to the guideline among Chinese adolescents in grade K8 compared to previous studies. A previous study by Liu et al. (2022) of 14–17 year old adolescents in grades K9-K12 in the USA found that the proportion of adolescents meeting all three of the 24-HMG was 3% . The stun = 123,975, 10–17 years) had symptoms of anxiety and 3.1% had symptoms of depression [n = 10, 123, 13–18 years) was 31.9% [n = 57,927) [n = 144,060) reported a 24.3%  prevalence of depression in adolescents [In a study by de Castro et al. (2023) on depression and anxiety among adolescents in 26 low- and middle-income countries, 5.5% of adolescents  . The diflescents .Previous studies had systematically evaluated the independent effects of physical activity, screen time and sleep on adolescent mental health outcomes ,20,21,22This study found that meeting sleep recommendations significantly reduced the risk of depression and anxiety in adolescents. The relationship between insufficient sleep duration and anxiety and depression has been confirmed in many studies ,50. InsoThis study found that the greater the number of 24-HMG recommendations met, the lower the risk of depression and anxiety in adolescents. Meeting PA + sleep or meeting ST + sleep of the 24-HMG recommendations reduced the risk of anxiety and depression in adolescents compared to not meeting any of the recommendations. This is consistent with previous findings from Zhu et al. (2019) . The resMeeting the 24-HMG recommendation categories differed in their effect on reducing the risk of depression or anxiety in adolescents. For example, meeting one 24-HMG recommendation for sleep duration alone significantly reduced the risk of depression and anxiety in adolescents. In two 24-HMG recommendations, meeting only physical activity time and sleep time together, and meeting both screen time and sleep time together significantly reduced the risk of adolescents developing anxiety. This further analysis, in which specific behavioural combinations are most beneficial to adolescents’ mental health, enables the implementation of more effective interventions. This suggests that the promotion and guidance of these specific behavioural combinations should be taken into account when implementing integrated or holistic interventions with adolescents, and that priority should be given to guiding which behavioural recommendations to meet if 24-HMG cannot be met in its entirety.To our knowledge, this is the first time that the effects of meeting specific behavioural combination categories of the 24-HMG recommendations on adolescent mental health have been observed in a sample of Chinese adolescents, and is a further development and extension of the findings of Lu et al.’s (2021) study of children . Our stuThis study determined the risk of developing depression and anxiety in adolescents who met the recommendations for 24-HMG alone and in combination. Overall, meeting more of the recommendations in the 24-HMG was associated with lower anxiety and depression risk outcomes in adolescents. For boys, reducing the risk of depression and anxiety can be prioritised by meeting PA + ST + sleep, meeting ST+ sleep and meeting sleep in the 24-HMG. For girls, reducing the risk of depression and anxiety may be preferred by meeting PA + ST + sleep, meeting PA + sleep and meeting sleep in 24-HMG.However, only a small proportion of adolescents met all recommendations, highlighting the need to promote and support adherence to these behaviours.


TM II H28 Detection assay . The H28 assay is a multiplex semi-quantitative real-time PCR test using the tagging of oligonucleotide cleavage and extension (TOCE) technology. The VL was semi-quantified as high , intermediate , or low . Out of 5940 HPV VL analyses, 356 assays (5.99%) were reported as low VL (1+) of HPV DNA. Matched cytology diagnoses were mostly negative findings , except for seven cases of atypical squamous cells of undetermined significance (1.9%) and two cases of atypical glandular cells (0.6%). During the follow-up periods, abnormal cytologic diagnoses were identified, including one case of high-grade squamous intraepithelial lesion (HSIL) and two low-grade squamous intraepithelial lesions (LSILs). The matched, confirmative histologic diagnosis of HSIL cytology was compatible with chronic inflammation, wherein the two LSILs had regular check-ups. None revealed clinically concerned outcomes associated with HPV-related squamous lesions. The cytology was most likely negative for malignancy when the VL of HPV DNA was low (1+). Additional strategic monitoring and management may thus be unnecessary.Infection with high-risk (HR) Human Papillomavirus (HPV) is associated with the development of precancerous lesions or invasive carcinoma of the uterine cervix. Thus, the high viral load (VL) of HR-HPV DNA currently serves as a representative quantitative marker for cervical cancer. However, the clinical significance of low HPV DNA VL remains undetermined. This study aimed to evaluate the clinical association between the low HPV DNA VL and cytology/histologic diagnosis of cervical samples. We searched the electronic medical databases for the resultant analyses of HPV genotyping among patients who underwent treatment for any cervical lesion or who had undergone gynecological examinations with any positive HPV results according to the national cancer screening service between 2015 and 2016. HPV testing with genotyping and semi-quantitative VL measurement was conducted using an Anyplex Worldwide, cervical cancer is the fourth most common cancer and the fourth leading cause of cancer death in women, with an estimated 604,000 new cases and 342,000 deaths in 2020 . Cervicawww.hpvcenter.se; accessed on 20 May 2022), and this number continues to expand [More than 200 different HPV types have been listed by the International HPV Reference Center  is due to HR-HPV . IntegraAs an effective screening test for cervical cancer, cervical cytology has so far played a key role in reducing the incidence of cervical cancer in countries with organized screening ,12,13,14To date, the viral load (VL) of HPV has been proposed as a potent discriminator of significance from insignificant HPV infections ,19. SeveThe VL of HPV can be measured by various methods, including semi-quantitative  or quantitative polymerase chain reaction (PCR) ,27. MostTM II HPV28 Detection assay  is a multiplex qRT-PCR test using the tagging of oligonucleotide cleavage and extension (TOCE) technology for simultaneous detection and genotyping of 19 high-risk (HR) HPV types , and 9 low-risk (LR) HPV types  in a single reaction . The H28 assay also estimates the VL through a repeated melting temperature analysis during the TOCE reaction and reports a semi-quantitative system as low , intermediate , or high  [In recent practice, a qRT-PCR method is commonly used to estimate the amount of HPV DNA. The Anyplex cycles) . Meanwhile, unlike the high VL of HPV, there has been little research on the clinicopathologic significance of low (+) VL of HPV based on H28 assay in cervical lesions. It is not surprising that the clinical association between low HPV VL and cytology/histologic diagnosis of cervical samples remains undetermined, mainly because of the over-sensitivity and inconsistent reproducibility of the test. Such a little-known characteristic may impede gynecologic physicians’ and patients’ best shared decision making for therapeutic plans and consequently bring about unexpected problems, such as excessive levels of patient-perceived anxiety or unnecessary waste of time and money. Therefore, a clear association between low HPV VL and cytology/histologic diagnosis of cervical samples using H28 assay needs to be investigated thoroughly.In this study, we aimed to evaluate the clinicopathologic significance of an HPV infection with a low (1+) viral DNA load on cervical/vaginal cytology samples obtained from patients with a clinical follow-up due to previous cervical lesions, such as SIL or invasive cervical carcinoma, and from patients who have shown a positive result for HPV in an earlier HPV examination.We searched the electronic medical database of the Department of Pathology of Kyungpook National University Chilgok Hospital in the Republic of Korea for HPV genotyping analyses among patients with any previous cervical lesions or who had undergone gynecological examinations according to the National Cancer Screening Services, between January 2015 and December 2016 at Kyungpook National University Chilgok Hospital.A total of 5940 HPV analysis results were obtained. Each of the matched clinical characteristics included age and HPV status at the initial cytology/histopathologic diagnosis plus the follow-up information for the subsequent cytology/histopathologic diagnosis and HPV status. A flowchart shows the sample selection and analysis process in this study .Briefly, liquid-based cytology (LBC) samples were collected using broom-like devices with detachable heads  according to the manufacturer’s instructions. The cervical broom was placed into the cervical canal and was rotated 360 degrees around the entire cervical canal. The detachable head was placed in a vial with preservative fluid. The LBC sample collection and transient storage temperature followed the manufacturer’s instructions.Subsequently, the HPV test with Anyplex HPV28 assay using LBC specimens was performed according to the manufacturers’ instructions. DNA from each LBC sample was extracted using STARMag 96 X4 Universal Cartridge Kit . HPV genotyping was conducted using a multiplex polymerase chain reaction (PCR) using a CFX96 PCR Thermal Cycler , according to manufacturers’ guidelines, using 5 μL of template DNA in a total volume of 20 μL for Anyplex™ II HPV28.TM II H28 Detection kit .At the initial examination and at least once during a follow-up visit, HPV testing with genotyping and semi-quantitative VL measurement were conducted according to the manufacturer’s instructions using the AnyplexTM II H28 assay. Descriptive statistical analysis using SPSS Statistics software for Windows, version 21.0  was only conducted for the demographic data, including age and follow-up.We performed a double-blind test for the cytology/histopathology diagnosis and the HPV status using the AnyplexAt a baseline examination for the cytology and HPV typing, the mean age was 48.1  years old. The mean follow-up period was 58.3 ± 12.2 months.Out of 5940 HPV analyses, 356 assays (5.99%) were reported as a low (1+) VL of HPV. Of 356 cases with low (1+) VL of HPV, 150 patients had a previous confirmative diagnosis of HPV-related epithelial lesion. The results are summarized in From the HPV test at the starting time (baseline) of this study, 233 (65.4%) out of the 356 cases were HR-HPV genotypes . HoweverDuring the follow-up periods, 263 (73.9%) of 356 patients with a low VL of HPV DNA underwent at least one repeated HPV test. Almost all (97.3%) showed a negative HPV result at the initial repeated test, while the remaining patients (n = 7) were finally negative for HPV at the subsequent tests . FurtherHR-HPV genomic integrations into the host genome are associated with a persistent infection . Either The recurrence risk of SIL or invasive carcinoma remains higher among women who undergo treatment for primary HPV-related epithelial lesions. For that reason, such patients need to be put under close surveillance and follow-up examination . Given tTM II HPV28 assay is a multiplex semi-quantitative real-time PCR assay using TOCE technology. The viral load is semi-quantified as high , intermediate , or low  [The Anyplex cycles) . TOCE te cycles) . The sen cycles) . The ass cycles) .TM II HPV28 and AnyplexTM II HPV HR assays had superior performances with higher sensitivity than HC2 (p < 0.0001) and were concordant with other commercial assays for HR-HPV detection despite presented semi-quantitative results [TM II HR assay, sharing the same TOCE technology as the AnyplexTM II HPV28 assay, compared to that of Cobas 4800 HPV and HC2. They assessed the precision of the assay by comparing the positive control results from 15 replicates using clinical specimens with low , intermediate (Cq < 32.2), and high (Cq < 26.7) concentrations of HPV DNA in triplicate per run a day on five different days [TM II HR assay and the Cobas 4800 [TM II tests, including the H28 assay, would be helpful in follow-up testing and patient management by providing genotyping information beyond HPV 16 and HPV 18 positivity [The H28 assay has been validated in recent HPV-related studies. Cornall et al. showed that both Anyplex results . Furtherent days . The prebas 4800 . Therefositivity .However, few studies have been conducted on the significance of low VL of HPV. Its value has been virtually ignored due to the difficulty in accurate quantification of low VL and (in some cases) the possibility of contamination by sexual partners or another viral status, which may lead to a false-positive reaction of viral DNA for a short term . Such a We initiated this study to contribute to medical science by addressing the clinical relevance between the low VL of HPV and the risk of cervical lesions. In this study, none of the patients who reported as low (1+) VL of HPV revealed clinically concerned outcomes associated with HPV-related epithelial lesions during follow-up. Therefore, in accordance with what the study found, we carefully propose that clinicians and patients would have a better shared decision making with simply the monitoring and management of HPV VL, instead of unnecessary