Candida spp. has been shown to facilitate oncogenesis, the interactions between HPV and Candida spp. remain unclear. This study aimed to determine the prevalence and genotype distribution of HR-HPV infection HR-HPV-positiveCandida albicans in HR-HPV-positive individuals in Diyarbakır province in Turkey. Cervical samples were taken from 350 participants aged 20–69 years who applied to Diyarbakır Gazi Yaşargil Training and Research Hospital, Gynecology and Obstetrics Clinic. For detection of HPV presence and HR-HPV genotyping, PCR/direct cycle sequencing was used. E6/E7 mRNA expression of HPV-16, -18, -31, -33, and -45 was determined by type-specific real-time NASBA assay (NucliSENS EasyQ(®)HPV v1.1). The presence of Candida albicans in cervical specimens of HR-HPV-positive women was investigated by RAPD-PCR and culture methods. Results. Of the 350 women who participated in the study, 24% were HPV positive and 10.5% were found to be HR-HPV positive. HR-HPV positivity was most frequently detected in the age range of 40–49 years. Among HR-HPV-positive women, C. albicans was found in 59.4%. Conclusion. The most frequent HR-HPV genotype was HPV16, followed by HPV31. Of women who tested positive for HR-HPV, C. albicans was discovered in 59.4%. C. albicans infection may occur when the immune system is weakened or the balance of the vaginal flora is disturbed, increasing tissue damage in the vaginal area and the risk of carcinogenesis of HR-HPV. Therefore, knowing the presence of Candida infection in HR-HPV-positive women is essential to plan the treatment and prevent the risk of secondary disease.The human papillomavirus (HPV) is a significant public health concern due to its association with the development of cervical cancer. Although inflammation caused by  Cervical cancer (CC) is the second most common malignancy affecting women, following breast cancer. It is characterized by the most significant morbidity and mortality rates among all tumors affecting the female genital tract . The leaHuman papillomavirus (HPV), widely recognized as the most frequent sexually transmitted infection worldwide, has been found to have detrimental effects on individuals' personal and social lives . Human pCandida spp. is one of the sexually transmitted infectious agents and is a part of the human commensal flora, causing superficial and systemic infections. It has been suggested that these microorganisms alter the inflamed cervical epithelium, which increases the chance of HPV infection by enabling the virus to enter the basal cells of the epithelium [Candida spp. interact to cause cervical cancer [ithelium , 3. Despl cancer –5.Candida albicans in HR-HPV patients in Diyarbakır province in Turkey.This study aimed to determine the prevalence and genotype distribution of HR-HPV infection and Cervical samples were taken from 350 participants aged 20–69 years who applied to Diyarbakır Gazi Yaşargil Training and Research Hospital, Gynecology and Obstetrics Clinic.The Ethics Committee of Biruni University's Faculty of Medicine approved this study . Before the cervical specimens were taken, all participants provided their written informed consent after being informed of the study's goals and procedures.All participants completed a questionnaire asking about their sociodemographic and clinical characteristics, including age, coit age, number of partners, use of condoms, oral contraceptives, intrauterine devices, and smoking history.The “Thin PrepTM Pap Test” solution, utilized in an FDA-approved, commercial liquid-based cytological procedure, collected cervical specimens from the patients to detect cervical HPV DNA and sexually transmitted illnesses. During the colposcopic examination, the patients were positioned in the lithotomy posture. The sample was obtained by rotating the brush 360° for 10 seconds in the transformation zone of the squamocolumnar junction and ectocervix after entering the endocervical canal with the aid of the inspection speculum. The brush's tip was cut off and thrown into the mixture. Centrifugation separated the Thin PrepTM Pap Test fluid from the cell pellets for 10 min at 4000 g. Before DNA extraction, the samples were divided into two tubes and stored in the refrigerator at −20°C.https://blast.ncbi.nlm.nih.gov/Blast.cgi). The most comparable and substantial alignment results served as the foundation for identifying the HPV genotype.Direct cycle sequencing was used to determine the HPV genotype in the presence of MY or GP amplicons. Internal PCR primers (MY09 or GP5+) and the BigDye Terminator v3.1 Cycle Sequencing kit  with dye terminator dideoxynucleotide were used to analyze PCR products for cycle sequencing in accordance with the manufacturer's directions for sense sequence analysis. An automated capillary sequence reader called the ABI PRISM 3130XL Genetic Analyzer  was used to capture the data from cycle sequence reactions. The obtained nucleotide sequences were compared with the HPV reference sequences already present in the GenBank database using the Basic Local Alignment Search Tool (BLAST®) software . Human U1 small ribonucleoprotein (U1A mRNA) was used as an RNA integrity/adequacy internal control.The detection of E6/E7 mRNAs of the five most prevalent high-risk HPV genotypes 16, 18, 31, 33, 45, and 58 was performed qualitatively, with a commercial NASBA assay  test according to manufacturer's instructions. For E6/E7 mRNA detection, RNA was extracted from 200 Cytobrushes were used to collect cervical samples (the Pap test) and were then stored in medium with 95% ethanol at 4°C until processing. The viral extraction, detection, and typing approach has already been reported , 7. The Candida spp., samples were collected from 350 female patients who had history of high-risk HPV positive. By injecting 2 ml of physiological saline solution (NaCl) into the vagina and recovering 1 ml of the vaginal fluid after scraping the vaginal walls, the vaginal discharge was collected as a vaginal lavage, and before inoculating on Sabouraud agar, first, the lavage on liquid Sabouraud medium was cultured to increase the number of cells. The cells from the liquid medium were grown on Sabouraud agar the following day and incubated for 48 hours at 37°C. By injecting chromagar , colonies formed on sabouraud agar were further differentiated for Candida species. Chromagar is a differential culture medium that enables the selective isolation of yeasts while also uniquely identifying the colonies of Candida albicans, Candida glabrata, Candida krusei, and Candida tropicalis by producing a distinct colony color after incubation for 24 hours at 37°C. Based on colony color and texture, which are formed by the hydrolysis of chromogenic substrates in the medium, strains are presumptively identified. The species were distinguished using the colors green for Candida albicans, pink for Candida glabrata, pale pink for Candida krusei, and blue for Candida tropicalis.To determine the presence of μl of each DNA sample was used to evaluate the concentration and purity of the DNA using the Nanodrop device (BioDrop/UK). A good yield of the necessary PCR products required a DNA concentration between 50 and 200 ng/l, according to Saiki [The genomic isolation kit provided by Geneaid Company/Taiwan (Cultured Cell Protocol Procedure Ver. 11.21.13) was used to produce and purify the DNA. The commercial kit was used with liquid nitrogen (170 C), as the extremely low temperature helped to avoid DNase activation . AccordiThe specific primers and their sequences are chosen in accordance with Clinical information was logged, including age, education level, menarche age, method of contraception, and smoking status. Using SPSS for Windows version 10.0, chi-square and Spearman correlation analysis were performed to analyze the data.p < 0.05) between HR-HPV positivity and having women with multiple partners. HR-HPV-positive women all reported multipartnership. Of 350 women, 84 (24%) were HPV positive and 37 (10.5%) were found to be HR-HPV positive. A statistically significant relationship was found between HPV positivity and age range, and 46 patients were between the ages of 40 and 49 (p < 0.05). No statistically significant relationship was found between the use of OCS, condoms, IUD, and HPV positivity (p > 0.05)  .p < 0.05) (37 out of 84 HPV-positive patients (44%) had positive HR-HPV results. There were six distinct types identified, with type 16 being the most common (70%); the most common HR-HPV genotype was HPV16 (70%), followed by HPV31 (21.6%), HPV18 (2.8%), HPV33 (2.8%), and HPV45 (2.8%). HPV 58 was not detected in HR-HPV-positive samples.  < 0.05) .Candida spp. was detected in 25 (67.5%) of the HR-HPV-positive individuals, and 22 (59.4%) were found to be C. albicans. Candida albicans was detected in 19 (73%) of 26 HPV-16 type positive women, which was statistically significant (p < 0.05) ( < 0.05) .About 200 HPV genotypes have so far been identified. Some of these, known as HR-HPVs, have increased carcinogenic potential and infect the vaginal tract. Given the link between HR-HPV and cervical cancer, it will be essential to identify patients with the infection to provide vital information for their prevention and treatment. In this study, samples from 350 patients were tested for 6 HR-HPV genotypes, and 10.5% of the samples returned positive results.This study did not find a statistically significant relationship between menopause, condom use, oral contraceptives, and IUD use among the sociodemographic factors examined with HPV. This finding contrasts with a previous study conducted by Coser et al. , which rSeveral studies have indicated that using the intrauterine device (IUD) is associated with a protective effect against HPV infection. This phenomenon can be attributed to the robust immunological response elicited by the IUD within the uterine cervix, leading to the prompt eradication of diseases. According to Ortiz and Croxatto , alternaIn this investigation, no significant correlation was found between the patients' assessed personal habits and the presence of HPV. Coser et al.  evaluatep < 0.05). More information about women's sexual behavior was hindered by the taboo around sexual disclosure. In the current study, the number of single women who participated was low since the annual gynecologic exam as a routine checkup for single women is not a common practice in Diyarbakır province in Turkey. The prevalence of HPV in our study sample was 24%, which was higher than in other studies [The findings about the variables obtained at the initial stage of the study were primarily congruent