The aim was to define sub-optimal response to TNF inhibitors (TNFi), compare long-term drug survival rates and identify predictors of sub-optimal response in axial spondyloarthritis (axSpA) patients in a UK cohort.All axSpA patients attending two centres who commenced TNFi between 2002 and 2016 were included. Routinely recorded patient data were reviewed retrospectively. Patients with paired BASDAI at baseline, 3 and/or 6 months were included for analysis. Sub-optimal response was defined as achieving a ≥ 2-point reduction in BASDAI but not BASDAI50, post-treatment BASDAI remaining at ≥4, and in the opinion of the treating physician these patients demonstrated a meaningful clinical response.s.d.). Time to diagnosis was 10 (8.6) years, age at diagnosis was 37 (11.7) years, and age at initiating index TNFi was 48 (11.1) years. Individual index TNFi were Humira , Enbrel , Remicade , Simponi  and Cimzia . The rate of attrition was greater among sub-optimal responders at 2 and 5 years (P < 0.05), but not at 10 years (P = 0.06), compared with responders. Older age at initiation of TNFi was a predictor of sub-optimal response .Four hundred and ninety-nine patients were included: 82 (16.4%) patients were classified as having a sub-optimal response; 64 (78%) males, 78 (95.1%) AS and 55/67 (82.1%) HLA-B27 positive. Results are reported as the mean (A significant proportion of patients continued TNFi despite demonstrated sub-optimal response. Further research needs to be undertaken in order to understand this group. A significant proportion of axial spondyloarthritis patients continued index TNF inhibitor treatment despite having sub-optimal response.Older age is a predictor of sub-optimal response to TNF inhibitors in axial spondyloarthritis.The use of TNF inhibitors (TNFi) has been proved to be an effective treatment for most patients with axial spondyloarthritis (axSpA). Patients treated with TNFi have reported efficacy, with significant improvements in pain, disease activity and physical function . SerologDespite the successes of TNFi in treating axSpA, some patients fail to demonstrate a good response to TNFi. The rates of switching first TNFi owing to lack of or loss of efficacy range from 14 to 56% . Older aAs the use and experience of using TNFi in axSpA increases, it is apparent that a second group of TNFi responders exist. These are patients who respond to TNFi, but the response is sub-optimal. The aim of this study was to define sub-optimal response to TNFi in axSpA, compare long-term drug survival rates and assess predictors in this group of patients.n = 499) who commenced TNFi at two specialist centres  between 2002 and 2016 was undertaken, and patients with paired BASDAI [A retrospective analysis of axSpA patients -point reduction at either 3 and/or 6 months from baseline but did not achieve BASDAI50, and BASDAI remained at ≥ 4 at 6 months, and in the opinion of the treating physician these patients demonstrated a meaningful clinical response. However, it is important to note that despite demonstrating a clinical response, the decision to continue TNFi therapy was based on a shared decision between the patient and the physician. The primary outcome was patients achieving sub-optimal response at 3–6 months. All patients who continued on index TNFi treatment after 6 months were identified and included in the survival analysis.Predictors of sub-optimal response to TNFi were analysed. Patients’ age, sex, time to diagnosis (symptom onset to date of diagnosis), age at diagnosis, age at TNFi initiation, smoking history, family history, HLA-B27 status, presence of extra-articular manifestations, choice of individual TNFi drug, baseline BASDAI and its sub-components were included as variables. Detailed records of concomitant NSAIDs use were not available.2, were used to compare between groups, whereas the Wilcoxon signed-rank test was used for comparison within the group. Survival probabilities were estimated using the Kaplan–Meier method and compared using the log-rank test. Logistic regression analysis was used to assess predictors of sub-optimal response. Multivariable models were used when adjusted for sex, time to diagnosis, age at diagnosis, age at TNFi initiation, smoking history, family history, presence of extra-articular manifestations , HLA-B27 status, choice of individual TNFi drug and baseline BASDAI sub-components. Baseline total BASDAI was excluded from the final model because it has a high collinearity with the individual sub-components of BASDAI. A P-value of <0.05 was considered statistically significant.Statistical analysis was undertaken using SPSS Statistics v.22.0 . Predictors of sub-optimal response to treatment were identified. Non-parametric testing, including Mann–Whitney and χn = 467, 93.6%) who commenced TNFi, and for whom paired BASDAI at baseline and at either 3 and/or 6 months were available, were recruited.Four hundred and ninety-nine axSpA patients (AS s.d.). The number of patients who were classified as having sub-optimal response (≥ 2-point reduction without achieving BASDAI50 but BASDAI remained ≥ 4 at 6 months) was 82/499 (16.4%). These sub-optimal responders consisted of 64 males (78%), 78 (95.1%) diagnosed with AS, and 55/67 (82.1%) were HLA-B27 positive. Time to diagnosis was 10 (8.6) years, age at diagnosis was 37 (11.7) years, and age at starting index TNFi was 48 (11.1) years. Extra-articular manifestations included acute anterior uveitis , psoriasis  and IBD . Family history was positive in 12/40 (30%) patients, and 17/70 (24.3%) were active smokers.Results are reported as the mean , Enbrel , Remicade , Simponi  and Cimzia . At 6 months and 1 year, the survival rates among sub-optimal responders who remained on index TNFi treatment were 90.2 and 85.1%, respectively. The rate of attrition was greater among sub-optimal responders at 2 years  and 5 years , but at 10 years there was no difference between the sub-optimal responders and responders   . SeventyP < 0.05).Univariate and multivariate analyses of sub-optimal index TNFi response at 6 months are summarized in This is the first study to define sub-optimal response and describe the characteristics of sub-optimal TNFi responders in axSpA. From a cohort of 499 axSpA patients on TNFi, we have identified 82 (16.4%) patients who achieved a sub-optimal response. Older age at initiation of TNFi predicted this response. Approximately 90% of these sub-optimal responders continued on index TNFi treatment after 6 months.To our knowledge, there is currently no consensus on the definition of sub-optimal response to TNFi in axSpA. The BASDAI is used widely in clinical practice in the UK to define active disease and as a threshold for eligibility. A cut-off value of 4 has been validated , and thiIn our study, >90% of patients with a sub-optimal response continued on the index TNFi at 6 months. This decision to continue TNFi treatment was at the discretion of the treating physician, which implies that the treating physician considered that they were responding adequately; however, this might have been influenced by switching limitations imposed by NICE guidelines at that time. It is important to note, however, that the option for switching TNFi was available in both centres by local agreement or via an individual funding request process. Studies on continuing TNFi compared with switching in patients with a sub-optimal response are lacking.We report older age at initiation of TNFi as a predictor for sub-optimal response in axSpA. Younger age has been previously reported as a positive predictor for TNFi response , 20, wheThere are limitations to this study. This was a retrospective study based on two centres with limited follow-up data and subjected to selection bias. Missing data might also have contributed to selection bias, because we did not carry out imputation methods during the statistical analyses. The BASDAI collected might not encapsulate the real decision to continue treatment. Data on the presence of peripheral arthritis, enthesitis, CRP, secondary FM, degenerative spinal disease, NSAID use and imaging data were not available for the present study and might have influenced sub-optimal response. One interpretation for continuing treatment in sub-optimal responders is that BASDAI might not be capturing meaningful clinical benefits as determined by patients and physicians. This study also did not include data on all currently available therapies. At the time of the study, IL-17 inhibitors were not available; therefore, there was no option to switch to another mode of action.In summary, a significant proportion of patients continued TNFi despite demonstrating a sub-optimal response. Older age at starting TNFi is a predictive factor. Further studies are required to understand sub-optimal response to TNFi from the perspective axSpA patients and to investigate the optimal treatment choice for this group of patients.Funding: No specific funding was received from any funding bodies in the public, commercial or not-for-profit sectors to carry out the work described in this manuscript.Disclosure statement: K.G. has received speaker fees, consultancy and/or grants from Abbvie, Celgene, MSD, Novartis, Pfizer and UCB. R.S. has received speaker fees, consultancy and/or grants from Abbvie, Celgene, MSD, Novartis, Pfizer and UCB. F.Y. has received funding for attending congresses, speaker fees, consultancy and/or grants from Pfizer, Janssen, Novartis, UCB and Abbvie.


