Besides the controversy of the association of high glycemic index and glycemic load with precancerous cervical lesions, only a few studies have examined the impact of fasting blood glucose levels on human papillomavirus (HPV) multiple infections. In the present study, we appraised the relationship between blood glucose levels and multiple HPV infections in a population of HPV-positive women with cervical high-grade squamous intraepithelial lesions (HSIL). The present study was designed as a cross-sectional correlative analysis. A total of 560 participants with a pathologically confirmed HSIL with HPV infection were included from a hospital in China during January 1, 2018, and December 31, 2019. The target variables and the outcome variables were the glucose levels at the baseline and HPV multiplicity, respectively. The odds ratio and 95% confidence intervals were calculated to estimate the risk of multiple infections via logistic regression analysis. The average age of the 560 participants was 44.63 ± 10.61 years; the nonlinear relationship was detected between the glucose levels and multiplicity of HPV, with an inflection point at 5.4. After adjusting for the full range of variables, the effect sizes and confidence intervals for the left and right sides of the inflection points were found to be 0.379 (0.196–0.732) and 5.083 (1.592–16.229), respectively. In this cross-sectional study, both high and low blood glucose levels increased the risk of multiple HPV infections, demonstrating a U-shaped relationship between the blood glucose levels and multiple HPV infections. Persistent human papillomavirus (HPV) infection is widely known as the etiological cause of cervical intraepithelial neoplasia (CIN) and cervical cancer.,3 Past studies have demonstrated that the development of cervical cancer takes years to even decades, including the intermediate stage of CIN. Some studies have reported that multiple HPV infections contributes to the growing risk of cytological abnormalities, when compared to a single HPV infection, and hence, it is considered as a risk factor for cervical cancer development.–8 Cervical infections with more than one HPV genotype are common in young women, and approximately 25% to 49% of the affected women have been found to have multiple infections.–11 More than 200 types of HPV have been isolated so far, of which 12 to 15 form the high-risk types.,13 High-risk HPV is the leading cancer-causing type, HPV-16 and -18 are the main carcinogenic HPV, and other high-risk types include HPV-31, -33, -35, -45, -52, and -58. In addition, the type and pattern of HPV infection vary by geography and economy.,16Cervical cancer is the fourth leading cause of cancer in women worldwide, posing a great threat to the entire world population, especially the developing countries. In HPV-positive cervical cancer, the expression of GLUT1 indicates a worse prognosis. Oncoproteins E6 and E7 expressed by HPV play critical roles in cervical carcinogenesis. Jia Yi Tang et al reported that HPV E6/E7 upregulated GLUTs in lung cancer and that E6 and E7 mediated GLUT expression and glucose absorption were related to lung cancer. Therefore, we inferred that HPV E6/E7 upregulates glucose E6, E7-mediated GLUT expression, and glucose absorption, which lead to the malignant transition of the cervical epithelium with HPV infection. Conclusively, GLUT1 is a promising diagnostic approach, wherein the glucose metabolism can potentially act as an intervention target in the treatment of cervical cancer.Past studies have reported that glucose transporters (GLUTs) are associated with the malignant transition of cervical epithelium with HPV infection. Numerous studies have indicated a strong association between increased levels of glucose and adverse health outcomes, including hypertensive diseases, metabolic disturbance, kidney diseases, heart diseases, and tumor.–24 However, according to the current studies, the relationship between glucose and cancer is inconsistent. Several epidemiological studies and meta-analyses have examined the association among glycemic index (GI), glycemic load (GL), and the risk of some cancers, such as ovarian cancer,,27 endometrial cancer,,29 breast cancer,,31 liver cancer,,33 colon cancer,,35 bladder cancer, and renal cancer. However, the results of these studies are conflicting. Some studies have demonstrated a strong correlation between dietary GI or GL and cancer risk,,30,37,38 whereas others have reported no such association.,33,35,39 Navarro-Meza et al reported that high levels of glucose in the plasma and obesity can act as risk cofactors in the development of precancerous lesions of the cervix. Similarly, in a Korean case-control study on 1340 cases , GL and GI were identified to be positively associated with increased risk of CIN1, but not with the risk of CIN2/3 and cervical cancer.Glucose, as the vital energy resource in cells, is extremely common in the human blood. The present study aimed to evaluate the relationship between glucose levels and the risk of HPV infection among Chinese women with pathologically confirmed HSIL.However, no previous epidemiological studies have reported any relationship between glucose and the risk of multiple HPV infections. One study reported a strong relationship between a high level of blood glucose and a high risk of cervical cancer with a poor prognosis.In this research, a retrospective study was conducted to explore the relationship between glucose and multiple HPV infections. The independent variable was the glucose level obtained at the baseline. The dependent variable was the type of HPV infection.The data of participants were gathered from the electronic medical records system of the Gynecology Department, Yuebei People’s Hospital, Shaoguan City, China. To safeguard patient privacy, no personally identifiable enrollment data were included. The data were obtained from the hospital’s electronic medical record system. Informed consent from participants was waived off as this was a retrospective cohort study. The Hospital Institutional Review Board approved the study protocol.Figure We acquired the glucose level at the baseline and recorded it as a continuous variable. The procedure was as follows: blood samples were collected in EDTA-anticoagulated tubes and subjected to biochemistry tests the next morning after the patients were admitted. The blood samples collection and analysis of the fasting blood specimens were performed after a minimum of 8 hours of overnight fast to define the fasting glycemia. According to the existing research, we obtained the outcome variable (dichotomous variable).The detailed process of people who were infected with HPV was described as follows: infection types were “any HPV infection” and “multiple HPV infection” (2 or more genotypes). HPV genotyping was performed on specimens collected by using the HPV typing test kit (PCR + membrane hybridization) analysis. A Chinese FDA approval was obtained for this test .HPV genotypes were identified using the YanengBio Human Papillomavirus Genotyping Kit  according to the manufacturer’s instructions. The 15 HPV types include 13 high-risk types  and 2 low-risk types . According to the information provided by YanengBio Human Papillomavirus Genotyping Kit , the parameter for amplification was set to the following: 95°C for 9 minutes, 40 cycles , 72°C for 5 minutes. After amplification, hybridization, and color development, positive test results were noted as a blue spot. Positive dots were identified according to the distribution of the HPV types in the film strips. Both negative and positive controls were set up throughout. The experiment was subjected to internal quality control and external quality assessment, and the results were found to meet the requirements. The cytology samples were interpreted by a pathologist following the Bethesda SystemNILM or ASC-US code with 1, A SC-H or HSIL or LSIL code with 2). A histological diagnosis of the excised specimen was based on the World Health Organization specified classification system.The covariates employed in this study fell into the following categories: population demographics; variations that affected the blood glucose levels or HPV multiple infections that had been previously reported in the literature or were based on our clinical experience. Hence, totally adjusted models were constructed using the following variables: continuous variables: age (year), weight (kg), neuron-specific enolase (NSE = µg/mL), squamous cell carcinoma of the anus (SCCA = ng/mL), alanine aminotransferase (ALT = U/L); aspartate aminotransferase (AST = U/L); uric acid (UA = Ummol/L); glucose (GLU = mmol/L); creatinine (CREA = Ummol/L); urea nitrogen (BUN = mmol/L) (obtained at the baseline); categorical variables: vagina cleanness , menopausal status (premenopause or postmenopause) was defined as no menstrual period for the past 12 months. Several pregnancies , the number of childbirth . Several miscarriages (0 denotes no such event and 1 + denotes 1 or more events). Cytology samples were interpreted by a pathologist with reference to the Bethesda System.P value of the log-likelihood ratio test. Step 3: Subgroup analyses were undertaken by employing a hierarchical binary logistic regression model. For continuous variables, we first transformed them into categorical variables based on the clinical cut points or trisections, followed by interaction tests. The likelihood ratio tests were performed after correcting for the effects of subgroup indicators. To ensure that the data analysis was robust, a sensitivity analysis was performed. We switched glucose to a trichotomous variable and counted the P for trend. The study aim was to validate the results for glucose as a continuous variable and to determine the possibilities for nonlinearity. All analyses were performed using the statistical software packages R (www.r-project.org) and Empower Stats . Significant P values < .05 (both the sides) were deemed to be statistically significant.In this study, our representations of the continuous variables were based predominantly on whether they are normally distributed. If they were normally distributed, we expressed continuous variables as the mean ± standard or median and conversely as median . The categorical variables were then expressed as frequencies or percentages. We used χ2 , a 1-way ANOVA test , or Kruskal–Wallis H-test (skewed distribution) to test for a difference between different multiples of HPV groups (dichotomous). The process of analyzing the entire data was separated into 3 steps. Step 1: Using univariate and multivariate binary logistic regression analyses. A total of 3 models were constructed: Model 1, with no adjustment for covariates; Model 2, adjusted for socio-demographic data only; Model 3, Model 2 + other coefficients are shown in Table P = .047).Altogether 560 participants were selected for analysis of the final database after screening using inclusion and exclusion criteria . The effects sizes (odds ratio) and 