with existing literature on factors that predict the occurrence of any HPV infection, as well as the presence of oncogenic HPV types. Specifically, our results demonstrated relationships between these variables and age and the number of sexual partners , 20. A p studies . HPV rat studies , 23. In More than 40 closely related but genetically distinct HPVs that infect the genital tract have been classified as HR or LR according to their oncogenic potential , 26. HR-The prevalence of HPV16 and HPV31 genotypes among European, Mexican, Turkish, and Chinese Uyghur women exhibiting cervical cytologic abnormalities aligns with the results reported in previous research investigations. According to the findings of these investigations, HPV31 showed the second highest frequency , 31–37.Candida spp., which is classified as a commensal yeast that is a constituent of the indigenous human microbiota. However, under specific conditions, it can transit into a pathogenic state [C. albicans in HR-HPV-positive patients was 59.5%, a value that falls below the global prevalence (65.3%) and the majority in Europe (67.9%) [Candida tropicalis (5.4%) and Candida glabrata (2.7%) were found to be isolated at very low frequencies, which aligns with the findings reported in the global literature [Candida spp. infection and bacterial infection. Recurrent inflammations have been found to promote cell proliferation, enable the growth of malignant cells, and trigger the release of cytokines, chemokines, and free radicals. These findings suggest that individuals with abnormal microbiota may have more incredible cellular changes than those with normal microbiota [C. albicans. These strains can penetrate mucosal barriers, induce edema, cause exfoliation of cells [Candida spp. was investigated by performing both Candida PCR and Candida culture in vaginal discharge in patients with HR-HPV for cervical cancer. The findings revealed that the prevalence of positive cases was 59.5% for C. albicans, 2.7% for Candida glabrata, and 5.4% for Candida tropicalis. These percentages were slightly higher compared to those typically observed in patients without HPV, as reported by Melo et al. [Vulvovaginal candidiasis is a prevalent infection that impacts around 70–75% of women within the reproductive age range. Based on estimates, a significant proportion, ranging from 40% to 50%, of the total cases is expected to exhibit recurrences, whereas approximately 5% to 15% are anticipated to have recurring occurrences . The etiic state . One insic state . The pre (67.9%) . Candidaterature . The stucrobiota . An illuof cells , and proo et al. .Candida spp. and their medical history, mainly about sexually transmitted diseases. Notably, infection by the HPV emerges as a prominent factor. Voog et al. [Candida spp. infection to trigger the reactivation of latent HPV infections. Previous research has identified these infections as cofactors in the development of cervical neoplasias about HPV, as noted by Sobel [Candida albicans was found in 73% of HPV-16-positive patients. The presence of noteworthy correlations between bacterial vaginosis and HPV 58, as well as between Candida spp. and HPV-16 and HPV-53, underscores the necessity of incorporating sexually transmitted disease management into a comprehensive cervical cancer prevention program [Candida spp. infection is relatively frequent and commonly observed in asymptomatic colonization and vulvovaginal candidiasis. However, it has been observed that specific species of Candida spp. exhibit a higher level of pathogenicity than other species. These particular species can induce the production of hyphae and pseudohyphae and enhance proteolytic activity and antigen modulation [Candida spp. to infiltrate the mucosal surface and initiate mucosal inflammation, characterized by swelling, redness, and shedding of cells. Several authors, notably Engberts et al. [Candida spp. in the pathogenesis of HR-HPV. Their findings indicate the presence of Candida spp. It does not correlate with a heightened risk of acquiring HR-HPV.The research conducted by Nogueres et al.  establisg et al.  postulatby Sobel  and Meloby Sobel  In our s program . Candidadulation . The chaThe study's limitations are that our analysis was performed only on the patients who attended gynecology polyclinics at the health institution in the Diyarbakir province of Turkey. Although our results do not reflect Turkey in general, it is an advantageous study for directing vaccination studies in our region. Our subsequent work will evaluate the types by classifying the samples as pathological. The other limitation of our study is its case-control design. Establishing causality between sexually transmitted infection coexistent with HPV and cervical neoplasia is difficult in a cross-sectional study. However, doing a prospective study to assess the linkage between HPV, other genital infections, and developing high-grade cervical neoplasia will be both time- and resource-intensive.Candida infection is a fungal infection that can occur when the immune system is weakened or the vaginal flora is out of balance. Candida infection can increase tissue damage in the vaginal area and increase the risk of cancerization of HR-HPV. The presence of Candida infection in an HR-HPV-positive woman may affect treatment planning. Candida infection may need to be controlled first to improve the efficacy of treatment. It is also important to monitor HR-HPV infection during treatment of Candida infection.


To study the outcome of human papillomavirus (HPV) infection in women with cervical pathology results of non-cervical intraepithelial neoplasia (CIN) or cervical cancer and positive high-risk HPV test, as well as analyze the associated risk factors affecting the outcome of infection.2 test or Fisher’s exact test, as appropriate. After the univariate analysis, several significant factors were included in the Cox model and independent risk factors were analyzed.To investigate the outcome of high-risk (HR)-HPV infection in the female genital tract and analyze the associated risk factors affecting their outcome, a total of 196 women with positive HR-HPV test results and non-CIN or cervical cancer cervical pathology results were selected for follow-up at the Cervical Disease Clinic of the Obstetrics and Gynecology Hospital, Zhejiang University School of Medicine from January 2017 to March 2020. The follow-up interval was every 6 months, and both cervical cytology (TCT) and HR-HPV testing were performed at each follow-up visit. If the cervical cytology results were normal upon recheck and the HR-HPV test was negative, the woman was considered to be cleared of the HPV infection and was entered into the routine cervical screening population. When the repeat HR-HPV test remained positive after 6 months, the woman was defined as having a persistent HR-HPV infection. If HR-HPV persisted but the TCT results were normal, follow-up was continued. If HR-HPV persisted and the TCT results were abnormal, a colposcopy-guided biopsy was performed immediately. In this situation, if the histological results were still non-CIN or cervical cancer, the follow-up was continued. If the histological results confirmed the development of CIN or invasive cancer, then enter another study follow-up to further track its development and outcome, and the woman commenced the treatment process. The HPV infection clearance time was analyzed by the Kaplan-Meier method, and the comparison of the HPV clearance rate and infection clearance time between each of the different groups was performed using aχP < 0.05).A total of 163 women were enrolled in this study. The median age was 40.0 years (22–67 years) and the median follow-up time was 11.5 months (6–31 months). The spontaneous clearance rate of HR-HPV infection was 51.5%, and the median time to viral clearance was 14.5 months. Age and the initial viral load were high risk factors affecting the spontaneous clearance of HR-HPV infection. The factors significantly associated with HPV clearance rate and time to HPV clearance consisted of menopause and full-term delivery (In women with normal or low-grade lesions on the cell smear, the spontaneous clearance rate of HR-HPV infection was 51.5% and the time to clearance was 14.5 months. Age and the initial viral load were independent associated factors affecting the spontaneous clearance of HR-HPV infection in the female genital tract. These findings suggest that non-young women or those with high viral loads have a higher rate of persistent HR-HPV infection. Thus, intensive screening should be recommended.The online version contains supplementary material available at 10.1186/s12905-023-02764-8. It has been well established that cervical cancer is the fourth most common malignancy affecting women worldwide . The IntIn China, there are approximately 130,000 new cases of cervical cancer each year, ranking first among gynecological malignancies in China, with 20,000–30,000 women dying from cervical cancer each year. Among all malignant tumors, cervical cancer has the most definite factors associated with its development. In the mid-1990s, numerous epidemiological and molecular biology studies demonstrated that human papillomavirus (HPV) infection was required for the development of cervical cancer, and high-risk (HR)-HPVDNA could be detected in 99.7% of specimens collected from cervical cancer patients , 5. In tPapillomavirus is an envelope-free, double-stranded, circular DNA virus. HPV infection is very common in humans, with reported infections from birth in infants to elderly individuals over 80 years of age. During a woman’s lifetime, the chance of HPV infection in the genital tract is greater than 75%  and can The risk factors associated with HPV infection have been widely reported. The more certain factors include sexual behaviors , large number of births, HPV type, and age –17. HoweThis study aimed to investigate the outcome of HR-HPV infection in the female genital tract ) by selecting women who tested positive for HR-HPV for the first time and who also had non-CIN cervical pathology and cervical cancer for follow-up. We also conducted a questionnaire survey of women with HR-HPV infection to obtain epidemiological information and analyze relevant risk factors affecting their outcome. These findings will help enhance our understanding of the natural outcome of HPV infection and its associated factors in Chinese women and provide a basis for proper clinical management of HPV-test positive women.All methods in our study were carried out in accordance with relevant guidelines and