Videoconferencing has been employed in numerous medical education settings ranging from remote supervision of medical trainees to conducting residency interviews. However, no studies have yet documented the utility of and student response to videoconference meetings for mid-clerkship feedback (MCF) sessions required by the Liaison Committee on Medical Education (LCME).From March 2017 to June 2018, third-year medical students rotating through the mandatory, four-week emergency medicine (EM) clerkship at a single medical school were randomly assigned either to a web-based videoconference meeting via Google Hangouts, or to a traditional in-person meeting for their MCF session. To compare students’ MCF experiences we sent out an electronic survey afterward to assess the following using a 0–100 sliding scale: overall satisfaction with the meeting; the effectiveness of communication; the helpfulness of the meeting; their stress levels, and the convenience of their meeting location. The survey also collected data on these demographic variables: the name of the faculty member with whom the student met; student gender, age, and interest in EM; location prior to meeting; meeting-method preference; and number of EM shifts completed.During the study period, 133 third-year medical students responded to the survey. When comparing survey responses between individuals who met online and in person, we did not detect a difference in demographics with the exception of preferred meeting method (p=0.0225). We found no significant differences in the overall experience, helpfulness of the meeting, or stress levels of the meeting between those who met via videoconference vs. in-person . However, individuals who met in-person with a faculty member rated effectiveness of communication higher than those who met via videoconference (p=0.0002), while those who met online rated convenience higher than those who met in-person (p<0.0001). Both effects remained significant after controlling for preferred meeting method  and among EM-bound students .Our results suggest that LCME-required MCF sessions can be successfully conducted via web-based programs such as Google Hangouts without jeopardizing overall meeting experience. While the convenience of the meetings was improved, it is also important for clerkship directors to note the perceived deficit in the effectiveness of communication with videoconferencing. Mid-clerkship feedback (MCF) sessions are formal, one-on-one meetings between medical students and faculty members to assess student progress and address any remediation needs. It is a Liaison Committee on Medical Education (LCME) requirement for all medical school clerkships of four weeks or more in duration.Videoconferencing has been shown to be beneficial in various medical educationAll third-year medical students who rotated through our EM clerkship between March 2017 and June 2018 were invited to participate in the study. During each four-week rotation, 8–12 students participated in the EM clerkship. Individuals who consented to participate in the study were randomly assigned to either a web-based videoconference meeting or a traditional in-person meeting for their EM mid-clerkship feedback session by block randomization. The MCF sessions were conducted by one of three EM faculty members. Each student was assigned to a meeting time with a faculty member based on the faculty member’s availability. All meetings were scheduled for 30 minutes during standard business hours. If their meeting time coincided with a shift, the students were excused from their shift for the duration of the meeting. The meeting involved a case presentation by the student, a review of current clinical grades, and a discussion of the student’s strengths and weaknesses. In-person meetings were held in the EM faculty member’s office. For videoconference meetings, faculty remained in their offices, whereas students were informed they could access their meeting from anywhere with reliable Internet access. Google Hangouts  was used as the videoconference platform.What do we already know about this issue?Videoconferencing is utilized successfully in various medical education settings, though its use for medical student Mid-Clerkship Feedback (MCF) sessions has not yet been investigated.What was the research question?We investigated student perceptions on the use of videoconferencing for mandatory MCF meetings between third-year medical students and our emergency medicine faculty.What was the major finding of the study?MCF via videoconference can be successful without jeopardizing overall experience. However, perceived communication was rated lower and convenience higher than those that met in-person.How does this improve population health?Our finding provides evidence that clerkship directors can potentially incorporate videoconferencing for MCF meetings as an option depending on students’ needs.After their meeting, the participants were invited via university email to complete an anonymous electronic survey  to assesWe used a 0–100 scale since it provided students with greater flexibility, and it would result in greater statistical power compared to an ordinal scale. The directionality of the scale was indicated on the survey as seen in The survey also included questions regarding the following factors: faculty with whom they met, student’s gender and age, shifts completed prior to meeting, interest in EM, location prior to meeting, and meeting-method preference. To maintain confidentiality, the names of the faculty members from the survey have been removed in th/75th percentiles were reported, and p-values were calculated using Mann-Whitney U tests. We used multivariable linear regression models to adjust for potential confounding variables in the relationship between student ratings and group assignment. All analyses were done in R programming language, version 3.5.0 . Statistical significance was set to a p<0.05.Student variables were stratified by meeting method for analysis. For categorical variables, frequencies and column percentages were reported. We calculated p-values using chi-square and Fisher’s exact tests, as appropriate to determine statistical significance. For normally distributed continuous variables, we reported means and standard deviations, and we calculated p-values using t-tests; otherwise, medians and 25Of the 163 third-year medical students who rotated through EM during the research period, 141 consented to participate in the study (86.5%). Eight of the 141 students (5.6%) were excluded from the study prior to the completion of their survey. Five of the eight were excluded due to scheduling conflicts that resulted in a change in their assigned meeting method; one student withdrew from the study due to a personal preference for the alternative meeting method; one was unable to meet online due to technical difficulties; and one was excluded from the study due to a leave of absence from medical school. Of the 133 remaining participants, the survey completion rate was 100%. Sixty-seven participants were randomized to the videoconference group and 66 participants were randomized to the in-person group.Demographic variables are detailed in To determine if there were differences in experience between those who met online vs. in-person, we compared participants’ sliding scale ratings of overall experience, communication, helpfulness, stress levels and convenience of meeting location between the two groups , Table 2Since preferred meeting method was found to differ significantly between the two groups, we used multivariable linear regression models to control for its effect on the relationship between study group and the rating score . OverallTo assess the impact of videoconferencing on students interested in a career in EM, we completed a subgroup analysis on the 31 participants who selected “Yes” to the question, “Do you have an interest in EM career?” Among the demographic variables, no significant difference was identified between individuals meeting via videoconference compared to in-person in any of the variables including preferred meeting method (p=0.0688, Our study assessed the use of videoconference for medical students’ MCF sessions using a prospective, randomized controlled study. We found no difference in overall experience, stress levels and helpfulness of the meeting between students who met via videoconference compared to those who met in-person. However, we did identify significant differences in convenience and communication between the two groups. The non-significant, equally high ratings of overall experience in all participants support our hypothesis that the videoconference can be as effective as in-person meetings for MCF sessions. Our randomized controlled study design provides solid evidence for the non-inferiority of videoconference, indicating that the use of videoconference is a viable option for MCF meetings. However, it is important for faculty and students to note that, while videoconferencing improved convenience, as it can be conducted from any location with Internet access, students felt it jeopardized their communication capabilities. Hence, our study has helped faculty and students identify these as important factors to consider when selecting a meeting method. Additionally, as suggested in students’ qualitative comments, providing them a choice of preferred meeting method may be the optimal solution. Students may have personal preferences regarding which qualities they valued more. Additional studies are needed to confirm whether using meeting methods consistent with student preference has additional benefits on meeting satisfaction as, outside the context of a research study, it is unlikely that students would be randomized to a meeting method.We suspect that the lack of improved overall experience despite higher convenience may be due to the hindrances in communication experienced by the participants. In addition to the lower communication ratings in the videoconference group, seven videoconference participants indicated in the free-text response section that they experienced some level of technical difficulty during their meetings, and one student was unable to complete a meeting due to technological issues. We did not include a question on our survey that specifically asked about technical challenges, as we wanted to keep the survey identical between the two groups. Therefore, it may be possible that additional students experienced technical difficulties but did not mention them in the “additional suggestions” section. In this regard, further investigation of the quality of communication problems would lend insight to future implementation of videoconferencing for MCFs. As technology continues to advance, we expect the audiovisual quality and Internet speeds to concurrently improve and lead to globally enhanced communication capabilities. Lastly, several other studies have used multiple platforms for online medical education, such as FaceTime and Skype.As expected based on previous literature,We are pleased to show that there was no difference in student ratings of their stress levels and perceived helpfulness of their MCF meetings. These results provide additional evidence for the non-inferiority of using videoconference for MCF meetings. It is important to note that stress levels were equally low in both groups of students, indicating MCF meetings at our institution are carried out under low-intensity conditions.Faculty experience was not formally assessed in this study; however, the general feedback from all three attending physicians who participated in the study was positive. The faculty reported that the videoconference format allowed the concurrent completion of the institution’s electronic evaluation forms, which improved the efficiency of the meetings and the perceived accuracy of the evaluation forms. A drawback to videoconferences reported by the faculty was that several students required extra time to obtain video and audio function or to download plug-ins. However, similar delays also occurred with the in-person meetings due to tardiness. The exact number of individuals and the exact durations of the delays were not formally documented in our study. Formal assessments of faculty experience are encouraged in future studies.There are several limitations to our study. First, eight students were excluded from the study after randomization because they elected to meet via the alternative meeting method. We are aware that this may have eliminated several undesirable or desirable ratings of the particular meeting method. Similarly, there was also a minority of students that rescheduled their meeting times based on the meeting method they were randomized into. For instance, if a student had been randomized to do an in-person meeting on a day after an overnight shift, the student may have elected to email the faculty member to ask if they could meet on an alternative day to avoid having to come to campus on post-call day. The faculty members made alternative arrangements whenever possible. Rescheduling for a more convenient time may also have affected survey ratings.Additionally, there may have been biases in the population that consented to participate in the study. It is highly likely that those individuals with strong preferences on particular meeting method deferred the study and self-selected the preferred meeting method; therefore, their experiences are not captured. However, the highly significant differences in meeting convenience and communication despite controlling for the preferred meeting method suggest that a student’s preference for a particular meeting method did not affect the overall results of our study.Lastly, with regard to the study’s methodology the survey instrument has not been previously validated. Although the survey questions do not satisfy any of the “common pitfalls of survey design” detailed by Artino et al.Our study provides preliminary evidence for the efficacy of videoconferences for routine meetings between faculty and medical students during MCF sessions. The survey data showed no differences in the overall experience of individuals meeting via videoconference compared to in-person. Given the improved convenience of videoconferencing, it may be beneficial for clerkship directors to provide it as a meeting option to provide more flexibility for students. However, it is also important for faculty to be aware of the perceived decrease in communication effectiveness related to videoconferencing along with the possibility of technical difficulties. Additional studies in multiple academic locations and using better-validated study tools are needed to confirm the results of our study.


