One cause of the increase in cervical cancer rates in Japan is the long-term stagnation in the cervical cancer screening consultation rate. Therefore, improving the screening consultation rate is of urgent concern to reduce cervical cancer incidence. Self-collected human papilloma virus (HPV) tests have been successfully adopted in several countries, such as the Netherlands and Australia, as a measure of individuals who have not undergone cervical cancer screening in national programs. This study aimed to verify whether self-collected HPV tests presented an effective countermeasure for individuals who had not undergone the recommended cervical cancer screenings.This study was conducted from December 2020 to September 2022 in Muroran City, Japan. The primary evaluated endpoint was the percentage of citizens who underwent cervical cancer screening at a hospital with positive self-collected HPV test results. The secondary endpoint was the percentage of included participants who were diagnosed with cervical intraepithelial neoplasia (CIN) or higher among those who visited a hospital and underwent cervical cancer screening.The included study participants were 7,653 individuals aged 20–50 years with no record of previous cervical cancer examination in the past 5 years. We mailed these participants information on self-administered HPV tests as an alternative screening procedure and sent the kit to 1,674 women who requested the test. Among them, 953 returned the kit. Among the 89 HPV-positive individuals , 71 (79.8%) visited the designated hospital for an examination. A closer examination revealed that 13 women  had a CIN finding of CIN2 or higher, among whom one each had cervical cancer and vulvar cancer, eight presented with CIN3, and three presented with CIN2; two cases of invasive gynecologic cancer were also identified.We conclude that the self-collected HPV tests showed a certain efficacy as a measure of individuals who had not undergone the recommended cervical cancer screening. We devised ways to have the unexamined patients undergo HPV testing and ensure that HPV-positive individuals visited the hospital. Despite a few limitations, our findings suggest the effectiveness of this public health intervention. Cervical cancer is highly preventable if cervical dysplasia is detected and treated before it becomes an invasive cancer. In 2020, 604,127 and 12,785 women were diagnosed with cervical cancer, and approximately 341,831 and 4,213 women died from the disease worldwide and in Japan, respectively [In Japan, the target rate for cervical cancer screening is set at 50% or higher. However, the effective rate is currently approximately 40%, which places Japan within the lowest categorization for screening utilization among the Organization for Economic Co-operation and Development countries . To incrA recent meta-analysis encompassing 37 studies and enrolling a total of 18,516 women from 24 countries across five continents indicated strong acceptance of self-sampling interventions as well as a preference for self-sampling over clinician sampling [HPV testing using self-collected cervical and urine samples is convenient as well as effective for improving the screening rate. However, to serve as a viable alternative screening technique, this intervention must have a sensitivity equivalent to HPV testing using physician-collected cervical samples. Our research group had previously reported that HPV testing results using self-collected cervical and urine samples were consistent with those obtained from physician-collected samples . HPV tesIn the present study, we verified whether self-collected HPV testing was effective as a countermeasure for individuals who had not yet undergone cervical cancer screening. We conducted this study with the cooperation of the Health and Welfare Department, Health Promotion Division of Muroran City in Hokkaido, Japan. We hypothesized that many participants who had been identified as HPV positive would visit the hospital, and those with positive screening results would be more likely to present with cervical cancer or cervical dysplasia  on closer examination.This study was approved by the ethical review board of Sapporo Medical University  and was conducted in accordance with the principles of the Declaration of Helsinki. The privacy and anonymity of the participants were maintained. Written informed consent was obtained from all participants.Self-collected cervical sampling was performed using Evalyn Brush® . The procedure for sampling using this brush involves inserting the brush casing as far as possible into the vagina, following which the brush is pushed out, rotated five times, and then removed from the vagina with the brush still pushed out. This accomplishes effective swabbing of the entire vagina for cervical cancer testing. For the urine samples, 18–22 mL of first-catch urine was collected using a COLLI-PEE® kit .The samples were tested for HPV with the Cobas® 8800 system . HPV test results were divided into type 16, type 18, and other high-risk types .This research was conducted in Muroran City , which was selected as the site of the current study because there are only three general hospitals in Muroran City that offer gynecological outpatient clinics, and it takes more than 1 h to visit a gynecologist in another city for those residing outside Muroran City. Moreover, almost all people who test positive on routine screenings visit these gynecological outpatient clinics. Therefore, accurate consultation rates and follow-ups are possible.The Health and Welfare Department, Health Promotion Division of Muroran City, searched for residents who had not undergone cervical cancer screening between December 2015 and November 2020. The present study targeted 7,653 women aged 20–50 years for the evaluated intervention. We mailed information regarding the screening intervention to 7,653 women who had not undergone