additional tests or procedures, when the low (1+) VL of HPV status is detected in an H28 assay.In particular, there are two further significant implications obtained from this study. Although cervical cancer can develop as long as HPV infection persists, a quantitative contribution to cervical carcinogenesis remains unclear regarding the duration and viral load of HPV infection. Fortunately, our results could provide a practical reference for the clinical treatment of patients. Those with a low VL of HPV should be managed more conservatively and safely or in a step-by-step manner considering familial and social environmental factors, such as pregnancy, rather than immediate management.The other is that, even though the LR-HPVs are not subject to screening and follow-up for cervical cancer, it is impossible to know whether the viral subtype is from an LR- or HR-HPV group before performing the HPV subtyping test. Moreover, one should be aware of the possibility of cross-reaction or multiple HPV infections. This study demonstrated the clinical significance of the low VL of HPV in practical management. In other words, the cases with a lower VL of LR-HPV, as expected, did not have any precancerous or cancerous lesions during the follow-up; furthermore, in cases of HR-HPV groups, they did show identical findings. Therefore, we proposed that the low VL, regardless of LR- and HR-HPV subtyping, can emphasize the significance of conservative strategies for screening or follow-up of cervical cancer.It is also obvious that quality control of the laboratory performance is very important for either the primary screening test or a strategic assessment of the post-treatment testing utility for HPV infection. The laboratory performance should adhere to a well-established protocol of intra-laboratory quality assurance and be kept under close review, thereby ensuring a reliable data processing system within the institution. Once an individual laboratory is accredited for HPV molecular testing, intra-institutional strategic guidelines may also be proposed, which ultimately contribute to a standardized decision on “what to do” for the best follow-up care.This study had several inherent limitations regarding small sample size, sample type, and analytic methods. In detail, first, by selecting patients with HPV infection from one tertiary medical institute in the Republic of Korea, we might have biased our cohorts towards patients with HPV DNA persistence, thus undermining generalization. Second, we only assessed the HPV DNA load using a semi-quantitative measurement by a repeated melting temperature analysis of the HPV28 assay, which may damage validity to some extent. Further studies should propose a clinical cut-off for the viral load for the reliability of HPV testing. Third, the method of HPV28 detection may present inflated positive results due to its excessive sensitivity for the primary HPV screening test. By extension, there remain the possibilities of transient HPV infection or contamination, requiring further efforts to refine the sensitivity of the measurement and increase reliability in future studies. These limitations support a need to verify the study finding through large data obtained from rigorous replication of research in multi-institute settings and the general population. However, we believe that our results outweigh the limitations in that it is the first study to provide at least a minimum of medical evidence on the possibility of strategic utilization of low VL of HPV for monitoring cervical lesions.This study showed that none of the patients with a low VL of HPV DNA revealed clinically concerned outcomes associated with HPV-related squamous lesions, regardless of HR- or LR-HPV genotypes. Therefore, we could provide a practical guideline for the patient with a low VL of HPV DNA. When referring to the strategic monitoring and management of patients who undergo treatment for previous HPV-related epithelial lesions and patients who had an HR-HPV detection earlier, those with a low VL of HPV using the AnyplexTM II H28 assay should be managed in a conservative and safe or step-by-step manner considering familial and social environmental factors, such as pregnancy, rather than immediate management. In these particular situations, the accuracy and confidence of laboratory HPV testing need to be consistently guaranteed.


Few studies have investigated the vaginal microbiota (VM) in women living with HIV (WLWH) in the context of high-risk human papillomavirus (HR-HPV) infection, even though WLWH are at an increased risk of HPV-related malignancies, including cervical cancer. To explore the impact of HIV and HPV infection on the VM in WLWH, we determined the prevalence of HR-HPV infection and cervical cytologic abnormalities in a cohort of 44 WLWH and 39 seronegative-women (SNW), characterized the vaginal microbiota by 16S sequencing, assessed genital inflammation and systemic immune activation by multiplex bead assay and flow cytometry, respectively. Finally, we explored relationships between bacterial richness and diversity, the top 20 bacterial genera, genital inflammation and systemic immune activation.Lactobacillus iners was the dominant Lactobacillus species in WLWH and SNW alike.We found that HR-HPV prevalence was similar between WLWH and SNW. High-grade squamous intraepithelial lesions (HSIL) were only detected in WLWH negative for HR-HPV infection. In regression analyses, no risk factors were identified. Women co-infected with HIV and HR-HPV had the highest level of systemic immune activation, and these levels were significantly different compared with SNW without HR-HPV infection. We found no evidence of differences in vaginal microbial richness and diversity, microbial community structure, and genital inflammation by HIV, HPV, or HIV and HPV status.The online version contains supplementary material available at 10.1186/s12866-023-02769-1. Lactobacillus dominance are the hallmark of an optimal vaginal microbiota  cells/mm3). All women tested negative for hepatitis B and C viruses.Data on HIV clinical parameters are summarized in Additional file As summarized in Table p = 0.0127, Fig. p = 0.0012), while the frequency of CD4 + T cell activation was lower (p < 0.0001) compared with SNW. No differences in systemic immune activation were observed when stratifying by HPV infection. WLWH with HR-HPV infection had the highest levels of CD8 + T cell activation and these levels were significantly different compared with SNW negative for HPV infection  and systematically (plasma) by quantifying soluble markers . We found no differences in genital inflammation when stratifying by HIV status or HPV status , HPV status  or both . Pairwise comparisons revealed that microbial communities of