Although penetrative sex is the most common route of HPV infection, there is strong evidence of non-sexual modes of transmission. As the first of its kind, this study aimed to investigate the knowledge and awareness of Jordanian physicians on such routes.A questionnaire was conducted among a national Jordanian sample of physicians from Jordanian health sectors. The survey included questions assessing participants’ knowledge on HPV, non-sexual routes of infection and HPV vaccines. Physicians’ attitudes towards HPV screening and vaccination were covered. Statistical analysis was carried out using SAS 9.4, ANOVA, post-hoc Tukey-Honest test and Kruskal-Wallis test. All significant differences were set at α = 0.05.A total of 412 participants completed the survey. Physicians showed a huge deficit in knowledge on nonsexual routes of HPV transmission. They agreed that the most and least common routes of non-sexual transmission are skin to mucosa (64%) and contaminated water (15%), respectively. Females showed significantly better knowledge in all aspects of HPV transmission and vaccination (p<0.0001) and more positive attitudes towards HPV screening and vaccination compared to males (p = 0.03). Age group ≤ 25 and academic physicians demonstrated higher knowledge on HPV vaccines compared to their counterparts in non-academic places (p = 0.002). Specialty and experience seemed to have no impact on knowledge or attitudes of participants. Higher knowledge physicians had more positive attitude towards vaccination and screening compared to lower knowledge fellows (p<0.001).The noteworthy findings of this study is the extremely low level of knowledge on non-sexual routes of HPV infection among Jordanian physicians. Increasing the level of awareness of physicians and healthcare workers on these routes and their association with cervical and other cancers through university curricula and other reliable sources is strongly recommended. Papillomaviridae family. There are over 200 genotypes of HPV. Fourty of these belong to the α genus, 15 of which are considered high-risk (HR)-HPV types as they can lead to carcinogenesis [Human papillomavirus (HPV) is a non-enveloped epitheliotropic double stranded DNA virus from the HPV is estimated to cause 570,000 cases of cancer in women and 60,000 cases of cancer in men worldwide every year. Globally, HPV is the cause of 99% of cervical cancers, 90% of anal cancers, 70% of vulvar and vaginal cancers, 60% of penile cancers and 70% of oropharyngeal cancers, making up more than half of all malignancies related to infections –5.HPV infection can be asymptomatic and clear on its own or can cause a wide spectrum of symptoms ranging from a group of benign lesions such as skin and genital warts to the formation of malignancies . Beside Penetrative and non-penetrative sex are the main routes of HPV transmission through skin-to-skin or skin-to-mucosa contact . HPV canThree HPV vaccines were licensed since 2006. The bivalent Cervarix targeting HR HPV16 and HPV18. The quadrivalent Gardasil protecting against LR HPV6 and HPV11 and HR HPV16 and HPV18. The nanovalent Gardasil 9 targets 5 other HR types, namely HPV31, HPV33, HPV45, HPV52, and HPV58. All three vaccines proved to significantly reduce the development of premalignant and malignant lesions and decrease anogenital infections in women [HPV infection rates vary in different countries, with a global prevalence of 11.7% and highest infection rates recorded in Africa 21%) . In Arab% . In ArIn Jordan, data and updates on the prevalence of HPV infection are deficient . In 2017During 2000–2013, cervical cancer was ranked the 10th most common cancer among women aged 15–44 years in the country . In 2012Reports on the rate of cervical smear test uptake in Jordan are scarce. Despite a slow improvement in recognizing the importance of the test and the rate of screening among Jordanian women including healthcare workers over time, all reported low rates of test uptake, with the highest reaching 38% of female study participants. These reports identified knowledge deficiency on the existence of the test, not being referred to undergo the test by a health professional and fear of unfavorable results as major obstacles faced by Pap smearing in the country. All reached to same conclusion of a pressing need to implement a national screening program advertised by health education through the media. , 36.Several studies assessed knowledge on HPV infection, HPV caused cancers, and attitudes towards HPV vaccination in Jordan. Target participants included students , women visiting clinics, dentists and gynecologists. Although awareness of HPV infection, risks of HPV related cancers , Pap screening, presence of HPV vaccines and their protective potential varied among investigations, with older medical students and physicians being more knowledgeable, all studies reported a deficit in knowledge and a relative resistance to vaccination . The maiUndoubtedly, there is a religious and cultural based social discomfort in Jordan and Muslim countries towards HPV and sexually transmitted diseases. This led to the hindering of HPV vaccination and screening. We believe that an understanding of potential non-sexual HPV transmission could relief such discomfort and could help increase rates of vaccine acceptance. We hypothesize that Jordanian physicians have low knowledge on non-sexual routes of HPV transmission and therefore do not encourage anti-HPV vaccination and/or HPV screening. Hence, this study aimed at investigating the knowledge and awareness of Jordanian physicians on the non-sexual routes of HPV transmission and to correlate such knowledge to their attitude towards HPV vaccination and screening.A self-administered electronic questionnaire was conducted among a national Jordanian sample of physicians, residents and general practitioners (GP). The questionnaire was distributed to all health sectors, including Ministry of Health (MOH), the Royal Medical Services (RMS), university hospitals (Academia), and private practice.The survey was developed and presented to participants in English. Before conducting the pilot test, the face validity of each item was checked by the authors. The instrument was validated in a pilot test with ten physician respondents who were not included in the final analysis. A minor revision of some items was done following the pilot test.We used the following formula to obtain the minimal sample size needed for the study:Where z is the normal standard deviation which equals 1.96 for a 95% confidence level, p is the expected prevalence of the condition of interest, q equals 1-p, and D is the margin of error acceptable to the researcher. Assuming a prevalence of 50% and a margin of error of 5%, and a 95% CL, the needed sample size was 384 participants. The study had more than 400 participants.Accurate targeting of the respondents was done through the authors’ direct contact with physicians and residents in medical hospitals. Also, it was distributed among the author’s direct contacts and on different social media platforms (Facebook and WhatsApp). The survey distribution took place in August 2022, with no incentives for participation. Informed consent was added in the introductory section of the survey to assure the respondents of their anonymity, agreement to participate in the study upon answering the questions, and their right to withdraw from the study at any time.The study was approved by the Department of Biology and Biotechnology/Faculty of science/ Hashemite University (No.22/7/2021/2022).The survey includes four sections: the first section represents an invitation to participate in the survey by displaying its aim, assuring the participant’s agreement in participation, along with their right of withdrawal and anonymity. The second section comprises nine items assessing various characteristics of the participants .The third section comprises an introduction regarding participants’ general knowledge of HPV. The section starts with yes or no questions concerning whether they have heard of HPV before the survey, asking if HPV was common in Jordan, and whether HPV infection could be asymptomatic. Their knowledge of whom HPV infects was covered . Asking about HPV routes of transmission was included with check boxes of yes and no near each possible route , self-inoculation, and none). The most adverse possible health outcomes of HPV infection for males and females were added for the participants to choose from. Last but not least, this section covered HPV treatment availability, recommendations for regular testing for females and high school students in Jordan, and the issue of lack of knowledge regarding HPV among the community and healthcare workers.The final section of the survey covered HPV vaccination. The section incorporated yes or no questions regarding the presence of a vaccine, whether it is protective in case of a current HPV infection, its availability in Jordan, and whether the participants agree that the vaccination should be obligatory in Jordan. The percentage of cervical cancer prevention by vaccination was covered and followed by the best time to receive the vaccine . Also, the participants were asked if they would take the vaccine if