the recommended cervical cancer examination within the past 5 years. The applicant was asked to complete a consent form, including their name and address, and to reply to the Department of Obstetrics and Gynecology at Sapporo Medical University if they were interested in participating in this screening program. It was stated that the investigator would decide whether to send a self-collection HPV test or urine collection set.Then, the self-collected HPV test kits were mailed to interested participants. At this time, we enclosed an explanation of the study, including its associated risks and benefits, along with a separate consent form. Applicants mailed the kit and consent form to the Department of Obstetrics and Gynecology at Sapporo Medical University. Then, the kits were anonymized and submitted to the abovementioned external inspection company , which notified the designated obstetrics and gynecology department of the testing results. Then, the obstetrics and gynecology department mailed the HPV testing results to each participant and recommended that those who tested positive for HPV should visit a designated hospital for follow-up. The gynecologist at the designated medical institution notified the physicians at the Department of Obstetrics and Gynecology at Sapporo Medical University of the findings of the cytological and histological examinations and asked these physicians to inform the participants of the follow-up testing results.The participants who underwent the test also completed a questionnaire. The questionnaire consisted of the following five items: (i) how did you feel about the free HPV test? (ii) how was the test method? (iii) do you know about HPV? (iv) what do you think about the HPV vaccine? and (v) if it was a paid test, how much would it cost in Japanese yen?The primary evaluated endpoint was the percentage of citizens who underwent cervical cancer screening at a hospital with positive self-collected HPV test results. The secondary endpoint was the percentage of included participants diagnosed with cervical intraepithelial neoplasia (CIN) or higher among those who visited a hospital and underwent cervical cancer screening.P-values of < 0.05 were considered statistically significant. All analyses were conducted using SPSS statistical software .The age difference between those with CIN2 or higher and those with CIN1 or lower was examined using a t-test. Pearson’s chi-square test was used to examine the differences in screening history and delivery history between those with CIN2 or higher and those with CIN1 or lower. Two-sided Although information was sent to 7,653 participants, 88 of them did not receive the information because their recorded addresses were invalid. Therefore, the information was effectively sent to a total of 7,565 participants. Among those individuals, 1,674 women requested for the test on receipt of information regarding the study intervention, submitted a research consent form to our university, and were mailed the sampling kit. There were 23 women who responded that they would not use the self-collection kit but would use the urine collection kit. Therefore, we sent the urine collection kit to them. The total percentage of respondents for either screening test was 22.1%.After the kit was sent, 39 participants did not receive it owing to an invalid address and 9 participants withdrew their consent. A total of 953 participants returned the kit, although one had a flawed consent form; 952 kits were ultimately submitted for inspection, and 58.6% of those who mailed the kit agreed to HPV testing Fig. .Fig. 1Stn = 14, 4, and 77 for type 16, type 18, and other HPV types, respectively; 4 of the 77 participants with “other” HPV types were co-infected with HPV type 16 , and 71 of the HPV-positive individuals (79.8%) visited the designated hospital for an examination  had a CIN finding of CIN2 or higher. Specifically, the breakdown of diagnostic findings was as follows: one for cervical cancer, one for vulvar cancer, eight for CIN3, and three for CIN2 .The average age of the participants presenting with findings of CIN2 or higher was 41.8 ± 7.0 years, and the average age of those presenting with findings of CIN1 or below was 35.0 ± 8.7 years. Those presenting with CIN2 or higher were significantly older on average than those presenting with findings of CIN1 or below  or CIN1 or below  and 36.2% (n = 21), 23.1% (n = 3) and 27.6% (n = 16), and 69.2% (n = 9) and 36.2% (n = 21), respectively (Table p = 0.0445), whereas the rate of being diagnosed with CIN2 or higher was significantly higher in those aged 40–50 years (p = 0.0294).On evaluating the age distribution in those with findings of CIN2 or higher or CIN1 or below, the percentages of those aged 20–29, 30–39, and 40–50 years were 7.7%  . Among wOnuma et al. reported that HPV self-sampling results showed good agreement with physician sampling results and that the sensitivity of CIN2 detection by self-sampling was as high as that of physician sampling . SimilarIn addition, Saville et al. reported that HPV16/18 results showed high observed agreement between self- and practitioner-collected samples in all assays (range: 0.94–0.99), with good agreement for non-HPV16/18 oncogenic HPV types (range: 0.64–0.73). These researchers concluded that self-collection showed good concordance and sensitivity for HPV-based cervical screening compared to those for practitioner-collected samples in assays conducted within the Australian National Cervical Screening Program . These rSeveral studies have reported that self-collected HPV tests have led to an increase in the consultation rates –16. For Moreover, Arbyn et al. examined the acceptance rate of self-collecting HPV tests in a randomized controlled trial . The meaThe detection rate for presentation of CIN2 or higher was as high as 18.3% on cytology triage of the HPV-positive individuals enrolled in this