regulations or the declaration of Helsinki. The studies involving human participants were reviewed and approved by the Ethics Committee of Obstetrics and Gynecology Hospital of Zhejiang University School of Medicine. The patients/participants provided their written informed consent to participate in this study.Those who attended the cervical disease clinic of the Obstetrics and Gynecology Hospital of Zhejiang University School of Medicine between January 2017 and March 2020 and met the following conditions were selected as study subjects: 1) positive results of a HR-HPV-DNA test ; 2) Thinprep Cytologic Test (TCT) results may be negative, or AUSCU or LISL, but whose the pathological results of colposcopy biopsy are non-CIN or cervical cancer; 3) not pregnant; 4) absence of a history of autoimmune diseases and oral immunosuppressive drugs; 5) no history of CIN or cervical cancer; 6) no history of cervical surgery; and 7) voluntarily participated in this study and signed an informed consent form. A total of 196 women met the inclusion criteria and were enrolled in the study.No intravaginal medication or douching was permitted for 3 days before sampling, sampling was avoided during menstruation, no sexual intercourse was permitted for 24 hours before sampling, and an acetic acid/iodine solution was not to be applied before sampling. The tube was not shaken vigorously when opening the cap or breaking the small brush to avoid the spilling of reagents, which could affect the detection or cause the specimens to spill, causing contamination.A second-generation hybrid capture test  was used with a DIGENE HPV sampler  to collect specimens from the cervical canal. The samples were sent to our central laboratory for HC-II testing. The wall of the test tube was labelled with the patient’s name or number, and the cap was tightened.The DNA from 13 oncogenic HPVs , were detected. The test result of the viral load value was calculated as Relative Light Units/Standard Positive (RLU/PC) ratio. The Standard Positive value is 1.0 pg/mL. The viral load value ≥1 indicated a HPV positive result.The initial viral load was divided into two groups: 1) a low load group, defined as a HR-HPV RLU/PC ratio of 1–99; and 2) a high load group, defined as a HR-HPV RLU/PC ratio was ≥100 .No intravaginal medication or douching was permitted for 3 days prior to sampling, sampling during menstruation was avoided, no sexual intercourse was allowed for 24 hours prior to sampling, and acetic acid/iodine could not be applied prior to sampling.All cervical cell samples were collected using a special sampler for cervical cytology (TCT) and the sampler was placed in a vial with a cell preservation solution for rinsing.The sample was then dispersed and filtered using a fully automated cytometer to reduce the amount of blood, mucus and inflammatory tissue residues for microscopic detection and diagnosis.The results of the TCT assay were determined in accordance with the Bethesda system (TBS)  as folloThe subjects were instructed to avoid intravaginal medication or douching, bimanual examination, or sexual intercourse for 72 h prior to the examination. For the examination, the cervicovaginal area was fully exposed with a vaginal speculum, and cervical secretions were gently wiped away with a cotton ball. Next, the focal length was adjusted, and the examined area was first observed roughly at a 10× low magnification microscope under white light. Next, a cotton ball soaked in 3% acetic acid was used to rub the cervicovaginal area to obtain a more precise observation. Finally, aniodine solution was applied, and a biopsy was collected from the negative iodine test area or suspicious lesions for pathological examination.Each woman entering the study completed a questionnaire that included information regarding socio-demographic characteristics, lifestyle, menstrual and reproductive history, contraceptive practices, and aspects of sexual behavior. Medical staff conducted the survey through face-to-face or telephone questioning. During this process, the staff first explained the purpose, methods, and significance of this study to these respondents and obtained permission to conduct the survey. The completed questionnaires were collected on site and professional medical knowledge was provided to each of the subjects so that they could understand the causes of HPV infection, the characteristics of HPV as a virus, what was required for a formal follow-up, and the possible outcomes of a persistent HPV infection. At the same time, the patients were counseled to reduce their psychological stress and fear. A copy of the questionnaire form is attached for reference . By the end of the follow-up in this study, 84 of the 163 women tested negative for HR-HPV during follow-up, which represented a Spontaneous clearance rate of 51.5% for HR-HPV infection. The median time to the spontaneous clearance of HPV infection was 14.5 months (6–27 months). Of the 163 patients, 79 had persistent high-risk HPV infection and underwent colposcopy biopsy, of which 68 had no CIN or cervical cancer while 11 had CIN. There were 11 of 163 women who developed CIN (6.75%) and the median time was 13 months (6–31 months), including four with CIN I, four with CIN II, and three with CIN III.P < 0.001), as shown in Table In the group younger than 35 years old, the spontaneous clearance rate of HPV infection was 63.2% (36/57), compared with 45.3% 48/106) in the group older than 35 years old. The difference between the two age groups was statistically significant (06 in theP < 0.001), as shown in Fig. In the group younger than 35 years old, the median time to the spontaneous clearance of HPV infection was 10.0 months (95% CI: 8.8-11.2 months). In contrast, in the group older than 35 years old, the median time to natural clearance of HPV infection was 27.0 months (95% CI: 14.6–39.4 months). The log rank test showed a statistically significant difference in the time to clearance of the HPV infection between the two age groups .The relationship between the initial cytologic findings, viral load and, and spontaneous clearance of HPV infection is shown in Table P < 0.05). The other factors were not significantly correlated with the natural clearance of HPV infection.Other factors associated with the HPV clearance rate and time to clearance included smoking or passive smoking, menopause, number of sexual partners, age at first sex, history of full-term delivery, and frequency of sexual intercourse. As listed in Table 2 = 65.596 and P < 0.01.Age, initial viral load, menopause, and history of full-term delivery were included in the COX model in an ENTER manner that was significant in the univariate analysis. This regression equation was significant with χAs seen in Table Both epidemiological data and clinical studies have demonstrated that most HPV infections, as well as the corresponding precancerous cervical lesions , resolve spontaneously. However, the time to spontaneous clearance of HPV infection varies from 7 to 18 months due to different populations included in each study, methods of HPV testing, and modes of follow-up. Dalstein et al. conducted a prospective study of 781 women with normal/ASCUS/LSIL cervical cytology in 2003 .These 78It has been suggested that a high-risk sexual lifestyle, including young age of sexual initiation, multiple sexual partners, male sexual activity, high number of births, and frequent sexual intercourse, as well as a history of smoking or passive smoking, contraceptive method, menopause, history of childbirth, and initial cytological findings, constitute the main risk factors affecting the spontaneous clearance of HR-HPV infection in women –26. HoweAmong the many factors that affect the natural clearance of HR-HPV infection in previous studies, age is another factor that has been extensively studied. Several studies have found that while age represents the most important factor affecting the distribution of HPV infection rates , it alsoViral load is another high-risk factor for possible persistent HPV infection. Dalstein et al. studied 781 women with normal and different grades of cervical lesions, who were followed-up every 6 months with a median follow-up of 22 months . The autAmong women with normal cell smears or low-grade lesions, the spontaneous clearance rate of HR-HPV infection was 51.5% following a mean follow-up of 11.5 months, with a clearance time of 14.5 months. Age and initial viral load are independent correlates of the spontaneous clearance of HR-HPV infection in the female genital tract, suggesting that HR-HPV infection in non-young women or those with a high viral load is associated with a higher rate of persistent infection. Therefore, an aggressive screening approach is an appropriate recommendation. Menopause and full-term delivery were significantly correlated with clearance of HPV infection.Additional file 1. HPV Risk Factors Questionnaire


Veterans are at high risk for lung cancer and are an important group for lung cancer screening. Previous research suggests that lung cancer screening may not be reaching healthier and/or non-White individuals, who stand to benefit most from lung cancer screening. We sought to test whether lung cancer screening is associated with poor health and/or race and ethnicity among veterans.poor health, defined as fair/poor health status and difficulty walking or climbing stairs, aligning with eligibility criteria for a pivotal lung cancer screening trial, and (2) race/ethnicity. The outcome was a receipt of lung cancer screening. All variables were self-reported.This cross-sectional, population-based study included veterans eligible for lung cancer screening  in the 2017–2020 Behavioral Risk Factor Surveillance System surveys. Exposures were (1) Of 3,376 lung cancer screening–eligible veterans representing an underlying population of 866,000 individuals, 20.3%  had poor health, and 13.7%  identified as non-White. Poor health was strongly associated with lung cancer screening ; one third of veterans screened for lung cancer would not qualify for a pivotal lung cancer screening trial in terms of health. Marked racial disparities were observed among veterans: after adjustment, non-White veterans were 67% less likely to report lung cancer screening than White veterans .Lung cancer screening is correlated with poorer health and White race/ethnicity among veterans, which may undermine its population-level effectiveness. These results highlight the need to promote lung cancer screening, especially for healthier and/or non-White veterans, an important group of Americans for