available and whether they would recommend it to their patients, with reasons to choose from for those who disagree. See A team of authors evaluated the relevance and representativeness of the current questionnaire’s content validity. To assess the overall knowledge of the participants regarding HPV and its vaccine, we used three HPV knowledge (K) scores , HPV K-NonSexual (NS), HPV K-Vaccine (V)). HPV K-G includes the following five points: 1) ability of HPV to infect both females and males; 2) asymptomatic HPV infections are possible; 3) HPV transmission through sexual routes 4) cancer is a serious consequence of HPV infection in both men and women; 5) HPV infections can be treatable. Regarding the HPV K-NS, it also consists of five points: 1. transmission of HPV through skin to skin or skin to mucosa contact; 2. mothers being a source of HPV in neonates; 3. contaminated medical equipment’s capacity to spread HPV to patients; 4. HPV spread is accelerated by self-inoculation; 5. presence of HPV in water. Finally, the HPV K-V score encompasses four points: 1- existence of HPV vaccine; 2- protectiveness of the vaccine against HPV associated cancers in those already infected with certain strains of HPV; 3- percentage of protection from malignancies attributable to HPV that the vaccine confers; 4- age group that benefits most from vaccination. The maximum possible score was 6, 5, and 4 according to the HPV K-G, K-NS, K-V respectively while the minimum was zero for all three of them. See The physicians’ attitude towards regular screening for HPV in the community as well as their perspective and recommendation of HPV vaccine was assessed using the attitude scale . Four points were evaluated: 1) The willingness of the participants to receive the HPV vaccine for free; 2) The confidence to suggest the vaccine to their patients; 3) The necessity of routine HPV screening among young adults in the community; 4) The significance of regular HPV screening among high schoolers. Each of the above was assessed with a dichotomous scale (“Yes” or “No”) and given 1 point. Thus, the maximum score was 4 and the minimum was zero. Higher Attitude scale values indicated a more positive attitude of the physician toward advising regular testing of HPV and promoting HPV vaccine. See Statistical analysis was carried out using SAS 9.4 . Descriptive statistics were used to describe demographic and general characteristics of participants. Percentages and frequencies were used to describe categorical variables, while mean and range or median and inter-quartile range (IQR) were calculated to describe continuous variables. ANOVA was used to compare the differences between mean scores of age groups, gender , specialty , experience , and workplace  for each one of the following variables about HPV, knowledge about non-sexual routes, knowledge about HPV-vaccine, total knowledge scores, and attitude scores. Post-hoc Tukey-Honest test was run for significant associations to identify which pairs where significant after adjustment for p-values. Because of the data nature of scores, we also ran Kruskal-Wallis test to compare differences between median scores of age groups, gender, specialty, experience, and workplace for each one of the following variables about HPV, knowledge about non-sexual routes, knowledge about HPV-vaccine, total knowledge scores, and attitude scores. All significant differences were set at α = 0.05.A total of 412 participants completed the survey; 158 participants from the MOH (38.4%), 128 from academia (31.1%), 105 were from private practices (25.5%), and 21 from the RMS (5.1%). More than half of study participants were females (53.2%) and unmarried (54.8%). The age group 26–40 was dominant (71.8%) .In terms of specialty, gynecologists, surgeons, internists and pediatricians comprised 17.5%, 14.6%, 11.2% and 6.1% of the participants, respectively. The remaining specialties (named others) comprised 50.7% . No significant differences were found in K-HPV general scores of physicians based on age, specialty and experience .As female participants showed more general knowledge than males, they also evinced more knowledge on non-sexual routes of HPV transmission and higher knowledge on anti-HPV vaccination .Age group ≤ 25, workers in academia and RMS demonstrated higher knowledge scores on anti-HPV vaccines than other age and workplace groups .The HPV total-score was used to evaluate the overall general, non-sexual routes and vaccines knowledge of physicians per age, gender, specialty, experience and workplace. The total HPV was higher among female physicians compared to their male counterparts (p<0.0001) and also in academic physicians in comparison to their colleagues in other workplaces (p<0.001). In addition, youngest physicians (≤25 years old) scored higher than older age groups (p = 0.04). Notably, specialty and years of experience demonstrated no impact on HPV knowledge in total Tables .Although skin to mucosa and skin to skin contact are means of both sexual and nonsexual transmission of HPV, only 64% and 52% of participants respectively, agreed that these could form an HPV transmission route. Physicians’ belief in contaminated water (15%), self-inoculation 23%), medical equipment (34%) and mother to fetus (51%) as potential routes of HPV transmission is extremely low .As shown in 151 of the participants (37%) reported that they won’t take the vaccine if it was available. Not having extra-marital activity was the utmost cause for not taking the HPV vaccine (46%). 28% of the participants won’t take the vaccine because they are virgin, while 3% of the participants won’t take it due to the misconception that HPV occurs in females only. 3% and 1% of the participants believe that the HPV vaccine isn’t safe or protective, respectively. 29% of the participants have other reasons .Out of 403 participants, 331 (82%) stated that they will recommend the HPV vaccine to their patients if the vaccine was available in Jordan for free, while 72 (18%) won’t. The majority of those who won’t recommend the vaccine (40%) believed that it is not necessary to implement HPV vaccination in Jordan, while 26% won’t recommend it due to cultural reasons. Only 6% and 3% of the physicians won’t recommend the vaccine because it is not safe or not protective, respectively. On the other hand, 25% of the participants justified their “no” answer for other reasons .Participants with a K-total score of ≥7.5 out of 15 were classified as “high knowledge” participants and those who got lower than that were classified as “low knowledge” participants. Similarly, based on attitude, physicians with attitude scores ≥3 out of 4 were classified as physicians with “positive attitude” and those who scored <3 out of 4 were classified as physicians with “negative attitude”. A Mann-Whitney test demonstrated a statistically significant difference in terms of attitude towards HPV vaccination and screening among the “high knowledge” but not the “low knowledge” participants (p = 0.039). As shown in Among participants who heard about HPV, 93% know about HPV vaccine through medical education and 20% read about HPV vaccine on their own. However, 14% attained their knowledge about HPV vaccine through both, medical education and their own readings.Social media was the only source of knowledge in 4% of the participants. Friends and family formed the HPV vaccine knowledge source of 10% and 5% of the participants, respectively. Multiple sources of knowledge (three or more) were reported by 1% of the participants, among those 2% reported that they know about HPV vaccine through medical education, their own readings and social media. Good to mention that there is missing data from 77 participants.This is the first study to shed light on the awareness of Jordanian physicians on the non-sexual routes of HPV transmission. Although penetrative sex is considered the premium cause of HPV infection and genital cancers, non-sexual transmission can add to those cases and to other types of malignancies such as skin, oral and head and neck cancers. Medical equipment that get into direct contact with the genitals and the oral cavity can form major sources of infection, especially if they are not well disinfected to kill the virus. Physicians, dentists and healthcare workers involved in using/disinfecting such equipment must know that HPV cannot be killed by alcohol-based disinfectants and must switch to hypochlorite based ones . In JordSurprisingly, physicians in this study showed extremely low levels of knowledge on non-sexual routes of HPV infection. All in all, out of 5, the average K-nonsexual score of 403 physicians who have previously heard of HPV is ~2.3. Although skin to mucosa and skin to skin contact is a means of sexual transmission of HPV, only 64% and 52% of participants respectively, agreed that these could form an HPV transmission route. Physicians’ disbelief in contaminated water (85%), self-inoculation (77%), medical equipment (66%) and mother to fetus (49%) as potential routes of HPV transmission is worrisome.In fact, to the best of our knowledge, this is the first published study that reveals the knowledge of physicians on non-sexual routes of HPV transmission as a primary focus. However, a few