study. When screening using cytology alone, the detection rate for presenting CIN2 or higher was reported as being approximately 4.4% in the literature . The corOur study has some limitations. First, it is currently unclear which ages should be recommended for completing self-administered HPV kits. For example, there is currently no clear consensus as to whether women aged > 20 years should be contacted or if the targeted age group should be those aged > 30 years. Moreover, the upper age limit for this intervention remains unclear. Including women of younger age may lead to the detection of transient HPV infections as well as presenting a cause of unnecessary anxiety. In fact, our study revealed that the rate of being diagnosed with a finding of CIN2 or higher was significantly lower in those in their 20 s given positive HPV findings. However, to widely recommend medical examinations to the unvaccinated generation, it is necessary to inform the younger generation of this critically important public health concern and initiative.Second, there was an unclear optimal subsequent follow-up period for women who were found to be HPV-positive. Although it is sufficient for the participants to visit the hospital regularly following the detection of positive HPV findings, there is a possibility that a woman will elect not to undergo examinations. Therefore, effectively managing post-testing follow-up is of critical importance. Moreover, the specific testing that should be provided to individuals who have been diagnosed as HPV-positive remains unclear. Options include colposcopy as well as cytology prior to colposcopy. It may be possible to triage testing strategies according to the HPV type. For example, while colposcopy may be performed for HPV type 16, it may be possible to evaluate cytology prior to performing colposcopy for other HPV types.Third, this study included women who were not truly unexamined . We conclude that it is necessary to evaluate the status of the city's medical examination system in the future. It is also necessary to publicize the reliability of the evaluated screening intervention, as some citizens may not have participated in this study because they did not trust the self-collected HPV testing method.Fourth, we conducted an opt-in study. It may be preferable to send the kit only to those who request it, send the kit to all the unexamined people, or distribute a coupon for testing at the city facility. This remains to be elucidated in future studies. Two previous meta-analyses have revealed that sending self-collection kits directly to the participants’ home address generated a higher response rate than sending an invitation letter , 19. HowThe strength of this study is that many of the patients who had not been examined had an opportunity to visit the hospital and that several patients successfully underwent treatment for cervical cancer or precancerous lesions through surgery. This strategy should be useful for health management in the future because most participants continue to follow through after undergoing the test.We showed that the self-collected HPV tests evaluated in the present study showed certain efficacy as a public health measure of those who had not yet undergone cervical cancer screening. Moreover, we devised a method for encouraging unexamined patients to undergo HPV testing and to ensure that HPV-positive individuals visited the hospital for follow-up testing; however, some issues remain to be resolved in the future, such as selecting among various countermeasures and two patients being diagnosed with malignant cancer and several more found to require surgery. Therefore, we would like to highlight the demonstrated effectiveness of this public health intervention. Future studies will help identify the optimal strategy for increasing the cervical cancer screening rates and efficacy.


Furthermore, being “separate” and having multiple sexually transmitted diseases were also significantly associated with genital HPV infection. In contrast, oral HPV infections were significantly associated with women aged 36 to 50 years  and oral sex .Additionally, being separate, being cohabitant, lifetime sexual partners of >10, 3–5 lifetime sexual partners, <20 years of age, >10 sexual intercourse per month, occasional and regular anal sex, >20 cigarettes per day, a history of sexually transmitted disease (herpes and multiple), and having a history of genital warts were significant. Screening and early diagnosis are considered to be practically unfeasible for this category of cancer, given the lack of visible lesions; the 9-valent HPV vaccine remains the only means that could help to successfully counter the growing incidence of oral squamous cell carcinoma. The oral transmission of HPV and, consequently, the risk of oral cancer has increased in the last years. Oral sex has often been implicated among the risk factors for oral HPV infections, however, there is still no consensus on these topics, nor on the relationship between genital and oral HPV infections. The present study aimed to evaluate the coexistence of papilloma virus, at the levels of the oral and genital mucosa, in women with a histologically confirmed HPV lesions (and a positive HPV test) at the genital level and a negative HPV control group. We also evaluated how some risk factors, such as smoking, the number of partners, age, and sexual habits can influence the possible presence of the virus itself in the oropharynx of the same women. In total, 117 unvaccinated women aged between 18 and 52 were enrolled. We found that the prevalence of oral HPV infection was high among the women with concomitant genital HPV infection (22%) compared to the HPV-negative women (0%), and the estimated odds ratio was 17.36 . In none of the women with oral HPV did we find any relevant clinical lesions. The potential risk factors for HPV infections in the oropharynx and genitals