WLWH with HPV infection (WLWH HPVP) were marginally different from those of WLWH without HPV infection , with no other differences being observed . The relative abundance of the 20 most abundant genera is shown in Fig. Lactobacillus (60.83%), Gardnerella (14.49%), Prevotella (6.92%), Atopobium (2.58%), Sneathia (1.97%), Bifidobacterium (1.76%), Shuttleworthia (1.64%), Mycoplasma (1.05%), representing 97.62% of all genera. Interestingly, both women with HPV16 (1 SNW and 1 WLHW) had polymicrobial communities, dominated by Gardnerella and Atopobium (for WLHW), and Gardnerella, Atopobium, Prevotella and Sneathia (for SNW), and depleted in Lactobacillus  and richness (number of observed species). No difference in alpha diversity Fig.  was obseBifidobacterium  and Alloscardovia . When considering HPVN and HPVP irrespective of their HIV status, Veillonella was identified in HPVN , Megasphaera , and Shuttleworthia , while Veillonella  was identified in WLWH without HPV infection   per sample. The gating strategy is shown in Additional file 10-transformed .Concentrations of 19 cytokines , IL-13, IL-15, IL-17 and TNF-α), 7 chemokines  and 4 growth factors  were determined in cytobrushes´s supernatants and plasma samples using the Human cytokine Magnetic 30-Plex Panel , read on Luminex™ 100™/200™ detection system and analyzed on xPONENT™ software . All standards and samples were run in duplicates. Plasma and cytobrush supernatant samples were diluted 1:2. All procedures were performed by the same operator according to the manufacturers´ instructions. Lyophilized standards were reconstituted as instructed and diluted at serial concentrations for the generation standard curves. A 5-parameter logistic regression formula was used to calculate sample concentrations from the standard curve (pg/mL). To be included in subsequent analysis, the following criteria was used for each analyte: quantified within the detection limits (above the lower and below the higher detection limit) in more than 60% of samples, values that were extrapolated beyond the standard curve were assigned the determined value. Concentrations of growth factors, chemokines and cytokines were logp values were adjusted for multiple comparisons using Dunn´s multiple comparison test. Statistical analyses were performed using STATA/SE 14  and GraphPad Prism v8 . Correlation coefficient (rho) and p values were obtained using the Spearman’s correlation test. Logistic regression analyses were conducted to identify risk factors association with HPV infection . For all analyses, p values < 0.05 were considered statistically significant.Demographic and behavioral data were reported using descriptive statistics. Wilcoxon Rank Sum test was used to compare continuous variables and chi square test or Fisher's exact test for categorical variables. Kruskal–Wallis test was used to compare more than 2 groups, Additional file 1. Data on reproductive health and sexual practices.Additional file 2. HIV clinical parameters in WLWH (n=44).Additional file 3. Risk factors associated with HPV infection.Additional file 4. Log10 concentration of cytokines, chemokines and growth factors in cytobrush supernatant stratified by HIV or HPV status.Additional file 5. Log10 Concentration (pg/mL) of plasma cytokines, chemokines and growth factors stratified by HIV or HPV status.Additional file 6. Log10 plasma IL-6 concentration (pg/mL) stratified by HIV and HPV status.Additional file 7. Frequencies of HLADR+ CD38+ CD4+ and CD8+ T cells stratified by HIV or HPV status.Additional file 8. Frequencies of HLADR+ CD38+ CD4+ and CD8+ T cells stratified by HIV and HPV status.Additional file 9. Alpha diversity is neither different by HIV status nor HPV status.Additional file 10. Beta diversity is neither different by HIV status nor HPV status.Additional file 11. Taxonomic profile of the vaginal microbiota at genus level in seronegative women and women living with HIV with or without HPV infection.Additional file 12. The vaginal microbiota of women living with HIV and seronegative women with or without HR-HPV infection at species level (top 20 species).Additional file 13. Inverse correlations were found between Lactobacillus and Gardnerella, Prevotella, Dialister, and Atopobium.Additional file 14. Representative gating strategy.


P < 0.001], age at initial sexual activity ≤ 19 years , sexual partners > 1 , ASCUS and above , non-condom contraception , and HSIL and above . Compared with women aged 56–65 and 35–45 years  the HPV infection rate was significantly lower in those aged 46–55 years . Furthermore, ≤ high school age , not breastfeeding , ASCUS and above  were potential risk factors for cervical cancer and precancerous lesions. In women with HPV infection, ≤ high school education level, initial sexual activity at ≤ 19 years of age, number of sexual partners > 1, ASCUS and above, non-condom contraception, HSIL and above were risk factors for HPV infection. Compared with women aged 56–65 years, those aged 35–45 and 46–55 years had significantly lower HPV infection rates, and high school age and below, non-breastfeeding, and ASCUS and above were all potential risk factors for cervical cancer and precancerous lesions.Cervical cancer is the most common gynecological malignancy and screening for risk factors with early detection has been shown to reduce the mortality. In this study, we aimed to analyze the characteristics and risk factors of human papillomavirus (HPV) infection and precancerous lesions in women and provide clinical evidence for developing strategies to prevent cervical precancerous lesions and cancer in women. Furthermore, we evaluated the influencing factors for high-risk HPV infection. From April 2018 to December 2021, 10,628 women were recruited for cervical cancer screening at Liaoning Cancer Hospital, Shenyang Sujiatun District Women’s and Infants Hospital, Benxi Manchu Autonomous County People’s Hospital, and Shandong Affiliated Hospital of Qingdao University. The study participants were tested to determine if they were HPV-positive (HPV +) or underwent thinprep cytology test (TCT) for atypical squamous cells of undetermined significance (ASCUS) and above. Furthermore, colposcopies and biopsies were performed for the histopathological examination. Finally, 9991 cases were included in the statistical analysis, and the factors influencing HPV infection and those related to cervical cancer and precancerous lesions were analyzed. HPV + infection, high-grade squamous intraepithelial lesion-positive (CINII +) in cervical high-grade intraepithelial neoplasia, and early cervical cancer diagnosis rates were 12.45, 1.09, and 95.41%, respectively. The potential risk factors for HPV were education ≤ high school [odds ratio (OR) = 1.279 (1.129–1.449),  Cervical cancer