Although humility is an outstanding characteristic of many beloved and respected leaders, little is understood regarding the effect of leader humility on follower job performance. The current study examines how leader humility affects follower performance. Drawing on the self-determination theory, we suggest that leader humility, via follower harmonious passion, contributes to follower performance. With multiphase leader-follower paired data, we find that leader humility is positively related to follower performance, this positive relationship is partially mediated by follower harmonious passion, and the indirect effect of leader humility on follower performance via follower harmonious passion is stronger with a high level of follower humility. Treated as an essential characteristic of leaders by scholars , humilitLeaders have been regarded as an important contextual factor on followers’ work attitudes and behaviors . In thisThe influences of leader humility on their subordinates’ attitudes and behaviors are attracting more attention. Previous studies on leader humility find that it has positive relations with follower engagement , followeAccording to self-determination theory, employees have “three innate psychological needs—competence, autonomy, and relatedness” , p. 68, We would like to suggest a mediating mechanism of leader humility on followers’ performance via their harmonious passion. Passion refers to “a strong inclination toward an activity that people like, that they find important, and in which they invest time and energy” , p. 756.In summary, by the self-determination theory, the main purposes of our study are to examine the link between leader humility and follower performance, and to discover the role of follower harmonious passion and follower humility within this. This study aims to contribute to leadership and passion literature in three ways. (1) Although several studies have examined leader humility’s influence on performance by focusing mainly on collective mechanism , they soOur study follows All three dimensions may work in a self-determination process to benefit follower performance by supporting followers’ work competence and autonomy, given that support for competence and autonomy facilitates their motivation and human growth . First, To go further with the underlying mechanism, our study theorizes that harmonious passion plays a mediating role in the link between leader humility and follower performance. Harmonious passion, resulting from an autonomous internalization of an activity into a person’s identity , is a stFirst, willingness to judge him/herself fairly  and to hSecond, appreciating and acknowledging followers’ strengths and contributions , a leadeThird, open to advice, new ideas, information, and feedback , a humblMotivation is about many aspects of activation and intention, such as energy, direction, and persistence . With a Perceiving a leader’s humility, a team member may feel more autonomy support from the leader, and more freely experience choices and decisions with less pressure. Accomplishing tasks in a way that fits his/her identity, more harmonious passion for his/her job may be stimulated. With a higher level of harmonious passion at work, and being better motivated , he/she Hypothesis 1: Follower harmonious passion mediates the positive relation between leader humility and follower performance.Although humility is a virtue  bringingFor the relationship between leader humility and follower harmonious passion, a key condition is how the followers judge leader humility as a leader’s interpersonal behavior characteristic: Will a follower accept leader humility as a beneficial characteristic which offers follower autonomy support, or a sign of someone weak or lacking confidence which sends out the message that the leader is not qualified or powerful enough?Compared with “superhero” kinds of leaders, such as charismatic or narcissistic leaders, leaders with humility are like unsung heroes . To makeWhen a follower behaves humbly, it is more likely for him/her to appreciate others’ humility as a virtue, considering that the follower approves the advantages of behaving humbly or the merits of being humble. For example, such a follower may have a better understanding of the opportunities offered by a leader with humility and feel more comfortable in the environment created by this leader than other team members who prefer clear orders, instead of being asked to behave independently and creatively. A follower with humility, being the same kind of person as the leader in this sense, is more likely to sense a humble leader’s autonomy support and be more comfortable in an autonomy supportive context, meaning more harmonious passion at work is stimulated. Thus, we hypothesize:Hypothesis 2: Follower humility positively moderates the relationship between leader humility and follower harmonious passion, such that the positive relation between leader humility and follower harmonious passion is stronger when follower humility is high versus low.We have hypothesized the positive relationship between leader humility and follower performance, the positive relationship between leader humility and follower harmonious passion at work, a mediating process linking leader humility and follower performance with follower harmonious passion, and a moderating role of follower humility in the relationship between leader humility and follower harmonious passion. To combine these hypotheses, we raise an integrative moderated mediation model, suggesting that when a follower is of high level humility, perceiving leader humility will lead him/her to sense more autonomy support and feel more comfortable than those of low level humility, causing a greater amount of harmonious passion of him/her at work to be stimulated and contributing to stronger performance improvement. Thus, we hypothesize:Hypothesis 3: Follower humility positively moderates the indirect positive relation between leader humility and follower performance via follower harmonious passion, such that the indirect effect of leader humility on follower performance is stronger when follower humility is high versus low.SD = 4.21). The followers’ average team tenure was 26 months (SD = 31.25).We surveyed 214 employees within 52 work teams from a Chinese high-tech company, during June and July 2017. To test our hypotheses, we designed two versions of questionnaires: a follower version for team members and a leader version for their immediate supervisors, the team leaders. We collected data in two steps: (1) at Time 1, we sent out 214 follower and 52 leader questionnaires and received completed usable responses from 206 followers and 50 leaders ; and (2) 1 month later, we sent out Time 2 questionnaires to those who completed the Time 1 survey, and received completed usable responses from 200 followers and 50 leaders . With the two-step data collection, we obtained the data of 200 leader-follower pairs. The final sample was mostly of males (70%), with an average age of 28.8 years . For all used scales, one member of our research team first translated the English scales into Chinese, another member translated these versions back into English, and a third member compared two versions of English scales and readjusted the translation where the meanings were inconsistent.Leader humility was measured with a 9-item other-report scale . We usedFollower humility was also assessed by We used Follower performance was measured with In this study, we controlled follower age, follower gender, follower team tenure, leader age, leader gender, leader team tenure, and Time 1 follower harmonious passion. We controlled follower age and leader age because people of different generations may value humility differently, especially with the consideration that Chinese society has experienced several significant changes during the previous four decades. Follower gender and leader gender were controlled due to previous studies suggesting female members are more responsive to humble behaviors . FolloweBefore the hypotheses testing, a set of confirmatory factor analyses (CFAs) were conducted to test the discriminant validity of factors in the proposed model – whether the proposed four-factor model is better than more parsimonious models: a three-factor model, a two-factor model and a one-factor model. With a hypothesized model, a CFA is to compare the difference between an estimated covariance matrix and the observed covariance matrix . The smaThe first step of hypotheses testing in this study was to test the mediating effect (Hypothesis 1). One of the most popular logics of mediation testing consists of three steps suggested by 1, β2β) are equal to 0, and p-values for the coefficients  are both below 0.05 (significant) or below 0.10 ; in the third model, the coefficient for X (3β) is equal to 0 or less than that in the first model (1β), meanwhile the coefficient for M (4β) is not equal to 0 and its p-value meets the significance requirement.With a regression module in SPSS, results indicating a significant mediation are: in the first and second model, none of the coefficients for X (To test the moderation (Hypothesis 2), considering that both the independent variable (X) and the moderator (W) are