Human papillomavirus (HPV) genotype testing has limited utility to identify human immunodeficiency virus‐infected (HIV+) women's risk for developing cervical cancer (CC) due to high positivity rate of high‐risk (HR) HPVs. We investigated the accuracy of HPV testing in isolation/in combination with CD4 and HIV viral load (VL) to identify HIV+ women at risk for developing CC.Study consisted of 344 HIV+ women on combination antiretroviral therapy (cART), tested for cervical cytology/HPV using the Cobas test and had data on absolute CD4 count and VL measurements. We calculated the positive predictive value (PPV) and negative predictive value (NPV) of HPV testing, pre‐, post‐cART, and current CD4 and VL in isolation and in combinations to identify those with or free of higher than atypical squamous cells of unknown significance (ASCUS+) or low‐grade intraepithelial lesions (LSIL+).HPV test in combination with pre‐/post‐cART or current CD4 counts and VL had higher PPVs compared to HPV test alone for identifying ASCUS+ or LSIL+. PPV of HPV‐CD4 combinations yielded higher PPVs compared to HPV‐VL combinations. The NPVs with pre‐, post‐cART, or current CD4 count and VL in isolation or in combinations were comparable to that of HPV test alone.Our results provide a more accurate tool for managing HIV+ women by combining Cobas HPV with CD4 and VL, especially those who had an undesirable pre‐cART CD4 and VL status. Our results also indicate the usefulness of CD4 and VL measurements to identify those at lower risk in the absence of HPV testing. The purpose of the study was to investigate the accuracy of HPV genotype testing in isolation and in combination with CD4 and HIV viral load (VL) for the identification of women infected with HIV at risk for developing cervical cancer. Our results indicated the importance of knowing CD4 and VL status in addition to HPV infection status in identifying women infected with HIV who are at risk for developing CC. Food and Drug Administration approved the Cobas HPV test for use in co‐testing with cervical Papanicolaou smear or as a standalone test for screening women >25 years of age. However, these historical cervical screening approaches and biomarkers of HPV‐related carcinogenesis may have limited utility for that purpose in WWH because of the high positivity rate of high‐risk (HR) HPVs.Based on these factors, it is logical to assume that HPV testing in combination with CD4 cell count and HIV viral load (VL) which are surrogate markers for immune system function and the degree of CD4 cell destruction are likely to more accurately identify women at risk for CC. To our knowledge, however, this is the first study that investigated the accuracy of HPV genotype testing in isolation and in combination with CD4 and VL for the identification of WWH at risk for developing CC.2Study population consisted of 344 Caucasian American (CA) or African American (AA) WWH who have been followed for an average of 15 years and recently seen at the University of Alabama at Birmingham (UAB) 1917 HIV Outpatient Clinic from 2018 to 2020 where they were screened for abnormal cervical cytology and reflex tested for HPV status using the Cobas HPV assay (Roche Molecular Diagnostics). All women have been on cART for ≥6 months and had ≥three CD4 count and VL measurements after the cART initiation date. We used CD4 counts and VL measures at all visits since the time of HIV diagnosis and at the date closest to each patient's cervical cytology diagnosis and Cobas HPV testing. At the clinic, a nurse practitioner collected exo‐ and endocervical samples using clinic standard collection protocols. PreservCyt vials containing cells labeled at the bedside were transported to the UAB cytopathology laboratory for cytological testing and the molecular diagnostic laboratory for HPV testing.33. Post‐cART CD4 count was summarized as proportion of time CD4 count was <100 or <200 or <350 cells/mm3, categorized as higher (≥50% or ≥30%) or lower frequency (<50% or <30%) based on the 50% or 30% cut point. Current CD4 count was the measurement closest to the date of the cytology diagnosis/HPV test results, categorized by the cut points <100 or <200 or <350 cells/mm3. Pre‐cART VL was the mean HIV RNA VL per ml measures prior to the initiation of cART categorized based on the threshold cutoffs ≥10,000, ≥50,000, and ≥100,000 copies/mL. The current and post‐cART VL was categorized as detectable at the level of ≥20 copies/mL, considering 20 copies/mL is the lowest threshold for detecting plasma HIV RNA for the test used at UAB for this population. Post‐cART VL was summarized as the proportion (50% or 30% cut point) of the time VL is detectable.The main variables of interest for the current study were race, age at cervical cytology diagnosis/Cobas HPV testing referred to as current age, HPV results, and pre‐cART, post‐cART, and current absolute CD4 count and VL measures. Pre‐cART CD4 count was the calculated mean CD4 count of all visits prior to cART initiation and was categorized based on the cut points <100, <200, or <350 cell/mmOf the 344 WWH, 98 were diagnosed with atypical squamous cells of unknown significance (ASCUS) or higher‐grade , and 246 were negative for intraepithelial lesions or malignancy . Women were categorized for HPV status based on Cobas HPV test results. Cobas® HPV test (Roche Molecular Diagnostics) uses an automated sample preparation by Cobas 4800 system and concomitant amplification and identification of 13 HR‐HPV genotypes and identifies the presence of HPV16 and HPV18 individually using Cobas Z 480 analyzer. Based on Cobas results, we observed the following categories; positive for HPV 16 and negative for HPV 18 and other HR‐HPVs (n = 4), positive for HPV 18 and negative for HPV 16 and other HR‐HPVs (n = 2), negative for HPV 16 but positive for HPV 18 and other HR‐HPVs (n = 6), negative for HPV 18 but positive for HPV 16 and other HR‐HPVs (n = 14), negative for HPV 16 and HPV 18 but positive for other HR‐HPVs (n = 85), positive for HPV 16, HPV 18 and other HR‐HPVs (n = 2) and negative for HPV 16 HPV 18 and all other HR‐HPVs (n = 231). Because of the small numbers in some categories, we combined women positive for either HPV 16 or 18 or other HR‐HPVs as positive for any HR‐HPV (n = 113) and all those negative for HPV 16, 18, and other HR‐HPVs as negative for any HR‐HPV (n = 231). Studies with larger sample size are required to test associations of interest with specific HPV genotypes.4The characteristics of the population variables were summarized as percentages. We assessed the positive predictive value (PPV) and negative predictive value (NPV) value of Cobas HPV test results (positive or negative), alone and in specific combinations with pre‐cART, post‐cART, and current CD4 count and VL measurements for identifying those with or free of ASCUS+ or LSIL+ in the entire population and stratified by race.5The median age of the study population was 48 years. The majority (83%) of WWH were AAs and 17% were CAs. About 28% of women were diagnosed with ASCUS+ while 17% were diagnosed with LSIL+. About 33% of women tested positive for any HR‐HPV detected by the Cobas HPV test. The number and percentages of women in various categories of individual test results and their specific combinations are shown in Table 3 except for ≥50% of the time post‐cART CD4 <100 (80% PPV for ASCUS+ and 75% for LSIL+), yielded lower or similar PPVs for identifying ASCUS+ (56%–37%) or LSIL+ (50%–26%) compared to the Cobas HPV test result alone. We observed a stepwise decrease in PPV for identifying ASCUS+ or LSIL+ when the CD4 count points ranged from <100 to <350 cells/mm3.The PPV for identifying ASCUS+ or LSIL+ when Cobas HPV test was positive was 61% and 48%, respectively. The NPV for identifying 72% of women diagnosed with NILM against ASCUS+ or LSIL+ was 87% and 95%, respectively. As shown in Figure However, Cobas HPV positive test result in combination with all cut points of pre‐cART CD4, ≥50% of the time post‐cART CD4 and current CD4 had higher PPVs compared to Cobas HPV test alone for identifying ASCUS+ or LSIL+ even with a stepwise decrease in PPVs with pre‐cART CD4 count  and ≥50% of the time post‐cART CD4  Figure  and S2. Similar to CD4 counts, we observed that all pre‐ or post‐cART or current VL measures in isolation had lower PPVs for identifying ASCUS+ or LSIL+ compared to Cobas HPV positive test result Figure  and S4. 3, when combined with any of the pre‐cART VL detectable categories ranging from ≥10,000 to ≥100,000 copies/mL. Similarly, PPV for identifying those diagnosed with ASCUS+ or LSIL+ was ≥79% and ≥70% when pre‐cART CD4 cut point was <200 and <350 cells/mm3, respectively, when pre‐cART VL ranged from ≥10,000 to ≥100,000 copies/mL  and LSIL+ (74%–85%), when combined with any of the ≥50% of the time post‐cART VL detectable categories ranging from ≥10,000 to ≥100,000 copies/mL.  or LSIL+ (75%) were substantially higher than Cobas HPV positive test alone only among individuals with ≥50% of the time post‐cART CD4 <100 cells/mm. Figure  and S6. . Figure  and S6.In addition, we observed that the NPVs for identifying women free of ASCUS+ or LSIL+ with pre‐cART CD4, post‐cART CD4 (≥50% of the time), current CD4 count or VL in isolation or in combination with Cobas HPV test were consistently >70% and >85%, respectively, and therefore, NPV in some categories reached the NPV of the Cobas HPV test result alone for identifying women free of ASCUS+ (87%) or LSIL+ (95%), respectively, Figures . In addiWe also assessed the PPV and NPV of the various tests for detection of ASCUS+ and LSIL+ stratified by race. CA had a higher PPV for identifying ASCUS+ (71% vs. 59%) or LSIL+ (63% vs. 44%) when positive for Cobas HPV test compared to AA. CA women also had higher PPVs for identifying ASCUS+ and LSIL+ for all pre‐/post‐cART CD4 and VL‐related variables in isolation and in combination with Cobas HPV positive test result compared to AA women. However, we observed that AA and CA women had similar NPV with Cobas HPV test for identifying women free of ASCUS+ (88% vs. 87) or LSIL+ (95% vs. 97%). AA women also had similar or slightly higher NPVs for identifying women free of ASCUS+ or LSIL+ for all pre‐/post‐cART CD4 and VL‐related variables in isolation and in combination with Cobas HPV negative test result compared to CA women (data not shown).6HPV DNA detection has been widely incorporated into CC prevention programs since HPV tests are biochemical, readily standardized and have higher NPV for identifying women without precancerous lesions compared to cytology tests that are subjective and require visual identification by experienced pathologists.As expected, we observed that the NPV of the Cobas HPV test was highly satisfactory for identifying women without abnormal cytology, especially LSIL+ irrespective of race. However, the