95% confidence intervals (CI) are presented in Table P for the trend in glucose in the fully adjusted model with a categorical variable was inconsistent with the results when glucose was a continuous variable  for sensitivity analysis, and the le Table . In addiP was selected for the log-likelihood ratio test.In the present study, we investigated the nonlinear relationship between glucose and multiple HPV infections Table , Fig. 2.P for the log-likelihood ratio test was < .05, we selected dichotomous binary logistic regression to fit the association between glucose and HPV multiplicity as it could accurately represent the relationship. Using a 2-segment binary logistic regression and recursive algorithm, we computed an inflection point of 5.39. On the left-hand side of the inflection point, the effect size and 95% CI were 0.379 (0.196–0.732), respectively. On the right-hand side of the inflection point, the effect size and 95% CI were 5.083 (1.592–16.229), respectively ; right 3.249 ]. This result implied the presence of an independent U-shaped association between the glucose levels and multiple HPV infections.To the best of our knowledge, it is imperative that a U-shaped curve has been used to describe the relationship between fasting glucose levels and the risk of HPV multi-infection, and these data can be applied to ascertain that the risk of multi-infection was the lowest in women with a high-grade cervical abnormality without diabetes at the glucose level 5.37 to 5.92 mmol/L. This information can facilitate the application of evidence-based quality improvement measures aimed at reducing the risk of multi-infection by maintaining the glucose level within a defined range of practices so as to reduce the risk of multiple infections. β-glucan is a homogeneous polysaccharide composed of glucose as a monosaccharide and abundantly found in the cell walls of yeast, bacteria, and fungi. They consist of glucose molecules connected by (1-3), (1-4), or (1-6) beta-glycosidic links, have different branches structured separately from the linear trunk, and are known to mediate immunogenicity via receptor-mediated interaction with M cells.–44 In addition to being immunogenic, it has a promising antiviral effect. For example, Jung et al demonstrated that the pulmonary lesions caused by infection with SIV were significantly more serious in animals predosed with β-glucan than those due to infection in the non-oral group. Moreover, there was a marked improvement in the levels of interferon-gamma (IFN-γ) and nitric oxide in the bronchoalveolar lavage liquid of the treatment group. These discoveries support the potential use of beta-glucan as a prophylactic/therapeutic alternative for flu virus infections. These results may cumulatively indicate that low blood sugar level is not good for the body to clear viruses.Although the mechanisms linking the blood glucose levels to increased risk of HPV multiple infections are unclear, our research revealed that patients with a low blood sugar level are at a higher risk of multiple HPV infections. Moreover, hypoglycemia may be a manifestation of malnutrition, metabolic disorders, and poor immunity, while normoglycemia may represent more reliable immunity. These are some of the possible explanations. A past study showed that β-glucans have immunogenic and antiviral properties.,47 which may make HPV clearance difficult, thereby leading to the promotion of cancer progression. Another study indicated that alterations in the insulin signaling pathways that promote glucose uptake and cell proliferation are frequently detected in cervical cancer. Positron emission tomography reveals that cancer constitutes more glucose than the surrounding normal tissues. Furthermore, mass spectrometry analysis revealed that glucose molecules, in addition to being an important source of energy, provides the building blocks required for cell replication, which explains the increased glucose metabolism in cancer cells and the outcomes of PET scanning. Upon viral infection, cells also experience increased glucose uptake to meet the substrate requirements for greater virus production. The increase in glycolytic metabolites and enzymes following adenovirus infection of the cells was found by Vander Heiden et al. Early on, Landini et al reported increased glucose uptake and metabolism in cells infected with cytomegalovirus as well as in cells infected with other subsequent viruses.–54 Xie et al revealed that hyperglycemia leads to more severe coronavirus disease 2019 infections and poor prognosis. Thus, increased glucose uptake is a commonly observed feature of virally infected cells. Multiple studies have demonstrated that multiple infection patterns may be related to geographic, demographic, and socioeconomic factors.,57In our study, subjects in the high glucose level group displayed a statistically significantly higher risk of acquiring HPV multiple infections. Hyperglycemia is associated with increased susceptibility to viral infection and cell-mediated immunodeficiency,This study has the following clinical merits. To the best of our knowledge, this is the first time that an independent link between glucose and multiplicity of HPV in Chinese patients of a pathologically confirmed HSIL with HPV affection; and the outcome of this research should contribute to future studies in constructing models for the diagnosis or prediction of HPV multiplicity.There are several strengths to our study. We addressed the issue of nonlinearity in this study and explored it further. This was an observational study and therefore prone to potential confounding influences. We minimized any residual confounding factors through rigorous statistical adjustments. We dealt with the targeted independent variables as constant and classified variables. This approach decreases the chance of data analysis and enhances the robustness of the results. There are some limits to this study, including the following: Chinese female patients with pathologically confirmed HSIL showing the HPV effect were selected as the study participants. Consequently, there were some inadequacies in the universalization and generalization of the study. As we eliminated HPV negative or missing HPV data, disease of the immune system, or diabetes, FBG ≥ 7 or ≤ 3 mmol/L, the outcome of this study does not apply to these individuals.The blood glucose levels are associated with the risk of multiple HPV infections. High or low blood sugar level may increase the risk of multiple HPV infections, and the possible induction of TRIM by β-glucan can elicit protective effects by altering the immune response against a range of viral infections. Viral infection of cells also requires increased glucose uptake for viral replication and production. However, further research into the mechanisms of this problem is warranted. The assessment of glycemic management as an intervention is also recommended.X.C.W. presented the preliminary idea for this study. J.Z. was involved in initial draft writing. H.X., H.H. responsible for data analytics and discussion. F.X.L., Z.L., W.J.Z. gathering and cleaning data. Y.C. advice on revising articles.The authors acknowledge the patients.


Veterans who kill in war are at risk of developing negative mental health problems including moral injury, PTSD, spiritual distress, and impairments in functioning. Impact of Killing (IOK) is a novel, cognitive-behaviorally based treatment designed to address the symptoms associated with killing that focuses on self-forgiveness and moral repair through cultivation of self-compassion and perspective-taking exercises, such as letter writing, and active participation in values-driven behavior.In a pilot trial assessing IOK, participants demonstrated a reduction in multiple mental health symptoms and improvement in quality-of-life measures, and they reported IOK was acceptable and feasible. Furthermore, trauma therapists have reported that moral injury is relevant to their clinical work, expressed a desire for additional training on the impact of killing, and identified barriers that make addressing killing in clinical settings challenging. Data are currently being collected in a national multi-site trial to examine the efficacy of IOK, compared to a control condition.IOK fills a critical treatment gap by directly addressing the guilt, shame, self-sabotaging behaviors, functional difficulties, impaired self-forgiveness, and moral/spiritual distress directly associated with killing in war. Typically provided following some initial trauma-processing treatment, IOK can be integrated in existing systems of trauma care, creating a pathway for a stepped model of treatment for moral injury. Historiexposure –5, 6•. Gexposure .Despite high rates of killing in war  and the We began by examining the impact of killing through a mixed-method approach. Initial quantitative research examined mental health outcomes associated with killing in war, showing that those who killed in war were at increased risk for posttraumatic stress disorder (PTSD), alcohol abuse, suicide, and functional difficulties after returning home, even after adjusting for the impact of general combat –14. We fWe then conducted focus groups with veterans of multiple war eras  inquiring about their experiences with killing, how killing impacted their lives post-deployment, and whether they believed killing experiences were addressed in existing PTSD treatments. Veteran feedback was qualitatively analyzed to determine common experiences, beliefs, and barriers to addressing moral injury in existing models of treatment . Focus gN = 33) revealed that individuals in the IOK treatment group, compared to the waitlist condition, experienced a statistically significant improvement in PTSD symptoms (p = 0.033), general psychiatric symptoms (p = 0.0068), and specific items on quality-of-life functional measures. For example, veterans who received the treatment were more likely to endorse taking part in community events or celebrations (p = 0.0074) and were more likely to confide personal thoughts and feelings to loved ones (p = 0.049). Anecdotally, multiple veterans described reconciling with adult children they had been estranged from for years, reaching out and apologizing to ex-partners for their behavior post-combat, volunteering, visiting meaningful sites , and even returning to places of worship after decades away as a result of participating in this pilot study. Assessment of the KCS showed that following completion of treatment, veterans who received IOK demonstrated statistically significant decreases in their level of distress around various killing-related beliefs such as “I deserve to suffer for killing” (p = 0.009) and endorsed greater understanding of the factors that led to killing. Furthermore, those who received IOK reported that the treatment was acceptable and feasible.We tested our initial treatment protocol in a randomized, controlled pilot study • with coTo further examine the IOK treatment protocol, we collected