lung cancer screening. Previous work by our group using population-based survey data has shown that LCS is higher among those in poorer health and among those of non-Hispanic White race and ethnicity.health status, defined using criteria similar to those of the pivotal NELSON trial, and/or (2) race and ethnicity, with those in better overall health and of non-White race/ethnicity less likely to receive LCS.Understanding the current use of LCS in veterans would provide useful public health information to maximize veterans’ benefits and be a benchmark for ongoing implementation of LCS given this group's uniquely elevated risk of lung cancer. This study sought to test our hypothesis that the use of LCS among U.S. military veterans differed by (1) Have you ever served on active duty with the U.S. Armed Forces, either in the regular military or in a National Guard or reserve military unit? Smoking behavior was assessed with the questions, How old were you when you first started to smoke cigarettes regularly?, How old were you when you last smoked cigarettes regularly?, and On average, when you [smoke/smoked] regularly, about how many cigarettes [do/did] you usually smoke each day? Exclusion criteria were personal history of lung cancer and being aged <55 or ≥80 years. Individuals with missing values for key eligibility variables were excluded from the analysis , an annual phone survey of community-dwelling U.S. adults conducted by the Centers for Disease Control and Prevention.This study utilized publicly available, deidentified data and was exempt from IRB review. Reporting conformed to the STROBE reporting guideline for cross-sectional studies.Would you say that in general your health is – Excellent, Very Good, Good, Fair, Poor? and (2) ability to climb stairs (yes/no): Do you have serious difficulty walking or climbing stairs? Thus, individuals who rated their health as fair or poor and reported serious difficulty in walking or climbing stairs would not meet trial eligibility criteria and were categorized as having poor health; those who rated their health as excellent, very good, or good and/or reported no difficulty in walking or climbing stairs likely met initial trial eligibility criteria and were categorized as having good health. Health status was missing for n=8 veterans in the final sample (0.2%).The primary exposures were health status and race and ethnicity. Health status was categorized into a binary variable indicating whether a respondent met/did not meet criteria similar to the initial eligibility criteria of the NELSON trial; the BRFSS questionnaire wording differed slightly from that of the NELSON trial screening questionnaire. NELSON trial investigators excluded those who rated their health as moderate or bad and who could not climb 2 flights of stairs. For this analysis, health status was ascertained using 2 survey questions: (1) self-rated health: n=66 veterans in the final sample (2.0%).Race/ethnicity was self-reported with the following categories defined by the BRFSS survey: White non-Hispanic, Black or African American non-Hispanic, American Indian or Alaska Native non-Hispanic, Asian non-Hispanic, Native Hawaiian or other Pacific Islander non-Hispanic, other race non-Hispanic, multiracial non-Hispanic, and Hispanic. In the main analysis, race and ethnicity were included in the models as a 2-category variable (non-Hispanic White [White] or not non-Hispanic White [non-White]) for model stability because the unweighted numbers of screened individuals in racial/ethnic subgroups other than White were <30. To confirm with reporting standards,In the last 12 months, did you have a CT or CAT scan? A respondent was counted as screened if they chose Yes, to check for lung cancer. Screening status was missing for n=59 veterans who would otherwise have been included in the final sample .The primary outcome was self-reported LCS, ascertained in the optional Lung Cancer Screening module with the question, ,We chose covariates a priori on the basis of previous research and our own previous analyses.2), health insurance status, receipt of influenza vaccine in the previous 12 months, and difficulty in paying for medical care, which was ascertained with the question: Was there a time in the past 12 months when you needed to see a doctor but could not because of cost? Diagnosis of COPD was assessed with the question, Were you ever told you had chronic obstructive pulmonary disease, COPD, emphysema, or chronic bronchitis? Personal history of nonskin, nonlung cancer was assessed with 2 questions:  types of cancer? and What type of cancer was it? Any functional limitation was defined as a self-report of any of the following: difficulty in walking or climbing stairs, dressing or bathing, or running errands. Number of comorbidities  was the sum of the following self-reported comorbidities: chronic kidney disease, arthritis, COPD, asthma, vascular disease, diabetes, and personal history of cancer other than skin cancer.Variables on SES and demographics included age, sex, marital status, and educational attainment. To describe health factors and healthcare access, we captured smoking pack-year history, BMI  between August 2021 and June 2022. Individuals with missing data were excluded from the analysis. Given the low prevalence of missing data (below the accepted threshold of 5%), a complete case analysis would if anything be conservative and tend to bias our estimates toward the null.p<0.001)  of LCS-eligible veterans were aged ≥65 years, 94.3%  were male, and nearly half  had a ≥50 pack-year history of tobacco use . Most vep=0.002)  of veterans screened for lung cancer would not have qualified for the NELSON trial of LCS that showed its efficacy. Veterans who were not healthy enough to meet initial NELSON eligibility criteria were significantly more likely to report LCS than healthier veterans: of NELSON-ineligible veterans, 31.2 (20.9–41.4) reported LCS compared with just 16.4 (13.1–19.7) of those who were eligible (p=0.002) . After ap<0.001) (The use of LCS differed significantly by self-identified race and ethnicity among veterans: only 6.2% (2.5%–10.0%) of non-White veterans reported LCS, compared with 21.7% (17.7%–25.7%) of White veterans (p<0.001) . After aIn this population-based, cross-sectional analysis of 3,376 respondents representing 866,000 veterans, veterans represented nearly one quarter of all LCS-eligible Americans. One third (33%) of LCS among veterans reached those who would not qualify for the pivotal NELSON trial on the basis of poor health. Furthermore, veterans with poor health were 64% more likely to report screening than healthier veterans. Marked racial and ethnic disparities in LCS use were present in veterans, with non-White veterans 67% less likely to receive screening than White veterans.poor health as rating one's health as fair or poor and endorsing significant limitations with walking or climbing stairs, in line with the NELSON trial exclusion criteria, 1 of 2 randomized trials that showed the mortality benefit of LCS. These patterns of LCS use may limit the benefit of LCS owing to competing causes of death and/or inability to receive curative lung surgery for early-stage disease.,,Our previous research indicates that LCS is more common among less healthy individuals, using a variety of measures of health status.For all screening tests, patients and their clinicians must weigh the immediate risks of screening against the possible long-term benefit; screening is only justified if an individual is healthy enough to likely live to see the benefits of screening.National guidelines use a variety of health metrics to define being healthy enough for LCS. The U.S. Preventive Services Task Force recommends LCS for those willing and able to undergo thoracic surgery, in line with NLST and NELSON trial criteria. Others state that screening should not include those with <10-year life expectancy (American College of Chest Physicians),,,There is an urgent need for more research in this area to help patients and clinicians rationally weigh the risks and benefits of LCS in the context of an individual's health status,,The racial and ethnic differences in LCS use among veterans merit urgent attention. Previous work by our group,Strengths of this study include the population-based survey design, which allows for population-level inferences that are likely generalizable to the veteran populations of the 28 states that included the optional LCS module. We chose a measure of health status combining self-rated health and the ability to climb stairs that is highly relevant to LCS and could be replicated in future research. Self-rated health and ability to climb stairs provide a clear point of comparison with randomized trials; NELSON investigators excluded those who rated their health as moderate/bad and could not climb 2 flights of stairs.,Similar to other analyses using BRFSS data to study LCS, this study has several limitations, including the self-reported nature of variables, including smoking history, LCS, race/ethnicity, health status, and veteran status. However, we have no reason to suspect that the accuracy of self-reported variables would vary differentially across categories defined by veteran status, health status, or race/ethnicity; thus, any misclassification would bias our estimates toward the null. In addition, BRFSS has a limited proportion of non-White individuals who responded to the survey . Owing to low numbers of individuals in subcategories defined by race and ethnicity, our analysis relies on aggregated results (White/non-White), which may obscure important differences between groups of individuals who identify as non-White.,Although we could not restrict to veterans receiving care through the VHA, these results may still be useful to VHA, which has embarked on a multimillion dollar endeavorLCS use is strongly correlated with poorer health among veterans, and one third of screened veterans would not qualify for a pivotal trial of LCS on the basis of poor health. It is unclear whether actively screening for asymptomatic lung cancer provides more benefit than harm for these veterans or whether they may be better served by focusing on their other, known health issues. Marked screening disparities exist between White and non-White veterans, despite likely greater screening mortality benefits among Black individuals. These results add to the importance of current efforts to increase LCS and support additional outreach to screen healthier veterans, especially non-White veterans who are appropriate candidates for screening.