PPV value of the Cobas HPV test for identifying LSIL+ was only 48% in the overall population and 44% in AA women. Our observation that most of the pre‐cART, post‐cART, and current CD4 cut points and VL measures in isolation yielded lower or similar PPVs for identifying ASCUS+ or LSIL+ compared to Cobas HPV test result alone indicated that these HIV clinical variables in isolation are not useful for identifying those with underlying lesions. In contrast, NPV of the same variables in isolation reached the NPV of the Cobas HPV test result alone, especially for excluding the presence of LSIL+ indicating their usefulness in identifying women with no disease. This finding provides a tool for identifying low risk women in a clinical setting where HIV‐related variables are available but not equipped to do HPV testing.More importantly, Cobas HPV test in combination with all cut points of pre‐/post‐cART and current CD4 counts had higher PPVs compared to Cobas HPV test alone for identifying ASCUS+ or LSIL+, yielding higher than 90% PPV with some cut points. We noted that women with pre‐cART CD4 counts <100 in combination with HR‐HPV positive status had the highest PPV of 95% and 94% for identifying women diagnosed with ASCUS+ or LSIL+, respectively. It is known that HIV+ receiving cART can partially restore immune functions. However, persistent systemic inflammation driving their immunodeficiency may persist, particularly in people initiating ART at lower CD4 countsEven though the PPV of Cobas HPV test in combination with VL load was higher than the Cobas HPV test alone, those were somewhat lower than for CD4‐Cobas HPV combinations, suggesting that CD4 counts are more informative than VL in identifying women at risk. Cobas HPV test in combination with all cut points of pre‐cART, post‐cART, and current CD4 counts and VL yielded the best PPVs, especially, >90% PPV with some categories of pre‐cART variables, indicating the importance of knowing patients CD4, VL status during pre‐cART in identifying their risk of developing CC. Overall, our results also suggested that variation in VL from ≥10,000 to ≥100,000 copies/mL had no significant effect on PPV emphasizing the fact that CD4 counts are more informative than VL in identifying women at high risk. Our results also indicated that Cobas HPV test alone or in combination of pre‐cART, post‐cART, and current CD4 counts and VL measures at all cut points are likely to be more useful in identifying abnormal cytology among CA women than AA women suggesting the need to explore other markers that will be beneficial for identifying abnormal cytology in this ethnic group.Our results may also apply to women who had been given HPV vaccines or with effective adherence to cART for the following reasons; Even though HPV vaccines mainly target young adolescents, vaccines are also recommended up through 26 years of age in immunocompromised individuals, including those infected with HIV despite that fact they may get only partial benefit because of their exposure to HPV and its entry into disrupted mucosal epithelium facilitated by HIV tat and gp120 proteins prior to vaccination.Our study has several strengths including a population representative of WWH receiving care in the Deep South, which is disproportionately impacted by the HIV epidemic in the United States; a good assessment of cervical cytology, HPV status, and the availability of CD4 and VL results over a long‐time period. A limitation of the study is using cytology and HPV results at only one time point. Gathering follow‐up data on these variables and using a summary measure of those and confirmation of histological diagnoses of lesions by targeted referral of women for colposcopy based on our results will strengthen the findings of this study. Replication of these findings in other populations of WWH will increase the scientific credibility and application of our findings in the management of WWH at risk for developing CC.None.The UAB Institutional Review Board for Protection of Human Subjects approved the study.Table S1Click here for additional data file.Table S2Click here for additional data file.Table S3Click here for additional data file.Table S4Click here for additional data file.Table S5Click here for additional data file.Table S6Click here for additional data file.


In federal response to the aging population of Vietnam-era Veterans, Congress directed the Department of Veterans Affairs (VA) to create a pilot program to identify and develop best practices for improving hospice care for this population. A first step in VA’s response was to identify whether the end-of-life (EOL) care needs and outcomes of Vietnam-era Veterans differed from previous generations. Using medical records and bereaved family surveys, we examined clinical characteristics, healthcare utilization, and EOL quality indicators for Vietnam-era Veterans who died in VA inpatient settings between 2013-17. Contemporaneous comparisons were made with World War II/Korean War-era Veterans. Compared to prior generations, higher percentages of Vietnam-era Veterans had mental health/substance use diagnoses and disability. Similar percentages of family members in both groups reported that overall EOL care was excellent; however, post-traumatic stress disorder management ratings by families of Vietnam-era Veterans were significantly lower. Although current VA EOL practices are largely meeting the needs of Vietnam-era Veterans, greater focus on mental health comorbidity, including post-traumatic stress disorder, Agent Orange-related conditions, and ensuring access to quality EOL care in the community is warranted. Policymakers and healthcare professionals should anticipate more physical and mental health comorbidities among Veterans at EOL as Vietnam-era Veterans continue to age. Findings are being used to inform the development of standardized EOL care protocols and training programs for non-VA healthcare providers that are tailored to the needs of this population.


Early diagnosis of colitis‐associated cancer and dysplasia through surveillance endoscopy is vital for patients with ulcerative colitis (UC). This study aimed to evaluate the efficacy of autofluorescence endoscopy (AFE) using 5‐aminolevulinic acid (ALA) and to investigate the fluorescence signal localization pattern following 5‐ALA administration in tumorous lesions diagnosed as colitis‐associated cancer and dysplasia. The sensitivity and specificity of tumorous lesions detected by white light endoscopy (WLE) with and without AFE were evaluated.Overall, 13 endoscopic procedures were performed in 11 patients with UC using WLE and AFE following the oral administration of 5‐ALA. The biopsied lesions detected via endoscopy and resected specimens from cases underwent colectomy were assessed histopathologically. The sensitivity and specificity of detecting tumorous lesions by WLE with and without AFE were evaluated.Of the 68 lesions detected and biopsied, 63 were detected via WLE, and five were detected via AFE alone. The sensitivity of detecting colitis‐associated cancer and dysplasia via WLE combined with AFE was 36.4%, and the specificity, positive predictive value and negative predictive value were 94.2%, 57.1%, and 87.5%, respectively. Tumorous lesions displayed three types of fluorescence patterns on AFE.AFE using 5‐ALA can detect colitis‐associated cancer and dysplasia in patients with long‐standing UC and lesions that could not be detected via WLE. The distinctive fluorescence patterns in lesions may permit qualitative diagnoses of colitis‐associated cancer and dysplasia. Patients with long‐standing UC are at an increased risk of adverse outcomes, including colorectal cancer. Currently, the risk of colorectal cancer in UC patients has been recognized to increase with disease durationEndoscopic surveillance of CC and D is commonly performed using a high‐definition white light endoscopy (WLE) and chromoendoscopy (CE), both of which are highly recommended.AFE with exogenous sensitization using substances with an affinity to tumors such as 5‐aminolevulinic acid (5‐ALA) has also been attempted to detect CC and D in UC, but the results are inconclusive.22.1This prospective study was conducted at our hospital between October 2010 and September 2014. The study included patients diagnosed with UC based on clinical, endoscopic and histological diagnoses,The study protocol was approved by the Institutional Review Board and Ethics Committee of The Jikei University School of Medicine . The study was registered retrospectively on March 16, 2016 (UMIN000021402) and implemented in accordance with the Declaration of Helsinki. All participants provided their written, informed consent to be included in the study.2.2After a 12‐hour fasting, 5‐ALA 20 mg/kg  dissolved in 250 mL of distilled water was administered orally, followed by pretreatment with polyethylene glycol  that was performed one hour later. An endoscope equipped with the AFE function  was used. The endoscope was inserted as far as the ileocecal region and the colon was visualized in five sections: the cecum and ascending colon, the transverse colon, descending colon, the sigmoid colon, and the rectum. For each segment, WLE was performed first using CE with indigo carmine (0.08%). All elevated, flat and depressed lesions with boundaries and regional redness detected via WLE were checked for green fluorescence at 615 nm via AFE.2.3The histopathological diagnoses were performed by consensus between two expert gastrointestinal pathologists using the Vienna criteria.2.4All nonsurgical cases were followed up annually with a surveillance endoscopy yearly for 3 to 5 years. The absence of new lesions during the follow‐up period confirmed that CC and D had not been overlooked during the endoscopy.2.52 test was used for analysis. The sensitivity, specificity, positive predictive value, and negative predictive value were calculated. A P value of < 0.05 was considered statistically significant.Statistical analyses were performed by using the STATA software version 15  on the groups identified as cases of suspected neoplastic lesions by WLE/CE and those identified as fluorescence‐positive or ‐negative, as tested by AFE using 5‐ALA. Continuous variables were expressed as mean and range, whereas categorical variables were expressed as numbers and percentages. The diagnostic yield based on the use of AFE using 5‐ALA was unclear and only available as categorical data. However, as the sample size in this study was limited, the Fisher's exact test or Pearson's χ33.1A total of 11 patients  were enrolled and underwent 13 endoscopic procedures , showing that AFE‐positive group detected with 5‐ALA was significantly different from the AFE‐negative group in participants with suspected neoplastic lesions in WLE/CE.In contrast, of the 63 target lesions of suspected