is the most common gynecological malignancy and in 2020, with 604,000 new cases worldwide, with approximately 342,000 related deaths . CervicaIn contrast, developed countries have high coverage and availability of cancer screening and compliance by the target population . The incThe incidence rate of cervical cancer at a younger age is showing an increasing trend . FurtherThe German scholar Hausen first identified HPV infection as the main pathogenic factor of cervical cancer and precancerous lesions, which could be considered a milestone discovery in the prevention and treatment of this disease . A consiP < 0.05)  .The study of HPV prevalence and its subtype distribution may provide relevant information for routine vaccination and the types of HPV strains used in vaccination. HPV infection rates among women worldwide range from 11.70 to 7.20% . The higIn China, significant differences were also reported in HPV infection rates in different regions, ranging from 13 to 31.9% . HPV alsThis study was approved by the Ethics Committee of Liaoning Cancer Hospital and informed consent was obtain from all individual participants included in the study (No.: 20180106).From April 2018 to December 2021, we recruited 10,628 women for cervical cancer screening in Liaoning Province at Liaoning Cancer Hospital, Shenyang Sujiatun District Women’s and Infant Hospital, Benxi Manchu Autonomous County People’s Hospital, and Shandong Affiliated Hospital of Qingdao University. The average and median ages of the selected research participants were 49.61 ± 7.195 years, and 49 years, respectively.All women in the study underwent HPV testing and the thinprep cytology test (TCT). Community population and hospital outpatient opportunistic screenings were used to evaluate whether participants met the following inclusion criteria: (1) lived in Liaoning for > 3 years; (2) a history of sexual activity; (3) no sexual activity, vaginal medication, or drug flushing within 1 week before examination; (4) no serious organ dysfunction or mental illness; (5) voluntary participation and signed consent; and 5) willingness to complete the questionnaire survey. The exclusion criteria were: (1) women who were pregnant, lactating, or menstruating; (2) history of cervical surgery or hysterectomy; and (3) diagnosed with a tumor and being treated for other serious internal and external diseases. This study was approved by the ethics committee of Liaoning Cancer Hospital.TCT . The examination application forms of each patient was filled and their name and age and collection date was placed on the specimen bottle . The completely filled application form was checked to ensure the information was consistent with that on the preservation solution vial. The cervical brush was then placed in the preservation solution and rinsed by plunging it up and down 20 times, while spreading and rotating the bristles back and forth to make the cells fall into the solution.Finally, the cervical brush was rapidly rotated to release the collected cells into the preservation solution, the sampler was discarded ensuring the brush head was not left in the bottle, and then it was sent to the pathology department for liquid-based analysis. The operating procedures of the system for the TCT, which is a liquid-based cytology production process, includes the following three steps, which were strictly adhered to: cell mixing, collection, and transfer. Briefly, the sample was placed into 95% alcohol for wet fixation, the production was completed, and then the next staining and diagnosis step was performed. The negative slides should be stored for 1 year, whereas the positive slides should be stored for a long time. Finally, the diagnosis was made by a full-time cytological diagnosis doctor in the pathology department.The detection kit was purchased from Beijing Haolejie Healthcare Medical Equipment Company (Beijing). The E6/E7 mRNA detection kit was used to detect the following 14 high-risk HPV mRNAs known to cause cervical cancer , and displayed the detection results of 16 and 18 to provide more clinical guidance information. The kit detects E6 and E7 mRNA of high-risk HPV to avoid missing the detection of high-level lesions and cancer, which could result from only detecting the L1 region. Furthermore, no cross reaction occurred with low-risk HPV and there were fewer false positives, which reduced unnecessary colposcopies and over diagnosis.The questionnaire used in this study adopts the principle of voluntariness and was designed professionally by the members of our research group. The questionnaire includes questions on the participants’ personal information; relevant medical, reproductive, sexual activity, smoking, contraceptive, and sports history; educational level; and economic income.Cervical exfoliative cells were examined using cervical liquid-based thinprep cytology test (TCT). The diagnostic criteria are based on the Bethesda system (TBS) classification: atypical squamous cells of undetermined significance (ASCUS) without clear diagnostic significance, excluding ACS-cannot exclude high-grade squamous intraepithelial lesion (ASC-H), low-grade squamous intraepithelial lesion (LSIL), high-grade squamous epithelial lesion (HSIL), squamous cell carcinoma (SCC), and atypical glandular epithelial cells (AGCs) .For HPV+, TBS classified ASCUS or above, or both, or clinically suspicious abnormalities, a colposcopy is further recommended. The examination results suggested the need for a multipoint tissue biopsy of cervical lesions and bite the tissue for pathological examination. The pathological results were the gold standard, and the diagnostic criteria included normal or inflammatory reaction and cervical intraepithelial neoplasia-intraepithelial neoplasia (CIN) and cervical cancer. CIN is divided into CIN I, CIN II, and CIN III  accordinThe quality control evaluation of the cervical exfoliative cell examination was conducted using 20 and 5–10% of the randomly selected positive and negative smears, respectively. All smears were reviewed by experts in the field and the acceptable quality rate of the smear results was 80%. The quality control of the colposcopy examination involved a spot check of 10 and 20% of the normal and abnormal reports, respectively. The results were rechecked by experts in the field and the standard quality rate of the reported results was expected to reach 90%. The quality control of the histopathological examination was performed by spot checking 10% of the pathological sections and the results were recheck by experts. The coincidence rate of diagnostic results was expected to reach 90%.2) test. The influencing factors were analyzed using univariate and multivariate logistic regression to evaluate the correlation between the relevant