Trans women are highly affected by the human papillomavirus (HPV) and are at risk of suffering from HPV-related diseases such as oropharyngeal, anal, penile, or neovaginal neoplasia. HPV vaccination seems to be a good strategy to reduce HPV-related diseases, mainly during the early age before the first sexual intercourse, but only cisgender girls are covered by the National Health Services, while some high-risk groups such as trans girls are not included. Achieving a high vaccination rate is important in the adolescent population, but there are many factors that could affect it, such as lack of knowledge about HPV or fear of side effects by patients and main caregivers. The aim of our study is to analyze the knowledge of trans girls’ main caregivers about HPV-related diseases in the general population and, in particular, in trans women, as well as factors associated with HPV vaccination intention.A cross-sectional study was performed with the collaboration of main caregivers of adolescent trans girls, between 9 and 16 years old, assisted in two reference centers’ multidisciplinary Gender Diversity Units. Information was requested through a self-completed questionnaire: HPV-related diseases Knowledge Transwomen questionnaire (HPV-TQ) was elaborated based on a 19-item self-administered questionnaire and score was standardized from 0 to 19 points. Percentage of correct answers was calculated and defined by the group of high scores that showed over 70% correct answers.A total of 65 main caregivers were included. Almost all main caregivers were mothers with a Caucasian ethnicity. The HPV-TQ average score was 11 (3.7) with an average correct answer of 58.1% (19.6). Only 17/65 (26.1%) of main caregivers were highly knowledgeable in HPV. Of 65 trans girls, 14 were already vaccinated (29.8% of trans girls over 12 years old); 78.5% were not vaccinated and only 21.5% had intentions to be vaccinated. The group with a high score in HPV-TQ had a longer follow-up at the transgender unit, a higher maternal vaccination rate, and a positive family history of HPV-related disease, especially in mothers.Adolescent trans girls attended to in our units had a low rate and a low intention of vaccination against HPV. Education on and promotion and prevention of transgender HPV-related diseases should probably be implemented to achieve a higher knowledge and vaccination coverage in adolescent trans girls. SeveralTransgender women are not exempted from HPV risk infection. Indeed, some studies demonstrate a high prevalence of high-risk serotypes and the presence of anogenital warts in adult trans women, such as that of Brown et al. 2016), which shows that up to 96% of trans women have HPV infection, 58.8% of whom were high-risk serotypes and up to 19.1% have anogenital warts . Along t, which sHPV vaccination programs are mainly designed to protect people from cervical cancer. However, in recent years, scientific evidence suggests that the vaccine may protect against other neoplastic entities , 13. FurAchieving a high vaccination rate is important in the adolescent population, but many factors contribute to vaccination refusal by adolescents and their families . Many stCurrently, there is no published study that focused on the feelings and knowledge of main caregivers of trans adolescents, in order to improve the adherence to vaccination. Our aim is to determine the main trans women caregivers’ knowledge about HPV infection and risk, and to detect which factors could influence the intention of vaccination.2A cross-sectional study was conducted based on interviews of main caregivers of adolescents under 16 years old followed up in two reference centers with a multidisciplinary Sex Reassignment Treatment Unit: Hospital Puerta del Mar  and Hospital Universitario Reina Sofia . Inclusion criteria were as follows: main caregivers of transgender women between 9 and 16 years old who were involved in Sex Reassignment Treatment Units between January 2022 and July 2022, completed the questionnaire, and signed the consent form.The survey instrument was HPV-related diseases Knowledge Transwomen questionnaire (HPV-TQ), a 19-item self-administered questionnaire with True–False forced-response questions based on a validated survey but adapted to the transgender population . It coveAll participants provided a written informed consent before data collection in accordance with the Declaration of Helsinki, and researchers guaranteed the anonymity of data. The study was approved by the Ethics Committee of Puerta del Mar University Hospital .t-test was performed to compare continuous variables and χ2 was used when proportions are compared. p < 0.05 was considered statistically significant.Statistical analysis was performed with SPSS version 23.0 . Descriptive statistics were calculated for all variables. Continuous measures were summarized by using mean and standard deviation, and dichotomous measures were summarized by using proportions. Student’s 33.1A total of 65 main trans women adolescent caregivers were included. The average age of trans girls was 13.3 (2.7) years, and the mean age of those visiting the unit was 9.1 (3.4) years old; the main ethnic group was Caucasian . Currently, puberal blockage and crossed hormone therapy have been started in 41/65 (63.1%) and 26/65 (40%) women, respectively. Comparing this variable within low- and high-HPV knowledge groups, we only found longer follow-up in the high-HPV knowledge group in comparison with its low counterpart, with differences being statistically significant. Almost all main caregivers were the trans girls’ mothers, whose mean age was 44.1 (5.6) years old. The most frequent educational level was general certificate of secondary education in 27/65 caregivers (41.5%), followed by university studies with 17/65 caregivers (26.2%); 44/65 caregivers (67.7%) were married. No differences were found in the sociodemographic characteristics of the main caregivers when they were compared by HPV knowledge level. All data are shown in 3.2Of 65 girls, 14 were already vaccinated, all over 12 years old. They represent 21.5% of the total sample and 29.8% of the total girls over 12 years old in the sample, which is the recommended age for vaccination in cisgender girls. Only 1/7 (7.1%) of all vaccinated trans girls was vaccinated to prevent transgirl HPV-related risk, while the rest were vaccinated by following a cisgender girl program. The non-vaccinated rate was high, 51/65 (78.5%), and only 11/51 (21.5%) intended to be vaccinated. Similar data are shown in groups under and over 12 years old, 22.2% and 14.8%, respectively; thus, no differences were found. Data are shown in 3.3The HPV-TQ mean score was 11 (3.7), and the mean percentage of correct answers was 58.1% (19.6). Only 17/65 (26.1%) main caregivers were highly knowledgeable in HPV. 3.44Gay, bisexual, and other men who have sex with men and transgender women are disproportionately affected by HPV. HPV vaccination is most effective when given before exposure to HPV through sexual activity. Vaccination is routinely recommended in some countries such as USA for adolescents at age 11–12 years, with catch-up vaccination through age 26 years. However, Meites et al. 2022) showed a median age at first dose of 19 years and a median age at first sexual intercourse of 17 years; 493 (73.3%) reported that their age at first dose was older than their age at first sexual intercourse . Spain p showed aThe group of main caregivers who were highly knowledgeable about HPV showed a significantly longer follow-up at our specialized units, which might be explained by the fact that related information about risk of HPV in trans girls could be provided by gender diversity unit specialists who are knowledgeable about the importance of HPV vaccination. Vaccination in our region is programmed in primary care centers. A study in Andalusian primary care revealed that low knowledge of professionals leads to doubts in vaccination as well as unclear information provided to patients and families . In addiA similar situation has been experienced in other countries. In a 2014 survey conducted in USA involving rural participants enrolled online that included 23 transgender women who were age-eligible for HPV vaccination, only one reported receiving a healthcare provider recommendation for HPV vaccination, and only one reported ever receiving ≥1 dose of HPV vaccine. Such data suggest missed opportunities to address the need for HPV vaccination among transgender people as well as in our country . IncreasSeveral studies revealed the main predictors of vaccination, which included, apart from healthcare provider recommendation, younger age, having a healthcare visit in the past year, receiving other recommended vaccinations, and living with HIV , 29, 30.Although other studies revealed higher knowledge in vaccinated adolescents’ parents , we did Mean knowledge in our study was acceptable but some questions had a low proportion of correct responses such as those related to clinical presentation, natural history of HPV infection, diagnosis method, and treatment. This could reflect ignorance about basic aspects of HPV infection. These findings are similar to a study involving the main caregivers of adolescent cis boys from UK. Firstly, in the question “HPV can be cured by antibiotics” in our study, only 43.1% of main caregivers answered correctly, compared to 48.5% in the adolescent cis boys’ main caregiver study . Also, tThe strength of our study resides in the fact that limited data about HPV in the trans population are available . In fact5This study showed a low vaccination proportion, only 21.5%. Also, 21.5% of main caregivers of unvaccinated adolescent trans girls intend to be vaccinated. We observe that intention of vaccination is related to HPV knowledge. Knowledge in HPV was related to a previous family history of HPV-related disease, maternal HPV vaccination, and longer time of follow-up in our units. The results should encourage the development and implementation of health education programs that discuss the HPV vaccine and its benefits for trans women at early age. General recognition and approval of vaccination programs for trans women by health international institutions and campaigns focused on main caregivers to increase knowledge and awareness about the virus and vaccination can help raise the vaccination rate and improve health equality.The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding author.The studies involving human participants were reviewed and approved by COMITÉ DE ÉTICA DE LA INVESTIGACIÓN DE CÁDIZ. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.JD-R and IM-G conceptualized and designed the study, contributed to the clinical recruitment of participants, supervised the database, performed statistical analyses, drafted the initial manuscript, revised it, and wrote the final version. CB-C performed the dataset and reviewed and revised the manuscript. A-BA-J reviewed the study design, contributed to the clinical recruitment of participants, and reviewed and revised the manuscript for the final version. All authors contributed to the article and approved the submitted version.