neoplastic lesions based on WLE/CE (checked by either WLE or CE), a comparison was made between the groups identified as negative and positive in the AFE using 5‐ALA  to confirm that there were no new‐onset tumorous lesions.3.3Protruding lesion with fluorescent margins: WLE and CE showed a lesion protruding 5 mm in the transverse colon. AFE with 5‐ALA showed a strong green fluorescence signal along the lesion margins. The histopathological assessment revealed a strongly p53‐positive LGD  of CC and D lesions. While among the 63 lesions detected by WLE, only 17.5% (11/63) were tumorous, and 8.3% (1/12) of the tumorous CC and D lesions were missed by WLE. In contrast, seven CC and D tumorous lesions that were detected during WLE were not detected during AFE. This suggests that the AFE examination alone is inadequate for UC surveillance. Combining WLE (which has a high sensitivity) with AFE (which has a high negative hit ratio) would enhance the specificity and negative predictive value,During endoscopic surveillance it is important to reduce mucosal inflammation as much as possible to enable the identification of the characteristic morphology of CC and D. As mucosal inflammation in UC is known to contribute to false‐positive CC and D detection on AFE, lower levels of mucosal inflammation during UC remission were expected to reduce the incidence of false‐positive findings. Therefore, endoscopic surveillance is recommended when patients are in remission.Various technical aspects of endoscopic AFE techniques are critical and should be clinically recognized. The AFE system used in this study detected only autofluorescence and reflected light at a 500‐nm wavelength and did not optimally capture PpIX autofluorescence with a wavelength of 615 nm. This could have reduced the sensitivity and positive predictive value and the number of false‐positive lesions but conversely, may also have increased the specificity and negative predictive value. Since the fluorescence intensity of PpIX increases with 5‐ALA, dose modulation could increase the sensitivity of AFE.This study also showed that tumorous lesions could display at least three distinctive fluorescence patterns on AFE. LGD lesions display a strong green fluorescence pattern at the tumor margins, similar to that previously identified in a mouse model,An alternative technique for detecting UC is NBI. While some reports have found similar or better results in relation to WLE, a recent meta‐analysis found no difference between conventional magnifying endoscopy (CME) and NBI detection, or between CE and NBI.There were some limitations to this study. First, we only compared WLE/CE using indigo carmine and AFE using 5‐ALA and did not investigate its effectiveness using other sensitizing agents and imaging modalities, such as NBI and confocal laser endoscopy.5Careful endoscopic observation is indispensable for detecting CC and D. However, it is possible to perform fluorescence imaging with the same endoscope as that used for WLE/CE and use both WLE/CE imaging and a fluorescence assessment to diagnose suspicious lesions qualitatively. This study suggests that AFE using 5‐ALA can detect CC and D lesions in patients with long‐standing UC, including some lesions that are not detected with WLE. Additionally, distinctive fluorescence patterns in lesions can enable the qualitative diagnosis of CC and D lesions.The authors have no conflicts of interest to declare.


Methylene blue is a fluorescent dye discovered in 1876 and has since been used in different scientific fields. Only recently has methylene blue been used for intraoperative fluorescent imaging. Here, the authors review the emerging role of methylene blue, not only as a dye used in clinical practice, but also as a fluorophore in a surgical setting. We discuss the promising potential of methylene blue together with the challenges and limitations among specific surgical techniques. A literature review of PubMed and Medline was conducted based on the historical, current and future usage of methylene blue within the field of medicine. We reviewed not only the current usage of methylene blue, but we also tried to grasp its’ function as a fluorophore in five main domains. These domains include the near-infrared imaging visualization of ureters, parathyroid gland identification, pancreatic tumors imaging, detection of breast cancer tumor margins, as well as breast cancer sentinel node biopsy. Methylene blue is used in countless clinical procedures with a relatively low risk for patients. Usage of its fluorescent properties is still at an early stage and more pre-clinical, as well as clinical research, must be performed to fully understand its potentials and limitations. Ever since German chemist Heinrich Caro first prepared methylene blue in 1876, it has been described as the first fully synthetic drug used in medicine ,3.Methylene blue is commonly used in medical practice, especially as a dye in microbiological staining. This function has now lent itself to the operating theatre, where methylene blue is often used as an marker and indicator in various surgical techniques ,5,6. RecLastly, methylene blue can be used to detect lung nodules during thoracoscopic procedures  InterestThe main effect of methylene blue on molecular level is through modulation of the cyclic guanosine monophosphate (cGMP) pathway. Additionally, multiple cellular and molecular targets of the MB compound have been identified. Many studies describe in detail the mechanisms of MB at the molecular level ,29.Near-infrared (NIR) imaging is a novel technique that uses near-infrared light to help surgeons visualize different structures and allows them to see beyond the normal white light spectrum . The NIRFluorophores are excited by a specific wavelength of near-infrared light that reemits back an appropriate light visualization. The wavelength of this light is a longer one . Due to In most cases, lamps in the operating theatre have to be dimmed to the same level used during laparoscopic procedures .The Federal Drug Administration (FDA) and the European Medicines Agency (EMA), have approved the clinical use of Indocyanine Green (ICG), Methylene Blue (MB) and 5-amino-levulinic acid (5-ALA) fluorophores. In our review, we focus on methylene blue, emphasizing that it is not considered a pure probe, due to its visual light emission spectrum of 400–700 nm . MethyleMethylene Blue when used together with a special NIR system for the detection of fluorescence, allows for the visualization of previously hidden structures during surgery. Below, we describe the major domains where the MB NIR guided surgical technique can be used.Iatrogenic ureter injury during surgery is a rare adverse event, but is considered one of the most serious complications. It is especially common during lower abdomen surgeries—especially gynecological interventions, where the prevalence ranges between 0.15 to 1.5% ,40,41,42Verbeek et al. was the first to report the use of NIR fluorescence-guided surgery to visualize the ureters by intravenous injection of methylene blue . In 12 pBarnes et al. reported identification of 64 out of 69 ureters during colorectal surgery of 40 patients . MoreoveOne of the limitations of using methylene blue to visualize the ureters is the potential impairment of renal function because it is excreted by the kidneys. Another limitation is the restriction of MB use only for patients who are capable of converting MB into the non-fluorescing leucomethylene blue, which is caused by the reduction and/or acidity of the environment ,50.−1 × cm−1, peak emission at 688 nm [Allergic reactions to MB occur more frequently at doses above 5 mg/kg, therefore, use of methylene blue should be with the smallest efficacious dose ,51,52,53t 688 nm .When diuretics are used in conjunction with methylene blue, the increase in urinary excretion does not affect the fluorescence of the MB dye. This could be related to the greater dilution of urinary-methylene blue . Matsui Novel experimental dyes are currently in development . In the Localization and dissection of the parathyroid glands is still a formidable challenge during surgery. Detection of the enlarged glands is often difficult due to their variability in number and location. Incorrect diagnosis of the parathyroid glands during surgery may result in serious complications . The firCurrently, there are nine parathyroid identification methods available on the market: autofluorescence spectroscopy, autofluorescence imaging, ICG imaging, methylene blue fluorescence imaging, 5-ALA, optical coherence tomography, laser speckle contrast imaging, dynamic optical contrast imaging, and Raman spectroscopy ,63,64,65Methylene blue is traditionally injected intravenously in a high dose (3–7.5 mg/kg) to allow for the naked eye to be able to see the enlarged parathyroid glands as they are stained blue, but as mentioned earlier, these doses are associated with many adverse effects and should be used with caution ,67. The The lowest dose of methylene blue that has been administered intravenously to differentiate parathyroid glands from the surrounding thyroid tissue is 0.05 mg/kg, but the fluorescence only lasts for a few seconds, which makes it less than ideal for resections of the parathyroid glands .Fluorescence of an abnormal parathyroid gland is greater than a normal one . HoweverSurprisingly, we can observe auto-fluorescence of parathyroid glands prior to fluorophore injection . De LeeuIn search for parathyroid adenomas, Van der Vorst et al. administered 0.5 mg/kg of MB (at a concentration of 10 mg/mL) intravenously for 5 min to a group of 10 patients after dissecting the neck tissues . This reMethylene Blue accumulates in neuroendocrine tumors when injected intravenously, but the precise mechanism of this action is unknown. Initial reports of its clinical application have been described .p < 0.05). The lack of statistical difference in SBR doses of 1 and 2 mg/kg may be associated with a plateau phase of the signal strength, thus reaching the quenching threshold or saturation of the signal absorption process. Neoplastic lesions (insulinoma) of the pancreas were able to be distinguished from healthy tissue in NIR fluorescence within 2 min after intravenous injection of MB. Furthermore, NIR fluorescence was able to detect neoplastic lesions of the pancreas with a diameter less than 1 mm. The higher uptake of MB in the neoplastic tissue showed an insulinoma to pancreas ratio of 3.7 ± 0.5.The first neoplastic lesion of the pancreas (insulinoma) to be stained by using high doses (5 mg/kg) of MB was seen in 1974 . Winner Preoperative and intraoperative difficulties of visualization of the pancreatic neuroendocrine tumors (PNET) may lead to incomplete resection, but in the case of suspected PNET associated multiple endocrine neoplasia type 