were analyzed based on questionnaire responses. A multivariate analysis showed that genital HPV infections were significantly associated with a number of sexual partners > 10 (OR 138.60, 95% CI: 6.04–3181.30,  Genital HPV infection is the most prevalent sexually transmitted infection in the world . It is eThe papillomavirus also seems capable of infecting and replicating in the cells of the syncytiotrophoblast, causing adverse events in pregnancy  ,13.There are differences in the natural history of HPV based on gender and the anatomical site of infection. More HPV-related cancers are diagnosed worldwide in women than men, and HPV transmission appears to be higher in women than men ; moreoveThe main objective of our study was to evaluate the coexistence of papilloma virus at the levels of the oral and genital mucous in women with an HPV lesion at the genital level (positive HPV test) and a negative HPV control group. We also evaluated how some risk factors, such as smoking, number of partners, age, and sexual habits can influence the possible presence of the virus itself in the oropharynx of the same subjects.The study sample consisted of 347 women who came to our HPV center for a suspected HPV infection in the period between March 2021 and October 2022. Ours is a multidisciplinary HPV Unit providing gynecological, proctological, and otolaryngologic screening for women or couples. In each clinic, swabs were used to search for the virus, in addition to diagnostic tests, such as colposcopy, peniscopy, an exploration of the oropharynx, laryngoscopy, and anoscopy.The women underwent an inspection of their oropharynx, performed by an ENT specialist looking for relevant clinical lesions of the oropharynx. A cytobrush was then used to sample the oropharynx . The cytobrush was swirled vigorously in a PreservCyt vial. Immediately afterwards, the gynecologist took a sample of cells from the portio and cervical canal using an Ayre’s spatula and cytobrush, and the sample was transported into a thin prep container for papillomavirus detection and genotyping. In addition, after receiving their informed consent in writing, we gave each woman a detailed anonymous questionnaire  in orderConcomitant infections were defined as any HPV infection that occurred simultaneously in both the oral cavity and cervix.Concordant infections were identified in women who had at least one or more identical HPV types in the oropharynx and cervix, either at the same time or at different times.The term oropharynx refers to the anatomical region comprising the soft palate and uvula, the tonsils, the posterior pharyngeal wall, and the base of the tongue. This region is distinct from the oral cavity, which includes the lips, the floor of the mouth, the buccal mucosa, the gum, the hard palate, and the mobile part of the tongue. Oral cancer refers to the combination of oropharyngeal and oral cancers.An automated DNA extraction was carried out using the NucliSENS EASYMAG system , following the manufacturer’s HPV 1.1 protocol.The DNA was extracted from the cell suspensions as described above .The kit used for the genotyping was Ampliquality HPV-TYPE EXPRESS , which is able to determine the presence of 40 types of Papillomavirus, in particular: 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 73, 82, 26, 53, 66, 67, 6, 11, 40, 42, 43, 61, 69, 70, 44, 54, 55, 62, 64, 71, 72, 81, 83, 84, 87, 89, and 90. The kit is based on a rapid system for the identification of human Papillomavirus using a single-step PCR: in the preparation of the PCR session, in addition to the samples, a positive amplification and typing control (HPV 61 DNA), as well as a negative control (sterile distilled water), were also used; in addition, the kit can evaluate the suitability of the DNA extracted via the amplification of the TST gene (thiosulfate sulfurtransferase rhodanese). For details of the technique, see .p values of <0.05 were considered to be statistically significant.The statistical analyses were performed with SPSS version 22 for Windows. The Cohen kappa value was calculated to verify the concordance of HPV infections between the paired samples of the same patients. We evaluated the association between oral and genital HPV infections with a binary logistic regression analysis. To investigate the associations between the potential risk factors and HPV infections, we performed a multivariate analysis with a gradual binary logistic regression model. In cases where a frequency of 0 appeared, a correction was applied by adding 0.5. The study group, consisting of women with an HPV-positive cervix, had a positive oral mucosal HPV of 21.8% (19/87). In none of the oral samples taken from the subjects of the control group was the presence of HPV DNA detected in the oropharynx. For oral HPV infection, the estimated odds ratio was 17.36 (95% CI: 1.02–297.04) .In particular, 21.8% of women had concomitant HPV infections, while concordant infections were found in 31.6% of women (6/19) . The concordance between genotypes was poor (kappa = 0.125).Among the samples of the 87 women with HPV infections, we detected 121 HPVs , 9 of which were high-risk HPVs and 14 were low-risk HPVs; the most common high-risk genotype was HPV16 , followed by HPV31 , and genotypes 33, 51, 52, and 58 with 5 cases each, followed by 45 and 68 with 1 case each.Of the 19 women with oral HPV infections, 13 (68.4%) were infected with high-risk HPV and 6 (31.6%) with low-risk HPV. HPV16 was more common in the oral cavity .In the women with cervical HPV lesions, genital warts accounted for 36.7% of cases (32 cases), low-grade squamous intraepithelial lesions for (LSIL) 33% (29 cases), and high-grade squamous intraepithelial lesions (HSIL) for 30% (26 cases). In the oral examinations, no relevant clinical lesions were found .p < 0.001), but the data also referred to having between 3–5  or 6–10 partners  as being significant, as were