qualitative feedback from all participants who completed the pilot study • and surWe are currently conducting a multi-site, randomized, controlled trial to examine the efficacy of IOK when compared to Present-Centered Therapy (PCT) for PTSD. Given the use of PCT as a comparison treatment in the initial trials examining efficacy of EBPs for PTSD, we selected PCT to be the control condition. We modified PCT in the first two sessions to include general psychoeducation around moral injury and administration of the KCS, the measure we developed assessing beliefs around killing. Both IOK and PCT were originally intended to be administered face-to-face with participants, but due to restrictions on in-person treatment delivery during the COVID-19 pandemic, we shifted our delivery of treatment to include  telehealth. While this shift was challenging in many ways, it has expanded recruitment and allowed us to enroll participants from parts of the country beyond the surrounding areas of our study sites.IOK is a cognitive-behaviorally based intervention that consists of ten sessions of weekly, individual psychotherapy lasting 60–90 min each facilitated by a therapist who has specialized training in traumatic stress. Ideally, veterans will have either participated in an EBP for PTSD or engaged in some form of trauma-focused psychotherapy prior to engaging in IOK. This is due partly to the brevity in which the cognitive-behavioral model is reviewed and the intensity of emotion associated with moral injury. Clinical judgment is key, and we have found that veterans tend to be more engaged and benefit more from treatment if they have prior therapy experience processing traumatic emotional material.and to reinforce and validate any gains made through previous therapy, spirituality, or personal pursuits. As best we can, we validate steps already taken and encourage veterans to view IOK as an opportunity to take stock and map out steps towards acceptance, self-forgiveness, and moral repair.The first session orients veterans to what they should expect from IOK . Common responses to killing include physiological responses, instinctual decisions, and the role of training in being able to kill and group dynamics of the unit that impact how individuals make sense of killing. Therapists also share common, potentially concerning emotions and beliefs that may emerge immediately after killing or much later. At the end of this session, a writing exercise is assigned which asks veterans to reflect on how killing has changed their view of themselves and others, as well as their sense of meaning and ability to function in life. Beliefs generated from this assignment, responses on the KCS, and reactions from the common responses to killing session are used to identify problem areas. Therapists focus on these areas to both challenge some beliefs with cognitive restructuring and to earmark others for acceptance, grief, and self-forgiveness work in the latter part of treatment.The cognitive-behavioral framework is reviewed in the third session. Most veterans receiving IOK are familiar with it due to prior engagement in EBPs for PTSD. Here, therapists focus on the beliefs about killing that are most conducive to Socratic questions while acknowledging that sometimes as more details emerge, it becomes clear the thought may be better addressed through acceptance and self-forgiveness work. Veterans work with therapists in session and complete between-session assignments  to gain perspective, recognize the importance of context, and more fully integrate aspects of self that may be distorted or dismissed. Thought records for IOK include four columns , with opportunities for documenting revised thoughts as appropriate.In session 4, the importance of recognizing behaviors associated with reactions to killing cognitions is highlighted, as they often lead to seeking out or even creating confirmatory evidence to support self-condemning beliefs. We have found that veterans often interpret the self-destructive behavior that is a consequence of killing-related cognitions as further “evidence” that they are not a good person. To prepare for further sessions, it is imperative for veterans to understand how self-destructive behaviors contribute to long-held negative beliefs about themselves, others, and humanity, and to highlight how new behaviors can catalyze new beliefs that more fully reflect their true self.While some beliefs related to killing can be challenged, others  may be accurate and need to be acknowledged and addressed in a different way. By session 5, therapy shifts away from cognitive restructuring and focuses instead on acceptance, self-forgiveness, and making amends. The fifth session acknowledges the range of consequences that veterans who have killed in war face  and focuses more directly on the definition and concept of moral injury. There is also an acknowledgement that killing often happens in the context of other morally injurious events as well as profound loss .and moral repair. It is common in the sixth session for veterans to reject the concept of self-forgiveness because they believe it equates to condoning actions they feel are wrong, or “letting themselves off the hook.” Others feel forgiveness (of self or others) is not possible without justice, often resulting in self-punishment. Others believe only the individual harmed or God can offer forgiveness and that self-forgiveness is akin to violating one’s faith. The goal of the sixth session is not to reach agreement on a universal definition of forgiveness, but rather to allow veterans to define it for themselves and take specific actions to better understand what is needed to move towards forgiveness of self and others. Through carefully understanding how veterans define forgiveness, why they apply forgiveness to others differently than they do themselves, and what specific barriers they identify as preventing self-forgiveness and forgiveness of others, veterans are able to develop a forgiveness plan with specific steps they can take to work through and with these challenges.Therapists begin the conversation about forgiveness with an assignment asking the veteran to define self-forgiveness, share where they learned about it, and examine whether they apply the same standards of forgiveness towards themselves as they do towards others. Exploring veterans’ moral and spiritual development is essential in understanding the personal and cultural factors that influence moral injury A powerful next step involves writing forgiveness letters in sessions seven through nine. The first letter is generally written to an individual killed, harmed, or not saved . Veterans are instructed to state the wrong they committed and their understanding of the impact of that wrong and to ask for forgiveness. Typically, these letters are to individuals who are dead or completely inaccessible . The goal is to use the memory of these individuals and events to fully access emotions around the transgression, including the harmed individuals’ shared humanity (versus the dehumanization that often facilitates killing). The letters also help veterans to adopt and examine another’s perspective, which can alter ingrained ways of perceiving the identified morally injurious situation.Additional letters are assigned to target different areas of forgiveness—for example, a letter from the perspective of a trusted other guiding the veteran on how to move forward in their life, and a letter to the pre-war version of oneself asking for forgiveness. We encourage therapists to work collaboratively with the veteran to ascertain whether writing additional letters  would be helpful. Identifying the subject(s) of forgiveness letters is a collaborative process and involves the therapist’s clinical judgment. The point is to ensure that veterans are engaging in an authentic process of seeking forgiveness and the letters often reveal powerful themes of remorse, loss, grief, despair, and longing for change.Letters are the cornerstone of the forgiveness plans; however, we also encourage other activities to explore the definition and function of self-forgiveness. These include generating a pros/cons list anchored on the function of self-forgiveness, various reading materials about forgiveness, consulting with the chaplaincy or other spiritual leaders, and/or practicing meditation or prayer. Veterans who completed the pilot trial shared that the forgiveness assignments were by far the most challenging part of treatment and yet also the most powerful •. We havThe final two sessions of the protocol focus on developing a plan for veterans to make amends. Making amends is a personal process that provides veterans with a chance to incorporate cultural ideas about self-forgiveness into a concrete action plan for atonement and continued healing post-treatment. Amends may involve engaging in commemorative or healing rituals, volunteering, or spending more time with family or loved ones. When the person or people wronged may not be available for direct amends or when a direct apology might create additional harm, the veteran can instead commit to living their life in a way that honors the spirit of what that amends might be . Veterans in IOK are encouraged to live their lives in a way that honors their articulated morals and values, and the amends plan maps out specific steps that can be taken to continue to heal. Here, many veterans wrestle with whether or not to tell others about their killing experience. While disclosure is not a specific goal of IOK, it is important to help veterans examine their expectations and prepare for a range of reactions if they choose to share.Because IOK is designed to be a springboard for ongoing healing, the last assignment is a reflection statement that asks veterans to assess what has shifted or changed since they started treatment. Therapists also specifically ask about areas that remain conflicted and how the veteran plans to continue working towards acceptance, self-compassion, and forgiveness. By acknowledging the ongoing/persistent nature of forgiveness and self-forgiveness, veterans are encouraged to accept that some aspects of their experiences may never be fully resolved. Cautioning that false or forced forgiveness is temporary and may only add to the wound of moral injury, therapists encourage greater and deeper connections with their spirituality/faith communities, social support systems, and loved ones to help support them as they continue to heal.IOK is designed to complement and follow existing EBPs for PTSD, such as PE and CPT. Many veterans will benefit from these treatments, and yet for some, offering focused moral injury treatment might allow for further healing. Below, we outline some core features that are unique to IOK and offer something that is not always addressed in existing EBPs for PTSD.Exposure  and Socratic questioning with trauma reactions are powerful interventions that can challenge erroneous relationships made in the aftermath of traumatic