1 and 2, surgeons have been able to use NIR imaging during surgery to identify lesions . In one Pancreatic solitary fibrous tumors have also been detected using MB as a fluorescent dye with a 1 mg/kg dose, resulting in a SBR of about 3, which remained stable for nearly 15 min . As a reThe possibility of using MB in NIR visualizations of paraganglioma with a smaller second lesion not seen by the naked eye has also been identified .Intraoperative localization of breast cancer tumors is challenging and the high rate of positive margin resections is still a vast problem . Therefop = 0.22).An interesting application of methylene blue and its fluorescent properties is its role in breast cancer margin detection during breast-conserving treatment, as proposed by Tummers et al.  using NIp < 0.05) and that the detection of breast cancer using MB fluorescent contrast was strongly affected. It is worth mentioning that in 5 cases, the fluorescence showed additional tissue that was excised in the group of patients without neoadjuvant chemotherapy. During the histopathological examination, this additional tissue turned out to be benign hemorrhagic tissue. The statistical analysis of the 35 samples showed a sensitivity of 0.63 and a positive predictive value of 0.79 by using MB-based NIR fluorescence.Another study by Zhang et al. showed the possibility of using MB fluorescence imaging to identify breast cancer . This stIn the paper by Jiang et al., the authors presented the first cases of sentinel node biopsy using methylene blue together with fluorescence imagining . These pMethylene blue is a safe drug if used within therapeutic doses of <2 mg/kg . PatientLocalized skin and fat necrosis have been reported after subcutaneous injection during sentinel lymph node biopsy . Tattoo Serotonin syndrome may occur after using methylene blue, especially if used together with other serotonergic drugs like selective serotonin reuptake inhibitor (SSRIs) and serotonin-norepinephrine reuptake inhibitor (SNRIs) drugs. Most cases of serotonin syndrome occurred after doses of 1–8 mg/kg MB via intravenous injection used when trying to visualize the parathyroid glands ,82 in paMethylene blue is contraindicated in patients who experienced hypersensitivity reaction and in patients with renal insufficiency because it is excreted through the kidneys . It is aMethylene blue is potentially teratogenic and should not be used during pregnancy ,20,85,86Methylene blue has been used in the field of medicine for decades, due to its accessibility, wide safety profile, and proved versatility. Despite its limitations, it has shown tremendous promise when used as a NIR fluorophore, especially thanks to its fluorescent properties. The field of near-infrared imagining with methylene blue as a fluorophore is an interesting surgical technique that demands further clinical investigation.


Cervical, anogenital, and some head and neck cancers (HNC) are etiologically associated with high-risk human papillomavirus (HR-HPV) infection, even though additional cofactors are necessary. Epidemiological studies have established that tobacco smoke (TS) is a cofactor for cervical carcinogenesis because women who smoke are more susceptible to cervical cancer when compared to non-smokers. Even though such a relationship has not been established in HPV-related HNC, a group of HPV positive patients with this malignancy are smokers. TS is a complex mixture of more than 4500 chemical compounds and approximately 60 of them show oncogenic properties such as benzo[α]pyrene (BaP) and nitrosamines, among others. Some of these compounds have been evaluated for carcinogenesis through experimental settings in collaboration with HR-HPV. Here, we conducted a comprehensive review of the suggested molecular mechanisms involved in cooperation with both HR-HPV and TS for epithelial carcinogenesis. Furthermore, we propose interaction models in which TS collaborates with HR-HPV to promote epithelial cancer initiation, promotion, and progression. More studies are warranted to clarify interactions between oncogenic viruses and chemical or physical environmental factors for epithelial carcinogenesis. Cervical cancer is a malignant neoplasia that develops in the cervix, the lower part of the uterus that connects this with the vagina . This diHPV is a small non-enveloped virus that belongs to the Papillomaviridae family. Its genome consists of circular double-stranded DNA that contains approximately 8000 bp organized in three regions: a regulatory, noncoding region known as the long control region (LCR), the early (E) region, which encodes for products involved in viral replication, and the late (L) region, which encodes for structural proteins . The E rOnce in the cytoplasm, the viral particle traffics in late endosomes where it dissembles, allowing L2 protein-mediated nucleus translocation . In the The regulation of HPV gene expression is complex and it involves viral and cellular factors, CpG methylation ,40, alteHPV gene expression regulation does not only depend on transcription factors but also on post transcriptional events. During the viral replicative cycle, polycistronic RNAs are transcribed, which undergo alternative splicing through differential use of splicing sites located in the viral genome . Thus, mDuring cell differentiation, the late promoter located at p670 (HPV16) is activated, promoting the high expression of L1, L2, E1^E4, and E5. Additionally, the E8 promoter is activated leading the expression of E8^E2C product . It has Alpha (α)-HPVs are the genus with the best characterization because they have been implicated in cervical, anogenital and head and neck carcinogenesis . In factAs previously stated, additional factors are necessary for HPV-mediated carcinogenesis ,82. It hEpidemiological evidence strongly suggests a synergy between TS and HR-HPV infection for cervical cancer development ,87,88. IAlam et al. demonstrated that benzo[α]pyrene (BaP), a carcinogen present in TS, is able to increase the number of virions and genomes of HPV31 in organotypic epithelial cultures of cervical cells. The authors observed that high BaP concentrations resulted in a 10-fold increase in viral titers while low BaP concentrations increase the number of viral genomes . It was One study suggested that nicotine, an addictive component which is contained at high levels in TS, enhances the activity of HPV16 LCR synergistically with Brn-3a transcription factor and consequently promotes the expression of E6 and E7 oncoproteins . AdditioIt has been established that TS is associated with early cervical carcinogenic alterations and a decreased ability of the immune system to induce HPV clearance in the cervix ,122. In Regarding specific compounds, nicotine shows immunosuppressive properties in some animal models ,130. MorThe most important molecular alterations caused by TS are adduct generation and the activation of signaling pathways after binding tobacco components  to membrane receptors . Some coIt has been demonstrated that HPV16 and 18 infected cells are capable of generating high levels of BaP metabolites, thus increasing adduct formation, DNA damage and probably, favoring the possibility of HPV integration into the host . In accoIt is known that TP53 is frequently mutated in HPV negative tumors, such as those associated with TS ,143. SpeDue to the strong relationship between TS and lung cancer, the role of tobacco has been highly studied in lung cells and patients with this disease. In fact, it has been demonstrated that lung cells exposed to CSE show gene expression alterations in around 3700 genes, the cytochrome P450 enzyme among them . In lungAs previously mentioned, viral oncogenes E6 and E7 play a crucial role interfering with pRb and p53 tumor suppressor functions, which are important events in HPV-mediated carcinogenesis . Some stAnother study demonstrated that eukaryotic translation initiation factor 4E (eIF4E), a crucial factor in translation control and recently evaluated as a plausible oncogene, is induced by E6 and E7 proteins. It has been shown to influence cell proliferation, migration, and apoptosis ,152. MorPIR gene, which encodes the redox sensor Pirin and is upregulated by TS in bronchial cells [PIR is upregulated by HR-HPV E7 oncoprotein dependent on EGFR/MEK/ERK and PI3K/Akt signaling pathways. Subsequently, Pirin protein induces NF-κB activation and is involved in EMT and migration in HPV-positive cervical cancer cells [PIR may be important in both TS and HPV-mediated carcinogenesis. A similar role may apply to the redox-sensitive transcription factor NRF2, which is induced by TS and also upregulated in HPV16 positive cervical cancer cells, suggesting it may act as a potential oncogene [Gene expression alterations in HPV-driven tumorigenesis have been reported which may also be altered by TS. A compelling example of this is the al cells . Likewiser cells . Taken toncogene ,160. Moroncogene . Surprisoncogene . Altogetoncogene . Nicotinoncogene . PTPN14,oncogene . Anotheroncogene , demonstHR-HPV infection is a necessary although not sufficient condition for cervical carcinogenesis. Women who smoke are more susceptible to this disease, suggesting that TS is a cofactor. Additionally, although HPV-driven HNCs are a clinical entity distinct from those HPV-negative cases, a portion of HPV-driven HNCs are from subjects who smoke.Diverse mechanisms have been suggested for a collaboration between HPV and TS in epithelial cancers. First, both TS and HR-HPV affect a plethora of signaling pathways involved in cancer initiation, promotion, and progression, suggesting a complex network of interactions. In addition, experimental approaches demonstrated that TS exposure results in increased E6 and E7 expression and DNA damage in epithelial cells. Moreover, TS affects both innate and adaptative immune responses against HPV. Additionally, specific compounds such as BaP increase HPV replication in cervical cancer cells, with acrolein or nicotine showing immunosuppressive properties. We cannot deny the possibility that additional mechanisms that remain to be discovered may be involved in TS/HPV interactions in cervical and HNCs.Due to the fact that better survival and outcomes in HPV-positive HNCs has been established, it will be of interest to assess the clinical consequences of TS/HPV interaction in patients with HPV-driven tumors. In addition, other environmental factors or pathogens may be involved in collaboration with HR-HPV for epithelial carcinogenesis. The knowledge of such factors and mechanisms will be important to establish both prevention strategies and to find new therapeutic targets for cervical or HNC treatment. Finally, oncogenic viruses such as HPV are good models to study interactions with environmental or host-related factors for human carcinogenesis.