In this paper, we exploit the fact that pipe joints are equally spaced and develop a robot localization method based on pipe joint detection that operates in one degree-of-freedom along the pipe length. Pipe joints are detected in visual images from an on-board forward facing  camera using a bag-of-keypoints visual categorization algorithm, which is trained offline by unsupervised learning from images of sewer pipe joints. We augment the pipe joint detection algorithm with drift correction using vision-based manhole recognition. We evaluated the approach using real-world data recorded from three sewer pipes  and benchmarked against a standard method for visual odometry (ORB-SLAM3), which demonstrated that our proposed method operates more robustly and accurately in these feature-sparse pipes: ORB-SLAM3 completely failed on one tested pipe due to a lack of visual features and gave a mean absolute error in localization of approximately 12%–20% on the other pipes , whilst our method worked successfully on all tested pipes and gave a mean absolute error in localization of approximately 2%–4%. In summary, our results highlight an important trade-off between modern visual odometry algorithms that have potentially high precision and estimate full six degree-of-freedom pose but are potentially fragile in feature sparse pipes,  There is an opportunity to make this process more efficient via autonomous robot inspection. One of the key challenges to overcome for this is to solve the robot localization problem so that the location of damage is known.Sewer networks transport waste products in buried pipes. They are an essential part of our infrastructure but are prone to damage such as cracks, with an estimated 900 billion gallons of untreated sewage discharged into United States of America waterways each year . TherefoThere are a number of different methods developed for robot localization in pipes . The metCameras are another widely-used method of localization in pipe robots, using monocular visual odometry (VO) , visual The sensor technology that is most of interest in this paper for localization is cameras. This is because sewer pipe inspection is often conducted using vision-based methods  and mostThe main challenge facing camera-based localization in pipes is that standard visual odometry algorithms for localization based on keyframe optimisation methods, e.g., a priori from installation data records, or estimated from odometry. The robot location along a pipe length, in one-degree of freedom, can be approximately obtained from scaling the count of pipe joints by the inter-joint distance. This transforms the problem of robot localization to one of pipe joint detection. Manholes can be mapped from above-ground to serve as drift-correcting landmarks when detected from inside the pipe to further improve the localization system.In this paper, we propose a new solution to the problem of robot localization in feature-sparse sewer pipes based on joint and manhole detections using camera images. Joint detection can be used for localization because joints occur at regularly spaced intervals where the inter-joint distance can be known Joint detection in pipes has been previously addressed using vision methods for the purpose of damage detection , using forward facing cameras , omni-disame SURF image features as input to both the joint and manhole detection systems, making the approach more computationally efficient than using completely separate systems. Overall, the joint detection with manhole drift correction produces an accurate and robust method for localization.A potential limitation of only using pipe joints for localization is that detection errors can be made, such as a joint being missed , or counted when not present . To address this challenge, we develop a modular extension based on manhole detection to correct for drift in the localization algorithm: we assume the manhole locations are known or can be mapped from above-ground offline, and then use a linear classifier to detect the manholes from within the pipe. We use the https://figshare.shef.ac.uk/articles/dataset/Visual_Odometry_for_Robot_Localisation_in_Feature-Sparse_Sewer_Pipes_Using_Joint_and_Manhole_Detections_--_Data/21198070. We benchmark against ORB-SLAM3  along the lengths of feature-sparse sewer pipes using joint detections combined with a method for drift correction at manhole locations using vision-based automated manhole detection.• A method for robustly detecting joints in pipes using a bag-of-keypoints visual categorization algorithm that is benchmarked against a standard method for detecting pipe joints in images - the Hough transform.• Experimental testing and evaluation of the localization method using real-data gathered from three live sewer pipes.• Benchmarking of the localization method against a well-known, state-of-the-art visual SLAM algorithm - ORB-SLAM3 .In summary, the main contributions of the paper are as follows.The paper is structured as follows. In In this section we describe the joint detection algorithm, manhole detection and the experimental data collection used to evaluate the algorithm in a real-world live sewer pipe. The link between vision-based joint detection and robot localization along a pipe length is described in a priori or we assume can be estimated. The joint detection algorithm proposed here has a few main steps described below: feature extraction, circle fitting and windowed joint detection.The robot location along the pipe, Ik at time step k, to check for a joint. In this paper we use a method inspired by visual categorization with bags of keypoints (Ik using speeded up robust features (SURF)  is a distance-metric (Euclidean in this case) of feature zk,i from keypoint kj and β is a threshold parameter tuned offline. The keypoints, kj, are obtained offline by using a set of training data with a K-means clustering algorithm, similar to  ,Zk={zk,milar to . The useγ. Note also that the objective here is to detect the pipe joint, not obtain an optimal model of a circle, therefore we avoid computationally intensive circle fitting based on iterative optimisation  is the horizontal-vertical image coordinates corresponding to feature zk,i, u-coordinates and v-coordinates. This circle fitting method is computationally efficient but its disadvantage is that it will fit the circle to any set of points it is given, regardless of the actual geometry of the points . The grid search took a number of days to evaluate because it involved a relatively long distance with a large number of parameters  and although reaching a global optimum could not be guaranteed, as a global search method a grid search is relatively robust to not well-distinguishable local optima, and testing on independent validation data ensured good generalization.All parameters in Algorithms 1 and 2 were tuned using a grid search across real sewer pipe data . We construct a visual vocabularly of features offline along with clusters using K-means clustering  SVM to classify the presence of a manhole, where the decision hyperplane is defined asw and b are the parameters that define the decision hyperplane and the classifier predicts the class label using the sign of f(xk). Optimal parameters for the soft-margin SVM were estimated here using sequential minimal optimization , at The University of Sheffield, UK, using tethered mobile CCTV platforms commonly used in pipe inspections. As can be see in The pipe lengths were approximately 90 m for pipe 1, 50 m for pipe 2 and 30 m for pipe 3. Diameters were approximately 600 mm for pipe 1, 300 mm for pipe 2 and 150 mm for pipe 3.The data used to train both the joint detection and manhole detection systems was selected in part from the data used to test the systems, but also from data in other pipes at the same location and collected in the same experiment.Ground truth localization was obtained from the robot tether, which measured distance travelled.The localization system proposed here was compared and benchmarked against a standard method for visual odometry, ORB-SLAM3. To do this, the camera intrinsics were obtained from a standard checkerboard calibration procedure.Xi is the true robot location in terms of distance travelled along the pipe map (as measured using the tether on the robot) and To evaluate the overall effectiveness of the robot localization system using our proposed method and ORB-SLAM3 we used the mean absolute error in localization,Ethresh is the known distance between each pipe joint, which would be the maximum error if the system was performing ideally.We also used the percent of operating time spent with an error below a threshold,A (manholes only), recall R, precision P and F1 score F1  along with a comparison to the Hough transform, which is a standard method of circle detection in images , as usedr method  - the edr method .In this section we provide results of manhole detections using using linear SVM classification. Manhole detection performed well, with an accuracy on 10-fold cross validation of 98.5% : The network displays a high accuracy as can be seen in Localization accuracy using the proposed joint detection algorithm improved substantially over using ORB-SLAM3: the average mean absolute error for the joint detection algorithm was 1.8 metres, whilst for ORB-SLAM3 it was 11.5 m in pipes 1 and 2 and a complete failure in pipe 3 due to lack of features. Joint detection, however, worked well in all pipes tested with an F1-score of 0.72–0.95 . It is wThe aim of this paper was to develop a localization system for feature-sparse sewer pipes based on visual joint and manhole detection, to overcome the limitations of conventional keyframe optimisation visual odometry systems. The results have demonstrated that this objective was successfully achieved. While the system lacks the precision often desired for odometry systems due to its discrete nature, it is able to perform highly accurate localization given relatively limited knowledge of the operating environment. Additionally, discrete updates based on prior external information free the system from problems such as scale ambiguity and loss of tracking that are particularly difficult to overcome in pipe environments. Finally, while still present in the system, errors are accumulated every distance update rather than every frame and are smaller relative to the update than in traditional visual odometry systems, meaning that drift cannot accumulate quick enough to cause system failure before manhole detection corrects the state estimate.The systems main cause of failure is lower precision and recall in more varied pipe environments, however it should be noted that the systems parameters can be optimised to improve performance in a single pipe at the expense of others.In future work, a number of improvements could be investigated to the system presented here. The first improvement would be an online adaptive method for adjusting the joint detection algorithm parameters automatically while in operation, to account for minor differences between pipes.a priori, which is realistic for some pipes. However, this knowledge might not always be available. We have found that simple odometry methods, such as wheel odometry, may be accurate enough over the short distances between pipe joints to derive this information during operation. Alternatively, it should be possible to use the detection of manholes, mapped from above-ground, to estimate the inter-joint distances. These methods require development and testing in future work. In addition, future work could address specific problems where joints are irregularly spaced and pipe bends occur - the latter problem could be addressed by combining joint detection for measuring distance travelled with an IMU to sense changes of direction.The second improvement would be to automatically estimate inter-joint distances. Here we assume these distances are known Thirdly, false positives are primarily associated with manholes, however, other predictable environmental features, such as connecting pipes, are also known to reduce the accuracy of the detection system. These other predictable features provide opportunity for further improvement through their detection or further exploitation of prior knowledge.In this paper we developed a localization method for sewer pipe inspection robots, operating in pipes with sparse visual features. The method exploited the intrinsic characteristic of the sewer pipe environment, that pipe joints occur at regularly spaced intervals. Therefore the localization problem was transformed to one of pipe joint detection. To further robustify the procedure, manhole detection was also included, which enabled drift correction based on manholes that could be mapped from above-ground. The visual localization algorithm was evaluated on three different real-world, live sewer pipes and then benchmarked against a standard method for visual odometry - ORB-SLAM3. We showed that our method substantially improved on the accuracy and robustness of ORB-SLAM3. Whilst visual SLAM algorithms such as ORB-SLAM3 are sophisticated, potentially very accurate and estimate the full six degree-of-freedom robot pose compared to our discrete, approximate localization method that only works in one-dimension along the pipe length, we would note that there is a trade-off in accuracy and robustness here, with ORB-SLAM3 regularly failing to track features in these feature-sparse sewer pipes. Ultimately we might find both systems are used in parallel in future to take advantage of the attributes of both approaches. The developed method can be applied as part of real robot localization systems, as part of digital twins for pipe networks with different scale, under different environmental conditions and different prior knowledge.