events. However, for some veterans, it is the clarity of our human capacity for destruction and cruelty that is most haunting. IOK acknowledges the need for acceptance and grief work around acts of commission or omission that cannot be changed and violated deeply held beliefs about right and wrong. IOK is explicit in the process of separating out beliefs that can be challenged to reveal a more balanced truth from those beliefs that need to be acknowledged as a painful reality and earmarked for a forgiveness and amends framework.not to ask about killing experiences given veterans’ report of insensitive and voyeuristic interactions with civilians, or they felt at a loss of how to broach the subject [A major finding from the focus groups with combat veterans was how important they felt it was to use “killing” in our assessment and treatment of combat experiences . Some ve subject •.We have found two approaches helpful in initiating a conversation about killing. First, embedding questions about killing or other morally injurious events in the context of general combat exposure is a good way to destigmatize the topic and recognize that killing and engaging in acts that some may find crossed a personally held moral line is part of what we ask of our servicemembers when we send them to war. Second, the development of the KCS allowed a shared language for providers and veterans to tackle this challenging topic. Veterans are informed that the items on the KCS were generated by combat veterans of multiple eras and that some items may resonate while others may not apply.Another important difference in IOK is our use of forgiveness as a conceptual anchor. Self-forgiveness, which we focus on most in IOK, is an active process often rooted in veterans’ spiritual and/or moral upbringing, which is an area many providers express discomfort in addressing or report they have been trained to avoid as a topic of psychotherapy . HoweverAcknowledging barriers to self-forgiveness is key. For example, some veterans believe self-forgiveness equates to condoning actions they felt were wrong, or absolving themselves for something they should not, which might allow them to do it again. Other veterans think forgiveness (of self or others) is not possible without justice, therefore they serve as their own judge, jury, and at the extreme, executioner. IOK does not promise agreement on a universal definition of forgiveness; rather, it explores the concept to allow veterans to define it for themselves and take specific actions to better understand what is needed to move towards forgiveness of self and others.actively pursue, therapists can help move the needle in the daunting task of moral repair.OK was designed to be a starting point for continued work outside the therapeutic relationship and assert that healing is an ongoing process requiring persistent, active participation on the part of the veteran to accept, forgive, and move forward in a way that honors their sense of morality. In recognition of the weighty existential nature of the questions veterans struggle with , it is critical that therapists using IOK offer space to lay out all the pieces contributing to the conflict without getting stuck in a rhetorical loop or conceding to a premature conclusion that ultimately rings hollow. It is in the naming of specific barriers to forgive oneself  that veterans reveal their core values often shaped by their moral and spiritual beliefs. By reflecting these concerns and the values they bely, and collaboratively developing a plan that identifies specific tasks, rituals, or participation in communities that veterans can and experience significant distress related to these events. Though we address many additional events that created moral injury in the course of IOK, we anchor much of the treatment on acts of perpetration (commission and omission). Another unique aspect of IOK is the prominence of the assessment measure that was developed closely with veterans to identify a range of beliefs that reflect moral injury related to killing. Responses on the KCS heavily influence providers’ conceptualization and course of treatment, which is highly tailored to the individual. While IOK has a strong focus on self-forgiveness, much like Griffin and colleagues’ self-forgiveness workbook [In addition to IOK offering unique features that existing EBPs for PTSD lack, there are some important differences between IOK and emerging, evidence-based psychotherapies for moral injury. First, to be a good fit for IOK, veterans must endorse participating in killing or feeling responsible for the death of others workbook , IOK is workbook  and Adapworkbook , we alsoworkbook , spirituCombat veterans who have killed in war and experience moral injury, also commonly present with PTSD symptoms; however, there is evidence to suggest that depression, substance abuse, and other psychiatric conditions are also common following exposure to killing –5, 6•. AFor many veterans, the experience of killing made them feel excluded from humanity and they harbored beliefs for years or even decades about being less-than-human, or a “monster.” Although we specifically address the importance of integration into other communities outside of the VA , there is potential for more formal collaboration with community partners around the country. Having therapists with specialized training in moral injury and the impact of killing specifically can create a sufficiently safe space for initial work. However, it is crucial that the ten sessions described above are merely the start for veterans to reconnect and allow themselves to begin to see themselves in a more self-compassionate way. Self-compassion can be very elusive in isolation, so further development of ongoing programs to help veterans connect with others around activities that bring meaning and purpose may help ensure ongoing progress in the life-long pursuit of moral repair.We are in the midst of a multi-site randomized controlled trial of IOK and are continuing to evaluate and refine the intervention. At this time, we are only training study therapists on the protocol. Similar to our initial pilot study, study therapists are independently licensed social workers and psychologists who all have specialized training in PTSD, specifically in EBPs for PTSD such as CPT and PE. Anecdotally, study therapists have shared that it has been helpful to have previous experience with EBPs for PTSD prior to learning IOK to facilitate nuanced conversations around appropriate guilt and remorse versus more traditional distorted beliefs around level of responsibility or lack of consideration of context. We look forward to being able to disseminate IOK more widely and offer additional training following completion of the current multi-site trial.Veterans who kill in war are at a uniquely high risk for suicide and a range of negative mental health problems –5, 6• in


Using a cycle threshold cutoff (Ct) of 36.8 for the SCR assay and 1.27 log10  for the QT assay, relative clinical sensitivity for CIN2+ and relative clinical specificity for CIN2− as compared to Anyplex™ II HR-HPV were, respectively, 0.92 and 1.00 for SCR and 1.35 and 1.24 for QT. The distribution of high-risk HPV (HR-HPV) genotypes (p = 0.009) as well as the viral copy numbers ; CIN2+: 4.3 log10 ; p = 0.047) were found to differ in women with high- and low-grade cervical lesions, suggesting a possible role of HPV genotyping and normalized viral load as potential biomarkers to identify women at increased risk of cervical lesions.HPV testing in cervical cancer screening programs offers the possibility of introducing molecular standardized biomarkers for the triage of HPV-positive women. This study aimed to evaluate the role of HPV genotyping and viral load as possible diagnostic biomarkers of high-grade cervical lesions (CIN2+) by performing a preliminary evaluation of a new HPV test. Cervical specimens were obtained from 200 women referred for a colposcopy. Samples were tested using both Anyplex™ II HR-HPV as well as OncoPredict HPV Human papillomavirus (HPV) infection is considered a necessary cause for the onset of cervical cancer . As a rePrimary HPV-based cervical cancer screening offers the advantage of higher clinical sensitivity, associated with a higher negative predictive value, as compared to cytology, at the cost of a lower clinical specificity ,4. The rThe use of Pap smear or liquid-based cytology in the triage of HPV-positive women increases the specificity but has limitations: the performance is operator dependent, and the method is not easily reproducible and standardized. Moreover, cervical cytology cannot be performed on self-collected samples, which are increasingly being introduced in screening programs to improve the participation of women.The introduction of more standardized and reproducible molecular methods for the triage of HPV-positive women, such as full high-risk HPV (HR-HPV) genotyping and genotype-specific HR-HPV viral load, could improve the risk stratification in cervical cancer screening programs.Several studies have investigated the role played by HPV types and viral load in the development of low- and high-grade cervical lesions ,15,16,17HPV genotype and associated viral load have also been described as important predictors of cervical intraepithelial neoplasia grade 2 or more (CIN2+) as well as cervical intraepithelial neoplasia grade 3 or more (CIN3+) . FurtherThe value of individual genotype viral loads has, however, been controversial. Dong and Colleagues demonstrated that the viral loads of HPV16, HPV31, HPV33, HPV52 and HPV58 are useful biomarkers of high-grade cervical lesions , whereas® multiplex real-time PCR assays  was performed, by comparing their clinical performance to that of Anyplex™ II HR-HPV , a previously validated full HR-HPV genotyping assay. In particular, the two OncoPredict HPV® assays, targeting E6/E7 genes, allow for a reflex testing algorithm, comprising a first-line qualitative screening (SCR), with partial genotyping for HPV16 and HPV18 with 11 other types detected as a pool , followed by a second-line assay for the determination of normalized genotype-specific viral loads (QT) of 12 HR-HPV .A preliminary evaluation of two new OncoPredict HPVEvaluation of the HPV molecular assays was carried out in a population of two hundred women referred for colposcopy with a recent history of cervical dysplasia. Biopsy was performed at the time of colposcopy in 152 out of the 200 referred women (76.0%), based on clinical judgment and local protocols. Overall, in the study population, 16 women  were shown to have SCC , whilst for 51 , 25  and 17  women a diagnosis of CIN3 , CIN2  and CIN1  was made, respectively. In the remaining 43 women , no histological lesion was detected. Women with SCC, CIN3 and CIN2 lesions were classified as CIN2+ ; all women with CIN1, with no histological lesions and/or with negative colposcopy (who did not undergo biopsy), were considered as CIN2− .10  was selected for the QT assay (Based on the receiver operating characteristic (ROC) curve analysis, a preliminary positivity cutoff of Ct 36.8 was chosen for the SCR assay a and 1.2QT assay b.