Much is known about the mental health of combat Vietnam Veterans, but less is known about Persian Gulf and post-9/11 veterans and how they compare to those from earlier eras. Using data from an online survey of Oregon veterans, we examine how PTSD symptoms differ by combat exposure across these three cohorts. The sample , was largely composed of White (88%), male (69%) Veterans. Most served in the Persian Gulf (41%), followed by Vietnam (36%) and post-9/11 (23%) eras. ANCOVAs showed significant cohort differences in PTSD, after controlling for severity of combat exposure and demographics   = 4.24, p < .05). Post-9/11 veterans had significantly lower PTSD symptom severity than Vietnam-era veterans but were comparable to Persian Gulf. There were no cohort differences for noncombat veterans. Future research should investigate why Vietnam veterans continue to have worse mental health than younger veteran cohorts. Part of a symposium sponsored by the Aging Veterans: Effects of Military Service across the Life Course Interest Group.


This study uses online survey data from the United States and China to examine how contradictory information and social norms regarding HPV vaccines obtained through social media are related to young women’s attitudes and intentions surrounding HPV vaccination. The results show that exposure to contradictory information on social media had a greater negative association with intentions to receive HPV vaccination among the United States participants than among the Chinese participants, while social norms supporting HPV vaccines had a stronger positive association with intentions to receive HPV vaccination among the Chinese participants than among the United States participants. These findings extend the literature on social media communication regarding HPV vaccination and contribute to our knowledge of cultural contexts that influence intentions to receive HPV vaccination. Human papilloma virus (HPV) is the most common sexually transmitted infection (STI) and is the primary cause of cervical cancer and other HPV-related cancers in women and men . Recent As social media provide tremendous opportunities for people to exchange information and personal opinions related to health issues, including HPV vaccines , recent Additionally, this study applies a comparative approach to examine how the U.S. and China differ in the association between HPV vaccination-related contradictory messages/norms on social media and intentions to receive HPV vaccination. The HPV vaccine was not approved in mainland China until 2016, although the incidence and mortality rates of cervical cancer continue to increase . InteresMore importantly, this study contributes to research on health communication from the perspective of cultural psychology. Traditionally, cultural psychology focuses on the effects that individual-level cultural beliefs and values have on people; however, cultural psychologists also hold that supra-individual contexts play an important role in shaping people’s behaviors . RegardiContradictory information has been defined as statements that are logically inconsistent . Such inFor example, social media sites are rife with myths and anecdotes about the HPV vaccine, including accounts of severe side effects and HPV infection . Such miAnother line of research shows that contradictions can be present in messages containing negative and positive aspects of scientific findings. HPV vaccines are effective in preventing cervical cancer but also have some side effects, such as fever and arm pain. Research has shown that exposure to such two-sided health information can increase the ambivalence of a message and spur reluctance to act on health recommendations .Uncertainty management theory UMT,  holds thIn addition, previous research has measured contradictory information in different ways. Some works have used experimental methods to assess forced exposure to controlled contradictory information . For exaH1a:Greater exposure to contradictory HPV vaccine messages on social media is associated with a more negative attitude toward HPV vaccination.H1b:Greater exposure to contradictory HPV vaccine messages on social media is associated with lower intentions to receive HPV vaccination.In social psychology, social groups, family members, and peers are generally believed to be significant influencers of an individual’s attitudes and intentions . Such inMuch existing research operationalizes normative perceptions in reference to individuals’ offline social contacts, such as their parents and friends . InsteadThis study measures both injunctive and descriptive norms. Injunctive norms on social media refer to a person’s perceptions of approval of HPV vaccination among those with whom he or she interacts on social media; descriptive norms on social media refer to a person’s perceptions of the prevalence of HPV vaccine uptake among those with whom he or she interacts on social media. Thus, we propose the following hypotheses:H2a: Descriptive norms on social media are positively associated with attitudes toward HPV vaccination.H2b: Descriptive norms on social media are positively associated with behavioral intentions to receive HPV vaccination.H3a: Injunctive norms on social media are positively associated with attitudes toward HPV vaccination.H3b: Injunctive norms on social media are positively associated with behavioral intentions to receive HPV vaccination.Traditionally, attitudes have been viewed as a major variable that explains the intention to perform an action within the “attitude-intention-behavior model”  of sociaH4: Attitudes toward HPV vaccination are positively associated with behavioral intentions to receive HPV vaccination.In summary, this study proposes the research model illustrated in There is an increasing call for comparative cross-country/cross-cultural health communication research e.g.,  as healtCultural dimension theory  suggestsUncertainty avoidance measures the extent to which the members of a culture feel threatened by ambiguous or unknown situations . The mosFurthermore, in individualistic cultures such as the U.S., social behaviors are largely determined by personal goals and values; collectivistic cultures such as China are more influenced by the goals and values shared among collectives . It has RQ: How do the U.S. and China differ in the associations between HPV vaccination-related contradictory messages/norms on social media and behavioral intentions via attitudes toward HPV vaccination?We conducted cross-sectional online surveys of both U.S. and Chinese samples. The institutional review board of the university with which the researchers are affiliated approved the study’s protocols, and the participants were provided a consent form prior to completing the survey.For both the U.S. and Chinese samples, eligible participants had to be female, be 18 to 25 years of age and not have received the HPV vaccine. Additionally, this study, which focuses on the contradictory messages and normative influences of social media, only recruited subjects who are active social media users and who have encountered information on the HPV vaccine on social media. The researchers asked, “How often do you encounter HPV vaccine-related information on social media?” and excluded subjects who selected “Never.”df = 181, power = 0.80), proving that our sample was more than adequate. As M = 22.21, SD = 2.11). The majority of the U.S. participants had not obtained a bachelor’s degree , and more than half  were not single. Most of the participants were employed  and Caucasian . Most of the U.S. participants reported having had sexual intercourse .For the U.S. sample, an online survey link generated by the Qualtrics platform was distributed to qualified participants via Amazon Mechanical Turk (MTurk) in August 2018. Among 264 eligible U.S. participants, 133 who reported having been exposed to HPV vaccine-related information on social media were included in the study. The results of the power analysis of the overall test of model fit based on the RMSEA suggest a minimum sample size of 118 . The majority of the participants reported having a bachelor’s degree or above . Slightly more than half of the Chinese participants were single . Most of the participants were employed  and reported not having had sexual intercourse .The Chinese sample was recruited through the Chinese online panel WJX.CN in August 2018. In total, 285 eligible cases were recruited, and 31 cases were excluded because they had never been exposed to HPV vaccine-related information on social media. As Exposure to HPV vaccine-related contradictory messages on social media was measured with one item asking the participants to rate the amount of contradictory HPV vaccine-related information they had viewed on social media on a scale from 0 (none) to 10 (very much).Measures of social norms on social media were adapted from Using a seven-point semantic-differential scales adapted from The intention to receive the HPV vaccination was measured using the following three items adapted from Structural equation modeling was employed to test the hypotheses and examine the research question via the Lavaan package in R. The research question was answered using multigroup structural equation modeling.In this section, descriptive statistics are presented first. To examine the seven hypotheses, measurement and path models for the pooled samples were built. Then, the researchers evaluated the metric equivalence of the U.S. and Chinese samples before constructing a multigroup structural model. Finally, a multigroup structural model comparing the Chinese and U.S. samples was assessed.tSMDN = 5.78, p < 0.05; tSMIN = 5.50, p < 0.05), and they encountered higher exposure to contradictory information on social media than the U.S. respondents did . Furthermore, the Chinese respondents had more positive attitudes toward HPV vaccination than the U.S. respondents did . Finally, the Chinese respondents reported greater intentions to receive HPV vaccination than their U.S. counterparts did .As 2/df = 2.09, CFI = 0.99, RMSEA = 0.05, and SRMR = 0.03). Then, a structural model was built for the pooled samples, and the model fit statistics were found to be satisfactory .A measurement model for the four latent variables was built for the pooled samples. p < 0.01). H1b predicts that greater exposure to contradictory vaccine messages on social media is associated with reduced intentions to receive the HPV vaccine. H1b was supported .The first four hypotheses analyze the relationships between predictors and behavioral intentions related to HPV vaccination. H1a predicts that greater exposure to contradictory HPV vaccine messages on social media is associated with a more negative attitude toward HPV vaccination. H1a was supported . H2b predicts that descriptive norms on social media are positively related to behavioral intentions to receive the HPV vaccine. H2b was supported . H3a predicts that injunctive norms regarding HPV vaccination are positively associated with attitudes toward HPV vaccination and examines the mediating role of attitudes. H3a was supported . H3b predicts that injunctive norms on social media are positively related to behavioral intentions to receive the HPV vaccine. H3b was not supported .H2a predicts that descriptive norms regarding HPV vaccination are positively associated with attitudes toward HPV vaccination. H2a was supported .H4 predicts that attitudes toward HPV vaccination are positively associated with the intention to receive the HPV vaccine. H4 was