IHC showed that L1 and E4 were correlated and expressed on the tumour surface. NanoSuit-CLEM and TEM revealed HPV particles in L1-positive nuclei. L1 IHC-positive cases had a shorter surgical interval (p < 0.01) and more frequent surgeries (p = 0.04). P16 IHC, viral load, and physical status were not associated with disease severity. This study visualised HPV particle production in RRP for the first time. Persistent HPV particle infection was associated with severity. We suggest L1 IHC for evaluating RRP severity in addition to the Derkay score.Recurrent respiratory papillomatosis (RRP) has a wide range of severity. We investigate the relationship between human papillomavirus (HPV) particle production and severity of RRP. From September 2005 to June 2021, 68 RRP samples (from 29 patients) were included. HPV type was determined. HPV viral load, physical status, and demographic and clinical characteristics were assessed. Immunohistochemistry (IHC) was performed for p16, Ki-67, L1, and E4. We used NanoSuit-CLEM (correlative light and electron microscopy) and transmission electron microscopy (TEM) to examine the samples. The total number of surgeries in HPV-positive and HPV-negative cases were 3.78  and 1.30 , respectively ( RRP is also known as laryngeal papillomatosis (LP)3. In general, HPV involvement is reported in 80–96.9% of patients6; however, a few studies reported lower rate of HPV detection approximately 60%2. Moreover, some reports have not examined HPV involvement9. Some patients remain in remission after a single surgery, while others develop malignant transformation after multiple surgeries and have unfavourable outcomes11. The Derkay score, which evaluates disease severity based on clinical findings, is often used to determine the severity of RRP12. However, few studies have been conducted to investigate the clinical severity of the disease based on its pathogenesis, such as the HPV lifecycle. Since HPV DNA is detected in the laryngeal mucosa of patients in remission, it is believed that persistent HPV infection is involved in the pathogenesis of RRP13. However, no reports have examined the association between HPV involvement (or the state of HPV particles produced by tumours) and disease severity.Recurrent respiratory papillomatosis (RRP) is a benign tumour that is often caused by human papillomavirus (HPV) type 6 or 11Drosophila larvae using a field emission scanning electron microscope (FE-SEM), which requires high vacuum conditions15. The NanoSuit-CLEM (correlative light and electron microscopy) method, which applies NanoSuit technology, is a technique that forms a nano membrane on pathological tissues, thereby preserving the water-content of the tissue and maintaining its three-dimensional structure, while the area under optical microscopic observation is observed with a SEM16. The process can be completed in a few minutes, and FE-SEM observation can be easily performed. We previously examined various pathological tissues such as the gastrointestinal tract and salivary gland using the NanoSuit-CLEM method19. Furthermore, we have previously reported standard methods of observation for various viruses, such as cytomegalovirus, varicella zoster virus, and HPV, using the NanoSuit-CLEM method20.The NanoSuit method is a biomimetic technique inspired by the ability to observe live 22. Thus, we hypothesised that active HPV particle production would be associated with the severity of RRP because E4 is involved in the formation and release of HPV particles.It has been reported that HPV E4 and E5 mRNA expressions are high in RRP and may be involved in the pathogenesis of the diseaseIn this study, we attempted to elucidate the HPV lifecycle in RRP by observing HPV particles using the NanoSuit-CLEM method. Furthermore, we aimed to show that active HPV particle production is associated with disease severity.p = 0.02). Furthermore, the Derkay score was 6.27  in HPV-positive cases, and 4.84  in HPV-negative cases (p = 0.02). However, no statistically significant differences in the total number of surgeries and Derkay scores were identified for HPV types 6 and 11 (p = 0.10). No cases of disseminated lesions in the lower respiratory tract were observed. Malignant transformation occurred in three cases, all of which were HPV-negative.The patient characteristics are summarised in Table HPV-positive RRP cases often showed koilocytosis on the tumour surface (area between the dotted lines) Fig. A. On thep < 0.01). However, there was no statistically significant difference between HPV types 6 and 11 (p = 0.62). . However, there was no statistically significant difference between HPV types 6 and 11 (p = 0.87)    to evaluate p16 IHC staining  sections. We selected Case 5–2, who was HPV type 11-positive and well expressed L1 IHC. First, we performed L1 IHC and photographed the positive sites Fig. A. SubseqNext, we attempted TEM observations of the microparticles in the nucleus using FE-SEM. IHC for L1 was performed Fig. H, NanoSuIn addition, we attempted to determine whether HPV particles appear differently in each HPV type and how the particles are formed. In both HPV type 6- and 11-positive cases, L1 IHC was strongly positive using light microscopy in the superficial layers of the tumour, and these cells were seen to be filled with microparticles in the nucleus using FE-SEM Fig. A,B,G,H. p = 0.04)   Fig. B. Furthe01) Fig. C.Figure p = 0.96)   . The MIB-1 index and Derkay score, a measure of severity, displayed a weak positive correlation      Fig. F. This s23. Since HPV DNA is detected in the laryngeal mucosa in remission, persistent infection is thought to be the pathogenesis of RRP13. In this study, IHC revealed that L1, which is a capsid protein, and E4, which is involved in HPV particle formation25, were correlated in the RRP tissue. Furthermore, observation of L1 IHC-positive cells by NanoSuit-CLEM and TEM revealed that the nuclei were filled with microparticles approximately 50–60 nm in size, while similar findings were not observed in L1 IHC-negative cell nuclei, indicating that these particles were HPV particles. Furthermore, this study suggests that HPV particles begin to form the tumour surface layer and increase in number as they move upwards. This study proved for the first time that HPV particles are continuously produced in severe RRP, which may result in persistent infection. In other words, we successfully visualised part of the HPV lifecycle in the RRP with FFPE sections.HPV is a double-stranded DNA virus approximately 50–60 nm in size without an envelope6, but a few reports demonstrated an HPV involvement of approximately 60%2. Reports also exist where clinical diagnosis has been made without examining whether or not HPV is involved9. We examined HPV by PCR, L1 IHC, E4 IHC, and qPCR for E2/E6, all of which are undetectable in HPV-negative cases. These results indicate the presence of HPV-negative cases even in pathological cases of papilloma clinically diagnosed as RRP. In adult onset LP, the age group was lower for HPV-positive cases. Genetic mutations in RAS have been reported in HPV-negative cases26. They could be older since genetic mutation is the primary aetiology. The present data also showed a trend towards older age in HPV-negative RRP. On the other hand, the age of HPV types 6- and 11-positive RRP was not different in many reports; hence, the significant difference in this study could be attributed to the small sample size.This study also focused on HPV involvement. The HPV frequency is reportedly more than 80% based on recent papers on RRP27. However, two limitations of the Derkay score are that the score cannot predict the site of recurrence, and the score could vary from evaluator to evaluator since no clear criteria exist for tumour size or other factors. Another well-known risk factor is the involvement of HPV type 1129. In this study, the number of surgeries did not differ between HPV types 6 and 11; however, there was a statistically significant difference between HPV-positive and HPV-negative patients. Furthermore, we found that the surgical interval was shorter, and the number of surgeries was higher in L1 IHC-positive cases, which indicates active HPV particle production. These findings suggest that persistent production of HPV particles, resulting in persistent infection, is the main pathogenesis of RRP. The combination of surgery and HPV vaccination has been reported to reduce the risk of recurrence31. These reports support this hypothesis. Time to diagnosis could be a confounding factor. However, looking at the L1 IHC-positive cases in this study, they tend to be positive regardless of the surgeries performed . All methods were performed in accordance with the Declaration of Helsinki. Written informed consent was obtained from all patients. Medical information, including patient age, sex, alcohol exposure, smoking status, Derkay score, and date of surgery, was retrieved from patient records.12.The Derkay Score is a widely used severity assessment method. The formula of the Derkay score is ‘the sum of the points calculated from the size of the tumour at each site’ plus ‘the points calculated from the clinical findings’. The tumour size assessment is based on the aerodigestive tract divided into 25 subsites, each of which is given a score of 0 to 3 . The clinical findings assessment are based on the patient’s voice , patient’s stridor , urgency of today’s intervention , and level of respiratory distress https://blast.ncbi.nlm.nih.gov/).Tissue for DNA extraction was sampled from the area with the largest tumour volume. In cases where tissue sampling for this study was inadequate, DNA was extracted from FFPE tissue. DNA was extracted using a QIAamp DNA Mini Kit or QIAamp DNA FFPE Tissue Kit . The TaKaRa PCR Human Papillomavirus Typing Set  primer set was used to detect HPV. Samples that were detected as HPV-positive by PCR were subjected to direct sequencing analysis using a 3500xL Genetic Analyzer . HPV type was determined by searching for sequences using BLAST  forms exist, E2/E6 ≥ 1 indicates the predominance of episomal form, and E2/E6 = 0 indicates an integrated form only36.The viral load of HPV type 6 or 11 and the physical status were evaluated by qPCR using the StepOne Real-Time PCR System . Primers for HPV type 6 and 11 specific E2 and E6, and actin beta were designed  was used to block the sections. The primary antibodies used were HPV-L1 antibody (K1H8) , p16 (E4H6) , and Ki-67 (MIB-1) . HPV type 6 E4 and type 11 E4 antibodies, as described previously, were also used21. For secondary antibodies, a MAX-PO(M) or MAX-PO(R) kit  was used. The sections were visualised with DAB.FFPE tissue sections (4-μm thick) were prepared. Antigen retrieval was performed using the Epitope Retrieval Solution pH 9 . To block endogenous peroxidase activity, the sections were incubated in a 0.3% HL1 and E4 double staining was performed by L1 and visualised by DAB, and E4 was visualised using the ImmPACT Vector Red AP Substrate Kit .37.IHC evaluations were performed independently by two pathologists who were blinded to patient information. IHC was evaluated as positive or negative for L1 and E4, the MIB-1 index was calculated as percentage of Ki-67 IHC-positive cells/total tumour cells, and p16 was calculated as the immunoreactive score (IRS) using staining intensity as percentage of the positive tumour cells  . Hitachi S-4800 Field Emission Scanning Electron Microscope  was used for FE-SEM observations and operated at an acceleration voltage of 5.0 kV. The images were captured in the yttrium–aluminum-garnet backscattered electron (YAG-BSE) mode.IHC with L1 antibody was performed (DAB-stained). Next, images of the areas to be observed by FE-SEM were obtained. The slides were incubated with 1% osmium solution for 5 min. Osmium reacts specifically with DAB and is enhanced when observed using FE-SEM2) were cut out to unify the FE-SEM observation area. Ultrathin slides (60–80 nm) were prepared and stained with lead acetate and uranium acetate. JEM-1400  was used for the transmission electron microscopy (TEM) observations.FFPE tissue Sects. (8-μm thick) were prepared using non-coated glass. The NanoSuit Solution II  was applied to the slides, which were rotated 3000 rpm by spin coater to create a nanofilm. Then, FE-SEM observations were performed. The FFPE tissue sections on slide glass were re-fixed with 2% glutaraldehyde and 2% osmium tetroxide, and embedded in epoxy resin . Blocks  and KyPlot ver.6.0.2 .Data for the two populations in the two categories were subjected to Fisher’s exact test. Fisher’s exact test was conducted using two-tailed tests. The relevant data included sex, smoking, alcohol, and malignant transformation. Welch’s t-test was applied to compare the two sets of data. A Welch’s t-test was conducted using two-tailed tests. The relevant data included age, total number of surgeries, Derkay score, IHC data, and viral load. Since these data did not show homogeneity of variance, Welch’s t-test was performed. The Pearson product-moment correlation coefficient was used to assess the strength of the linear relationship between the two data or random variables. A binomial logistic regression analysis was applied for determining the association between L1 IHC and the Derkay Score. Statistical significance was set at Supplementary Information.