® assays: preliminary cutoffs corresponding to Ct 37.6 and 0.95 log10  were chosen for the SCR and QT assay, respectively , (SCR: kappa = 0.77 (0.67–0.86); QT: kappa = 0.80 (0.71–0.89)). Anyplex™ II HR-HPV was previously clinically validated as part of the VALGENT-3 (VALidation of HPV GENotyping Tests) framework, an international cooperation designed for the comparison and clinical validation of HPV assays with genotyping capabilities [® assays with Anyplex™ II HR-HPV was shown for the detection of HPV 16 (SCR: kappa = 0.94 (0.89–0.99); QT: kappa = 0.88 (0.81–0.95)) ) .® SCR and QT assays for the detection of CIN2+ were evaluated, and the clinical performance was compared to that of Anyplex™ II HR-HPV.The clinical sensitivity and specificity of OncoPredict HPV® SCR assay demonstrated a relative sensitivity of 0.92 and a relative specificity of 1.35, whilst OncoPredict HPV® QT showed a relative sensitivity of 1.00 and a relative specificity of 1.24 (OncoPredict HPV of 1.24 .® SCR and OncoPredict HPV® QT. HPV16 was detected in 56 women (28.0%) with Anyplex™ II HR-HPV, in 57 (28.5%) with OncoPredict HPV® SCR and in 62 women (31.0%) with OncoPredict HPV® QT. Clinical data and data on HPV positivity with OncoPredict HPV® SCR and QT and Anyplex™ II HR-HPV are reported in Respectively, 141/200 (70.5%), 133/200 (66.5%) and 138/200 (69.0%) of women were found to be HR-HPV positive using Anyplex™ II HR-HPV, OncoPredict HPV® QT assay, were observed. In addition, 40/59 (67.8%), 12/59 (20.3%) and 7/59 (11.9%) women had multiple infections with, respectively, two, three and four HR-HPV genotypes. A total of 79 women with a single HR-HPV type infection and 59 with coinfections with more than one of the 12 HR-HPV types, detected by the full genotyping OncoPredict HPV10 ; multiple infections: 4.1 log10 ; p-value = 0.04).No statistically significant differences were found in the distribution of coinfections among women with different grades of cervical dysplasia . The mean viral load in women with a single HR-HPV infection was lower than that in women with multiple infections, in whom the predominant genotype  was considered for comparison ; CIN2−: 3.7 log10 ; p-value = 0.047).Among HPV-positive women, the mean viral load of the predominant genotype was higher in women with high-grade cervical dysplasia than in those with low-grade cervical dysplasia , with partial genotyping for HPV 16 and HPV 18, and a full genotyping quantitative assay (QT) for the normalized, type-specific viral load determination for 12 HR-HPVs.This study provides a preliminary evaluation of the clinical accuracy of two recently developed assays: OncoPredict HPV® assays, clinical cutoffs were established based on ROC curve analysis following testing of cervical samples from women with documented high-grade lesions (CIN2+) and with low-grade lesions or negative colposcopy findings (CIN2−).In order to evaluate the performance of the novel OncoPredict HPV® SCR and QT assays demonstrated overall good analytical concordance for HR-HPV and HPV16 detection in comparison to the previously validated Anyplex™ II HR-HPV assay. Small differences in positivity rates for HR-HPV infections observed with the three HPV assays could partially be explained by the fact that Anyplex™ II HR-HPV detects 14 different HR-HPV types, whilst OncoPredict HPV® SCR and QT assays are able to identify 13 and 12 HR-HPV genotypes, respectively.The OncoPredict HPV® SCR and QT assays were also shown to have a clinical sensitivity and specificity relative to Anyplex™ II HR-HPV similar to those reported for other assays validated for use in cervical cancer screening [® SCR and QT assays will need to be performed on a larger number of samples, as indicated by the international criteria for the validation of HR-HPV tests [OncoPredict HPVcreening ,21. The creening ,22. Due PV tests .The statistically significant different distribution of HR-HPV types in women with high- and low-grade cervical lesions further supports the importance of full genotyping HPV assays for the triage of HR-HPV-positive women. As previously reported ,8,24, HPPrevious studies have shown an association between multiple HR-HPV infections and high-grade cervical lesions ,17, whil® QT assay. Furthermore, accurate quantification of sample cellularity allows the determination of a normalized, genotype-specific viral load, as recently advocated by the European Society of Gynaecologic Oncology (ESGO) and the European Federation of Colposcopy [® QT assay), allows assessment of the sample adequacy, an important quality control in HPV screening programs particularly if based on self-sampling. Thanks to a correct evaluation of cellularity, it is possible to identify a sample with a low number of cells that should be considered invalid and whose collection should be repeated.Several studies are reporting that viral load may be a candidate biomarker for the triage of HPV-positive women ,17,27, plposcopy . MoreoveThe main limitations of this preliminary study are the relatively small number of investigated women as well as their enrolment in a colposcopy rather than in a cervical cancer screening setting. As a result, the prevalences of HPV-positive women, multiple infections and viral loads might not reflect those of a general screening population.® SCR and QT assays, according to international criteria [Finally, the clinical validation of OncoPredict HPVcriteria , will recriteria . The VALFrom November 2017 to July 2021, 200 women referred for colposcopy with a recent history of cervical dysplasia were enrolled as part of an ongoing study approved by the Ethical Committee of the University of Milano-Bicocca, Monza, Italy (Protocol no. 0037320/2017 and 0086409/2018). The study was conducted in accordance with the Declaration of Helsinki, and informed consent was obtained from all subjects involved in the study.During the gynecological examination, women underwent biopsy and/or conization based on the local clinical protocols and on the outcome of the colposcopy. The classification of histological outcomes was conducted according to the WHO’s histological classification of tumors (2020) .® PreservCyt® . Cervical samples were then transported to the Laboratory of Clinical Microbiology of the Department of Medicine and Surgery, University of Milano-Bicocca, Italy, where they were processed.A cervical sample was collected by the clinician, from all women undergoing colposcopy, which was immediately suspended in 20 mL of ThinPrepCervical specimens were vigorously vortexed for 30 s, aliquoted and stored at −20 °C until nucleic acid extraction.Nucleic acids were extracted with a StarMag 96 × 4 Universal Cartridge , starting with 200 μL of sample, using the automated workstation Microlab Nimbus. Nucleic acids were then eluted in 100 μL and tested using the Anyplex™ II HR-HPV real-time PCR assay , according to the manufacturer’s instructions.Quick-DNA/RNA MagBead  and subsequently real-time PCR plate preparation using OncoPredict HPV® assays , according to the manufacturer’s instructions.A separate 400 uL aliquot of the same sample was processed on the automated Fluent 480 liquid handler , allowing nucleic acid extraction to be performed using ® solution is based on 2 separate assays, SCR and QT, which can be used independently or as reflex testing. The SCR assay is a qualitative assay allowing the separate detection of HPV16, HPV18 and one or more of 11 “other” HR-HPVs ; the QT assay detects and quantifies 12 HR-HPVs  and uses C-C chemokine receptor type 5 (CCR5) to evaluate sample adequacy and cellularity. HPV individual viral loads are expressed as log10 .The Anyplex™ II HR-HPV assay potentially detects 14 HR-HPVs  using type-specific melting profiles. The OncoPredict HPV® assays.The three real-time PCR assays were performed on a CFX96 PCR system  using 5 μL of template DNA in a total reaction volume of 20 μL for Anyplex™ II HR-HPV and in a total volume of 15 μL for both OncoPredict HPVt test, whereas the chi square test was used for qualitative ones.Descriptive statistics were used to summarize data. Comparison between quantitative variables was performed using Student’s ® assays for the detection of high-grade cervical lesions at different positivity thresholds. For the OncoPredict HPV® QT assay, the analysis was performed on log10-transformed data. Cutoff points were chosen on the basis of the best clinical sensitivity and specificity .Receiver operating characteristic (ROC) curves were used to assess the performances of both OncoPredict HPV® SCR and QT assays was evaluated by comparing HR-HPV results obtained with each assay in comparison to Anyplex™ II HR-HPV, previously clinically validated as part of the VALGENT-3 framework [Based on the cutoffs determined by the ROC curve analysis, the performance of the OncoPredict HPVramework .® QT assay, in case of coinfections, the HPV type with the highest viral load was used in the evaluation, for OncoPredict HPV® SCR, the HPV type with higher viral loads  was used.For the OncoPredict HPVp-value less than 0.05 was considered statistically significant. The statistical software STATA version 17  and MedCalc Statistical Software version 20.015  were used to perform statistical computations.Analytical agreement in HR-HPV detection obtained with different tests was evaluated with the Cohen’s kappa (κ) statistics. Agreement was defined as slight (0.00 < k < 0.20), fair (0.20 < k < 0.40), moderate (0.41 < k < 0.60), substantial (0.61 < k < 0.80) and almost perfect (0.81 < k < 1.00). A two-tailed ® SCR and QT assays provided insights on the use of HPV genotyping and normalized viral load as potential diagnostic biomarkers to identify women at increased risk of cervical lesion.Preliminary evaluation on the clinical performance of OncoPredict HPVThe full validation of the HPV assays on a larger cohort of women coming from a screening setting will confirm the role of these molecular biomarkers in cervical cancer prevention programs. Further studies evaluating the use HPV genotyping and normalized viral load in the follow up of HPV-positive women might also provide information on their use in the management and follow up of women at increased risk of disease progression.