supported  met the recommended cutoff points and were superior to those for the model in which all pairs of coefficients were constrained as equal  . The specific tests and results are reported below. Additionally, the study controlled for whether the respondents lived with their partners/spouses (dummy), whether they were sexually active (dummy), and for their education level (not displayed in the figures). Only education level was found to be associated with attitudes and intentions regarding HPV vaccination.To answer the research question, the researchers operationally examined how the seven sets of path coefficients (the four hypotheses) varied between the samples from the two countries. In practice, the researchers built one model with all seven pairs of path coefficients constrained to make them equal and another model with one pair of path coefficients that were different from each other while the other six pairs of regression coefficients were made equal. Then, the researchers conducted a χrent see . The fit2[1] = 2.19, p = 0.14); the non-standardized coefficient was -0.093 (p < 0.05). The relationship between descriptive norms on social media and attitudes (H2a) indeed varied between the two groups  but was not statistically significant for either group . The association between injunctive norms on social media and attitudes (H3a) differed between the Chinese and U.S. samples : a positive relationship was found for the Chinese sample  but not for the U.S. sample .The association between contradictory information exposure and attitudes (H1a) was the same across the two cultural groups . Exposure to contradictory information was not related to behavioral intentions in the Chinese sample , while for the U.S. respondents, exposure to contradictory information was negatively related to behavioral intentions . The relationship between descriptive norms on social media and intentions (H2b) was identical across the two groups ; the non-standardized and standardized coefficients were 0.25 and 0.24 (0.14 for the U.S.) (p < 0.05), respectively. The relationships between injunctive norms on social media and behavioral intentions (H3b) were also the same across the groups  and were not related .The association between exposure to contradictory information and behavioral intention (H1b) differed between the Chinese and U.S. samples . The magnitude of the coefficient of the association between attitudes and behavioral intentions for the Chinese sample  was much smaller than that for the U.S. sample .The association between attitudes and behavioral intentions (H4) exhibited between-group differences  plays a role only for Chinese participants. The study also shows some similarities between the two cultural groups. First, the respondents’ attitudes are similarly associated with perceived contradictions in HPV vaccination-related messages; second, descriptive norms are related to behavioral intentions but not to attitudes. Possible explanations for the observed similarities and differences are provided below.According to the descriptive statistics, the Chinese respondents have more favorable attitudes toward and stronger intentions to receive the HPV vaccine, and they report higher levels of exposure to contradictory information, descriptive norms, and injunctive norms regarding HPV vaccination than their U.S. counterparts. This might be because HPV vaccination is relatively new in China but not in the U.S. In 2018, the HPV vaccination rate in the U.S. was 51% among young people between the ages of 13 and 17 years , June 24Among the hypothesized main effects, contradictory information promulgated through social media is indeed negatively associated with attitudes and behavioral intentions, while attitudes are positively associated with behavioral intentions. Attitudes were found to mediate the relationship between contradictory information exposure on social media and the intention to receive the HPV vaccination. Previous studies on media effects mostly indicate that people’s attitudes and intentions are affected in the direction in which media content directs them. For instance, The study found that injunctive norms on social media are positively associated with attitudes, which in turn are positively associated with behavioral intentions. That is, injunctive norms on social media and behavioral intentions are associated via attitudes. These findings, which resulted from pooling the data for the U.S. and Chinese respondents together, are in line with our predictions and with theories and previous empirical studies e.g., . HoweverThe multigroup SEM found that the association between exposure to contradictory information on social media and attitudes vary little between the Chinese and U.S. respondents. This indicates that the attitudes are similarly related to contradictory messages for both groups. Media messages often change people’s behavioral intentions by changing their attitudes . HoweverThrough the multigroup analysis, it was found that descriptive norms on social media play the same role in both groups. Upon seeing that other social media users have received the HPV vaccine, both the Chinese and American respondents were more inclined to do be vaccinated, and attitudes did not mediate this relationship in either group. In analyzing the main effects, it was found that descriptive norms on social media are not related to behavioral intentions overall but are related when the data are separated by group. This might be related to the non-equivalence of factor error variance between the two country groups. When we separated the data by country, this link became statistically significant. This finding indicates an interesting mechanism by which descriptive norms can be directly related to behavioral intentions without necessarily changing attitudes. Future research could further examine whether such mechanisms affect other human behaviors. The results also suggest that leveraging social influence through social media during an HPV communication campaign can supplement traditional mass communication-based campaign strategies  that focAdditionally, injunctive norms perceived through social media were positively associated with behavioral intentions (via attitudes) only for the Chinese sample. Again, this shows the effects of collectivism versus individualism. Collectivistic cultures place greater pressures on individuals to identify with in groups than individualistic cultures . PreviouThis study has some limitations. First, some measurements could be further refined in future studies. Due to the study’s exploratory nature, it did not measure individual-level cultural beliefs; future studies can measure these beliefs to validate cultural differences between our two sample groups and to discover the precise mechanisms involved. The results of the study could be made more robust if individual access to health care and levels of insurance coverage for HPV vaccines were measured, as the two countries differ in terms of health care systems and insurance policies. This study measured perceived norms and attitudes using short scales, and future studies could use longer scales to improve reliability. Another variable, “exposure to contradictory messages,” was measured with one item, which might have introduced reliability problems and influenced the explanatory power of this variable. In terms of behavioral intentions, we failed to set a time frame for vaccination intent, which made it a weaker measurement in terms of tracking real differences in behavioral intent.The study’s sample could be further improved. The study included only young female participants, limiting the generalizability of the study. We focused on this population because HPV vaccines are currently primarily provided to this group in China due to limited supplies. However, it would be worth examining cultural differences using a more diverse sample. Our data also show that more U.S. respondents than Chinese respondents were screened out of this study because Americans are less likely to be exposed to HPV vaccine-related information through social media. There might be two main reasons for this difference. First, the HPV vaccine is still a new issue for most Chinese due to its more recent availability in China, and this novelty may generate more discussion of the issue on social media. Chinese social media users may thus also be more motivated than their American counterparts to seek information related to the HPV vaccine. In addition, high social media penetration rates among young people in China  and ChinThe present study also has some other general limitations. First, the research model employed was not tested with a random sample, which might have affected the robustness of the results; thus, we should be cautious when generalizing them to the population at large. In addition, as our data are cross-sectional, we cannot establish causal relationships among variables. Considering the abovementioned limitations, we should be careful when generalizing the findings of this study to the broader population, such as females above the age of 26 years, males, or people from other cultures.Despite these limitations, the present study still makes unique theoretical and practical contributions. Theoretically, the study expands the literature regarding the effects of contradictory information exposure and social norms on health attitudes and behaviors through the lens of social media, which has not yet been substantially studied. Moreover, the study reveals cross-cultural differences in how these factors are associated with intentions to receive the HPV vaccination. Since the U.S. population has been previously reported to show less tolerance for uncertainty than the Chinese population , the resPractically, the prevalence of unverified and flawed health information on social media has posed a great challenge to public health practitioners. Understanding how these factors impact health attitudes and behaviors is crucial for the planning and execution of health communication campaigns. Health institutions and social media platforms may work closely to identify how contradictory information about HPV vaccines is currently presented on social media and then make efforts to address confusion caused by such information by providing clear and easily understandable HPV information. Meanwhile, HPV communication interventions may also consider mobilizing those who have received the vaccine to share their experiences and express their endorsement so that pro-vaccination norms can be established on social media.More importantly, cultural differences such as those identified in this study require practitioners to adopt culturally sensitive approaches when designing health campaigns for social media. For instance, contradictory messages can be more closely monitored when promoting HPV vaccines in the U.S., while encouraging those who have received the HPV vaccine to spread the word seems to be more important in China.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 IRB of School of Journalism and Communication, Renmin University of China. The patients/participants provided their written informed consent to participate in this study.SP responsible for conceptualization, questionnaire design, data collection, and writing literature review. DZ responsible for data analysis and writing method, result and discussion sections. JZ responsible for conceptualization, questionnaire design, writing discussion section, and editing.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.