continuous variables, this study followed 7β ≠0 and p-value for 7β is below 0.05 (significant) or 0.10 .Z(X) and Z(Y) are standardized X and standardized Y using Z score, in order to reduce the multicollinearity . With a In a mono-level first stage moderated mediation model, such as the model proposed in this study, the moderated mediating effect can be tested with regression equation as Eq. (7), which is a combination of Eq. (5) and Eq. (6) .12 (β8+β10WHigh|β12(β8+β10Wlow)] does not contain 0. As suggested by The key to test the moderated mediation is the differences between indirect effects with W having different values. Therefore, a moderated mediating effect exists when, with a desired confidence interval, [βOverall, analytical strategy for this study is as follows. After conducting CFAs with AMOS 22, we applied hierarchical regression analyses in SPSS 23 to test the direct effect of leader humility on follower performance, the mediating role of follower harmonious passion (Hypothesis 1), and the moderating role of follower humility (Hypothesis 2). And we run supplementary tests for the mediating effect and the moderating effect with a more rigorous analysis method, bootstrapping analysis  with the PROCESS module in SPSS provided by The variables’ means, standard deviations, reliabilities, correlations, and collection schedule are shown in 2/df = 1.86, NFI = 0.95, IFI = 0.98, TLI = 0.97, CFI = 0.98, and RMSEA = 0.07. The four-factor model has significantly better fit than: a three-factor model, where leader humility and follower harmonious passion items loaded on one factor and all other variables on separate factors ; a two-factor model, where leader humility and follower harmonious passion items loaded on one factor and all other items on a second factor ; and a one-factor model . The CFA results demonstrate acceptable discriminant validity of the four variables.The CFA results for our four-factor model and the alternative models are summarized in β = 0.18, p < 0.01). As demonstrated by the results of model 5 in β = 0.09, p < 0.05). As indicated by the results of model 3 in β = 0.20, p < 0.10) and the significance level of leader humility (T1) is lowered . We then retested the mediation with bootstrapping analysis. As shown by the results in Hypothesis 1 proposes that follower harmonious passion mediates the positive relationship between leader humility and follower performance. We first followed β = 0.07, p < 0.10). We then used bootstrapping analysis to further test the moderating effect. As displayed by the results in The moderating effect of follower humility on the relationship between leader humility and follower harmonious passion is proposed by Hypothesis 2. The Results of model 7 in Hypothesis 3 proposes a moderated mediation suggesting that follower humility moderates the indirect positive relation between leader humility and follower performance via follower harmonious passion. The bootstrapping analysis results reported in This paper examines how leader humility affects follower job performance. The analysis results, supporting our proposed model, generated upon self-determination theory, indicate that both a direct positive relationship between leader humility and follower performance and an indirect positive relationship between them, via follower harmonious passion, are found. They also reveal a moderating role of follower humility on the indirect relationship: follower humility strengthens the positive relationship between leader humility and follower harmonious passion and strengthens the indirect relationship between leader humility and follower performance via follower harmonious passion. The findings of this study generate several interesting theoretical and practical implications.Our findings add knowledge to leader humility, passion and self-determination literature in four ways. First, we enrich the understanding of the routes from leader humility to follower performance. Many studies are interested in leader humility’s influence on team outcomes and follower outcomes e.g., , but onlSecond, we extend leader humility research by considering leadership effectiveness with follower humility, a follower characteristic. The effectiveness of leader humility is influenced by environmental factors, such as top management team faultlines , leadersThird, we link leader humility theories and self-determination theory with followers’ harmonious passion, while previous leader humility research focuses more on role modeling effects. Being role models for followers, leaders model ways of pursuing goals  and theiFourth, consistent with Our study has practical implications as well. By examining the interactive effect of leader humility and follower humility, we suggest that humble leaders need the followers who fit them or recognize their virtues to make their leadership more effective. Although not all persons judge humility as a leader virtue , followeOur study also offers a useful management tool, leader expressed humility, to stimulate follower harmonious passion at work. This study shows that follower harmonious passion at work is not independent of leaders’ behaviors. Express humility trainings can be added to organizations’ leader training programs to facilitate leaders to establish humble behaviors that are likely observed by followers, contributing to the generation of followers’ harmonious passion. Consistent with previous research findings that harmonious passion is positively related to performance , in our Our study has several limitations. First, although we found and logically reasoned the significant relationship between leader humility and follower harmonious passion, we did not test the possible underlying mechanism of this relationship. The focus of our study is the link between leader humility and follower performance, but we did not get into unlimited details in the effect chain. Future research can test our reasoning with felt autonomy support from leaders in the relationship between leader humility and follower harmonious passion or examine other possible psychological mechanism of this relationship. To make a more comprehensive research model, all three kinds of needs in self-termination theory, competence, autonomy and relatedness , can be N = 200), which is not a big one. Future research may test our model with more participants.Second, bootstrapping analyses  results support our proposed mediating effect and moderating effect, while hierarchical regression analyses results indicate that both the mediating effect of follower harmonious passion on the relationship between leader humility and follower performance, and the moderating effect of follower humility on the relationship between leader humility and follower harmonious passion are marginal significant. Therefore, we suspect the marginal significance may be related with our sample size (Third, we use self-determination theory to test the mediating role of follower harmonious passion, but there is another kind of work passion, obsession passion, being proved to be related with performance . ScholarFourth, expressed humility has three dimensions: willingness to view oneself accurately, appreciating others’ strengths and contributions, and being open to feedbacks, advices and new ideas . HoweverFifth, this study tries to discover followers’ psychological mechanism, which leads us to focus on followers’ perception of leader humility and their own judgments of their own humility. We therefore measured both leader humility and follower humility with follower reports. As proposed by several scholars, though, one’s self-rated humility may be different with an other-rated one due to self-serving biases and the nature of humility . Future The purpose of our study is to examine the effect of leader humility on follower performance. This study finds that leader humility contributes to follower performance improvement, and follower harmonious passion partially mediates this positive relationship. The influencing process is moderated by follower humility: when followers are of high level of humility leader humility has a stronger influence on follower harmonious passion, and then on follower performance, than when followers are of low level of humility. As an exploring study to investigate the association between leader humility and follower performance with a self-determination mechanism, this study highlights the link between leaders’ humble behaviors and followers’ work passion.This research was carried out in accordance with the ethical guidelines of the American Psychological Association in protecting participants’ wellbeing and confidentiality. The research was approved by the National Natural Science Foundation of China. By the cover pages of questionnaires and the introduction talk of the research, all subjects were informed of the research purposes, their freedom of participating and quitting the research, and the assurance of the confidentiality.LS proposed the research. HD drafted the manuscript. HD and YW carried out the data analysis. All authors contributed to the research model improvement, participated in the data collection and manuscript revision, read and approved the submitted version.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.