reports in the literature included questions about non-sexual routes of HPV transmission listed in their questionnaire, but not discussed thoroughly in the text. Results of such reports are very comparable to ours and all express low knowledge of physicians, health professionals and medical students on the non-sexual routes of HPV transmission.As reported by researchers from Rio de Janeiro state of Brazil, only 27.9% of the participating physicians were able to accurately identify all possible forms of transmission . In FujiRegarding all 3 knowledge categories , female physicians showed significantly higher scores compared to males. Similarly, females showed better attitude towards HPV vaccination and screening. In fact, this proved to be a general worldwide trend, not only in physicians, but also in students, general population and healthcare workers –50. In CLooking at age, age group ≤ 25 showed significantly higher K-vaccines scores and more positive attitude towards HPV vaccination and screening. In fact, this was reflected by the better attitude of GPs, as most of our GPs in this study are fresh graduates who belong the youngest age group. This is non-consistent with previous literature from Saudi Arabia where younger (20–30 years old) participants scored the lowest regarding HPV knowledge . On the Academic physicians showed significantly greater knowledge than their MOH, private practice and MRS counterparts. Despite the fact that physicians engaged with academic work might spend less time in the clinic and might have less direct contact with patients, they proved to know better about HPV in general and about HPV vaccines compared to their clinical fellows. Accordingly, this better knowledge reflected on the attitudes of academic physicians towards HPV vaccination and screening. Interestingly, in India, community physicians demonstrated better basic HPV knowledge compared to academic physicians, whereas academic physicians showed better vaccine knowledge and more positive vaccination attitudes . The betBased on specialty, no statistically significant difference was found between physicians with different specialties in terms of knowledge and attitudes towards HPV vaccination and screening. Noteworthy, although not significant, gynecologists showed higher K-vaccine scores compared to surgeons, pediatricians, internists and other specialty physicians P = 0.059). This lack of discrepancies between specialties regarding HPV knowledge and vaccination was reported by a recent study in Israel , 58. Far. This laIn terms of experience, general practitioners, residents and specialists showed no difference in all measures of HPV knowledge as well as attitude towards vaccination and screening. Similar results were reported by scholarly articles in the literature. In Israel, no difference was found between residents and specialists regarding HPV related knowledge . SimilarLimitations of this study included the use of a convenience sampling approach, with the possibility of selection bias. Thus, the generalizability of the results should be approached with caution. Careless or multiple responses can’t be ruled out. As noted with many older physicians, and physicians with specialties not much related to HPV infections  affected their decision on participating in the survey based on their lack of previous knowledge of the survey subject. Thus, the genuine level of knowledge among physicians can be lower than the level reported in this study. In addition, this survey study was conducted just after the COVID-19 crisis started to ease down, at times preceded by a tremendous amount of COVID-19 related survey based research in the country . PhysiciThe noteworthy findings of this study that should be highlighted include: 1- The extremely low level of knowledge on non-sexual routes of HPV infection among Jordanian physicians. 2- The significantly higher K-general, K-nonsexual and K-vaccines scores and better attitude towards HPV vaccination and screening reflected by female physicians compared to their male counterparts. 3- The stronger K-vaccines score of the youngest physicians (age group ≤ 25). 4- The significantly greater HPV knowledge and more positive attitude of academic physicians compared to their MOH, private practice and MRS fellows. 5-The lack of specialty and practice level influence on the knowledge and attitudes of participants.Increasing the level of awareness of physicians and healthcare workers on the non-sexual routes of HPV transmission and their association with cervical and other cancers through university curricula and other reliable sources is recommended. This must include proper ways of disinfecting medical equipment to eliminate contaminating HPV. Educating the community through socio-educational campaigns on these nonsexual routes can help break the religious/cultural barrier towards HPV infection. This can help in the acceptance and implementation of HPV vaccination and screening; in hopes to help in the prevention of HPV associated cancers.S1 Table* Out of 412; ** out of 403.(DOCX)Click here for additional data file.S2 Table** out of 403.(DOCX)Click here for additional data file.S3 Table** out of 403.(DOCX)Click here for additional data file.S4 Table** out of 403.(DOCX)Click here for additional data file.S5 Table** out of 403; *** out of 332.(DOCX)Click here for additional data file.S6 Table(DOCX)Click here for additional data file.S1 File(XLSX)Click here for additional data file.


Transient tachypnea of the newborn (TTN) is the consequence of delayed resorption of lung fluid. When TTN develops, the infant may develop severe hypoxemia and progress to persistent pulmonary hypertension of the newborn (PPHN).To examine factors associated with the development of PPHN in TTN infants.This retrospective study comprised 23 infants in whom a diagnosis of TTN with PPHN (TTN-PPHN) was confirmed and 59 infants with severe TTN without PPHN who required mechanical ventilation between 2009 and 2018 at Songklanagarind Hospital, Thailand. Logistic regression was used to assess factors associated with TTN and PPHN.2) <90% and respiratory rate (RR) ≥70 breaths/min at the time of admission, mean airway pressure (MAP) ≥8 cmH2O, oxygen index (OI) ≥10, partial pressure of oxygen (PaO2) ≤60, partial pressure of carbon dioxide (PCO2) ≥45 mmHg, and infants who did not receive positive pressure ventilation (PPV). In multivariate analyses, RR ≥70 breaths/min  and OI ≥10  remained statistically significantly associated with PPHN.The factors identified by univariate analysis that were associated with development of PPHN were oxygen saturation (SpOHigh RR and high OI were factors associated with PPHN in TTN infants. Transient tachypnea of the newborn (TTN) is a common cause of respiratory distress in newborns, and is believed to result from incomplete clearance of lung fluid. TTN is a self-limited disease and the symptoms generally resolve within 72 h of age . HoweverThe study was approved by the Human Research Ethics Committee Faculty of Medicine, Prince of Songkla University, Thailand .2) difference more than 5%–10%) ). Nominal variables are expressed as numbers and percentages. The Wilcoxon rank-sum test and Fisher exact test were used to compare differences between the TTN-PPHN and severe TTN groups. We performed univariate and multivariate analyses to assess the factors associated with TTN and PPHN. Variables with 2 at the time of admission in all infants were 68 (64–78) breaths/min and 90% (88%–95%), respectively.During the study period, 883 infants were diagnosed with TTN. Of these infants, 82 with severe clinical conditions requiring endotracheal intubation and mechanical ventilation were enrolled in the study. Out of the infants with TTN, 23 were diagnosed with PPHN (TTN-PPHN); and 59 infants were diagnosed with severe TTN without PPHN. The mean ± SD GA and birth weight of all infants were 36.1 ± 2.1 weeks and 2712 ± 675 g, respectively. Fifty-six percent of the infants (46/82) were male sex and 89% of the infants (73/82) were delivered by cesarean section. The medians (IQR) of onset of respiratory distress and age at intubation were 0 (0–1) h and 2.8 (1–8) h, respectively. The medians (IQR) of RR and SpOTable 1 shows the comparisons of the baseline demographics and clinical characteristics between the infants diagnosed with TTN-PPHN and severe TTN. The infants diagnosed with TTN-PPHN had significantly higher RR, MAP, and OI as well as lower SpO2, which were significantly different from those of the severe TTN infants. The severe TTN infants received significantly higher PPV in the delivery room than the TTN-PPHN infants . However, the numbers of infants who received early continuous positive pressure were not significantly different between the 2 groups . The neonatal characteristics of gender, GA, birth weight, Apgar scores, blood sugar, and hemoglobin level were not significantly different between the 2 groups. In addition, the maternal factors, which included mode of delivery, underlying diseases, and obstetric complications, were not significantly different between the 2 groups.Table 2. Using univariate analysis, the following were the factors ascertained to be associated with the development of PPHN, not receiving