Sweden revised their cervical cancer screening program in 2017 to include cytology-based screening for women aged 23–29 years and primary human papillomavirus (HPV) testing for women aged 30–64 years; however, alternative strategies may be preferred. To inform cervical cancer prevention policies for unvaccinated women, we evaluated the cost-effectiveness of alternative screening strategies, including the current Swedish guidelines.We adapted a mathematical simulation model of HPV and cervical cancer to the Swedish context using primary epidemiologic data. We compared the cost-effectiveness of alternative screening strategies that varied by the age to start screening, the age to switch from cytology to HPV testing, HPV strategies not preceded by cytology, screening frequency, and management of HPV-positive/cytology-negative women.We found that the current Swedish guidelines were more costly and less effective than alternative primary HPV-based strategies. All cost-efficient strategies involved primary HPV testing not preceded by cytology for younger women. Given a cost-effectiveness threshold of €85,619 per quality-adjusted life year gained, the optimal strategy involved 5-yearly primary HPV-based screening for women aged 23–50 years and 10-yearly HPV-based screening for women older than age 50 years.Primary screening based on HPV alone may be considered for unvaccinated women for those countries with similar HPV burdens. Cytology-based cervical cancer screening programs have significantly reduced cervical cancer incidence and mortality in most high income countries , 2. AdvaIn Sweden, national cytology-based screening began in 1973 . The scrThe cost-effectiveness of cervical cancer screening using primary HPV testing has been previously evaluated in other settings ; howeverFor unvaccinated populations, primary HPV testing for these women may be considered resource intensive, potentially resulting in more colposcopies due to the higher prevalence of HPV in younger women . HoweverTo inform policy-making for cervical cancer screening in Sweden together with countries with similar HPV epidemiologic profiles, our objective was to assess the cost-effectiveness of cervical screening strategies for women not vaccinated against HPV infections within the Swedish context, including an extensive evaluation of primary HPV-based strategies for younger women.We adapted an existing mathematical model to reflect the natural history of HPV-induced cervical cancer in Sweden in order to project the health and economic outcomes associated with alternative scenarios of screening. For each screening strategy, we calculated the incremental costs and the incremental health benefits of a strategy compared to the next least costly strategy. We removed strategies that were more costly and less effective (strongly dominated) and strategies that were less costly and less cost-effective (weakly dominated). Effectiveness was represented by quality-adjusted life-expectancy (QALE), which is measured in terms of quality-adjusted life-years (QALYs), incorporating disutility due to cervical cancer . Life exThe previously developed microsimulation model  has beenWe adapted the model to reflect HPV-induced cervical cancer in Sweden using a likelihood calibration approach. The model was run over a grid of input parameters to produce simulation predictions, and then those predictions were compared with the ‘observed’ calibration targets to calculate a log-likelihood. The observed calibration targets included Swedish cancer incidence in a pre-screening population, Swedish age-specific HPV prevalence, HPV type distribution in high grade CIN and in cervical cancer. The input parameter set with the highest log-likelihood was taken as the maximum likelihood estimator and we selected the fifty most likely parameter sets using a likelihood ratio test. We used the 50 best-fitting parameter sets to reflect uncertainty in the underlying natural history of disease. Following the calibration, we validated the model to the Swedish context see the .The current guidelines in Sweden  recommend triennial cytology-based screening starting at age 23 years and switching at age 30 years to triennial HPV-based testing up to age 50 years, and reducing the screening interval to every seventh year until age 64 years  was assumed to be 100 percent in our base case analysis. Due to the growing literature on HPV-negative cervical cancer tumours –38, we vBoth the current (HPV-based after age 30 years) and previous  screening guidelines in Sweden were more costly and less effective than alternative screening strategies . The preGiven the Swedish cost-effectiveness threshold of €85,619 per QALY gained, the optimal strategy involved primary HPV testing starting at age 23 years with 5-yearly screening intervals until age 50 years, followed by 10-yearly screening until an exit test after age 60 years . The optSimilar to when using the cost per QALY gained efficiency metric, all efficient strategies involved primary HPV testing when reporting outcomes of colposcopies and QALEs , Table 3Primary HPV-based strategies at 5-yearly intervals starting at age 23 years remained optimal across all sensitivity analyses, but the optimal screening frequency for women aged 50 years and older as well as the wait-time prior to repeat testing for HPV positive, cytology negative women varied across sensitivity analyses , we found that the strategy involving 5-yearly screening with primary HPV starting at age 23, 7-yearly screening from age 50, and 24 months follow-up time for HPV-positive, cytology-negative women was consistently projected to be on the efficiency frontier in 94 percent of the parameter sets , and provides more health benefit at a lower cost. Note that introducing self-sampling, as a complement to office-based collection, and a reduction in costs due to testing at scale may further improve the cost-effectiveness of primary HPV testing.In our sensitivity analyses, primary HPV testing for all ages remained consistently more effective and less costly, the optimal start age remained at 23 years, and 5-yearly screening intervals for women under 50 remained optimal. Assuming either 90 percent sensitivity for HPV tests, or changing compliance or cost assumptions resulted in a strategy that reduced the screening interval to seven years for women over age 50 years compared to the optimal strategy identified in the base case analysis. Importantly, the optimal strategy from the base case analysis was identified as cost-efficient in 36 percent of the parameter sets, while the corresponding strategy with seven-year intervals for women over 50 years of age was on the efficiency frontier for 94% of the parameter sets.Overtreatment and unnecessary colposcopies are a potential concern when using primary HPV testing for women less than age 30 years. When using colposcopy as an outcome, we found that primary HPV screening alone continued to dominate the other strategies. An important difference compared to the cost-effectiveness analysis was that the majority of the strategies on the colposcopy frontier involved waiting 36 months for HPV-positive and cytology negative women rather than 24 months. There is, however, a trade-off between follow-up time for colposcopy and effectiveness, where longer follow-up intervals for colposcopy may reduce resource use and costs by allowing for HPV to spontaneously clear, while possibly leading to disease progression and poorer outcomes .The cost-effectiveness of primary HPV screening in women under 30 years of age may reflect country-specific variations in HPV prevalence, which in Sweden is lower compared to Denmark and Norway . HoweverA strong advantage of our modelling approach is that we calibrated the model to detailed, linked health and population registers from Sweden. Using the calibrated model, we were able to validate the model predictions with data that were not used to inform the model inputs; from the validation, we found strong consistency with observed Swedish data for contemporary cervical cancer incidence rates Click here for additional data file.S1 Material(ZIP)Click here for additional data file.