We observed several PeCa specimens with S100A8+S100A9+-infiltrating immune cells overlapping with CD15 marking neutrophils. The S100A8+S100A9+CD15+ profile was associated with dedifferentiated and metastasizing PeCa, predominantly of HPV-associated subtype. These data suggest a contribution of neutrophil-derived suppressor cells to the progression of HPV-driven penile carcinogenesis. CD147 was elevated, expressed in PeCa specimens, prominently at the tumor center and in HPV-positive PeCa cell lines. CD147+HPV+ PeCa specimens were with the higher-frequency metastasizing cancers. Moreover, an elevated expression of CD147 of HPV-positive PeCa cell lines correlated negatively with the susceptibility to IgA-based neutrophil-mediated tumor cell killing. Finally, stratifying patients regarding their HPV/S100A8/S100A9/CD15/CD147 profile may help identify patients with progressing cancer and tailor immunotherapeutic treatment strategies.Currently, no established biomarkers are recommended for the routine diagnosis of penile carcinoma (PeCa). The rising incidence of this human papillomavirus (HPV)–related cancer entity highlights the need for promising candidates. The Calprotectin subunits S100A8 and S100A9 mark myeloid-derived suppressor cells in other HPV-related entities while their receptor CD147 was discussed to identify patients with PeCa at a higher risk for poor prognoses and treatment failure. We thus examined their expression using immunohistochemistry staining of PeCa specimens from 74 patients on tissue microarrays of the tumor center, the invasion front, and lymph node metastases. Notably, whereas the tumor center was significantly more intensively stained than the invasion front, lymph node metastases were thoroughly positive for both S100 subunits. An HPV-positive status combined with an S100A8 The tumor microenvironment (TME) displays a critical and fate-deciding compartment of neoplasia . It has Penile carcinoma (PeCa) displays a rare disease with notable regional differences regarding the incidence rates –12. Patiactivep63highCXCL8high axis as a possible underlying mechanism that drives neutrophil infiltration , a surrogate marker for active HPV oncoprotein–driven transformation, using a published protocol  in accordance with the Declaration of Helsinki approved the experiments with human material used in this study, and a written consent form was provided by the study participants. The TMA cohort consists of patients derived from Russia and Germany between 1992 and 2015. Data on clinical outcome and HPV status were published previously . Brieflyprotocol . HPV sta5 cells, passages 3–5) embedded in 1 ml of rat collagen  in 24-wThe engineered 225-IgA2m(1)-N166G-P221R-C331S-N337T-I338L-T339S-dC471-dY472 further named 225-IgA2.0 was produced using the variable regions of the m225 antibody and the engineered IgA2m(1) constant region as previously described (4) per well were labeled for 30 min at 37°C with 10 μM Calcein-AM  in suspension. Effector cells were isolated as previously described  per 150,000 cells for 30 min on ice. After washing, bound antibody was stained with mouse-immunoglobulin G kappa chain (IgGκ) phycoerythrin (PE)-conjugated binding protein  and measured with a FACS Canto II (BD Biosciences). Relative fluorescence intensity (RFI) was calculated using the following equation: mean fluorescence intensity specific Ab/mean fluorescence intensity control Ab. Soluble CD147 was quantified in 3D culture supernatants using Human CD147/EMMPRIN ELISA  according to the manufacturer’s instructions.2O2/tris buffered saline (TBS) for 10 min . formalin-fixed paraffin-embedded (FFPE) sections were incubated with the S100A8-specific , S100A9-specific , or CD147/Emmprin-specific  antibodies overnight followed by Alkaline phosphatase/horseradish peroxidase  or HRP substrates . After counterstaining with Hematoxylin Nuclear Counterstain (Gill’s Formula) (Vector), the slides were covered with Vectamount and documented. Staining was documented using a Leica DMI6000 (RRID : SCR_018713) with LAS X software (RRID : SCR_013673).formalin-fixed paraffin-embedded (FFPE) tissue (TMA) slides were stained by IHC. Antigen retrieval was performed by heating the sections in 1 mM citrate buffer (pH 6.0) at 95˚C for 10 min, and endogenous peroxidase activity was blocked with 3% HGraphical, correlation, and statistical analyses were performed using GraphPad Prism 9.02 . The annual percentage change (HRPC) was calculated using the following formula: HRPC = {Exp(slope) − 1} × 100. Group data are reported as mean ± SEM. Data of multiple experiments were illustrated as a box and whisker plot showing individual results with minimum and maximum values. Significance was determined by two-way or one-way ANOVA repeated measures test with Tukey’s correction or Fisher’s exact test as indicated, and odds ratios were calculated using the Baptista-Pike method. Significance was accepted when p-values were ≤ 0.05.+ status was defined as positive for GP PCR and p16INK4A IHC , TMA IF , and especially of the TMA LM   and IF , which flips regarding TMA LM . There was a remarkable and significant increase of positive IRS regarding the tumor center compared to the invasion front for both HPV+ (p = 0.0093) and HPV− (p = 0.0013) PeCa for the Calprotectin subunit S100A9 but not for S100A8 , the invasion front , and the corresponding lymph node metastases . The HPVNK4A IHC . Slides NK4A IHC 2. Stainr S100A8 –43.+CD15+ characterizing PeCa with a higher staging regarding invasion and metastasis  PeCa specimens were with higher-frequency HPV− for the TMA TC and IF, whereas the majority of LM were positive for all four parameters (S100A8+S100A9+CD15+HPV+)  and significantly enriched in the HPV+ group of metastasizing PeCa   , our dat 0.0232) , and bas 0.0232) —followed 0.0232)  were cha+ and HPV− groups  and of the TMA IF compared to NO in the HPV− group (p = 0.0122) (+ PeCa specimens were significantly enriched in the HPV+ group at the TC compared to NO (+ LMs were positive for CD147 (+ had with a higher-frequency metastases in case of an HPV+ than HPV− status (N classification pN1-3)  slides of these 3D cultures revealed a more intense staining of HPV-positive PeCa cell lines than that of NFK . In linePSCC is a malignant disease of the male urogenital tract with rising incidence rates. High age-standardized incidence rates (ASRs) were calculated for countries of South America and Africa, with a Brazilian hot spot in Maranhão with an ASR of, meanwhile, 6.15 per 100,000 . With anHere, we describe novel and potential markers for the stratification of patients with PeCa regarding their risk for lymph node metastases. The Calprotectin subunits S100A8 and S100A9 as well as the receptor CD147 were elevated expressed in PeCa compared to non-malignant tissue, with a markedly higher expression at the tumor core and lymph node metastases. Overexpression of S100A8/A9 has been reported in precursor lesions at other mucosal anatomical sites susceptible to HPV-driven transformation and may display an early event of the oncoprotein-driven carcinogenesis , 47–49. +S100A9+ immune cells was detected. The TME instructed by cancer and stromal cells, in HPV-negative and HPV-positive cancers, provides soluble factors that recruit myeloid cells including both S100 proteins , Tumor necrosis factor-alpha (TNF-α), interleukin-1a (IL-1α), interleukin-1b (IL-1β), interleukin-10 (IL-10), interleukin-22 (IL-22), Vascular endothelial growth factor-A (VEGF-A), and Tumor growth factor beta (TGF-β) with LPS indicating a bacterial involvement together with a suggested activation of NFκB and Signal transducer and activator of transcription 3 (STAT3)-based signaling pathways  and intramural funding .We gratefully acknowledge the excellent technical assistance from Katrin Thieser and Barbara Best from the Institute of Virology and Alexander Vogt from the Department of Urology at the Saarland University Medical Center. We are very thankful for the help with the microscope  by Prof. Dr. Gabriela Krasteva-Christ .The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.The reviewer LM declared a shared affiliation, with no collaboration, with some of the authors AH and C-IG to the handling editor at the time of review.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Cervical cancer is a leading cause of mortality among women globally. Approaches to reduce cervical cancer incidence and mortality are “screen-and-treat,” where positive primary test only is used in the treatment and “screen, triage and treat,” where treatment is based on positive primary and triage tests with/without histological analysis. Methodology. This was a comparative cross-sectional study where women aged 18-46 years women underwent cervical screening and colposcopy-biopsy test as a positive-confirmatory test in the Referral Hospitals of Eastern Kenya.  To determine cervical screening outcomes among HIV-infected and noninfected women using VIA, Pap smear, and HPV-PCR cervical screening methods and to determine the sensitivity, specificity, PPV and NPV of VIA, Pap smear, and HPV-PCR as primary test and sequential triage based on abnormal histopathology among HIV-infected and noninfected women. p < 0.001). 78/317 (24.6%) participants had positive histology test  (p > 0.001). A higher primary diagnostic accuracy was established by HPV DNA-PCR  than Pap smear and VIA test while in triage testing, high sensitivity was obtained by HPV DNA-PCR parallel testing with VIA test (92.6%) and Pap smear test (92.7%) and VIA cotesting with Pap smear (99.9%). HIV-infected women had increased specificity and reduced sensitivity and diagnostic accuracy by both primary and triage testing approaches. Discussion. Abnormal cervical screening outcome was high among HIV-infected than noninfected women. HIV-infected women had significantly high cases of cervical neoplastic changes. The diagnostic value of primary tests increased upon concurrent testing with other test methods hence reducing the number of women who would have been referred for biopsy.  