The Swiss Federal Office of Public Health has recommended vaccination against human papillomavirus (HPV) to prevent cervical cancer since 2008. To establish monitoring of the future public health impact of vaccination, baseline population-based data are required. The objectives of this study were to examine the distribution of oncogenic HPV genotypes in biopsies with cervical intraepithelial neoplasia stage 3 or more severe lesions (CIN3+) at the beginning of HPV vaccination programmes and to compare sociodemographic and behavioural factors of women with CIN3+ with women in the Swiss general population.We conducted a retrospective and prospective cross-sectional study with women diagnosed with CIN3+ in Switzerland. Ten pathology institutes from six cantons and three language regions participated. We conducted HPV typing on formaldehyde fixed-paraffin embedded specimens from 2014 and 2015. Women enrolled in 2015 were asked to complete a questionnaire. We described frequencies of HPV types. We also compared demographic characteristics and socioeconomic status in the CIN3 + plus group with the Swiss National Cohort in 2014 and compared risk factors for HPV infection with the Swiss Health Survey in 2012.We included 768 biopsies from 767 women. Four hundred and seventy-five (61.8%) biopsies were positive for HPV 16 and/or 18, 687 (89.5%) were positive for oncogenic HPV genotypes 16, 18, 31, 33, 45, 52, and/or 58 and five (0.7%) were HPV negative. Twenty-eight (10.3%) of the 273 women who completed the patient questionnaire reported having received at least one dose of an HPV vaccine. When compared with Swiss women in the six study cantons, fewer women in the CIN3+ plus study group were of Swiss nationality, more were born abroad and more were single. The study group also had a higher proportion of women with ≥2 partners in the last year, current smokers and was younger at age of first sexual intercourse.Introduction of the nonavalent vaccine could cover approximately 90% of CIN3+ lesions in Swiss women compared with around 60% with the quadrivalent vaccine. Surveillance of HPV genotype distribution in CIN3+, together with information about vaccination and CIN3+ incidence will allow monitoring of the public health impact of vaccination programmes.NCT02323997. Registered 24 December 2014.ClinicalTrials.gov, The online version of this article (10.1186/s12885-018-5248-y) contains supplementary material, which is available to authorized users. Human papillomavirus (HPV) vaccines provide strong protection against persistent HPV infections. Most HPV infections of the cervix are cleared by the immune system, but persistent HPV infections with some genotypes cause cervical cancer . Of moreThe real-world impact of HPV vaccination programmes on morbidity and mortality can only be evaluated by post-licensure comparison of HPV-associated outcomes before and after HPV vaccine introduction. The World Health Organization (WHO), European Centre for Disease Prevention and Control (ECDC) and Australian government  recommenWe designed the CIN3+ plus study to provide information about the feasibility of a future surveillance system and the impact of HPV vaccination in Switzerland. In Switzerland, HPV vaccination programmes for young girls and women began in 2008, organised by health authorities in the 26 cantons (states) and targeting 11 to 14 year old girls, with recommendations for catch up vaccination for women up to 26 years of age. The Swiss Federal Office of Public Health conducted a national survey in 2014 with 2363 women aged 18–24 years and found that 41.3% (95% CI 36.4–46.3) reported receiving three HPV vaccine doses, 4.7% (95 CI 3.3–6-6) two doses and 5.4% (95% CI 3.6–8.0) one dose . CantonaThe CIN3+ plus study period was January 2014 to December 2015. We conducted a cross-sectional study in the year 2015, consisting of retrospectively analysed formaldehyde-fixed paraffin-embedded (FFPE) specimens from 2014 and samples and data from women enrolled prospectively during 2015. We assumed that the majority of women diagnosed with CIN3+ during the study period would not have received HPV vaccination, either because the target age group for vaccination would be too young to have developed CIN3+, or because the uptake of HPV vaccination amongst older women was too low to have had an impact on CIN3+ incidence. Ten pathology institutes from six cantons  and three language regions  participated in the study. Three institutes were based at publicly funded university hospitals, three were publicly funded non-academic institutes and four were private institutes. To select specimens collected in 2014, we provided the institutes with lists of random numbers, which they used to label biopsy specimens with a diagnosis of CIN3+ from women living in any of the participating cantons. We calculated the number of biopsies for each institute, based on the proportion of the total number of CIN3+ cases that each laboratory diagnosed in 2014. We used open access software  to generate the random number lists. If there was not enough biopsy material for testing, we asked institutes to use the next biopsy with CIN3+. We enrolled women prospectively during 2015. We sent information about the CIN3+ plus study to gynaecologists of women who were diagnosed with CIN3+ and who met the inclusion criteria and asked them to obtain written informed consent from the woman. Inclusion criteria were: ≥18 years of age, living in one of the participating cantons and literate in German, French, Italian or English. We published a short description of the study methods and basic results in the bulletin of the Swiss Federal Office of Public Health .We conducted HPV typing on specimens prepared from stored FFPE blocks from cervical biopsies, cone biopsies, endometrial curettage specimens and/or hysterectomies. If more than one biopsy was available for a patient, we analysed the most recent and/or best preserved biopsy. Each institute conducted HPV typing according to their routine practice and standard operating procedures for deparaffinisation, tissue digestion and DNA extraction. All institutes used their routine nucleic acid amplification test, all of which included targets for the IARC-defined high-risk HPV genotypes 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58 and 59 and a variety of other HPV genotypes . We calculated a proxy of socioeconomic position (SEP) for all patients with a valid address using the Swiss neighbourhood index of SEP (Swiss-SEP) . The SwiWe planned a sample size of approximately 900 samples. The inclusion of samples from 2014 allowed us to increase the precision of estimates of type-specific HPV prevalence. The sample size was based on the number of CIN3+ cases diagnosed per year (approximately 760 per year in the participating cantons), a prevalence of 70% for HPV 16/18  and an en = 10) were considered only once in the analysis. One woman had two biopsies with different HPV results and both were included. From 2014, we retrospectively included 474 biopsies from 465 women. During 2015, we contacted the gynaecologists of 795 women diagnosed with CIN3+. Three hundred and four (38.2%) women gave informed consent, 20 declined participation and we received no reply from 471. In addition, 273 patients in 2015 completed and returned a patient questionnaire . Seven-hundred and two of 768 (91.4%) biopsies were diagnosed with CIN3, 33 (4.3%) with adenocarcinoma in situ, 24 (3.1%) with squamous cell carcinoma and nine (1.2%) with adenocarcinoma. Characteristics of retrospective and prospective patients were similar  of the 768 biopsies were positive for HPV 16 only, HPV 18 only or both HPV 16 and 18. Four hundred and thirty five  biopsies were positive for HPV 16 alone and 50  were positive for HPV 18 alone. One or more of the oncogenic HPV genotypes contained in the nonavalent HPV vaccine were present in 687  of the biopsies. One or more of the HPV genotypes classified as oncogenic by IARC were present in 727  of the biopsies. The HPV distribution for retrospectively and prospectively included biopsies was similar (Table p = 0.167).Multiple HPV genotypes were detected in 95  of the tested biopsies. The ranking of the ten most frequent HPV genotypes in our samples was: HPV 16, 56.6%; HPV 31, 12.5%; HPV 33, 7.2%; HPV 18, 6.5%; HPV 52, 5.7%; HPV 58, 4.3%; HPV 51, 3.4%; HPV 35, 2.5%; HPV 45, 2.0%; HPV 42, 1.3%  of the biopsies diagnosed as CIN3 and 24/33  of invasive cervical cancers (adenocarcinoma and squamous cell carcinoma). At least one of the HPV genotypes contained in the nonavalent vaccine was detected in 626/702  of the biopsies diagnosed as CIN3 and 32/33  of invasive cervical cancers  samples were positive for HPV, 20 (2.6%) were negative for HPV and 19 (2.5%) were non-evaluable owing to the presence of PCR inhibitors or lack of material  showed that both groups had the same Swiss-SEP index . Fewer women in the CIN3+ plus study group were of Swiss nationality , more were born abroad  and more were single . Differences in proportions were also observed between the groups in regards to the canton of residence (p < 0.001) and highest education level obtained (p = 0.004) (Table We obtained a Swiss-SEP index for 748/767 (97.5%) of the enrolled women. The comparison of the CIN3+ plus study group with the SNC (n = 3537) (Table p = 0.001) and reported younger age at first sex . Women in the CIN3+ plus study were more likely to report that they were smokers . The proportion of women who reported hormonal contraception use in the last 12 months was 35.5% in the CIN3+ plus group and 41.7% in the SHS group (p = 0.072). A higher proportion of women in the CIN3+ plus study group reported ever having a cervical cancer screening test .Some factors associated with HPV infection differed between the CIN3 + plus study group and SHS (7) Table . Women iIn this cross-sectional study of women with CIN3+ in 2014 and 2015, HPV genotypes 16 and/or 18 were detected in 61.8% of the biopsies analysed and HPV genotypes 16, 18, 31, 33, 45, 52 and/or 58 contained in the nonavalent vaccine, were detected in 89.5% of biopsies. 