factors mentioned in the questionnaire and HPV infection, cervical cancer, and precancerous lesions.The statistical analysis of the relevant data was conducted using the statistical package for the social science (SPSS) version 19.0 software and the count data rate (%) was analyzed using the chi-square  and 65 (5.4%) were HPV 16 + and 18/45 + with detection rates of 1.84 and 0.65%, respectively. Furthermore, 980 (80.8%) patients were positive for other high-risk types of HPV, with a detection rate of 9.81%. Among the tested patients, 16 women had mixed HPV infections of the above three groups. The positive rate of HPV16 and HPV18/45 in the total screened population was 2.5%  .In this study, 9,991 participants were recruited for high-risk HPV screening in 2018–2021, which included 1,244 (12.45%) that were positive for high-risk HPV. The average age of the women was 49.99 (35–65) years and they were all divided into the following five age groups: 35–40, 41–45, 46–50, 51–55, and 56–65 years old. The prevalence of high-risk HPV infection had two peaks at 35–40, 55–60/61–65 years with infection rates of 13.09, 14.29, and 15.80%, respectively .Further colposcopy was performed in 1,571 cases. There were 1,015 cases with complete colposcopy report, and the referral rate was 64.61%. There were 812 abnormal cases suspected to be diagnosed by colposcopy, 673 cases of low-grade lesions, and 66 cases of high-grade lesions, with a detection rate of 0.66% .P < 0.05)  .P < 0.001], initial sexual activity age ≤ 19 years old , number of sexual partners > 1 , ASCUS and above , non-condom contraception , and HSIL and above  were risk factors for HPV infection. Compared with women aged 56–65 years, the HPV infection rate of those 35–45  and 46–55 [OR = 0.79 (0.683–0.915)] years old (P = 0.002) decreased significantly  = 1.279 (1.129–1.449), ficantly .Among the 9,991 patients included in the analysis, 1,004 had complete pathological results, including follow-up update, whereas 109 and 895 cases were CINII + and LSIL/inflammation, respectively. Furthermore, 136 and 1 patients were referred for a colposcopy because of TCT/HPV and clinically suspected abnormalities, respectively. The result of the colposcopy evaluation was negative and, therefore, no biopsy was performed. In addition, 137 patients were classified as LSIL and inflammation, and in the absence of pathological results, 8,210 women with double negative screening results (TCT-/HPV-) were regarded as having no cervical lesions. Therefore, 109 CINII + , 5 invasive carcinoma and 9, 242 LSIL/inflammation cases, respectively were included in the statistical analysis.P < 0.05). The detection rate of CINII + increased significantly with increasing age, early sexual activity, multiple sexual partners, total family income ≤ 50,000 yuan, bleeding during sexual intercourse and extramarital sex, but there was no significant difference , and the early diagnosis rate of cervical cancer was 95.41%(104/109). The results of the 28 logistic regression analyses using CINII + and diet as dependent variables showed a significant correlation between educational level, breastfeeding, and TCT positivity , P = 0.017], ASCUS and above  were potential risk factors for cervical cancer and precancerous lesions ,  lesions .In this multicenter, cross-sectional population study in women, we found that the overall prevalence of HR-HPV was 12.45%, which is lower than the national average. HPV infection can occur at any age and is related to age. In this study, the age-specific distribution showed a bimodal curve, and the first peak appeared in the 35–40-year-old age group, with the infection rate of middle-aged women showing a low trend. The second peak of high-risk HPV infection was observed in women aged 55–60 and 61–65 years, who were born in the 1960s–1970s and the economy of China has improved considerably since then. In addition, the education level of these age groups is significantly lower than that of the younger women, which contributes to their lack of knowledge about HPV infection. In addition, the low level of autoimmunity and hormones further impairs the resistance of the cervix to HPV infection, which may explain the significant increase in their HPV + rate.Presently, there is no specific or effective drug treatment for HPV infection, and although a vaccine has been developed and listed in China, it is expensive and does not prevent all subtype infections . TherefoIn this study, multicenter cervical screening was used to analyze the incidence of HPV infection, cervical cancer, and high-grade precancerous lesions in women. The results led us to conclude that high school and below, initial sexual life age ≤ 19 years old, number of sexual partners > 1, ASCUS and above, non-condom contraception, HSIL and above were all risk factors of HPV infection. The reason may be that women with a low educational level lack the awareness of cervical screening and prevention strategies . Women ≤Numerous studies have shown that an active sex life is closely related to the occurrence and development of cervical cancer. Literature reports from countries other than China state that factors such as sexual partners and frequency are closely related to cervical cancer . CondomsCervical lesions mostly occur in married women and it is the most serious cervical disease, and shows higher occurrence in younger women . CervicaP < 0.05) risk factors of cervical cancer and CIN II/III.HPV has been reported to be transmitted through direct or indirect skin or sexual contact . The infThe CINII + detection rate increased with increasing age, early sexual activity, multiple sexual partners, total family income ≤ 50,000 yuan, bleeding during sexual intercourse, and extramarital sex, but not significantly. This study has been compared with other similar related research data in the near future see . As a prCervical cancer is a prominent public health problem and proms focusing on its prevention and control should be strengthened. In this study, multicenter cervical screening of women to determine the HPV infection rate and incidence of cervical high-grade precancerous lesions, demonstrated a high school education and below, initial age of sexual activity ≤ 19 years old, more than one sexual partner, ASCUS and above, non-condom contraception, and HSIL and above as risk factors of HPV infection. Furthermore, a high school education and below, non-lactation, and a positive TCT result were identified as risk factors of cervical cancer and high-grade precancerous lesion infection. In conclusion, the investigation of risk factors for HPV infection and cervical high-grade precancerous lesions are of great significance for reducing the incidence rate of cervical cancer. Consequently, we recommend the establishment of strategies to enhance the awareness of the risk factors of high-risk HPV infection; to promote healthy sexual behavior, life, and health habits; and to improve immunity and strengthen physical exercise, which could effectively reduce the incidence rate of cervical cancer.