A total of 317 (HIV negative: 156/317 (49.2%) and HIV positive: 161/317 (50.8%)) women were enrolled. Of these 81/317 (25.6%), 84/317 (26.5%), 96/317 (30.2%), and 78/122 (63.9%) participants had VIA, HPV DNA-PCR, Pap smear, and cervical histology positive results, respectively; average: 27.4% . Majority of women with LSIL [17/317 (5.4%)], HSIL [22/317 (6.9%)], invasive cancer [5/317 (1.6%)], cervicitis [45/317  were HIV-infected ( High sensitivity and specificity in detection of CIN+ were established among HIV-infected than HIV noninfected women by HPV DNA-PCR and Pap smear than VIA test. HPV DNA-PCR test and Pap smear are more accurate in primary and sequential triage cervical screening based on abnormal histopathology outcomes among HIV-infected than noninfected women. Cancer of the cervix is the second type of cancer among women aged 15-44 years in Kenya . It is pThe World Health Organization (WHO) approaches to reduce cervical cancer mortality are the “screen-and-treat approach,” where the decision to treat is based on a positive primary screening test only without triage  and the “screen, triage and treat approach,” where treatment is based on a positive primary and secondary screening test results with/without histologically confirmed diagnosis –10. The Several visual inspections and cytologic and molecular methods are used in cervical screening to detect neoplastic cells. Visual inspection methods include less resource-intensive visual inspection with acetic acid or Lugol's iodine (VIA/VILLI) test which provides prompt results and less cytotechnology, hence excellent for low-income settings. Here, the cervix with CIN lesions is whitened following acetic acid swabbing and visualized using naked eyes, magnifying camera, colposcope, or automated digital imaging. Cytologic methods include conventional Pap smear, liquid-based cytology, and dual staining in the identification of P16 and Ki-67 cancer markers. They are more resource-intensive methods and require a laboratory for slides-staining procedures by a cytologist, and reporting by a pathologist using the Bethesda 2001 guidelines  takes a Literature reviews a wide range of diagnostic values in the detection of cervical dysplasia by studied population, applied methodology, and personnel. VIA screening method is associated with low specificity, while the Pap screening has reported higher specificity and sensitivity. HPV DNA-PCR method is associated with higher sensitivity, specificity, and positive predictive value (PPV) than other methods . Since cThis study aimed to (1) determine cervical screening outcomes among HIV-infected and noninfected women using VIA, Pap smear, and HPV-PCR cervical screening methods and (2) determine the sensitivity, specificity, positive and negative predictive value, and diagnostic accuracy of VIA, Pap smear, and HPV-PCR as primary test and sequential triage based on abnormal histopathology among HIV-infected and noninfected women. These will assist in the development of effective screening strategies for early and accurate cervical abnormalities detection.We followed the methods described in our previous research publication  that focThis was a comparative cross-sectional study carried out in Meru, Embu, Kirinyaga, Isiolo, and Chuka Referral Hospital's Reproductive Health Clinics and HIV Voluntary Cancelling and Testing (HIV-VCT) Centers from January 2018 to December 2019. Included were consenting women aged between 18 and 47 years. Excluded were menstruating, pregnant, and mentally incompetent women and those with an eroded cervix or a history of ablative procedures or medical treatment for cervical disease in the last six months .HIV serostatus was determined as per the national algorithm. Alere Determine®HIV-1/2 test  was used as a baseline screening test, First Response® HIV 1-2-0 card test  as a confirmatory test, while Uni-Gold™ Recombigen® HIV-1/2  was used as a tie-breaker test , 15.A disposable speculum was prewarmed in sterile warm distilled water and then lubricated before use. It was then used to examine the external genitalia and locate the cervical opening (OS) while the participant lays in a lithotomic position , 13, 16.The cervix was smeared with a 3-5% acetic acid solution and observed under sufficient light after 30-60s for acetowhitening around the cervical transformation zone. The test was reported as positive if acetowhitening occurred and negative if there was no acetowhitening , 19.A standardized protocol for Pap smear staining and examination was followed to detect cellular charges to the nuclei and cytoplasm following HPV infection. Cytopathologists supervised by a pathologist at Embu and Meru Hospitals were required to fill a pathology synoptic reporting form using the Bethesda 2001 guidelines for reporting Pap smear slides using a binocular microscope. Slides were later transferred to Kenya Medical Research Institute (KEMRI) for examination by a pathologist for results confirmation. Pap smear results were classified as normal or abnormal  .All samples underwent HPV DNA nested PCR by the following procedure:Samples were subjected to the kit protocol to obtain DNA extracts by magnetic bead technique using a 96-well format HighPrep™ Viral-DNA/RNA, MagBio Genomics, Inc. USA/Canada Lysis kit and eluate stored at -20° C , 20, 21.μMPGMY09 primer (50 μL PGMY09 100 μM primer) and 5μMPGMY115μM (50 μL PGMY11 100 μM primer) were added to 350 μL and 750 μL molecular biology-grade water, respectively, and each filled to 1 mL total volume. They were later distributed each 5 μM working stock in 45–90 μL aliquots and stored at -20°C , aged ≤35 years [219 (69.1%)], were educated up to secondary school level [135 (42.6%)] and married [226 (71.3%)], and those with low-income status earning less than $1.90 per day [208 (65.6%)]. Age was significantly associated (35 years .3.2.p < 0.001) ) than other VIA tests (81/317 (25.6%)) and HPV-DNA-PCR (84/317(26.5%)) which were confirmed by histology (78/122 (63.9%) cervical screening outcome. A significantly higher HPV infection, positive VIA test, abnormal cytology, and histology rate were established among HIV-infected than noninfected women (< 0.001) .3.3.p < 0.001) ], HSIL [22/317 (6.9%)], invasive cancer [5/317 (1.6%)], cervicitis [45/317  were HIV-infected (< 0.001) .Overall, 78/317 (24.6%) participants had positive histology tests which were significantly associated with other cervical diagnostic methods test outcomes. Several CIN1+ cases were reported as normal by VIA (CIN1: 1/78), HPV DNA-PCR , and Pap smear test . However, the number of these cases was reduced upon triage testing by VIA-Pap smear test (CIN1:1/78) and Pap smear-HPV DNA-PCR (CIN1:2/78) .p < 0.001) (HPV DNA-PCR had the highest sensitivity (61.9%), positive predictive value (61.9%), and diagnostic accuracy (81.7%), while Pap smear had the highest specificity value (87.0) in the primary testing approach. HPV DNA-PCR cotesting with Pap smear showed the highest specificity (95.4%), diagnostic accuracy (94.3%), and the highest negative predictive value when cotested with the VIA test (99.9%) in triage testing. All screening methods results were significantly associated with histological confirmation (< 0.001) .There was reduced sensitivity and increased specificity among HIV-infected than noninfected women in the primary and triage cervical screening approach. There was no difference in NPV by primary or triage screening approach but the diagnostic accuracy increased by HIV-negativity status in all approaches .3.6.Agaraose gel electrophoresis (2%) of PCR product. Lane T1: Size marker (500kb ladder); Lane T2: negative control; Lane T3: positive control; Lane T4 and T5: negative for HPV PCR product; Lane T6-T8: positive for HPV PCR product.This study used cervical histology outcomes to evaluate the diagnostic value of VIA, Pap smear, and HPV-PCR cervical screening methods in “screen-and-treat” and “screen, triage and treat” approaches among HIV-infected and noninfected women. This allows the findings to be pursued in a range of low- and middle-income settings with limited public health resources for early detection and treatment of cervical neoplasia.Candida spp. and bacterial infection that is associated with cervical basal layer disruption allowing HPV and HIV entry [p < 0.001) with VIA test (25.6%), Pap smear (30.2%), and HPV DNA-PCR (26.5%) results. There is growing evidence regarding the impact of ART among HIV-infected women on HPV-associated lesions [On average, HIV-infected women had significantly high abnormal cervical screening outcomes by all methods and HIV status ). Pap smear test reported high abnormal cervical screening outcomes 30.2%) than other methods. A high HIV infection rate was also established by Pap smear outcome of IV entry , 25. HIVIV entry . This co0.2% thanIV entry , 24. Abn lesions  which caThe diagnostic value of primary test with VIA (true positive (TP): 16.4%; true negative (TN): 61.2%; false negative (FN): 14.2%; and false positive (FP): 8.2%) significantly reduced upon concurrently testing with Pap smear  and HPV DNA-PCR. False-positive results that are incorrect outcomes of lesion-free women as CIN+ and FN results where CIN+ cases are not detected are a common occurrence in cervical screening . PapilloIn cervical screening, specificity, PPV, and diagnostic accuracy of a screening method are reflexes of FP outcome which can be a result of abnormal cervical cytology cases that spontaneously regress without progressing to cervical neoplasia upon biopsy . In thisTest sensitivity and negative predictive value increased when (1) a triage testing approach was applied instead of primary testing, (2) when HPV DNA-PCR was part of any triage, and (3) when applied for the detection of CIN+ without ASCUS. Sensitivity in the detection of ASCUS with CIN+ by VIA (53.6%), HPV-DNA-PCR (61.9%), and Pap cytology (61.7%) increased to 92% (VIA–Pap), 84.3% (HPV DNA-PCR–VIA), and 90.4% (Pap–HPV DNA-PCR) hence reducing the number of women who would have been referred for colposcopy in a resource-constrained setting. Specificity and PPV were high in (1) primary and triage cervical screening approach when confirmed with CIN+ without ASCUS and (2) among HIV-infected than noninfected women. The reason could be that there was a high number of true-positive cases obtained when CIN+ samples were applied in confirmation unlike when ASCUS and CIN+ were combined. Latent and initial stages of HPV infection often have a low incidence of cervical neoplasia and a higher chance of false-negativity as the viral load is too low to be detected using HPV-PCR .HIV-infected women showed reduced FP and FN and increased TN results than HIV noninfected in both primary and triage tests and hence increased specificity and sensitivity by all cervical screening methods. The reason could be HPV regression upon acquisition among HIV-infected women is low meaning that most infections will progress into cervical lesions and test positive by all cervical screening methods decreasing the number of false positives and increasing true positives.This study, therefore, agrees with one of the seven prioritized WHO algorithms for HPV DNA detection in a screen, triage and treat approach . The useThe strength of this study was performing cervical screening on all participants using a primary and triage screening approach that led to accurate reporting and appropriate referral based on CIN+ histological outcomes, especially among HIV-infected women as recommended by WHO.The clinical relevance of cervical screening is highly dependent on the sensitivity, specificity, positive and negative predictive, and diagnostic values of screening modalities. Pap smear tests produced more positive outcomes by HIV serostatus than other cervical screening methods. High sensitivity and specificity in detection of CIN+ were established among HIV-infected than HIV noninfected women by HPV DNA-PCR and Pap smear than VIA test. HPV DNA-PCR and Pap smear tests were also more accurate in primary and sequential triage cervical screening based on abnormal histopathology outcomes among HIV-infected than noninfected women. A high diagnostic value was obtained by all cervical screening methods when CIN+ histopathology outcome was used as a reference than CIN+ with ASCUS.Values obtained and accuracy of results interpretation may differ with other studied populations and hence the need for expanded studies in other regions. More longitudinal data are needed on the effectiveness and cost-effectiveness of different cervical cancer screening strategies in cervical cancer reduction, especially among HIV-infected women.