84.9% contained a single HPV type, 12.4% contained multiple HPV types and only 0.7% of samples had no HPV detected. Only 10.3% of the women who completed a patient questionnaire reported receiving a HPV vaccine. Socioeconomic position was the same for women in the CIN3 + plus study group and the SNC. The CIN3+ plus study population consisted of more single, non-Swiss women born abroad when compared to the Swiss general population. The CIN3+ plus study group had a higher proportion of women with ≥2 partners in the last 12 months, current smokers and were younger at the age of first sexual intercourse when compared with the SHS.A strength of our study for public health surveillance of vaccine impact is that we analysed whole tissue biopsies with CIN3+ rather than cytological samples from cervical smears. This outcome is closer to the clinical endpoint of interest, cervical cancer, than HPV infection or mild dysplasia, which often regress. Additional strengths include the enrolment of women from all three language regions in Switzerland, collection of demographic and behavioural data that allowed a comparison with women in the general population and the inclusion of public, private and university laboratories. Although we only conducted the CIN3 + plus study in six of the 26 Swiss cantons, these cantons include 38.4% of the entire Swiss female population (1612992) , 28. HowWe found few reports of studies conducted to provide baseline data for the monitoring of HPV vaccination impact. Dobec et al. examined specimens from 202 women in Switzerland with cytological abnormalities in 2007 . High riThe top ranking HPV genotypes found in our study are comparable to other European countries, although the relative importance varies, depending on the specimen type and histological diagnosis –36. In tIn the CIN3+ plus study, 61.8% of the biopsies were positive for HPV genotypes 16 and/or 18 and could be covered by the use of bivalent and quadrivalent vaccines. Cross-protection against HPV genotypes 31, 33 and 45 provided by the bivalent or quadrivalent vaccine could increase this estimate . Up to 8When compared with the Swiss general population, women in the CIN3+ plus study group were more likely to have been born abroad, be single and to have completed secondary level education. The higher proportion of non-Swiss in our study population could be due to low screening rates in this population before arrival to Switzerland. These observed differences could also be due to the canton of residence and reflect regional differences. These results are partially consistent with a study analysing data trends from 1992 to 2012 in Switzerland that found that single women, those with a lower education level and who were non-Swiss were less likely to receive cervical cancer screening . The SwiMonitoring of CIN3+ lesions, which are the clinical endpoints of interest, will be particularly important in countries with sub-optimal HPV vaccine coverage in which vaccination herd effects are less likely. The data from this study also suggest that introduction of the nonavalent HPV vaccine could help to prevent most CIN3+ cases in Switzerland if the uptake of HPV vaccination can increase further. The introduction of a two-dose vaccine schedule in 2012 for girls 11–14 years old and for boys since 2015  should hThe results of this study provide valuable information for the establishment of a surveillance system for HPV-associated cancers, especially cervical cancer, in Switzerland and other countries with similar healthcare systems . MonitorIn conclusion, we have documented the HPV type distribution in high-grade cervical lesions at the beginning of the Swiss cantonal HPV vaccination programmes. Quadrivalent and bivalent vaccines cover around 62% of CIN3+ lesions and 73% of invasive cervical cancers, whereas the nonavalent vaccine would cover about 90% of CIN3+ lesions and 97% of invasive cervical cancers. Together, sentinel surveillance of HPV genotype distribution in CIN3+ lesions, including information about HPV vaccination, and of cervical cancer incidence in cancer registries will provide the information needed to monitor HPV vaccine effectiveness in Switzerland and to plan the required public health activities.Additional file 1:Table S1. Primary tests used by laboratories and HPV genotypes included in test. Table S2. Comparison of retrospective and prospective patient characteristics. Table S3. HPV genotype distribution according to rank after confirmatory testing by WHO HPV Reference Laboratory (n = 768). Table S4. HPV genotype distribution according to histological diagnosis. Table S5. Comparison of female general population in Switzerland and female population in CIN3+plus study cantons in 2016. Figure S1. Retesting of HPV negative and non-evaluable biopsies by WHO HPV Reference Laboratory. (DOCX 70 kb)


Anyplex II HPV28 (`Anyplex`) is a semi-quantitative DNA PCR assay divided into set A, comprising 14 high risk (hr)HPV types; and set B, comprising 5 possibly hrHPV types and 9 low risk (lr)HPV types. We compared the ability of Anyplex to that of Hybrid Capture 2 (HC2) and PreTect HPV-Proofer (`Proofer`) to detect cervical intraepithelial neoplasia grade two or worse (CIN2+) by HPV types and viral load. This cross-sectional study included 296 women referred to colposcopy with abnormal cervical cytology and/or persistent HPV infection. CIN2+ was identified in 175/296 women. Liquid based cytology samples were used to perform HPV testing. The sensitivity of Anyplex to detect CIN2+ was 98.9% (95% CI 95.9–99.9) and specificity 43.0% (95% CI 34.0–52.3). Restricting to medium and high viral loads in Anyplex set A, sensitivity and specificity were 97.1% (95% CI 93.5–99.1) and 59.5% (95% CI 50.2–68.3) with positive (PPV) and negative predictive value (NPV) 77.6% and 93.5%, respectively, comparable to HC2. Restricting Anyplex to the hrHPV types in Proofer, HPV16, 18, 31, 33 and 45, sensitivity and specificity for CIN2+ were 85.1% (95% CI 79.0–90.1) and 71.1% (95% CI 62.1–79.0), comparable to Proofer`s. When adding HPV52 and 58, the sensitivity for CIN2+ was 92.6% (95% CI 87.6–96.0) and CIN3+ 96.5% (95% CI 92.0–98.8). No value of Anyplex set B was found in detecting CIN2+. In conclusion, the clinical performance of medium and high viral loads in Anyplex set A was comparable to HC2. Restricting the test to the 7 hrHPV types included in the 9-valent HPV-vaccine, HPV16, 18, 31, 33, 45, 52 and 58, satisfies the international criteria for cervical cancer screening with relative sensitivity compared to HC2 for CIN2+ and CIN3+ of 0.98 and 1.01, respectively. Detecting all 28 Anyplex HPV types adds no benefit in a referral population. Human papillomavirus (HPV) testing is frequently used in triage, follow-up and increasingly used in primary cervical cancer screening. HPV genotyping has focused on HPV 16 and 18, based on their contribution to cervical cancer. But in a screening perspective, the aim is to prevent cancers by detecting precursor lesions, where other types are highly important. Most commercial HPV tests targeting high risk (hr) HPV types are detecting the 12 carcinogen HPV types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58 and 59), in addition to HPV 68, classified as probably carcinogenic, and HPV 66, a possibly carcinogenic type , while sThe need for better risk stratification of HPV DNA-positive women increases as the positive predictive value (PPV) of any HPV test, both in terms of HPV positivity and identifying women with CIN2+, will be affected by the decreasing prevalence in women who undergo repeated HPV screening. In addition, genotyping tests might prove useful in the screening of vaccinated women.The full genotype information provided by Anyplex allows for immediate risk stratification based on genotype and viral loads, and might prove highly useful in screening, follow-up and in a post-treatment setting. In this study, we compared the ability of Anyplex to that of the DNA test HC2  and the highly clinically specific mRNA test PreTect HPV-Proofer  to detect CIN2+ by HPV type and viral loads in a population with high HPV prevalence population. In particular, we looked at the following five specific groups of HPV types in Anyplex: 1) HPV16 and 18, 2) the five hrHPV types in Proofer, 3) the seven hrHPV types in the 9-valent HPV vaccine Gardasil9, 4) the HPV types in Anyplex set A, and 5) the HPV types in set A and B.The study population and data collection has been described previously . BrieflyFollowing HPV testing, we excluded nine patients who did not have results for all three HPV tests, leaving 296 patients for the current analysis . WrittenAll HPV tests were performed within the framework of a collaboration between the laboratory of St. Olav’s University Hospital and Norwegian University of Science and Technology.HC2 was performed on cell sample aliquots according to the manufacturer’s instructions. HC2 detects 13 hrHPV types . The test does not include genotyping, thus a positive test refers to detection of one or more of the included HPV types. The test has no internal sample control. The residual cell suspensions in LBC samples were stored at 4–8°C for up to 12 weeks before further processing.Nucleic acid extraction for Proofer and Anyplex testing was performed using the semiautomatic NucliSens miniMAG  protocol, which has been validated for both DNA and mRNA tests . A cell The rest of the isolated nucleic acid was stored at -80°C until Anyplex testing was performed retrospectively in 2013, once all women had been recruited, according to the manufacturer’s instructions. Anyplex is a HPV DNA genotyping test that can simultaneously detect, differentiate, and semi-quantify 28 HPV genotypes (19 hrHPV types and 9 lrHPV types) in only two PCR wells per sample. The test is divided into two sets: set A comprises 14 hrHPV types , and set B comprises 5 phrHPV types  and 9 lrHPV types . HPV 70 is categorized as a lrHPV type in Anyplex, although it has been classified as a class 2b carcinogen . The tesBoth for Anyplex and Proofer, samples with negative internal control and a negative HPV result, were re-analyzed by the same test. If the internal control was negative, but the test result was positive, the test result was considered valid. Negative tests with a positive internal control were not re-analyzed, neither were samples with negative HC2 results, since this test has no internal control.All endocervical curettage samples and biopsies were reviewed by two pathologists who were not blinded to referral cytology. Histology was classified according to the