PPV after birth, or who had RR ≥70 breaths/min, SpO2 ≤90%, MAP ≥8 cmH2O, OI ≥10, PaO2 ≤60 mmHg and partial pressure of carbon dioxide (PCO2) ≥45 mmHg. Using multivariate regression analysis, it was then found that RR ≥70 breaths/min at the time of admission (P < 0.001) and OI ≥10 (P < 0.001) were associated with PPHN.The univariate and multivariate analyses of the risk factors between the TTN-PPHN and severe TTN infants are summarized in The median (IQR) age at the onset of PPHN and the median (IQR) initial OI in the TTN-PPHN infants were 17 (10–34.5) h and 6.5 (4.2–14.3), respectively. Of the 23 infants with TTN-PPHN, 52% (12/23) received inhaled nitric oxide (iNO) therapy. The initial dose of iNO was 20 ppm and the mean ± SD duration of iNO was 76.3 ± 31 h. Pulmonary vasodilators were prescribed in cases of mild to moderate PPHN (OI <20) or used as an adjunct therapy to iNO. Among the infants, 4 received sildenafil and 15 received bosentan therapy. The mean ± SD durations of sildenafil and bosentan therapies were 7 ± 6.2 d and 6.6 ± 2.5 d, respectively.P = 0.03). However, serum creatinine on the second day of life and urine output were not significantly different between the 2 groups.We conducted assessments for acute kidney injury (AKI), which is a common comorbidity of critically ill neonates. None of the infants had AKI according to the neonatal KDIGO classification . There wTable 3. The TTN-PPHN infants had a significantly higher rate of morbidities including pneumothorax and VAP than the severe TTN infants. Mechanical ventilator days, duration of oxygen supplementation, and LOS were also significantly longer in the TTN-PPHN group than in the severe TTN group. The overall hospital costs of the TTN-PPHN infants were nearly 2 times greater than the hospital costs of severe TTN infants. All infants had a normal hearing screening at discharge. Of the 23 infants (14 severe TTN infants and 9 TTN-PPHN infants) who had cranial ultrasonography performed, 2 of the severe TTN infants and 4 of the TTN-PPHN infants had IVH grade 1. There were no infant deaths on record in the data utilized in the present research.The neonatal outcomes are summarized in This was a retrospective study performed to examine the factors associated with the development of PPHN in TTN infants. We compared both maternal and neonatal characteristics and respiratory parameters at the time of admission in TTN infants who developed PPHN and severe TTN infants without PPHN. We found that RR at time of admission more than 70 breaths/min and OI after intubation more than 10 were the only factors associated an increased risk of developing PPHN in TTN infants. These parameters may help to predict the progression of the disease.OI is the parameter used to assess the severity of hypoxic respiratory failure. An OI >25 is the criterion for iNO therapy while OI >40 is the criterion for ECMO therapy, which is associated with a higher mortality . GonzáleKahvecioğlu et al.  reportedIt is known that TTN is associated with PPHN. One of the most important factors related to both TTN and PPHN is cesarean section , which wP = 0.01), while the use of early CPAP in the delivery room was not associated with PPHN. On the other hand, recent publications have reported that the use of early CPAP in TTN infants reduced the duration and severity of respiratory distress and decreased the rate of NICU admission  1.15–25.29, dmission , 20.A previous study reported that factors associated with an elevated risk for PPHN included cesarean delivery, diabetes, and asthma . In contPPHN is associated with significant morbidity and mortality. The outcomes of the infants in our study with TTN-PPHN included VAP, pneumothorax, ventilator days, and overall hospital costs, all of which was significantly different from the outcomes of the severe TTN infants. There were no infant deaths on record in the data comprising the study, which indicated that TTN was not an aggressive disease.Our study had several limitations. This was a small retrospective study, which limited the study power. We enrolled only TTN infants who required endotracheal intubation and mechanical ventilation, which also possibly affected the study power. Furthermore, there was a lack of long-term follow-up visits in these infants for neurodevelopmental outcomes evaluation.2, and perhaps perform echocardiography if indicated for an early diagnosis of PPHN in these infants.In conclusion, we found that RR ≥70 breaths/min at the time of admission and OI ≥10 were the risk factors for developing PPHN in TTN infants. Clinicians should provide intensive care, monitor preductal and postductal SpO


Despite widespread availability of human papillomavirus (HPV) vaccines and recommendations for routine use, awareness and uptake of HPV vaccination are not universal. We assessed self-reported history of HPV vaccination in a sample of low-income men and women recruited from the community using respondent-driven sampling as part of the National HIV Behavioral Surveillance (NHBS) survey in San Francisco. Of the 384 respondents, a minority (12.5%) reported they had received the HPV vaccine. In multivariate analysis, independent associations with HPV vaccination history were female sex , younger age , and education above high school . Missed opportunities for HPV vaccination were evident in 84.4% of respondents having visited a health care provider in the last year, including 40.1% tested for a sexually transmitted infection, and entry into higher education programs (33.4%). Human papillomavirus (HPV) is the most common sexually transmitted infection (STI) in the United States . A well-Despite widespread availability and ACIP recommendations for routine use, awareness and uptake of HPV vaccination are not universal. One study found that awareness of the HPV vaccine had declined by 6.2% among females and 8% among males within the general U.S. population following the first 10 years after its introduction . It is wWe conducted a secondary analysis using data from the NHBS survey collected in 2019 among low-income heterosexual men and women. The CDC leads the NHBS series of cross-sectional surveys that are conducted in 23 U.S. metropolitan areas with high HIV burden. The data used in this analysis originated from the San Francisco site only. Details of the general methods are available in the CDC’s reports  and in ap < .10 were considered for entry into a multivariate model; those with p < .05 were retained in the final model.We used Stata version 17 software to analyze the self-reported history of HPV vaccination among low-income heterosexual men and women in San Francisco. The question on HPV vaccination history was: “Have you ever received a vaccine against HPV, for example, GARDASIL, which prevents genital warts, anal cancer, and cervical cancer?” Those who replied “Yes” were asked, “How old were you when you received your first dose of the HPV vaccine?” As in the CDC national report and previous publication , data arN = 384, Approximately half of the survey participants were women (51.3%) and above the age of 45 years (50.3). A majority were Black/African American (82.2%) and had a high school education or greater (83.0%) N = 384, . The majA minority of participants (12.5%) reported they had received the HPV vaccine. Among those recalling the age at which they received the first dose, a plurality (41.3%) were between 16 and 25 years old; 19.6% reported they were 26 years or older.p = .085) association with a history of HPV vaccination. In multivariate analysis, independent associations with HPV vaccination history were female sex , younger age , and education beyond high school . Age confounded the relationship between HPV vaccination and having dependents and being tested for an STI in the last year. In this sample, HPV vaccination history did not significantly vary by race.Our study found that only one in eight young adults (18–24 years) living in low-income neighborhoods of San Francisco could recall having been vaccinated for HPV. The CDC reports five in 10 adolescents (13–17 years) to be up to date with their HPV vaccine . Our datWe recognize the limitations of our study. First, as this is a secondary analysis of data collected for the NHBS, our examination of HPV vaccination was not structurally planned and therefore has the limitations of inclusion of participants and the content of the questionnaire. Second, data included only heterosexual men and women as being eligible for the NHBS heterosexual survey round. Examination of HPV vaccination among other groups at high risk, such as men who have sex with men (MSM) and trans women, can be done with future NHBS surveys for these populations. Third, data are self-reported and not verified by medical record examination or serological testing. Fourth, NHBS eligibility criteria did not include the younger age groups recommended for vaccination. Fifth, the NHBS questionnaire did not include the number of doses received. Another limitation is the representativeness of the sample. Recruitment through peer referral may create biases that are difficult to measure and correct for. Nonetheless, a strength of our sample is that recruitment was independent of clinics and therefore included persons who may not have access to services.Despite limitations, there are several programmatic implications based on these data. Those in low-income neighborhoods, regardless of the race, show a low HPV awareness and low HPV vaccination rate. On a positive note, a large majority of the population had visited a health care provider in the preceding 12 months, including many who were tested for STDs. Physician visits are opportunities for providing information and applying interventions. In Denver, also an urban setting, Denver Health applied several interventions to increase vaccination rates among adolescents from 2004 to 2014; these included the “bundling” of three adolescent vaccinations  during routine physician visits and providing training to physicians regarding offering the vaccines and addressing vaccine refusal. At the end of this period, Denver Health achieved vaccination rates that were above national coverage rates . Public