a high-grade education  and a frequency of sexual intercourse > 10 . In addition, a frequency of 5–10  sexual intercourse, oral sex , and >20 cigarettes/day  were significant. Furthermore, being “separate”  and having multiple sexually transmitted diseases were also significantly associated with genital HPV infection. (p = 0.000202) and oral sex , but also with being separate, being cohabitant, lifetime sexual partners of >10 , 3–5 lifetime sexual partners, being <20 years of age , >10 sexual intercourse per month , occasional anal sex , regular anal sex , >20 cigarettes per day , a history of sexually transmitted disease (herpes and multiple), and having a history of genital warts , , .The oral–genital transmission of HPV has the potential to affect the intimate life of women and their partners and has not often been explored in the literature. In our survey of 347 women, the collection of data, even if anonymously, was difficult and only 117 women (34%) answered the study questionnaire completely. The remainder either refused to participate or did not answer all the questions, invalidating their responses.The oral transmission of HPV and, consequently, the risk of oral cancer is increased in women with cervical cancer and their spouses ,24; thisIn the literature, the overall prevalence of oral HPV infections is varied, with values between 0.2% and 20.7% ,26, and In none of the women with oral HPV did we find any relevant clinical lesions. Therefore, an oral examination alone cannot exclude the possibility of an oral HPV infection, which is primarily subclinical.The HPV-negative women in our study did not experience oral infection. Recent studies on healthy adults have found an oral prevalence of high-risk HPV strains of 2.5 to 5% ,30.The acquisition of HPV at any anatomical site can occur through an infected partner, however, it is difficult to distinguish which sexual behaviors are responsible for the transmission of HPV from the genital tract to the mouth.In our study, the multivariate analysis showed that oral infection in women with HPV-positive genitals was significantly related to age and sexual habits, especially oral sex. If we look at the age of the women in the sample, we observe a statistically significant odds ratio of 27.38 (95% CI: 4.37–17.37) for women aged 36 to 50 years compared to patients aged less than 25 years. For the other classes, no statistically significant values were obtained.With regard to sexual habits, the determinants most related to the detection of oral HPV are a history of STD and genital warts, the frequency of sexual intercourse, and the habit of practicing oral and anal sex. Specifically, the probability of women who had a history of sexually transmitted diseases to present an HPV infection at the oral level was 9.47% higher than that of the women who had never had a sexually transmitted disease (95% CI: 3.05–29.34). If genital herpes is considered, the odds ratio doubles from 9.47 to 19.88 . Even with respect to the frequency of sexual intercourse, OR values greater than 1 that were statistically significant were obtained. The odds of being positive for oral HPV increased by 77% if the women had sexual intercourse more than 10 times per month , compared to those who had 0 or 1.p-value: 2.11 × 10−5). The odds ratio went up to 28.44 for those who practiced it regularly. Another risk factor detected in our sample, as in the case of genital HPV, seemed to be practicing oral sex regularly, compared to not practicing it at all, with an odds ratio of 95.59 (95% CI: 5.13–1782.75).A very significant result was found with regard to the habit of anal sex: in women who practiced it “occasionally”, there was an increase of 18.29% in the odds of being positive for oral HPV, compared to those who did not practice it  are considered to be practically unfeasible for this cancer category, so primary prevention remains the only way to counteract the growing incidence of OSCCs. The use of condoms is widely accepted by both partners in vaginal intercourse, but their use appears to be very limited in oral–genital intercourse. It seems that the male population is not yet aware that oropharyngeal HPV infection is more dangerous than genital infection. Prophylactic HPV vaccines are effective in preventing HPV infection and HPV-associated cancers, including HPV-related OSCCs. The available epidemiological data report on the efficacy of the HPV vaccine in the prevention of oral infections ,34,35,36HPV vaccination is currently the most promising prevention option for stemming the growing wave of HPV-positive oropharyngeal cancers in men. The lack of oral cancer precursor lesions to be used as an efficacy endpoint for OSCCs has delayed the approval of the HPV vaccine in males for oral cancer prevention; only since 2020 have the FDA in the United States and the EMA in Europe opened up to the use of the 9-valent vaccine also for males, with the specific indication of preventing oral cancer with the use of persistent viral infection as an endpoint for the risk of OCSSs ,38. MoreA limitation of this study could be its small sample size and the HPV sampling method. In our study, cytobrush test kits were used to collect superficial and deep samples of squamous cells from the oropharynx of the patients. Furthermore, in the literature, there is no agreement on sampling techniques and the best sampling method has yet to be identified. Oral HPV testing is not standardized and there are also no validated tests for assessing oral HPV in a clinical setting . AnotherIt is now commonly accepted that a subclinical oral HPV infection that persists for 10–30 years is an obligate precursor to most OSCCs ,40,41. OConsidering that the adoption of barriers in orogenital intercourse is much more limited than vaginal intercourse, today, the 9-valent vaccine remains the only means to successfully counteracting the increasing incidence of OSCCs.