WHO classification of 2003 , with CIPerformance of Anyplex, HC2, and Proofer were evaluated according to histology using sensitivity, specificity, PPV, negative predictive value (NPV), and their respective 95% confidence intervals (CIs). Specificity and NPV were reported for <CIN2, since detection of CIN2 was not considered a false-positive result. Agreement between the different HPV assays was calculated by using Cohen’s ĸ as an indicator of concordance; ĸ-values <0.2 indicated slight agreement, 0.21–0.40 weak agreement, 0.41–060 moderate agreement, 0.61–0.80 substantial agreement, and >0.81 almost perfect agreement . StatistMean age among the 296 women in the study sample was 35 years (range 19–75). Mean time from referral to follow-up was 98 days . Referral LBC indicated high-grade disease in 77.7% (n = 230) of the study sample, and histology revealed CIN2+ in 59.1% (n = 175), including five patients with ACIS, four of whom were concurrently diagnosed with CIN3, and three patients with microinvasive squamous carcinoma in cone specimens. All three cancers were diagnosed in participants aged 34–49 years and showed CIN3 in punch biopsies.A total of 245 samples (82.7%) were positive for HPV with at least one HPV test used in the study. Although Anyplex includes a total of 28 HPV types and HC2 includes 13 types, the overall agreement between these assays was substantial (87.8%), with a kappa value of 0.66 (95% CI 0.53–0.75), while the agreement between Anyplex and Proofer, which includes five HPV types, was moderate (73.0%), with a kappa of 0.42 (95% CI 0.32–0.52) .Based on Anyplex results, HPV16 was the most common type, being present in -28.7% of women, followed by HPV31, 52, 18, 33, and 45 in 17.2%, 12.8%, 11.8%, 8.8%, and 7.1%, of the study sample, respectively. HPV type distribution among women with CIN2+ reflected that of the entire study sample, but with higher positivity rates: 41.1%, 22.3%, 16.0%, 14.9%, 13.7%, and 9.1%, respectively . The incAmong the 242 women with positive Anyplex results, 95.9% had medium or high viral loads. When looking at only the 175 women with CIN2+, 173 had positive Anyplex, of whom 99.4% had a medium or high viral load . However, when we restricted analyses to cases with high viral load only, the sensitivity of Anyplex to detect the 175 CIN2+ cases decreased from 98.2% to 61.3% , reflectWe observed very few false-negatives for CIN2+ by Anyplex and by HC2: 2  and 10 , respectively. Among the 242 women with a positive Anyplex result, 69 had CIN1 or normal histology , leavingConsidering only the HPV tests that included genotyping (Anyplex and Proofer), there were some discrepancies in the detection of HPV16, 18, 31, 33, and 45. In women with CIN3+, four cases were negative by Anyplex for the HPV type identified by Proofer, but in three of the four cases, at least one other hrHPV type was identified by Anyplex.The sensitivity of Anyplex set A plus set B to detect the 175 women with CIN2+ was 98.9% (95% CI 95.9–99.9); for HC2 it was 94.3% (95% CI 89.7–97.2), and for Proofer it was 79.4% (95% CI 72.7–85.2) . All thrRestricting the analysis to infections with medium or high viral loads, the sensitivity of Anyplex set A plus set B to detect CIN2+ was still slightly higher than that of HC2 and significantly higher than that of Proofer, and for Anyplex set A, the sensitivity to detect CIN2+ remained high, the PPV raised slightly, and the specificity raised to the same level as HC2.Looking at Anyplex results for HPV16 and 18 only, the PPV was high (82.5%), but only half of the CIN2 and CIN3 lesions and two of the three cancers were detected, leaving a NPV of 55.5% .Adding more hrHPV types to the analysis lowered the PPV and raised the NPV. Analyzing Anyplex by the five hrHPV types in Proofer  raised the sensitivity to detect CIN2+ to 85.1% and the NPV to 76.8%, which was comparable to values for Proofer. The same pattern was observed for CIN3+, and all cancers were detected. When we restricted the analysis to the seven hrHPV types included in the 9-valent HPV vaccine, HPV16, 18, 31, 33, 45, 52 and 58, the sensitivity of Anyplex to detect CIN2+ was 92.6% and CIN3+ 96.5%, leading to a relative sensitivity according to HC2 of 0.98 (95% CI 0.93–1.04) and 1.01 (95% CI 0.97–1.07), respectively. Specificity fell to a level comparable to HC2. Including all HPV types in Anyplex set A, increased the sensitivity of CIN2 from 75.8% to 90.9%, while sensitivity of CIN3+ had a minimal increase to 98.6%. Despite high prevalence of other hrHPV and phrHPV types in CIN2+, the majority occurred in multiple infections together with the 7 vaccine hrHPV types and contributed to little extent in the detection of CIN2+. Specificity fell as more HPV types were included in the analyses, and when including set B in addition to set A in Anyplex, specificity according to CIN2+, fell to 43.0%.In our study, Anyplex, including all 28 HPV types, was a highly sensitive HPV genotyping assay, with a sensitivity of 98.9% to detect CIN2+. This is in line with recent studies that compared Anyplex and other, established genotyping tests , 7, 9. WThe agreement between Anyplex set A plus set B and HC2 was higher than between Anyplex set A plus set B and Proofer, which can be explained by the different HPV types included in the assays, as restricting the analysis to the hrHPV types included in Proofer led to comparable clinical test properties. The observed specificity for Anyplex set A and HC2 in our study was higher than earlier reports , 20. OneOur study supports other findings that the prevalence of multiple-type HPV infections is higher in younger than older women . A largeThere is a potential bias regarding sensitivity, as only the tests including an internal control (Anyplex and Proofer) were re-analyzed if internal control and HPV were both negative at the same time. This was the case in only seven samples tested with Proofer, so any potentially contribution should be minimal. The sensitivity of medium and high viral loads in Anyplex set A fulfilled the criteria for HPV tests in primary screening, which stated that the clinical sensitivity of the HPV test should be not less than 90% of HC2 for ≥CIN2+ , 5. EvenThe specificity of Anyplex to detect CIN2+ in our study might have been increased due to the extraction method performed on pelleted cell aliquots, which allows for the detection of HPV DNA in cell fractions, rather than free HPV viral particles in transport medium that are released during a productive transient HPV infection, as suggested by a previous study on enriched cells comparing type-specific qPCR with HC2 . PelletiWhen we restricted analyses to the seven hrHPV types included in the 9-valent HPV vaccine , almost all CIN3+ and three of four cases of CIN2 were detected, assuming that vaccination with 9-valent vaccine will greatly reduce the burden of HPV-induced cervical disease, but emphasizing the need for a test that will differentiate between hrHPV types other than HPV16/18. Our data show that genotyping beyond type 16 and 18, including the 7-type hrHPV types 16, 18, 31, 33, 45, 52 and 58, satisfy the international criteria for sensitivity in cervical cancer screening with a relative sensitivity of Anyplex compared to HC2 for CIN2+ and CIN3+ of 0.98 and 1.01%, respectively. Our results support that extended genotyping including the 7 hrHPV-types included in the 9-valent vaccine may lead to a more precise risk-based screening and follow-up strategy of hrHPV-positive women. Anyplex is one of very few commercial tests that can genotype more than HPV16 and 18 in a simple, PCR-based, real-time assay, and can be used in measuring vaccine impact among women attending cervical cancer screening and to stratify the impact of other genotypes by risk of cervical disease in the absence of the seven most oncogenic types. HPV type replacement post-vaccination might appear. In the absence of the most frequent hrHPV types, a non-significant increase in HPV51 was seen after introducing HPV vaccination in Scotland , 28. WheIn 2015, HPV testing in primary screening was established in a randomized setting in four counties in Norway among women 34–69 years old, using Cobas 4800. HPV prevalence in women aged 34 years and older was 6.5%. The prevalence of CIN3+ in this group was 1.3% . In a smThe main strength of our study is the schematic sampling, handling, and analysis of the HPV assays, performed by a few staff members at the same clinic. A single LBC specimen was used for all three HPV tests, and the two genotyping tests were performed on the same aliquot, which makes it likely that the amount of HPV was the same for all tests. Misclassification of disease was kept to a minimum, as all patients had biopsies available and histology revised.A limitation of the study is the small number of women without CIN2+, so caution should be taken in drawing conclusions about the specificity of Anyplex in a screening population. Indeed, the PPV and NPV of a positive HPV test in our study sample will differ from observed in a screening population, as the prevalence of HPV and CIN2+ was much higher in our study. Another potential limitation is that Anyplex was performed retrospectively on DNA samples kept frozen up to 3 years at -80°C. DNA has previously been shown to be stable for up to 3 years when kept below -20°C , and -80The hrHPV types included in Anyplex set A, similar to Anyplex II HPV HR Detection test, are sufficient to detect CIN2+ and CIN3+. When restricting Anyplex to moderate and high viral loads for the 14 hrHPV types in set A, the clinical performance was comparable to HC2 in this referral population. Restricting Anyplex to the 7 hrHPV-types 16, 18, 31, 33, 45, 52 and 58, satisfy the international criteria for the sensitivity of HPV tests in primary screening for CIN2+. Our findings indicate that extended genotyping beyond HPV16 and 18 will lead to a more precise risk stratification for CIN2+ and CIN3+ and a more precise risk based follow-up of HPV positive women. According to our results, there is no additional clinical benefit of including possible hrHPV types in diagnosing CIN2+, while a decrease in clinical specificity was observed. Anyplex, with all 28 HPV types, is not expected to add any benefit in primary cervical cancer screening, compared to the Anyplex II HR HPV Detection test or in a referral population.