Infection with human papillomaviruses (HPVs), in particular with HPV type 16, is now considered to be a key risk factor for the development of a subset of oropharyngeal squamous cell carcinomas (OPSCC) that show different epidemiological, clinical, and prognostic characteristics from HPV-negative (HPV−) OPSCCs. So far, extensive research efforts aiming to distinguish these two distinct entities have not identified specific biomarkers, nor led to different therapies. Previous research has shown that HPV16 E6 oncoprotein binds NHERF2, inducing its proteasomal degradation, and consequently increasing cell proliferation; we therefore aimed to investigate how this might be reflected in human histological samples. We analyzed NHERF2 expression patterns in HPV16-positive (HPV16+) and HPV− OPSCC samples, to investigate any potential differences in NHERF2 pattern. Interestingly, we observed a statistically significant decrease in NHERF2 levels in HPV16+ and poorly differentiated HPV− OPSCCs, compared with healthy tissue. Furthermore, we observed a significant reduction in the percentage of NHERF2 immunoreactive cancer cells in HPV16+ tumors, compared with well and moderately differentiated HPV− OPSCCs, suggesting the importance of 16E6’s targeting of NHERF2 in HPV-driven oncogenesis in the head and neck area. Head and neck squamous cell carcinomas (HNSCC) are the most prevalent type of head and neck cancers (HNC), accounting for over 90% of cases. They originate from the mucosal epithelium of the upper aerodigestive tract and comprise cancers of oral cavity, nasopharynx, oropharynx, larynx, and hypopharynx ,2. AccorAlphapapillomavirus (αHPV) species have been shown to preferentially infect anogenital and oral mucosal epithelia [HPVs are small, non-enveloped DNA viruses strongly implicated in the development of various cancer types. To date, nearly 220 HPV genomes have been sequenced and sorted into five genera. The well-characterized pithelia , and arepithelia . HR HPVspithelia ,15. In rpithelia ,16. Althpithelia . Howeverpithelia ,19. In tpithelia ,20,21. Tpithelia , primaripithelia ,24,25,26pithelia ,28. Manypithelia ,29. Intepithelia ,31. As rpithelia . The relpithelia . NHERF2 pithelia . The ablpithelia ,36. Addipithelia .Although the last two decades have yielded numerous studies that have significantly increased our general knowledge concerning the role of HPV in HNSCCs, insights for the generation of novel strategies for their prevention and early diagnosis are still missing. So far immunohistochemical (IHC) identification of p16 tumor suppressor is used as a substitute marker for HPV+ cancers since E7 oncoprotein stimulates its overexpression . Howevern = 48), grouped as either HPV16+ oropharyngeal cancer (n = 19), HPV− oropharyngeal cancer (n = 29), or healthy uninfected tonsillar tissue (n = 8). The tissue samples were obtained from the archives of the Department of Pathology and Cytology, University Hospital Dubrava  and the Department of Pathology and Cytology University Hospital Centre, Zagreb, Croatia . All the tissue samples were previously fixed in 10% buffered formalin and embedded in paraffin. The study was conducted on FFPE samples  according to the manufacturer’s instructions. The concentration of the isolated DNA was measured using NanoPhotometer® N60 , and the quality was validated by PCR using primers generating 99 bp long beta-actin fragments [From each FFPE sample, five to seven slices (10 µm) were used for DNA isolation, utilizing a commercial kit  according to the manufacturer’s instructions, and was compared with the HPV status of the corresponding tissue. Endogenous expression of NHERF2 was detected using EnVision® + Dual Link System-HRP  according to the manufacturer’s instructions, and mouse monoclonal anti-NHERF2 antibody  at 1:30 dilution. As a negative control, primary antibody was replaced with the provided negative control solution (CINtec® Histology kit system) and antibody diluent  for p16 and NHERF2 staining, respectively. The intensity of NHERF2 immunostaining was graded and scored by a pathologist as following: 0 (no staining), 1+ (low intensity), 2+ (medium intensity), and 3+ (strong intensity).Sections (7 µm) of the FFPE tissue sections were mounted on pretreated glass slides, deparaffinized in the xylene substitute BioClear , and rehydrated using a graded ethanol series of 100%, 95% and 70%), respectively. The p16 expression was analyzed using the CINtecDescriptive statistics were used to evaluate differences in NHERF2 expression and localization in healthy uninfected tonsillar tissue, HPV16+, and HPV− OPSCCs. The Kruskal–Wallis test was used to evaluate possible significant differences between the designated groups, HPV− OPSCCs grades 1–3 and HPV16+ OPSCCs with Dunn’s multiple comparison post-test. The ratio of NHERF2-positive staining in cancer cells was an estimation set by a pathologist. All statistical analyses were performed using GraphPad Prism 8 software.In this study we examined 48 formalin-fixed paraffin-embedded (FFPE) OPSCC tissue samples, and 8 healthy uninfected tonsillar tissue samples were used as controls. We isolated DNA and performed HPV genotyping by PCR as previously described . The resTo investigate and link p16 protein expression with tumor grades and/or HPV status, p16 IHC staining was performed in all samples . PositivPrior to studying NHERF2 expression patterns in cancer samples, its expression and localization were investigated in healthy, uninfected tonsillar tissue. NHERF2 was detected in all eight FFPE samples, with slight differences in immunostaining patterns. It was mostly detected in the stratified squamous epithelium of the tonsils, mainly in the middle layer of the stratified epithelium and occasionally in the basal layers, but it was almost always absent from the surface layer of the differentiated epithelium . In all The NHERF2 expression profile was then investigated in HPV− OPSCCs, where it was detected in all analyzed samples, but one. Representative samples of all tumor grades are shown in Since NHERF2 was characterized as a cellular target of HPV16 E6 , we werep-value of 0.0414. Greater variation was detected in the presence of HPV16, so this difference between the control tissue and HPV16+ OPSCCs was significant with a p-value of 0.0013, indicating that the presence of HPV16 E6 in these cancer types reduced the amount of NHERF2. In addition, the difference in the proportion of stained cancer cells in various cancer groups was examined (p = 0.0005), as well as between G2 HPV− OPSCCs and HPV16+ OPSCCs (p = 0.0009). Although the difference between G3 HPV− OPSCCs and HPV16+ tumors was clearly visible, it was not statistically significant with this small number of tested samples. These results further confirm the observation that NHERF2 protein levels are lower in the presence of HPV16 in comparison with those in well and moderately differentiated HPV− OPSCCs, indicating the importance of NHERF2 regulation for HPV-mediated carcinogenesis in the head and neck.Changes in the staining intensity and percentage of immunoreactive cancer cells were then compared between the HPV+ and HPV− tumors and the control group. As can be seen a, stainiexamined b and it In the past 30 years, HPV infections have been characterized as a risk factor for the development of HNSCCs, especially OPSCCs, accounting for 50–80% of these tumors . InteresWe did not observe any changes in NHERF2 localization in any of the groups tested, compared with the control group of uninfected tonsils. Interestingly, a previous study showed that NHERF1 with a mutation in the PDZ2 domain changes its localization in breast cancer ; since wTo our knowledge, this is the first study investigating NHERF2 expression patterns in the process of oropharyngeal carcinogenesis. We provided new information about alterations in NHERF2 protein expression levels in HPV16+ and HPV− OPSCCs of three various grades. We observed a significant decrease in NHERF2 expression levels in poorly differentiated G3 HPV− and HPV16+ tumors. Interestingly, this effect of NHERF2 downregulation was markedly more evident in HPV16+ tumors. We also showed a significant decrease in NHERF2 immunoreactive cancer cells in HPV16+ samples suggesting its importance in HPV-driven oropharyngeal carcinogenesis.