Aim: To investigate the anal component of the anogenital Human Papillomavirus (HPV) related disease during surveillance of patients treated for cervical intraepithelial neoplasia (CIN).Methods: Patients were analyzed within two groups according to the histopathological examination of the cervical biopsies: Low-Grade Squamous Intraepithelial Lesion (LSIL) and High-Grade Squamous Intraepithelial Lesion (HSIL) groups. Anal specimens were also collected in the first-year follow-up visit.Results: All patients had cervical high-risk HPV (HR HPV) infection at admission. At the first-year follow-up, positive HR HPVs were found in 47% of cervical samples. Despite this clearance, the anal HPV infection rate after the first year was 42.5% and 39.6% in LSIL and HSIL groups. Amongst the HSIL group, anal HR HPV positivity was observed in 29.6% of cases without any cervical HPV infection.Conclusion: A group of women cured of high-grade lesions have ongoing anal HPV infection. It is reasonable to propose that detecting anal HPV could impact the patient's treatment process. Therefore, prospective studies are needed to investigate this group of women's clinical outcomes and define the clearance rate of cervical HPV infection when anal HPV persists. Anogenital Human papillomavirus (HPV) infection-related neoplasias are considered as sexually transmitted diseases ,2. WomenThe time interval between the diagnosis of cervical dysplasia and the onset of anal cancer generally takes a relatively long period, up to a decade or more . NeverthThe current explanation for the development of cervical neoplasms states a step-by-step development, starting with a persistent high-risk HPV infection, followed by the development of high-grade lesions, resulting in invasive cancer . In womeStudy populationThis study was conducted at a single Cervical Disease Screening and Treatment Unit center. The Institutional Ethics Review Board approved the study. The study group was composed of women aged between 30-65 years. The inclusion criteria for the study group were as follows: women with a positive cervical HR HPV test before admission to colposcopy, women older than 30 years of age, histological diagnosis of Low-Grade Squamous Intraepithelial Lesion (LSIL) or High-Grade Squamous Intraepithelial Lesion (HSIL), conservative management if LSIL was diagnosed. If the initial histopathological diagnosis was HSIL, a standard cervical excision procedure by the same surgeons (TG and DK) was performed. Women without a histological diagnosis were excluded from the analysis. Other exclusion criteria included: history of any cervical therapeutic intervention before initial colposcopy, history of other cervical or genital dysplasia, known immunosuppressive disorder, being under immunosuppressive medication, undergoing ablative treatment for CIN, previous diagnosis of any cancer, history of vaccination against HPV. The participant's age, the number of sexual partners, age of sexual debut, parity status, smoking status, former or current oral contraceptive use, and other related patient data (HPV genotypes at admission and first-year follow-up) were recorded on a data sheet. Patients were analyzed within two groups according to histopathological examination of the cervical biopsies: LSIL and HSIL groups.Specimen collection and HPV genotyping procedureAnal specimens were collected in the first-year follow-up visit by inviting the patients to participate in the study. Informed consent was obtained from women willing to participate in anal HPV testing. Anal specimens were collected by inserting Dacron swabs into the anal canal and gently rotating them in a circular motion. Those swabs were placed into liquid transport media and transported to the microbiology laboratory. A technician blinded to the subject's medical history performed all laboratory procedures. According to manufacturer instructions, DNA extraction was performed using the "EZ1® Advanced XL Nucleic Acid Purification" instrument . Amplification and detection were carried out using the "HPV Genotypes 14 Real-TM Quant" kit  that allowed the identification of 14 high-risk genotypes . Anal swabs were reobtained if the first sample was inadequate for analysis.Statistical analysisStatistical tests were performed by PSPP 1.0.1 and R (with EasyR plugin) software. The Shapiro-Wilk test examined the continuous variables with normal and abnormal distributions, while the parametrical t-test was used for the normally distributed continuous variables. When applicable, the nominal variables were analyzed using Pearson's chi-square or Fisher's exact test. The continuous variables were presented using the mean±standard deviation (SD), and the categorical variables were presented as the number of cases and their percentage. The Bonferroni adjustment was performed for all possible multiple comparisons to control for type I errors. A p-value less than 0.05 (<0.05) was