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the Ethics Committee of Liaoning Cancer Hospital (No. 20180106). The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.HP and CW designed and supervised the project. DY, JZ, and XC collected clinical data samples. DY collected and processed data and data analysis, and drafted the manuscript. JM translated and polished the manuscript. All authors reviewed, discussed, and edited versions of the final report manuscript.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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Heart failure (HF) is a global epidemic that contributes to the deterioration of quality of life and its shortening in 1–3% of adult people in the world. Pharmacotherapy of HF should rely on highly effective drugs that improve prognosis and prolong life. Currently, the ESC guidelines from 2021 indicate that ACEI, ARNI, BB, and SGLT2 inhibitors are the first-line drugs in HF. It is also worth remembering that the use of coenzyme Q10 brought many benefits in patients with HF. Coenzyme Q10 is a very important compound that performs many functions in the human body. The most important function of coenzyme Q10 is participation in the production of energy in the mitochondria, which determines the proper functioning of all cells, tissues, and organs. The highest concentration of coenzyme Q10 is found in the tissue of the heart muscle. As the body ages, the concentration of coenzyme Q10 in the tissue of the heart muscle decreases, which makes it more susceptible to damage by free radicals. It has been shown that in patients with HF, the aggravation of disease symptoms is inversely related to the concentration of coenzyme Q10. Importantly, the concentration of coenzyme Q10 in patients with HF was an important predictor of the risk of death. Long-term coenzyme Q10 supplementation at a dose of 300 mg/day (Q-SYMBIO study) has been shown to significantly improve heart function and prognosis in patients with HF. This article summarizes the latest and most important data on CoQ10 in pathogenesis. Heart failure (HF) is a very common disease in the world and has been defined as a global pandemic . GloballHF is a disease associated with a high risk of death . The stuThus, HF significantly worsens the prognosis and shortens the survival of patients. Therefore, the diagnosis and treatment of HF are extremely important and should be maintained in accordance with the latest guidelines of the European Society of Cardiology (ESC) of 2021 ,11.Coenzyme Q10, also known as ubiquinone, is an organic chemical compound belonging to the group of quinones. Coenzyme Q10 was isolated by Festenstein et al. (1955) and Crane et al. (1957) ,13. Coene−), therefore its highest concentration occurs in organs characterized by intense energy transformations (concentration: heart (114 μg/g) > kidneys (66.5 μg/g) > liver (55 μg/g) > muscles > brain), because the most important role of this compound is to facilitate the production of adenosine triphosphate (ATP) in mitochondria , The main function of coenzyme Q10 has one important consequence for energy metabolism, since better, more efficient electron transport in the inner membrane at the mitochondria leads to more abundant production of ATP. This is a highly relevant factor, for instance, for the cardiac muscle and the correct functioning of the heart . CoenzymFrom the point of view of cardiovascular health, it is worth mentioning that coenzyme Q10 is a natural antioxidant, which is characterized by stronger antioxidant properties in relation to low density lipoproteins (LDL) than β-carotene or α-tocopherol ,17. MoreThe sources of coenzyme Q10 are, first of all, endogenous production in the mitochondrial inner membrane and supply with food (this route is only important in deficiency states). In the endogenous synthesis of coenzyme Q10, the precursor to the quinone ring is 4-hysroxybenzoate, while the isoprenoid tail is derived from the mevalonate (cholesterol biosynthesis) pathway ,17. FoodTo sum up, coenzyme Q10 is a chemical compound necessary for the effective production of ATP, which determines the proper functioning of the whole organism.p < 0.001) ..26].The relationship between the concentration of coenzyme Q10 and the severity of HF symptoms has also been demonstrated in other clinical studies ,28. The Thus, the results of the studies indicate that in patients with HF there is a reduced plasma and heart tissue concentration of the beneficial coenzyme Q10, which correlates with disease progression and the risk of death in this group of patients.Due to the biochemical properties of coenzyme Q10, it may play an important role in the prevention and treatment of HF, and in the treatment of some very common cardiovascular risk factors, such as arterial hypertension, insulin resistance, dyslipidemia, and atherosclerosis  10,15]..15].p = 0.007), especially among patients with ischemic heart disease , diabetes , arterial hypertension , and impaired functional capacity  [p < 0.0001) [2.- scavenging [p < 0.00001), is also important [In a prospective randomized double-blind placebo-controlled trial (Ki-Sel-10) involving 443 elderly healthy subjects, Alehagen et al. studied the effect of coenzyme Q10 supplementation at a dose of 200 mg/day + 200 μg/day selenium or placebo per 4 years for cardiovascular risk. Supplementation with coenzyme Q10 and selenium for 4 years in elderly healthy subjects significantly reduced cardiovascular mortality (28.1%) vs. placebo 38.7%) after 12 years of follow-up  . In the  = 0.02) . It is a = 0.02) . Moreove = 0.02) . Coenzym 0.0001) . Moreove 0.0001) . Moreove 0.0001)  and in t 0.0001) . The ant.7% aftermportant . A very mportant . In turnmportant . The antmportant .Due to all these cardioprotective mechanisms of action of coenzyme Q10 and its key role in the physiology of the heart muscle, clinical trials have been conducted for many years to assess the effectiveness of coenzyme Q10 supplementation in the treatment of HF. The first randomized trial of coenzyme Q10 in patients with HF was reported as early as 1972 by Hashiba et al. and suggested promising results . The stuThe effect of coenzyme Q10 supplementation (ubiquinone dissolved in vegetable oil) on the prognosis of patients with NS was assessed in the prospective randomized double-blind study Q-SYMBIO , biomarker (BI) status (brain natriuretic peptide—BNP), and long-term outcome (O) ) conducted by Mortensen et al. The study involved 420 