We investigated HPV genotypes in a large cohort of patients with definitive cervical histologic diagnosis.HPV testing was performed by real-time PCR assay, including 18 high-risk HPV (hrHPV) and 3 low-risk HPV (lrHPV). Totally 61,422 patients with documented HPV genotyping results within 6 months before cervical histologic diagnoses were included.in situ (AIS) was HPV18, followed by HPV16, HPV45 and HPV52. In SCC cases, HPV16 was the most common type followed by HPV58, HPV52, HPV18 and HPV33. However, HPV18 showed significantly higher prevalence in adenocarcinoma and adenosquamous carcinoma than in that in SCC. Theoretically, the protective rates of 2/4-valent and 9-valent vaccine were 69.1% and 85.8% for cervical cancers.HrHPV positive rate was 55.1% among all tested cases with the highest in adenosquamous carcinoma (94.1%), followed by squamous cell carcinoma (SCC) (93.7%), cervical intraepithelial neoplasia 2/3 (CIN2/3) (92.8%). HrHPV positive rates were significantly higher in high-grade squamous lesions than in those in glandular lesions. HPV16 was the most common genotype followed by HPV52 and HPV58 in CIN2/3. The most frequent hrHPV genotype in adenocarcinoma The prevalence of HPV genotypes in Chinese population was different from that in Western population. Some hrHPV types were identified in cervical precancerous lesions and cancers, which are not included in current HPV vaccines. These data provide baseline knowledge for future HPV vaccine development. Cervical cancer is the second most common type of malignancies among women and was responsible for 341,000 deaths in 2020 with approximately 80% in the developing countries  between October 2017 and May 2022 from Obstetrics and Gynecology Hospital of Fudan University (OGHFU). OGHFU is the largest women’s hospital and academic center in China and serves a variety of patient populations from Shanghai city, adjacent counties and cities, and nationwide referrals. Histologic specimens included colposcopic punch biopsies, endocervical curettages, cone biopsies, and hysterectomies. The worst diagnosis was recorded if the patient had multiple cervical histologic diagnoses. Cases with endometrial carcinoma extending to uterine cervix, metastatic carcinoma, sarcoma and melanoma were excluded. Only cases with documented prior HPV genotyping results within 6 months before cervical histologic diagnoses were included in this study. This study was approved by the Institutional Review Boards of OGHFU.HPV extended genotyping was performed by utilizing the BioPerfectus Multiplex Real-Time PCR assay (BMRT) assay , detecting 21 HPV genotypes, including 18 high-risk HPV (hrHPV) and 3 low-risk HPV (lrHPV) . The detin situ (AIS), AIS with CIN2/3 (AIS+CIN2/3), squamous cell carcinoma (SCC), endocervical adenocarcinoma (ADC) including usual type, gastric type, etc., adenosquamous carcinoma (ADSQ) and small cell neuroendocrine carcinoma (SNEC).Subspecialized gynecologic pathologists at OGHFU signed out all histologic pathology reports according to the World Health Organization (WHO) classification . The diat test was performed for 2 groups and analysis of variance (ANOVA) was performed for more than 2 groups. The differences between ratios were analyzed by Pearson χ (Student’s P<0.001). The mean ages of ADC and ADSQ were younger than that of SCC  , 10,058 CIN1 (16.4%), 3,773 CIN2/3 (6.1%), 778 SCC (1.3%), 57 AIS (0.1%), 111 ADC (0.18%), 87 AIS+CIN2/3 (0.14%), 101 ADSQ and 17 SNEC (0.03%) cases Table 1.The median of the time between HPV testing and histopathologic diagnoses was 24 days . 62.7% of cases had an HPV test within one month prior to cervical histopathologic diagnoses. Most patients with extended HPV genotyping also had a companying cervical cytology test at OGHFU. The current study was aimed to investigate hrHPV genotyping results in various cervical histological findings; therefore, cervical cytology test results were not included.HrHPV positive rate was 55.1% among all tested cases with the highest in ADSQ (94.1%), followed by SCC (93.7%), CIN2/3 (92.8%), CIN2/3+AIS (92%) and CIN1 (88.4%). HrHPV positive rates were significantly higher in high grade squamous lesions than those in glandular lesions Table 1.P<0.001)  than in 30-49 years group (P<0.001) Table 2.We further analyzed multiple hrHPV infection (≥2 types) in different age and histologic groups. Overall, multiple hrHPV infection occurred in 30.5% of hrHPV-positive cases , with up to 10 different hrHPV genotypes in a single case. CIN1 cases showed the highest percentage of multiple infection at 41.3% (3672/8896), while ADSQ cases had the lowest at 16.8% (16/95). Multiple infection occurred more frequently in young patients (<30 years old) than in older patients, and also more frequently in squamous lesions (CINs and cancers) than in glandular lesions (AIS and carcinomas) (38.4% vs. 21.8%) Table 3.The distribution of all 18 genotypes of hrHPV in patients with precancerous lesion or negative histologic result were summarized. HrHPV genotypes were more evenly distributed in negative cases than in precancerous lesions, with HPV52 (10.1%) being the most common genotype, followed by HPV16 (7.1%), HPV53 (5.9%), HPV58 (5.9%), and HPV39 (4.2%). CIN1 cases and negative cases shared similar patterns of HPV genotyping results but showed higher hrHPV positive rates with HPV52 (25.2%) as the most common genotype, followed by HPV16 (16.9%), HPV58 (16.5%), HPV53 (12.1%), and HPV56 (9.5%). In CIN2/3 precancerous lesions, HPV16 was the most common genotype (40.1%) followed by HPV31 (7.3%) and HPV33 (12.1%). The distribution of hrHPV genotypes was more limited in AIS than in squamous precancerous lesions and negative cases. The most frequent hrHPV genotype in AIS was HPV18 (42.1%) followed by HPV16 (40.4%), HPV45 (5.3%), HPV52 (5.3%), and HPV53, 58, 59 (each with 1.8%). The other 10 hrHPV types were not detected in the AIS group. The pattern of hrHPV genotyping of AIS/CIN2/3 was similar to AIS and showed significantly more HPV18 and HPV45 infections than CIN2/3. In comparison with negative/CIN1 cases, CIN2+  cases demonstrated significantly higher positive rates for HPV16 (40.3% vs 8.8%), HPV31 (7.1% vs 2.9%), HPV33 (11.75 vs 2.7%), HPV52 (22.2% vs 12.8%) and HPV58 (18.8% vs 7.7%) , HPV52 (8.1%), and HPV33 (6.9%). HPV18 showed significantly higher prevalence in ADC (27.9%), ADSQ (44.6%), and SNEC (70.6%) than in SCC. Four potential hrHPV genotypes, HPV53, HPV26, HPV82, and HPV73, were not included in FDA-approved commercial kits, which showed positive rates of 4.2%, 1.0%, 0.9%, and 0.2%, respectively  and 9-valent (HPV16/18/31/33/45/52/58 plus HPV6/11) commercially available vaccine. For precancerous lesions, the possible coverage of 2/4-valent and 9-valent vaccines were 43.1% , 86.0%  for CIN2/3, respectively. For AIS, the coverage of 2/4-valent was higher than those of CIN2/3, reaching to 82.5% (47/57). While the coverage of 9-valent vaccines was the same with 2/4-valent vaccines, both of which were 86.0%. The rates of AIS accompanied by CIN2/3 were higher than the above two lesions. In malignancies, the coverage of 2/4-valent for SCC, ADC, ADSQ, and SNEC were 68.8%, 64.0%, 75.2%, and 84.2%, respectively. The percentages for 9-valent were 87.9%, 67.6%, 90.1%, and 82.4%, respectively. The total protective rate for 9-valent vaccine were 49.6%  and 86.1%  for precancerous lesions and cancer theoretically Table 6.Although more than 100 genotypes of HPV can infect humans, only 25 HPV types  are considered high risk (oncogenic) types by the International Agency for Research on Cancer (IARC) . Fourtee®, and Gardasil‐9®) and two domestic bivalent HPV vaccines, HPV vaccination rate is very low in China. In our study, the total protective rate for 9-valent vaccine were 86.1% for precancerous lesions and 85.8% for cancer theoretically, higher than that for 2- or 4-valent vaccine. However, 2 and 4-valent HPV vaccines still can prevent 70% cervical cancers. 2 or 4-valent HPV vaccination can provide benefit for primary cervical cancer prevention for the women in low source countries. Our results provided a baseline of HPV genotype in cervical precancerous lesions and cervical cancers for future HPV vaccine development for Chinese population. Additionally, HPV vaccination may cause HPV genotype prevalence change among populations with increase of HPV genotypes, which are not included in HPV vaccine  and HPV58 (19.3%), while AIS showed HPV16 (40.4%) and HPV52 (9.2%) as the 2nd and 3rd most common types. HPV18 was only positive in 3.7% of CIN2/3. In cervical carcinomas, the first two most common types were HPV16 (56.2%) and HPV18 (14.2%), consistent with previous studies , which is similar to the findings of other studies with a prevalence of 75.3% to 90% , 43, impThe limitation of the current study is about the bias of the study sample. Although the sample size was large, it came from single institute, which might be different from other institutes or hospitals In addition, the patients were chosen from the hospital base, so the selection bias was present. hrHPV positive rate for ASC-US women in general population will be much lower than that in this study. Four potential hrHPV genotypes, HPV53, HPV26, HPV82, and HPV73, were not included in FDA-approved commercial kits, which showed positive rates of 4.2%, 1.0%, 0.9%, and 0.2%, respectively in current study. Previous studies demonstrated that HPV82, 53 had relatively higher risk for CIN2+ lesions in women with slight abnormality , 45. TheIn summary, this is by far the largest study of HPV genotyping in histologically diagnosed cervical lesions from 61,422 Chinese women. Our results have demonstrated the prevalence of individual HPV genotypes in the cervical lesions in Chinese population was different from that in Western population. Furthermore, we have identified some hrHPV types in cervical precancerous lesions and cancers, which are not covered by current HPV vaccines. These data would provide baseline knowledge for future HPV vaccine development in the Chinese population.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 Institutional Review Boards of Obstetrics and Gynecology Hospital of Fudan University. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.FZ, Conceptualization, investigation, data analysis, writing the original draft; ZL, Conceptualization, data analysis, writing the original draft; YS, data analysis, review and edit of the manuscripts; YX, data analysis, review and edit of the manuscripts; JL, data analysis, review and edit of the manuscripts; XZ, data analysis, review and edit of the manuscripts; QC, confirming colposcopy data, data analysis, review and edit of the manuscripts; LS, confirming colposcopy data, data analysis, review and edit of the manuscripts; XT, conceptualization, data analysis, review and editing of the manuscripts; CZ, Project supervision and conceptualization, data analysis, review and editing of the manuscripts. All authors contributed to the article and approved the submitted version.