To evaluate the association of human papilloma virus (HPV) infection with prognosis, specifically overall survival (OS) and disease‐free survival (DFS), in laryngeal squamous cell carcinoma (LSCC) patients.A systematic review and meta‐analysis were performed according to the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines. LSCC was confirmed on the basis of histopathology, whereas HPV status was confirmed by polymerase chain reaction.A total of 6539 articles were initially searched from 8 databases, of which 11 studies were eligible for our review. A total of 1442 LSCC cases were included in this analysis. Eight studies examined 3‐year OS for LSCC. The pooled hazard ratio (HR) from the 8 studies was 0.29 (95% CI: 0.25‐0.33). There was a statistically significant difference in 3‐year OS between the HPV‐negative and ‐positive groups, with the latter having a better survival. There was no statistically significant differences in 5‐ and 10‐year OS. Five studies examined 3‐ and 5‐year DFS for LSCC, whereas only 3 studies examined 10‐year DFS. There was no statistically significant difference in 3‐, 5‐, and 10‐year DFS between the HPV groups.This study evaluated the survival impact of HPV infection in LSCC patients. The OS of the HPV‐positive group was better than that of the HPV‐negative group in terms of short‐term survival. Compared with the HPV‐negative group, the HPV‐positive group had a better trend of DFS, suggesting that a larger sample size and further exploration of the pathology and local control of HPV‐positive tumors are needed. Human papillomavirus (HPV) infection is a cause of squamous cancers of the oropharynx (particularly cancers of the tonsils and tongue base), and emerging evidence showed that HPV infection may also be associated with an increased risk of laryngeal squamous cell carcinoma (LSCC). LSCC was increasingly reported to be associated with HPV infection, but the role of HPV in this type of cancer has not been conclusively established. The association of better prognosis with HPV positivity is controversial. Different test methods may result in inconsistent results, which may obfuscate the correlation between HPV status and prognosis in LSCC. More than 150 000 new patients have been diagnosed worldwide and 90 000 die each year.Like other head and neck cancers (HNC), LSCC has been clearly linked to smoking and alcohol consumption. The risk factors of LSCC are changing, as the prevalence of tobacco‐induced cancers has decreased and the prevalence of cancers not associated with tobacco has increased. Human papillomavirus (HPV) infection is a cause of squamous cancers of the oropharynx (particularly cancers of the tonsils and tongue base),All 120 HPV genotypes had been detected in squamous carcinoma, and they were classified into low‐ and high‐risk groups according their oncogenesis potential.The test of HPV infection is based almost exclusively on molecular methods. Few HPV testing options are currently available in the clinical setting: the two most commonly used detection methods are immunohistochemical analysis (IHC) of the p16 protein and polymerase chain reaction (PCR). The sensitivity of both assays is high, but the specificity of in situ hybridization (ISH) is higher than that of both assays.22.1This meta‐analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines.The inclusion and exclusion criteria were set by a three‐person panel. Two researchers independently compiled the criteria for trial selection, and all disagreements were resolved by a group discussion. Titles and abstracts were screened according to the criteria. After the screening, 11 trials qualified for the meta‐analysis.Data based on frozen tissue or formalin‐fixed tissueHPV detection by PCR, ISH, or the Linear Array HPV Genotyping TestThe total number of cases is greater than 50The number of cases in the exposed group was greater than 10Population: patients with laryngeal cancer onlyPrimary outcomes: OS or DFS.Trial inclusion criteria:Case reportsReviews, meta‐analyses, guidelines, and summariesHPV detection by IHCHPV is not the prognostic factor but risk factorWithout full‐textOther uncorrelated studies, such as trial for the detection method, for treatment method, base researches, or animal experiments.Trial exclusion criteria:2.2A standard data extraction protocol was prepared by 2 persons. Each article was collected independently, and all relevant data were in duplicates. All disagreements were resolved through a group discussion until a consensus was reached.Data collection from each trial included: the title, first authors, journal and year of publication, number of cases, patients inclusion criteria and age range, follow‐up period, HPV detection method, survival outcome , hazard ratio (HR) with a 95% CI, ln(HR), and SE(ln(HR)). In studies, LSCC survival was presented as Kaplan Meier curves. We used Adobe Photoshop to process the survival curve pictures, and Engauge Digitizer 4.1 software to extract the survival data, such as HR. When the difference between the extracted survival data and the value in the paper was more than 2%, data were extracted a second time.The quality of enrolled trials was independently assessed by 2 authors using the Newcastle‐Ottawa Scale (NOS) for cohort studies. The total score ranges from 0 to 9, and scoring discrepancies were resolved by discussion in the presence of a third author as a mediator. The trials scoring at least 6 were considered high‐quality studies. The characteristics of the included studies are shown in Table 2.3I2 metric respectively. If the Q test P‐value was <.05 or the I2 was <50%, suggesting heterogeneity, we calculated the HR using a random‐effects model. If no significant heterogeneity was detected, we applied a fixed‐effects model. All statistical tests were 2‐sided, and P < .05 suggested statistical significance. A HR >1 suggested that HPV increased the risk of poor survival, a HR <1 suggested that HPV infection was a beneficial prognostic factor, and HR = 1 suggested no significant difference in survival. Potential publication bias was assessed by a funnel plot and Egger's test, and P‐values higher than .05 presented there was no publication bias.We used R 3.5.3 software to analyze data from the selected studies. HR with a 95% CI was calculated to measure the survival outcome in the exposed group compared with the control group. The heterogeneity between studies was qualitatively and quantitatively examined using the chi‐squared Q test and the 33.1A total of 6539 potentially relevant articles were initially searched form 8 databases, of 3540 articles remained after automatically and manually deduplication. By screening the titles and abstracts, 3336 articles were excluded on the basis of the established criteria. Of the 204 articles remaining, 3 full articles could not be obtained. Furthermore, by carefully browsing 201 full‐text, 10 articles were excluded because of the detection method: in those papers, the detection method of HPV was IHC staining, whose sensitivity is lower than that of PCR. Six other articles were excluded because of the low number of cases, whereas 8 papers were excluded because of the lack of specific outcome indicators. At the end of the screening process, we selected 11 studies for the meta‐analysis  , obtained using the fixed effect model because of the low heterogeneity  was found. The pooled HR was 1.33 (95% CI: 0.60‐3.0), according to the fixed effect model   was found. The pooled HR was 1.54 (95% CI: 0.57‐4.2), using the fixed effect model  , using the fixed effect model . There was no statistical significance between the HPV‐positive and ‐negative groups (Figure For the 5‐year DFS, the pooled HR was 0.77 (95% CI: 0.37‐1.6; Overall, all calculated HRs were less than 1, but we observed no statistically significant difference in 5‐ and 10‐year DFS between the HPV‐negative and ‐positive groups.Through the evaluation of publication bias by funnel plot and Egger's test, we found that the study may have publication bias. The funnel plot and Egger's test results are in the attachment.4The status of HPV infection and its impact on treatment and survival outcomes in HNC is an important research focus. As in oropharynx cancer, the infection of HPV have been reported to be a potential risk factors also for laryngeal cancer.Currently, there are many studies investigating the relationship between different survival indicators and HPV infection. In those studies, the most frequently used survival indicators are OS and DFS. OS is measured as the time from the beginning of randomization to death from any cause. OS is considered the best endpoint to measure efficacy in clinical trials on tumors and is the preferred survival indicator. Some papers demonstrated that the OS of the HPV‐positive group was better than that of the HPV‐negative group in laryngeal cancer patients. However, other studies reported that the difference was not statistically significant.Furthermore, according to the latest NCCN guidelines, surgery or radical radiotherapy is preferred for patients with early laryngeal cancer. In this study, the 3‐year OS of the HPV‐positive group was significantly higher than the HPV‐negative group, suggesting that HPV infection is beneficial in the short‐term. This difference could be associated with the surgery techniques and methods and could be explained by the observation that HPV‐positive tumor patients have higher sensitivity to radiation therapy.DFS is measured as the length of time after treatment during which no disease is found. In some studies, it was reported that HPV infection status is an independent prognostic indicator of DFS and HPV‐positive patients have better prognosis.In recent years, an increasing amount of studies reported the relationship between HPV infection and the prognosis of patients with laryngeal cancer, but a consensus has not been reached yet. In this meta‐analysis, patients with HPV infection of LSCC have a better 3‐year OS, but we observed no significant differences in the long‐term survival rate. This result may be related to differences in the treatment plan, suggesting that future clinical research will need to evaluate different treatment outcomes. Compared with the HPV‐negative group, the HPV‐positive group had a better DFS, but there was no significant difference between the groups, suggesting that studies with a larger sample size and further studies on the pathology and local control of HPV‐positive tumors are needed.None declared.Conceptualization, X. J. and LH. D.; Software, B. W.; Validation, X. J. and LH. D.; Formal Analysis, B. W.; Investigation, HH. W.; Resources, HH. W.; Data Curation, Y. X.; Writing‐Original Draft Preparation, HH. W.; Writing‐Review & Editing, LB. M., Y. X., and X. J.; Funding Acquisition, X. J.. All authors read and approved the manuscript. Click here for additional data file.