set as statistically significant.Three hundred one patients underwent colposcopic investigation after primary HPV screening. During surveillance, 91 were lost to follow-up in the first year visit. After excluding the ones according to the abovementioned criteria, 83 women who met the inclusion criteria and had been managed with the diagnosis of CIN were included in the study. All had previously undergone colposcopy and cervical biopsy. Biopsy-proven HSIL cases had been treated with an excisional procedure. There was a total of 40 women with LSIL diagnosis and 43 women with HSIL lesions on their follow-up who agreed to participate in the present study. These were defined as the LSIL and HSIL groups. All participants had undergone anal sampling for HPV testing during their first-year follow-up visit. The characteristics of the patients are presented in Table Cervical and anal HPV infection status during the first-year follow-up visit was summarized in Table In the cervical samples of the HSIL group, type 16 and/or 18 were found in 11.6% and other high-risk types in 25.6% of the cases. On the other hand, in the anal samples of the same HSIL group type, 16/18 was determined in 23.3% of the cases. HPV infection status in the anal canal was also analyzed with respect to current cervical HPV infection . A similar trend was observed in the HSIL group, as active anal HPV infection rates in cervical HPV positive and negative cases were 56.2% vs. 29.6%, respectively. However, this difference did not reach statistical significance (p=0.084). In the HSIL group, HPV genotype 16 and/or 18 persisted only in 5 cases (11.6%) and cervical HPV infection was cleared in 27 (62.8%) women. Among these women with HPV clearance, 29.6% were found to be positive for HR HPV DNA in their anal canal Table .Moreover, 75% of this anal HPV infection was with HPV genotype 16 and/or 18. Overall in the HSIL group, 39.6% of women were found to carry HR HPV DNA in their anal canal after the first year. On the other hand, in the LSIL group, clearance of cervical HPV infection was lower 42.5%)  woman was found to have genotype 16 and/or 18 in her anal swab. However, amongst 9 women who were found to be positive for genotype 16 and/or 18 in their cervical swabs, 5 (55.6%) of these women were detected to carry genotype 16 and/or 18 in the anal canal.This current study analyzed cervical and anal HPV infection rates among women managed for LSIL and HSIL of the cervix. All women had initially undergone colposcopy, and those with histologically proven HSIL were treated with an excisional procedure . At the first-year follow-up, positive HR HPVs were found in 47% and 41% of cervical and anal samples, respectively. Cervical infection prevalence was 57.5% and 37.2% among LSIL and HSIL groups, indicating excisional procedures in women with HSIL resulted in complete HPV clearance in more than half of the cases. Despite this clearance, this study demonstrated that the anal HPV infection rate after the first year was 42.5% and 39.6% among LSIL and HSIL cases. In women with HSIL, type 16 and/or 18 was found in 11.6% of the cervical samples. However, type 16/18 took a more dominant place in the anal samples of the same women, with a prevalence of 23.3%.Moreover, amongst the HSIL group, anal HR HPV positivity was observed in 29.6% of cases without any cervical HPV infection. Surprisingly, 22.2% of women who were negative for cervical HPV were found to be positive for HPV 16/18 in their anal swabs. Anal HPV 16/18 persisted in 22.2% of the HSIL cases even after a complete cervical HPV clearance. Several previous studies have investigated coexisting anal HPV colonization and cervical HPV infection. Guler et al.  reportedAnother study investigating anal HPV prevalence in women attending a colposcopy clinic found the presence of HPV in the anus to be 56.3% . This isThe widespread HPV-based screening would result in an ever-increasing number of women with high-risk HPV infection with normal cervical cytology results . One valThis study did not include a long-term prognosis that precludes determining the sensitivity and specificity of anal HPV testing on the recurrence of cervical HPV infection and related dysplasia. Another limitation of this study is the lack of matching for diabetes mellitus status between the LSIL and the HSIL group. Since glucose status is important in intraepithelial lesions, there is a need to prospectively assess the clinical value of this issue in the development and association of anal HPV infection in LSIL and HSIL groups.In conclusion, this study found that women who have been categorized as being cured for high-grade lesions have been found to have ongoing anal HPV infection (including HPV types 16 and/or 18). This anal HPV infection is observed even in negative cervical HPV cases. Longitudinal studies are needed to define the value of anal HPV testing during anogenital HPV-related disease.