Human papillomavirus (HPV) vaccine is a safe and effective strategy for reducing HPV morbidity and mortality. Schools have become an increasingly attractive setting for delivering vaccinations and supporting vaccination health literacy and decisional support. This study assesses the effectiveness of a community-based, physician-led HPV education campaign (starting in 2016) and onsite middle school-based HPV vaccination program across six school districts  in a rural, medically underserved Texas area . Pre- and post-intervention HPV vaccination rates were tracked against the 2016 National Immunization Survey—Teen target rates . Summary statistics were stratified by gender, school district, and grade level. The study reached 19,951 students who received HPV vaccines directly or indirectly through our program  (August 2016–August 2022). Of those, 2145 students  were vaccinated directly through our program. The overall HPV up-to-date (UTD) rates were 58.8%. The overall median age at HPV vaccine initiation and HPV-UTD (range) was 11 years (9–21) and 12 years (9–20). The overall median interval between HPV vaccine doses (range) was 291 days (146–2968). Recommending HPV vaccine initiation at younger ages increases HPV vaccine completion and providing access to HPV vaccines encourages on-time vaccination and completion. Human papillomavirus (HPV) vaccinations have proven to be a valuable, cost-effective public health intervention for reducing HPV morbidity and mortality . HoweverPersonal, community, and provider-level factors may inhibit the translation of the willingness to vaccinate into an actual HPV vaccine update. Acceptance may not be the only precursor of the willingness to vaccinate. The most commonly cited reasons for low HPV vaccination rates in the US are missed clinical opportunities and the lack of strong and consistent vaccine recommendations from healthcare providers . Other kAccording to the National Immunization Survey—Teen ages 13–17), Texas ranks as one of the lowest states in terms of HPV-UTD vaccination rates (47 out of 50 states and the District of Columbia) . In 2016–17, TexaSchool-based vaccination programs are becoming a more widely considered method of delivering HPV immunizations to adolescent populations, with a grade-based vaccination strategy preferred over an age-based vaccination strategy ,22. IntrThis cross-sectional study summarizes multiple projects funded by the Cancer Prevention Research Institute of Texas (CPRIT) to increase HPV vaccine uptake in the RGV (Texas). The goals were to meet the 2016 NIS-Teen HPV vaccination rates  ,28,29. TThe study outcomes included HPV vaccine initiation and HPV-UTD status. For study inclusion, students received at least one HPV vaccine dose either directly (school-based vaccination program) or indirectly  through our program and had parental consent. HPV vaccine initiation was defined as receipt of the first dose of the HPV vaccine series. HPV-UTD was defined as receipt of ≥3 doses if initiated after age 15 years or with immunocompromising conditions, or receipt of 2 doses if initiated before age 15 years, with a minimum interval of 5 months between the first and second dose ,31.Results from a previously published survey were used to develop and strengthen strategies for implementing the two-component intervention to increase HPV vaccine uptake . As descThe physician-led educational events started in August 2016 in Cameron, Hidalgo, and Starr Counties (located in a 15-mile radius encompassing the pilot program in RGCCISD). In all school districts, school-based vaccinations were implemented with the largest student enrollments for the largest impact. Between 2019 and 2022, the school-based vaccination events were implemented in PSJA ISD  . BetweenDuring the school year, the HPV vaccine series was initiated and completed at back-to-school events, progress report nights, and preview events. To ensure on-time vaccination and adherence to the dosing schedule, catch-up vaccination was scheduled by our staff through nearby clinics and planned events for missed doses. Up to 5 reminder letters, texts, and phone calls for subsequent doses were sent to the parents/guardians of children who initiated HPV vaccination. Prior to coronavirus disease 2019 (COVID-19), school-based vaccination events were held in the nurses’ offices, conference rooms, nearby clinics at parents’ requests, and at community events. Adaptations to how vaccinations were implemented were made when the COVID-19 pandemic hit and caused school closures during the first year of the school-based vaccination program in the expanded school districts ,29. We hGiven the transient nature of the student population in this area, the baseline cohort was followed for simplification. HPV vaccination rates are based on the baseline study cohort for each school. The HPV vaccination data was refreshed each quarter using data collected from the vaccine vendor and school immunization records  and reconciled with Immtrac2 (Texas Immunization Registry) ,28,29. TBaseline HPV vaccination rates and demographic information  from the schools’ data processing departments were collected for the study cohort during the study period. The vendor collected student vaccination data  during the vaccine administration. We tracked HPV vaccine administrations that were given directly through our vaccination program  and those given indirectly through collaborating healthcare practices .SAS version 9.4  was used in conducting all analyses. Tables, graphs, and charts were used to perform descriptive analysis and report the frequencies. Logistic regression models were used to examine characteristics associated with HPV vaccine completion (HPV-UTD) using both school-based and non-school-based vaccination delivery modalities. Statistical significance was set at α| = |0.05 (two-sided).A total of 19,951 students received HPV vaccines directly or indirectly through our program . Of the 19,951 students reached by our program, 2145 students  were vaccinated directly (received at least 1 HPV vaccine dose) through our school-based vaccination program . Most wep-value < 0.05). In this study, older age at initiation (1-year increase) was 32% less likely to be HPV-UTD  (1–0.712) . Male st1–0.712) , older ap-value < 0.05).Over the last six years, our community-based education and school-based vaccination program has helped to build and strengthen adolescent health in the RGV ,35. The To our knowledge, our pilot project was one of the first school-based vaccination programs aimed at increasing HPV vaccination rates in RGV and Texas. Results from the pilot project in RGCCISD helped lay the foundation for the program by addressing known barriers affecting HPV vaccine uptake  ,9,10,11.As our results show, middle schools are a feasible, effective setting for increasing HPV uptake. School settings are conducive to active adolescent engagement about HPV and HPV vaccination, promoting adolescent involvement in decision making, reducing needle-related fear and anxiety, and leading to more vaccination-literate adolescents ,26. Our This study had its limitations. First, information on baseline characteristics of students and parents, such as students’ race and ethnicity, socioeconomic status (SES), insurance status, parents’ education, country of birth, or knowledge and confidence in the HPV vaccines, was not collected. Additional comparisons evaluating these important characteristics could not be undertaken. Second, we did not have complete information on other vaccines or confirmation that other providers bundled HPV vaccines with other recommended vaccines. This could be an important future extension of our study. Next, the study population is transient, with some students changing schools during the study period. For simplification, we followed our baseline cohort at each middle school. Last, we are unable to account for all HPV vaccines. Although the vendor and schools shared updated information, it may not capture all vaccines received outside the school setting when parents fail to report vaccinations to the school. Future studies should explore issues, such as inadequate school-based health centers and vaccine billing as barriers to school-based HPV programs. Last, the study may have limited generalizability to Texas and the US. The school districts were not randomized, with implementation occurring in schools with the highest enrollment. There is also no national mandate for HPV vaccination.School-based vaccination programs play an important role in increasing HPV vaccine uptake by reaching underserved adolescent populations who are most at risk for HPV-associated diseases. Through partnership with the RGV community and healthcare providers, our voluntary school-based vaccination program educated the community  about the importance of HPV vaccines, removed access and transportation barriers, developed care coordination between local physicians and the RGV community, bundled HPV vaccines with other required vaccines when provided by our program, and increased HPV-UTD to 58.8%. Recommending HPV vaccine initiation at younger ages increases completion of the HPV vaccine series and providing access to HPV vaccines encourages on-time vaccination and completion. Increasing HPV vaccine uptake has the potential to decrease HPV-associated diseases in the area in the future.


As providers increasingly create health messages on platforms such as TikTok, it is important that they remain aware of the potential for opposing or non-factual discourse.Despite the protective abilities of the HPV vaccine, roughly half of adolescents in the United States have not completed the recommended HPV vaccine series. Professionals have taken to using social media platforms to encourage health behaviors such as receipt of the HPV vaccine. As such, the purpose of this study was to identify content created by professionals related to HPV on TikTok. This descriptive, cross-sectional study was conducted in January 2022 using the hashtag #HPV Vaccine to examine the 100 English language videos created by people who claimed to be health professionals. In addition to capturing metadata, each videos' content and subsequent comments were coded. Overall, 75.0% of the videos mentioned HPV-related cancer but few discussed vaccination as a cancer preventive measure (40.0%). More than half (52.0%) of the comments were neutral in tone and most focused on cancer (54.0%), alternative medicine (58.0%), and general questions about vaccination (62.0%). Comments about videos with greater numbers of “likes” more often mentioned cancer (85.0% vs. 46.3%,  Human Papillomavirus (HPV) is the most frequently diagnosed viral infection of the reproductive tract  and is t®, and Cervarix but, of these, Gardasil® 9 is the only HPV vaccine used in the U.S. (The United States Food and Drug Administration (FDA) has approved vaccines that prevent cervical cancer and other diseases caused by the more virulent types of HPV . Currentthe U.S. . It prevthe U.S. . The Advthe U.S. . Despitethe U.S. .There are several factors which influence uptake of the HPV. Vaccine hesitancy is a major issue when it comes to receipt of the HPV vaccine. As this is a vaccine distributed to adolescents, it would be remiss not to consider parental attitudes in decision making –11. PareAn equally important consideration is the role that adolescents themselves play in influencing their vaccine uptake. Some states are making concerted efforts to allow for adolescents to receive the vaccine without parental consent , 20, 21.The influx of health information on the internet has been regarded by researchers as paradoxical: being both highly beneficial yet potentially hazardous at the same time. While the internet presents an opportunity for the general public to gather user-friendly information that is comprehensible and readily accessible , evidencHowever, increasingly, health professionals are creating TikTok health-related videos that use humor, trendy songs, and self-criticism to connect with young audiences . AdolescMany manuscripts in the published literature document that HPV content is prevalent on social media. Research has identified specific platforms such as Instagram –34, YouTThis descriptive, cross-sectional study was conducted in January 2022. Using TikTok's discover search feature, the hashtag #HPV Vaccine was identified as the most relevant hashtag with 6.4M views. The first 100 videos created by people who claimed to be health professionals were selected for inclusion. This methodology has been used successfully in other studies . Video ckappa coefficient (0.95).One researcher (ETJ) recorded the videos' metadata and coded the videos' content and comments and watched all videos. The coding categories used to describe the video content included: pro, con, and neutral sentiments about the vaccine; the mention of: HPV-related cancer; HPV prevention; HPV testing/screening; HPV transmission; HPV infection risk factors; HPV vaccines are safe/unsafe; and side effects of HPV vaccine. Categories used to organize the comments from the videos included: pro-vaccine/anti-vaccine/ neutral HPV vaccine messages; mention of cancer, age for the vaccine, males being vaccinated, cost/insurance, fertility concerns, use of alternative medicine, general vaccination questions, and sharing of stories related to HPV vaccination. A second researcher (CHB) coded a random 10% sample to determine inter-rater reliability, which was high based on Cohen's P-values <0.05 were considered statistically significant. All analyses were conducted using SPSS version 28  for dichotomous and continuous variables, respectively. rsion 28 . Since tp = 0.02); no differences with regard to video format and content was observed. Comments about videos with greater numbers of “likes” more often mentioned cancer , the age at which to get vaccinated  and more frequently posed questions about vaccination  and cost and insurance coverage of vaccination  compared to videos with fewer “likes”  with a mean of 3,554  “likes” . Only 15 “likes” .In a TikTok study of both professional and non-professional videos that varied in pro/anti vaccine stance, it was determined that cancer and prevention messaging on HPV was more prevalent among pro-vaccine videos . Our finOur findings demonstrated that most of the professionally-made videos in this sample discussed HPV-related cancers. Studies have focused on the effects of framing messages related to HPV around cancer prevention risk and/or prevention , 41, 42 This study is limited by several factors. Health professionals' status was self-reported and could not be verified. Content creators who worked in the health profession indicated their role on their page profile or conveyed it orally in their videos. As with all cross-sectional studies, the findings cannot be generalized. This is especially true with studies of social media as the content changes constantly and can influence the most popular hashtag, number of videos, number of comments, etc. Limiting the inclusion of videos to those in the English language limits the potential findings. Further, nuances in language choices and interpretation of sentiment can impact coding. For example, prevention tended to be specifically mentioned less in this sample, but could have been implied through non-exact terminology.The power of provider information is paramount with HPV vaccine uptake , 46. WitThe original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.CB and EJ conceptualized the study. EJ collected the data. GH conducted the data analysis. All authors contributed to the manuscript production.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.