D-optimality criterion for simultaneous inference and a K-means procedure which clusters the support points of the locally D-optimal designs of the individual models.An important problem in toxicology in the context of gene expression data is the simultaneous inference of a large number of concentration–response relationships. The quality of the inference substantially depends on the choice of design of the experiments, in particular, on the set of different concentrations, at which observations are taken for the different genes under consideration. As this set has to be the same for all genes, the efficient planning of such experiments is very challenging. We address this problem by determining efficient designs for the simultaneous inference of a large number of concentration–response models. For that purpose, we both construct a D-efficiencies and in terms of the quality of the resulting model fits using a real data example dealing with valproic acid. For the quality comparison we perform an extensive simulation study.We show that a planning of experiments that addresses the simultaneous inference of a large number of concentration–response relationships yields a substantially more accurate statistical analysis. In particular, we compare the performance of the constructed designs to the ones of other commonly used designs in terms of D-optimality criterion for simultaneous inference improves the inference of the different concentration–response relationships substantially. The design based on the K-means procedure also performs well, whereas a log-equidistant design, which was also included in the analysis, performs poorly in terms of the quality of the simultaneous inference. Based on our findings, the D-optimal design for simultaneous inference should be used for upcoming analyses dealing with high-dimensional gene expression data.The design maximizing the  An important problem in toxicology in the context of gene expression microarray data is the simultaneous inference of a large number of concentration–response relationships. While gene expression of each gene is observed individually within the concentration–response experiments, the corresponding different experimental conditions, i.e. the concentrations, have to be the same for all genes. Therefore, the crucial question is how the different conditions should be allocated in order to reduce the costs of the expensive gene expression experiments while achieving a high informativeness of the resulting data.Concerning the statistical analysis based on these experiments, the concentration–response relationships are typically modelled by nonlinear parametric curves to obtain certain parameters of interest for the individual genes, such as alert concentrations or the effect of a prespecified concentration on certain genes  designs for several concentration–response curves which share some parameters, but in both cases the resulting optimal designs are individually determined for each curve under consideration. Dror and Steinberg [K-means algorithm for multiple experiments, but in the context of multivariate generalized linear models, which cannot directly be adapted to the situation considered in this paper. In the setting of high-dimensional microarray data, Dong et al. [Although determining optimal experimental designs for parametric curves has found considerable interest in the literature for the individual analysis of concentration–response relationships  and espeteinberg  developeg et al.  introducg et al.  as well g et al. , respectD-optimality. Therefore, the resulting designs for simultaneous inference contain information both about the allocation of the concentrations and about the relative amount of observations that should be taken at each concentration, respectively. In particular, we construct a D-optimality criterion for simultaneous inference by adapting the approach of Bayesian optimality criteria introduced by Chaloner [D-efficiencies . To be Chernoff , for estx∈X (see ).D-optimal) design D-efficiency which is defined byD-optimality criterion D-efficiency. Note that the D-efficiency also depends on the unknown parameter In order to investigate the quality of a  of the form  ifD-optimal by checking whether the inequalityD-optimality criterion given in  (see ). For a function .h such that its information matrix D-optimal design D-optimal designs maximizing the criterion in  introduced by Bretz et al.  to deteca et al. , we fix h and the We now concentrate on the analysis of the remaining 20,791 genes and the corresponding concentration–response relationships. In particular, we fit a regression model of the form (h within the parameter space h), 84.5 % of the estimates take values in the interval . Both small values i.e. Due to the contrast levels an accumulation for genes with high steepness parameters independent of the Note that each of the seven areas in Fig. mentclass2pt{minimIn Fig. K-means design and the simultaneous D-optimal design, the locally D-optimal designs based on the D-optimal designs for these parameters are needed for the calculation of the D-efficiencies defined by  can be found in Table For the construction of an equally weighted entclass1pt{minimaD-optimal design in  is then given byg. Thus, it holds:We use the Root Mean Squared Error (RMSE) to evaluate the performance of the different designs. For a given scenario g Cheema , the RMSIn the section “In the left part of Fig. K-means, and the simultaneous D-optimal design, respectively. For that purpose, we also remove the outliers, as no structure of these could be detected in dependence of the design choice. Further analyses resulted in observations similar to the ones for the D-efficiencies: In particular, outliers occur mostly for extreme parameter combinations such as It is clearly visible that the NRMSEs corresponding to the log-equidistant designs are greater than the NRMSEs of the other designs. In particular, almost 50% of the considered genes have an NRMSE, that is almost twice as large as for the other designs. Moreover, the NRMSEs obtained with the log-equidistant design, are extremely varying compared to the others. Thus, it follows that using the log-equidistant design is not reasonable for the data at hand and we restrict ourselves to the analysis of the NRMSEs obtained for the original, the equidistant, the D-optimal design of each gene g is provided, respectively. Note that the locally D-optimal designs, in general called D-optimal designs has to be interpreted as benchmark.The right part of Fig. D-optimal design and the K-means, followed by the NRMSEs of the equidistant design. For instance, the median is 0.069 for both D-optimal designs, which indicates a good performance with respect to the NRMSE. Finally, the original design results in larger NRMSEs than the other designs. In particular, the lower quartile of NRMSEs is given by 0.072, which is even greater than the upper quartiles of the equidistant, K-means, and simultaneous D-optimal design.Apart from the locally optimal designs, the best results with respect to the NRMSE are achieved by the simultaneous D-efficiencies in the section “h. Summarizing, the comparison of the RMSEs of the designs (stratified to different parameter constellations) leads to similar results as within the total analysis. A detailed description and corresponding figures can be found in the Additional file Similarly to the theoretical analysis of the mentclass2pt{minimK-means design, results in appropriate NRMSEs, whereas for the log-equidistant design NRMSEs are substantially higher in comparison to all other designs. Both the simultaneous D-optimal design and the K-means result in the best NRMSEs and therefore in the best simultaneous inference of the 15,233 concentration–response relationships.Summarizing, the designs constructed in the section “N is varied, that is We consider the NRMSEs of the different designs when the sample size For all considered designs the NRMSEs are decreasing with increasing sample size, which implies an increase in the precision of the corresponding model fits. In particular, the median NRMSEs of all designs are located within 0.084 and 0.092 for D-optimal design , the following can be observed: The NRMSEs of the original design for D-optimal design for D-optimal design.Comparing the NRMSEs of the original design to the NRMSEs of the simultaneous K-means design which is based on locally D-optimal designs of individual concentration–response curves and the D-optimal design for simultaneous inference which incorporates the distribution of the nonlinear parameters of the different concentration–response curves. In order to investigate the performance of these designs, we used the VPA-data set by Krug et al. [D-efficiencies and in terms of the performance for the simultaneous estimation of 15,233 concentration–response curves in a simulation study .This paper introduced two ways to construct designs that address the problem of the simultaneous inference of a large number of concentration–response relationships: the g et al.  and consD-efficiency and terms of the simulation study, we observed similar results: the simultaneous D-optimal design results in the most precise model fits for the different curves under consideration, the model fits obtained if the K-means and the equidistant design used are also appropriate. The log-equidistant design performs worse and the corresponding precision of the model fits is the lowest. Consequently, it is not recommendable to use the log-equidistant design if a large number of different concentration–response relationships (with considerably different shapes) should be estimated.In terms of D-optimal design improves the inference substantially. While the K-means design also performs well in the situation under consideration, it might be less feasible due to its construction. The construction of the simultaneous D-optimal design is straightforward by including a rough distribution of the nonlinear parameter values. Note that the equidistant design also performs well with respect to the considered measures in the situation under consideration, but it might perform worse in others. The advantage of the simultaneous D-optimal design is its flexibility: it can easily be adapted to the situation at hand, based on a distribution which can be predefined by the user.In general, it follows that the simultaneous D-optimality criterion for simultaneous inference. Moreover, we restrict ourselves to the D-optimality criterion, other criteria could also be used to construct a design for simultaneous inference, e.g. addressing the precise estimation of the The paper is based on the assumption that all concentration–response relationships are modelled appropriately by the same nonlinear regression function (with varying parameters). Different parametric regression functions could be assumed and the distribution of the occurrence of these curves could be included in the Additional file 1. Equivalence Theorem for