I2 = 78%). Variations in the geographic study, tissue type, and detection method remain potential predictors of heterogeneity. In addition, publication bias and sensitivity analysis were not observed, and the results exhibited stable outcomes. Collectively, we specify the recent epidemiological evidence in a validation of the distributed HPV, which might be statistically associated with an increased risk of EC. However, additional high-quality studies with larger sample sizes are needed to further verify the link between HPV and EC.Recently, epidemiological evidence of high-risk human papillomavirus (hrHPV) and its association with the increasing risk of esophageal cancer (EC) have been described. However, the involvement of such a virus in the pathogenesis of EC is still inconclusive in the literature. Therefore, our objective was to clarify the epidemiology of HPV infections in primarily diagnosed EC cases and validate this correlation with hospital-based control patients using a retrospective study with a case–control model. Here, we reported that the overall prevalence of HPV DNA was statistically associated with an increased risk of EC . Interestingly, a history of gastroesophageal reflux disease (GERD) was constituted and significantly associated with HPV prevalence . Furthermore, our meta-analysis in public databases also indicated that the combined OR and 95% CI between HPV infection and EC risk were 3.31 and 2.53–4.34, respectively, with significant heterogeneity ( AccordiPapillomaviridae. Currently, more than 150 HPV genotypes have been identified and categorized into cutaneous and mucosal subgroups. It is well known that mucosal HPV types, specifically HPV16, 18, 31, and 33, are also recognized as high-risk HPV (hrHPV) and are the causative agents of several types of cancer in humans (Human papillomaviruses (HPVs) are a type of ubiquitous double-stranded circular DNA with non-enveloped, small viruses that have been classified as the family, n humans . Of thesn humans . In addin humans . In the n humans , while tn humans . These rn humans . For exan humans . Furthern humans . Howevern humans .Esophageal cancer (EC) is one of leading cancers in Thailand (ranked 16th). Based on world ASR per 100,000, the incidence and mortality of this malignancy in Thailand were 2.9 and 2.7, respectively . It appe2.2.1.This study was registered and approved by the Ethics Committee of the Khon Kaen University for Human Research (Reference no. HE621269). Informed consent was obtained from all volunteers who were participants in this study.2.2.Based on the prevalence of EC cases in Thailand , this st2.3.According to our previous study , 2022, w2.4.Formalin-fixed paraffin-embedded (FFPE) tissue samples of both EC patients and control were retrospectively retrieved from the Department of Pathology, Faculty of Medicine, Khon Kaen University, between 2015 and 2018. Based on the guidance from the International Classification of Diseases in Oncology, 3rd edition  platforms , according to the manufacturer. The DNA target is primarily crossed and binds to HPV CHIP membranes containing immobilized complementary probes that are specified in the beta-globin gene, consensus, and genotype-specific sequences of HPV. The colorimetric assessment was achieved by applying NBT-BCIP substrates that detect alkaline phosphatase activity, developing insoluble purple precipitates.2.6.The basic information on gender, age, and the well-known risk factors of EC, including status and frequency of smoking, alcohol consumption, GERD history, and a family history of cancer, was selected and analyzed. The posed data of these demographic characteristics and risk factors might be associated with infections of hrHPV. Furthermore, the answers of all participants seem to reflect their level of knowledge and overall attitudes toward the correlation between EC and potential environmental risk factors. In this study, each participant directly answered or read all the questions by trained personnel.2.7.The depth and evenness of the existence of HPV in EC imply a hypothetically vital role for HPV infection in the oncogenesis of esophagus origin. Therefore, we conducted a meta-analysis to assess the association between them.2.7.1.The four main public databases including PubMed, SCOPUS, Excerpta Medica database (EMBASE), and Cochrane Library were restricted in English until 31 September 2022 using the combination of medical subject headings  OR the following keywords in [All Fields] of (“esophagus” AND “cancer”) OR  OR (“esophagus” AND “neoplasm”) OR (“ESCC”) OR (“EC”) AND (“human papillomavirus”) OR “HPV”; . In addi2.7.2.in vitro or animal studies) or other types of publication including case reports, personal opinions, conference abstracts, letters, book chapters, and reviews were excluded. The notion of data overlap or duplicate articles was also not eligible for extraction and quality assessments.The reports had to meet the following criteria to be included: (1) the studies that assessed the infection of HPV in tissue samples from healthy participants (control group) and eventually compared them with the histologically approved EC with at least 10 cases, (2) the studies with inline a case–control model were eligible, (3) any place, race, sex, age, and cancer stage was no limitation. Patients with cancer treatments were not eligible for this analysis, (4) the articles provided sufficient data to observe and/or calculate odds ratio (OR) and relative risk (RR), with a 95% confidence interval (95% CI), and (5) the most recent reports on the same population included a larger number of participants. Furthermore, studies that were implemented with preclinical models  guidelines . Titles,2.9.c) with 95% CI was calculated for the bivariate analysis with uncontrolled confounders, the adjusted odds ratio (ORadj) with 95% CI was estimated by multivariate unconditional logistic regression for the controlling confounders  and GraphPad Prism version 8.0 .For our case–control study, descriptive statistics were used to synopsize the demographic characteristics of the participants. The categorical records and the continuous data were represented in frequencies and percentages and the numbers by mean ± standard deviation (SD), median, and minimum and maximum ranges, respectively. Bivariate analysis was performed using simple logistic regression to verify the association between EC and potential independent risk factors. While the crude odds ratio , moderate (I2 > 50%), and high (I2 > 75%) levels in the retrieved reports. Further analysis of heterogeneity was performed leave-one-out with a random effect model when significant articles (p < 0.01 or I2 > 50%) were observed  with the corresponding 95% CI were calculated from the total of EC cases and controls. Forest plots were visually constructed to determine the study’s pooled effects and specificity. Using Cochran’s Q test, the observed . Or elseobserved . After oobserved . Visual 3.3.1.To determine the association between HPV infections and increased risk of ECs, we conducted a recent study in a case–control-dependent manner. A total of 100 EC patients and 105 hospital-based volunteers (control) group were enrolled. Of the total cases, the median age of the EC patients at diagnosis was 59.5 years , and male patients (64.0%) had a higher prevalence of EC than those of female (36%) patients. This group’s most common histopathological diagnosis was squamous cell carcinoma  and tissue grading with poor differentiation (66.0%). Stage IV (66.0%) of the TNM classification was the highest frequency in registered patients. Interestingly, the difference in lifestyle behaviors between cases and controls was statistically observed. Cases had a higher prevalence of smoking (72.0% vs. 26.7%) and alcohol consumption (78.0% vs. 41.0%) than controls. Moreover, the cases also significantly diverged from the controls in a history of gastroesophageal reflux disease  and a family history of cancer . The presence of HPV DNA was subsequently found in a total of 45 (45.0%) EC cases, while 23 (21.9%) paradigms of the controls were correspondingly achieved for such viral DNA. These demographic characteristics of all participants are described in 3.2.c, 2.9; 95% CI, 1.6–5.4; p < 0.001) and ESCC subtypes . However, our result revealed that there was no statistical difference in the association between the existing viral DNA and the EAC , alcohol consumption , history of GERD , and FHC  were statistically associated with an increased risk of EC, synergizing with HPV infection  and patients who had a history of GERD  were statistically dependently correlated with HPV infection , in the EC risk context by the analysis of multivariate logistic regression  was not statistically associated with HPV infection in patients with EC  factors and/or intrinsic factors on EC