patients (NYHA class III/IV) in 17 countries, randomized to coenzyme Q10 3 × 100 mg/day or placebo 3 × 100 mg/day. The subjects were followed for 2 years. The study endpoints were unplanned hospitalization for HF, death from cardiovascular causes, implantation of a heart support device, and the need for heart transplantation. Coenzyme Q10 or a placebo was added to the standard treatment of heart failure in cardiology . After years of follow-up, it was shown that the addition of coenzyme Q10 to standard HF therapy decreased, which was associated with a significant reduction in the risk of individual endpoints . There wp = 0.110) [Long-term coenzyme Q10 treatment in patients with chronic HF was safe, relieved symptoms, and reduced serious adverse cardiovascular events. The number of adverse events tended to be lower in the coenzyme Q10 group compared with the placebo group  . In the = 0.110) .p = 0.02) and improves exercise capacity  compared with placebo. However, no significant difference was observed in the improvement of the left ventricular ejection fraction  or improvement in the NYHA scale  [p < 0.001) and left ventricular end-diastolic dimensions. Moreover, the risk of death in the group of patients treated with coenzyme Q10 decreased by 38% , while the risk of hospitalization was reduced by 61%  [The results of the above randomized clinical trials show that coenzyme Q10 significantly improves the prognosis of patients with HF. The results of these studies are partially confirmed by the meta-analysis of 14 RCTs conducted by Lei and Liu which included 2149 patients. Coenzyme Q10 was used at an average dose of 100–200 mg/day for 3–12 months. This meta-analysis showed that administration of coenzyme Q10 reduces mortality by 31%  . Jafari < 0.001) . A Cochr< 0.001) .When analyzing the literature on the effectiveness of coenzyme Q10 supplementation in patients with HF, it should be mentioned that the results of the studies and their meta-analyses may be partially different. It is believed that supplementation with coenzyme Q10 should ensure a plasma concentration of this substance exceeding 3 µg/mL, which can be obtained in most cases by using 3 × 100 mg of this form of coenzyme Q10 . InteresFrom a clinical point of view, the question of the effect of statin use on the concentration of coenzyme Q10 is important. These drugs are the gold standard in the treatment of hypercholesterolemia and, among lipid-lowering drugs, they have the best documented efficacy in the primary and secondary prevention of CVD. Statins are inhibitors of 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase by which they reduce endogenous cholesterol synthesis  . The mevThe AHA/ACC/HFSA 2022 guidelines on HF mention coenzyme Q10 in the treatment chapter, but do not define its exact place in the management of HF . A similTo sum up, the knowledge about coenzyme Q10 and about the latest research with the use of this substance in people with chronic HF should be promoted. Due to the lack of unambiguous recommendations regarding the use of coenzyme Q10 in patients with HF ,86, its One should also not forget about other potential diseases in which the use of coenzyme Q10 can be of great benefit .


The incidence of squamous cell carcinomas of the oropharynx has rapidly increased in the last two decades due to human papilloma virus infection (HPV). HPV-positive and HPV-negative squamous cell tumours differ in radiological imaging, treatment, and prognosis; therefore, differential diagnosis is mandatory. Radiomics with texture analysis is an innovative technique that has been used increasingly in recent years to characterise the tissue heterogeneity of certain structures such as neoplasms or organs by measuring the spatial distribution of pixel values on radiological imaging. This review delineates the application of texture analysis in oropharyngeal tumours and explores how radiomics may potentially improve clinical decision-making.Human papilloma virus infection (HPV) is associated with the development of lingual and palatine tonsil carcinomas. Diagnosing, differentiating HPV-positive from HPV-negative cancers, and assessing the presence of lymph node metastases or recurrences by the visual interpretation of images is not easy. Texture analysis can provide structural information not perceptible to human eyes. A systematic literature search was performed on 16 February 2022 for studies with a focus on texture analysis in oropharyngeal cancers. We conducted the research on PubMed, Scopus, and Web of Science platforms. Studies were screened for inclusion according to the preferred reporting items for systematic reviews. Twenty-six studies were included in our review. Nineteen articles related specifically to the oropharynx and seven articles analysed the head and neck area with sections dedicated to the oropharynx. Six, thirteen, and seven articles used MRI, CT, and PET, respectively, as the imaging techniques by which texture analysis was performed. Regarding oropharyngeal tumours, this review delineates the applications of texture analysis in (1) the diagnosis, prognosis, and assessment of disease recurrence or persistence after therapy, (2) early differentiation of HPV-positive versus HPV-negative cancers, (3) the detection of cancers not visualised by imaging alone, and (4) the assessment of lymph node metastases from unknown primary carcinomas. Head and neck cancers represent around 3% of all malignancies and squamous cell carcinoma is the most frequent histotype (85%) ,2.The incidence of squamous cell carcinomas of the oropharynx (OPSCC) has been rapidly increasing in the last two decades due to human papilloma virus (HPV) infection that is associated with the development of carcinomas that primarily involve lingual and palatine tonsils .HPV-positive (HPV+) squamous cell tumours mainly affect males with a mean age of 40–60 years, and independent of risk factors such as tobacco exposure or alcohol consumption. Some HPV genotypes are considered oncogenic including genotypes 16 and 18. These are the most frequent ones  FDG PET examination .Texture analysis may lead to early differentiation between HPV+ and HPV− OPSCC and the detection of tonsillar lesions that may not be easily visualised by imaging techniques alone. Radiomics could also be an aid in the assessment of nodal metastases, tumour recurrences, persistence after combined radio-chemotherapy and prognosis. Based on our results, texture analysis is a useful additional tool for the detection of OPSCC in combination with currently used imaging techniques, such as CT, MRI and PET/CT. We believe that it will be increasingly used in the near future as an important support in diagnostic work-up and follow-up, potentially improving clinical decision-making.