The role of viruses as a cause of breast cancer (BC) has been significantly investigated in recent years. Human papillomavirus (HPV) has been detected in invasive breast carcinomas, while most studies have only focused on the detection of viral DNA, we aimed to examine the prevalence and genotypes of HPV among Iranian BC patients.We also examined the presence of herpes simplex-1 (HSV-1), herpes simplex-2 (HSV-2), varicella zoster virus (VZV), and cytomegalovirus (CMV) in these samples.We collected and analyzed 70 Formalin-Fixed Paraffin-Embedded (FFPE) blocks including 59 BC samples, and 11 benign breast lesions as control from Iranian patients using nested PCR. Real-time PCR utilized as a confirming test to nested PCR findings. Genotyping of HPV positive samples was performed, the samples were also subjected to a multiplex PCR to detect HSV-1, HSV-2, VZV, and CMV in BC.Papillomavirus DNA was present in 7 of 59 BC samples (11.8%); while none was detected in control samples. The most prevalent type was HPV18, followed by HPV 6. All HPV positive patients had high tumor grades (II/ III) with a histologic diagnosis of ductal carcinoma. The patient age range was 33 to 73 years with a median of 51 years. Most of HPV positive patients had low levels of education. HPV16 was not detected. Also, 5 of 59 BC specimens (8.47%), were positive for HSV-1. But none of the samples were positive for HSV-2, VZV, and CMV.Our results suggest a carcinogenesis role for High-risk HPV (HPV18) in breast tumors. Our findings of HSV-1 and low-risk HPV (HPV6) in BCs may propose a cancer-causing role for them. Further large-scale studies are warranted to assess the significance of our findings. Breast Cancer (BC) is the most prevalent cancer worldwide among women. BC accounts for approximately 30% of female cancers and is the most frequent cause of death in women , 2. OverSome studies have shown the role of human papillomavirus (HPV) in different cancers –17. OverThus far over 200 HPV types have been identified and most of them fall within three genera: alpha (α), beta (β), and gamma (γ). While alpha type (α) is mainly found on mucosal surfaces, beta (β) and gamma (γ) types are usually detected on the skin surface and in hair follicles , 24. HPVBesides, we decided to investigate the presence of herpesviruses  in our collected BC cases, as some studies have reported a relation between a group of herpesviruses and breast cancer –39.This cross-sectional, case–control study was conducted in Modarres hospital, Tehran, Iran, on cases archived between 2008 and 2019 years. A total of 70 blocks of Formalin-Fixed Paraffin-Embedded (FFPE) including 59 samples diagnosed as breast carcinomas, and 11 benign breast lesions as control were collected from the pathology department archives of Modarres hospital. Also, several parameters; such as type of BC, grading of breast cancer, age, and level of education were taken in written format as exclusion criteria and summarized in Table The genomic DNA was extracted from FFPE breast tissues. Then we performed a standard polymerase chain reaction (PCR) to detect HPV DNA. To extract DNA, FFPE tissues were cut in 10 μm thickness by a microtome. Deparaffinization was performed by adding 1 ml xylene and spinning. Afterwards, we centrifuged the samples for 5 min, and supernatants were removed. This step was repeated once, then 1 ml of 96% ethanol was added. Microtubes were put in a 50ºC heating block until ethanol was entirely dried up. Then digestion was performed by adding digestion buffer and proteinase K solution. Later, the microtubes were incubated overnight, and the next day they were placed in a 95 ºC heater. Respectively phenol, phenol–chloroform, and chloroform solutions were added to samples, each step followed by centrifugation, and subsequent removal of the supernatant. Ultimately, ethanol was added, then they were kept overnight in an incubator.gSamples were centrifuged at 12,000The quality of DNA extracted from paraffin-embedded tissue samples was assessed by a forward (ATGTTCGTCATGGGTGTGAA) and reverse (GGTGCTAAGCAGTTGGTGGT) primer pair targeting a sequence within the GAPDH gene. PCR amplification protocol consisted of 30 cycles of denaturation at 95 °C for 30 s; hybridization at 55 °C for 30 s, and elongation at 72 °C for 30 s. A final elongation step was performed at 72 °C for 10 min.2, 50 μM of each deoxynucleotide triphosphate (dNTP) and 2 U of Taq DNA polymerase , 100–200 ng of template DNA, 10 pmol of each consensus outer degenerate primer MY09 (5′-CGTCC(A/C)A(A/G)(A/G)GGA(A/T)ACTGATC -3′) /MY11(5′-GC(A/C)CAGGG(A/T)CTATAA(C/T)AATGG -3′) and distilled water. Thermal cycling (Bio Intellectica) performed with the following program: 5 min at 94 °C, 40 cycles of 1 min at 94 °C, 1 min at 55 °C, and 1 min at 72 °C, with a final extension step at 72 °C for 7 min.All samples were screened for HPV L1 conserved region. The nested PCR assay was performed using two sets of primers (MY09/11 and GP5+ /6+) for two consecutive amplification reactions. The first reaction was performed in 25 μl using 12.5 μl of master mix , 100–200 ng of amplified DNA, and 10 pmol each inner consensus primer GP5 + (5′- TTTGTTACTGTGGTAGATACTAC-3′) and GP6 + (5′-AAAAATAAACTGTAAATCATATTC-3′), and distilled water. Thermal cycling used the following program: 4 min at 94 °C, 40 cycles of 1 min at 94 °C, 2 min at 40 °C, and 2 min at 72 °C, with a final extension step at 72 °C for 4 min.The second reaction was also performed in 50 μl including 25 μl of master mix  , 0, 5 μl of each forward and reverse primers , 0.5 μl of probes  which listed in Table Duplicate reactions for each gene were performed. Probes were labeled with 6-FAM at the 5′ end and TAMRA at the 3′ end.Each PCR was performed with negative (DNA free water) and positive controls .The samples were also subjected to a multiplex PCR to detect HSV-1, HSV-2, VZV, and CMV. The PCR reactions were performed in a total volume of 25 μL containing 12.5 μl PCR Master Mix , 10 pmol of each primer  (Table mPCR (multiplex PCR) conditions were as follows: Initial denaturation (95 °C for 5 min), 35 cycles of denaturation (95 °C for 30 s) annealing (60 °C for 30 s) and extension (72 °C for 30 s); Final extension was given at 72 °C for 10 min. Samples were preserved at 4 °C and then the PCR product was detected by gel electrophoresis.The positive PCR samples were sequenced for HPV genotypes. The DNA sequence was determined with the Big-Dye terminator cycle sequencing kit and an ABI 377A sequencer (Applied Biosystems Inc.).The HPV sequences were edited with the BioEdit program version 7.2.3, and then phylogenetic and molecular analyses were organized using MEGA software program version 6.0.6 . The neiχ2 (Pearson chi-square) and Fisher’s exact test. Odds ratios and logistic regression were also calculated. Statistical significance was set as a P-value less than 0.05.Data were analyzed by SPSS statistical software program version 16.0. The correlations were subjected to The nucleotide sequences of HPV isolates that were found out in this study have been settled in the GenBank database [Accession numbers QED55703–QED55709]. The GenBank accession numbers for HPV6 types are QED55703 and QED55704, and for HPV18 types are QED55705, QED55706, QED55707, QED55708, and QED55709.HPV gene sequences were identified. The patient age range was between 29 to 81 years (mean of 50 years). Only 4 patients had low-grade malignancy (6.7%), and the remaining were diagnosed with high grade 93.3%). Regarding histologic types, 5% of tumors were lobular types, and the remaining (95%) were ductal carcinomas  was positive in all extracted DNA, indicating an adequate quality of DNA.  were positive for HPV DNA. The outer consensus primers MY09/MY11, and GP5+ /GP6+ inner primers were used in nested PCR. The length of products from the first and second steps of nested PCR was 450 bp and 150 bp respectively. None of the control samples were positive for HPV DNA Fig. .Fig. 2AnIn our study, the age range of HPV positive patients was between 33 and 73 years (average age 51). All HPV positive patients had high tumor grades (II/ III). Histologic diagnosis of all positive cases was ductal carcinoma. Most of the patients had low levels of education (57.1%), 14.2% had no education and the remaining had a university degree (28.5%).  of cases using mPCR Fig. . None ofAll positive PCR products were sequenced. Five out of 7 HPV positive samples were HPV18 genotype (~ 72%), and the rest two (~ 28%) were HPV6 genotype Phylogenetic tree was shown in Fig. Based on our findings, the most prevalent type was HPV18, followed by HPV 6. Contrary to our expectations, we didn’t find any HPV16 genotype.All of the HPV positive patients had invasive ductal carcinomas and high-grade tumors. The age range of 30 to 40 years had three positive samples; 2 of them were HPV18 and one of them was HPV6. The age range of 50 to 60 years had one HPV6 and one HPV18 positive samples. The age range of 60 to 70 years and 70 to 80 years, each with one HPV18 positive samples.The worldwide increase in incidence and mortality of breast cancer is considerable . This inDifferences in results may be due to variation in patient age range, the geographical distribution of viruses, techniques, and the quality of samples used in each study. According to a few published papers, the mean age of breast cancer in Iranian women is between 47.95 and 54.6 years –66. In oBC is often labeled as a “welfare disease” because the incidence rate was reported higher in women in Western societies with higher social class and higher education. Of course, this can be related to timely diagnosis and regular checkups, as well as better training in this group .But in 2017, J Bahk and colleagues conducted the age-period-cohort (APC) analysis in Korea. They reported the BC mortality was higher in women with higher education than in women with no education or a primary education during 1983–1992, and the reverse was true in 1993–2012 .In this study, a low level of education was found in 56%, and no education in 20% of patients. And in HPV-positive patients, 57.1% had low levels of education and 14.2% had no education. Regarding our results, most BC patients and HPV positive patients had low levels of education. Therefore, it can be noted that the education, training, and socioeconomic level of individuals can play a significant role in the prevention and timely treatment of breast cancer.In this study, regarding histologic types, 95% of the total tumor specimens were ductal carcinoma and 5% were lobular carcinoma. And all positive HPV samples were ductal carcinoma. Similarly, in 2019, N Khodabandehlou et al. showed ductal carcinoma as the most frequent type in their HPV-positive patients .Also, in the UK base study, NA Salman reported a higher prevalence of HPVs in patients with invasive ductal carcinoma . From thFew studies surveyed the relation of tumor grades and HPV positive breast cancers. As the study of C Kroupis and et al. recorded high-grade tumors in 70.6% of HPV-positive breast cancer cases . In our Ni Li and colleagues stated a remarkable point about the type of samples collected for studies. They showed a higher prevalence of HPV DNA in FFPE samples than fresh samples . AccordiBesides, due to the important role of herpesviruses as a co-factor in the oncogenesis of BC , 71, 72,These data determine further evidence of a possible role for Human papillomavirus and Herpesvirus in breast carcinogenesis, however additional studies in a larger patient population and by techniques with higher specificities can ascertain our results. Also for early detection of cervical cancer, the American Cancer Society guidelines recommend Pap test and HPV DNA testing. Currently, the American Cancer Society recommends mammography for regular breast cancer screening, while further studies on the association between breast cancer and HPV in the future may add HPV screening to this guideline .Overall, in the present study, we identified HPV18 and HPV6 genotypes in 11.8% and HSV-1 in 8.47% of FFPE samples from women with breast cancer.HPV18 was the most common genotype. And coinfection of HPV and HSV-1 was declared in 3.3% of them. Our conclusion suggests a carcinogenesis role for HPV and HSV-1 in breast cancer patients, but it is required to study more to find these viruses' role in Breast cancer.