pathogenesis have been suggested . Therefonfection . Regardlgression . However with EC . Compare3.4.It has been reported that the occurrence of EC related to HPV infection is a favorable upward trend in the whole world, including Southeast Asia . Then, w3.5.in situ hybridization (ISH), and immunohistochemistry (IHC), one study for cytology, and five studies that used combination approaches. The type of biological specimens was also stated, consisting of 41 studies that collected formalin-fixed paraffin-embedded tissue (FFPE), seven reports for blood/plasma/serum, two studies for fresh frozen (FF) tissue /biopsies, and one exfoliated cell. The mean NOS score was 5.5 , the analytic result indicated that a significantly increased EC risk was associated with HPV infection .Although our recent results mentioned the association between HPV infection and the increasing risk of ECs, the evidence for this correlation is capricious in previous studies. Therefore, a recent meta-analysis was performed to clarify such a relation and verified our findings. When searching the four main public databases, a total of 51 case–control studies were selected as candidates in a recent meta-analysis . Of such was 5.5 . Further was 5.5 . As showp > 0.05), except for the type of biological samples (p = 0.015), and moderately rationalized the source of heterogeneity. Our analyses in all subgroups and meta-regression are illustrated in p < 0.05) and publication bias  in Asia, 1.26 (0.27–2.24) in Europe, 0.50 (0.16–0.83) in Africa, 0.62 (−0.62–1.85) in America, and 1.32 (−1.04–3.67) in Oceania. Interestingly, we also perceived this association from the distinctive detection strategies that were 1.46 (1.14–1.77), 0.73 (0.01–1.44), and 0.83 (−1.61–3.27) in the detection of viral nucleic acid, viral protein, and combined markers, respectively, while we were unable to estimate the detection using the cytological assay. Furthermore, the log OR with 95% CI for the link between HPV infection and EC from different sample types was 1.41 (1.12–1.70) in the FFPE sample, 0.43 (−0.48–1.34) in the blood/plasma/serum sample, and 0.38 (−22.39–23.15) in the FF/biopsy sample, and not estimated in the sample obtained from exfoliated cells. Our analysis of this correlation from the variation in EC risk presented the log ORs with 95% CIs that were 1.22 (0.84–1.61) and 1.06 (0.48–1.63) in high EC risk countries and low EC risk countries, respectively. Additionally, the meta-regression unveiled that the characteristics of the enrolled studies did not significantly affect the analytic results  of EC cases. In addition, in the analysis of the TNM stage, we observed favorable downward trends of these risk factors in the EC cases. Collectively, these results indicated that the status of HPV might not affect the survival of EC patients for better or worst prognosis context.To determine the involvement of HPV in the prognosis of EC, the association between HPV infection and the prognostic characteristics of EC patients was consequently performed. As shown in 4.Currently, the number of pieces of epidemiological evidence that indicated an association between hrHPV and the risk of EC has increased. However, the involvement of such a virus in EC pathogenesis is still debated. The variation in its geographical incidence, which was affected by exposure to dietary, cultural, and environmental factors, and any specific factors, is revealed to be one of the reasons that might be described as potential factors. To clarify the carcinogenic roles of hrHPV in EC pathogenesis, we, therefore, conducted a retrospective case–control study and meta-analyses of public databases to describe the relationship between hrHPV infection and the EC risk among Thai patients who lived in the northeastern part. As our hypothesis, the results indicated whether HPV infection, synergized with the history of GERD in patients, was statistically associated with an increased risk of EC, supporting that HPV may, together with the history of GERD, act as a significant etiological risk factor for EC.Papillomaviridae family compartment. A total of 12 alpha-HPV genotypes from alpha-HPVs  are etiological agents of several types of cancer in humans, not only in the anogenital tract but also in a subset of the origin of the head and neck, particularly the oropharynx and oral cavity (Human papillomaviruses (HPVs) are double-stranded circular DNA with small, non-enveloped species-specific viruses, belonging to the l cavity . Accordil cavity . The mall cavity . The ratl cavity . HPV16 iINK4a protein was the potentially promising biological marker for HPV-related malignancies and presented more precise corroboration with DNA testing using a PCR- or immunohistochemistry (IHC)-based technique for HPV diagnosis . Nevertheless, most studies targeting HPV DNA without p16INK4a evaluation could not be a gold standard, therefore defining the association between HPV infection and increased risk of EC in this recent meta-analysis.Infections with HPV have been implied as the oncogenic driver, implicated in the pathogenesis of ECs, particularly in ESCC by the accumulated evidence . RecentlIt is extraordinary that the genomic landscape of ECs has been described by The Cancer Genome Atlas Research Network since 2017 . They ilINK4a has been described as a surrogate marker for hrHPV-associated cancer of the oropharynx through the eighth edition of the American Joint Committee on Cancer Staging Manual . Additionally, the potential of hrHPVs was emphasized in squamous histology.In harmony with the previous reports, we defined several limitations of the current analysis with a certain association. Most studies, which represent 50%, were derived from Asian people with differences in genomic landscape, mental origin, and daily life. Critically, variations in the evaluation essay, line sensitivities, and types of specimens used could have primarily shaped the summarized data. As we mentioned, FFPE tissues were supposed to be specimens of suggestive deprivation compared with FF or biopsies. Furthermore, the most enrolled studies ratified the existence of HPVs based only on PCR, despite the p16An aforementioned study of meta-studies indicated a positive correlation of HPV in EC patients only in the Asian population . HoweverDespite the recent study that clarified and supported the involvement of hrHPV in EC oncogenesis, some critical points must be elucidated. Remarkably, the differences in study design and viral detection approach  affected the quality of the OR results  as well as the prevalence of HPV in EC tissue samples, respectively. We were able to analyze the clinico-demographic data only in a structured questionnaire, and the other environmental risk factors might be lost from the original patient’s life. Importantly, some studies of HPV infection included inadequate sample sizes, affecting our analysis and difficult to summarize. Although more largely epidemiological studies are necessary to show the strength of this correlation, recent data have shed light on therapeutic purposes and preventive epidemiology of ECs. Furthermore, applicable studies adhere to the established procedural standards that were adhered to by other tumor articles and should be integrated into ECs to provide adequate knowledge on HPV-driven EC pathogenesis. Furthermore, the precision-treated responses and effective-prevented vaccines of HPV-associated ECs could be invented in future research.5.We specify the recent epidemiologic evidence in a validation of the distributed HPV which might be statistically associated with an increased risk of EC and seems to be enhanced by GERD history, suggesting that HPV may, together with GERD history, act as a significant etiological risk factor of ECs. However, additional high-quality studies with larger sample sizes are needed to further verify the link between HPV and EC.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 Khon Kaen University Ethics Committee for Human Research. The patients/participants provided their written informed consent to participate in this study.AB, CP, TE, and TN designed and guided the literature. AB, PT, WW, and AP executed data acquisition, analysis, and interpretation. AB, CP, and TE wrote the review and revised the manuscript. AU, PS, PU, and TN administrated, technically, or materially supported the study. CP and TN were the study’s supervisors. All authors contributed to the article and approved the submitted version.This study was funded by a scholarship under the Post-Doctoral Training Program from Khon Kaen University, Thailand (grant no. PD2565-08) to AB. This study was supported in part by Research and Graduate Studies, Khon Kaen University, Thailand (RP65-8-001) to CP.AU was employed by Ward Medic Ltd., Part., Bangkok, Thailand.The remaining 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.