Gastric cancer is becoming the 4th leading cause of cancer-associated death worldwide. The purpose of this study was to investigate the role of RGS1 in gastric cancer in vitro and in vivo. Proliferation, migration, invasion, and colony formation of NCIN87 cells and drug-resistant NCIN87 cells (NCIN87-DR) were determined. Cell apoptosis and cell cycle were examined using a flow cytometry assay. RGS1 gene knock-down vector (pLVshshRGS1) and Xenograft tumor mouse model was generated. RGS1 and epithelial-mesenchymal transition (EMT) associated markers, including E-cadherin (E-cad), N-cadherin (N-cad), Slug, and Vimentin were detected using a western blotting assay. Tumor size of Xenograft tumor mouse was measured and Ki67 expression was detected using the immunohistochemical assay. NCIN87-DR cells demonstrated significantly lower proliferation, migration, and invasion compared to those of NCIN87 cells (p < 0.05). NCIN87-DR cells showed obvious early apoptosis and displayed obvious alterations for the cell cycle. NCIN87-DR cells exhibited predominantly higher RGS1 expression than that in NCIN87 cells (p < 0.01). E-cad expression was markedly decreased (p < 0.01) and N-cad (p < 0.05), Slug (p < 0.01), Vimentin (p < 0.05) expressions were significantly increased in NCIN87-DR cells than those in NCIN87 cells. RGS1 gene silence remarkably reduced NCIN87-DR proliferation compared to that in NCIN87-DR cells without treatment (p < 0.01). RGS1 gene-silenced NCIN87-DR cell immunization predominantly inhibited tumor growth in Xenograft tumor mouse than that without RGS1 silence (p < 0.05). RGS1 gene-silenced NCIN87-DR cell immunization significantly downregulated Ki67 expression in tumor tissues compared with that without RGS1 silence. In conclusion, RGS1 gene silence reduced the proliferation of NCIN87-DR cells in vitro and inhibited tumor growth in vivo. Therefore, RGS1 served as an antitumor target for the gastric cancer treatment. In recent years, gastric cancer is becoming the 4th leading cause of cancer-associated death worldwide, demonstrating a higher incidence in China . AlthougRegulators of G-protein signaling (RGS) molecules regulate a variety of signal pathways through activating heterotrimeric G proteins . BioinfoThis study aimed to evaluate the proliferation, migration, and invasion, as well as the expression of EMT associated molecules  in gastric cells . Effects of RGS1 silence on tumor cell proliferation in vitro and tumor growth in vivo were also evaluated. This study would provide new insight into the improvement mechanism of gastric cancer.2 at 37 °C.The normal human gastric cancer cell line NCIN87 cells were used in this study. The cells were cultured in DMEM-F12 medium  containing 10% fetal bovine serum  and 1% streptomycin-penicillin solution . NCIN87 cells were cultured in a condition of 5% COFor drug-resistant NCIN87 cell line (NCIN87-DR cells), which were generated by treating with trastuzumab . Mice were housed in a standard cage with a light/dark cycle of 12 h/12 h and humidity of 45%–50%. Mice also had free access to water and food.This study has been approved by the Ethical Committee of Chongqing University Cancer Hospital, Chongqing, China . All animal procedures were carried out according to the NIH guidelines for Laboratory Animal Care and Safety.5 cells/mL and inoculated into 96-well plates. Post culturing for 24 h, 48 h, or 72 h, 10 μL CCK-8 solution (Beyotime Biotech.) was added to 96-well plates and incubated for another 4 h at 37 °C. Then, the absorbance of 96-well plates was detected using a microplate reader  at 450 nm. The cell viability of NCIN87 and NCIN87-DR cells were calculated as the followings: Cell viability = / × 100%. Here, the negative control group was designated as a group using only DMEM-F12 medium.The density of NCIN87 cells and NCIN87-DR cells were adjusted to 0.5 × 105/mL NCIN87 or NCIN87-DR cells were suspended with an FBS-free medium and seeded into the upper chamber of a transwell. While a total of 500 μL medium containing 10% FBS was added to the lower chamber of the transwell. Then, NCIN87 cells or NCIN87-DR cells were cultured for 24 h in humidified conditions and 5% CO2 at 37 °C. The migrated NCIN87 cells or NCIN87-DR cells were fixed using 70% methanol  for 5 min, stained using 0.5% crystal violet  for 20 min, washed using PBS solution for 3 times, and counted using microscopy . For cell invasion analysis, the upper chamber was pretreated using Matrigel (BD) for 3 h at 37 °C. The other procedures were consistent with the processes of the cell migration analysis. Data are defined as amounts of migrated cells and invasive cells.The transwell assay was conducted as described by a previous study . For cel2. Cells were incubated at 37 °C about 10 days. When the larger clones were appeared in 6-well plate, incubation of cells was stopped. Then, mediums were discarded, and cells were washed using PBS solution, fixed using 70% methanol for 10 min and stained using 0.1% crystal violet for 20 min. Eventually, images of the above stained NCIN87 cell clones or NCIN87-DR cell clones in plates were captured and counted.About 500 NCIN87 cells or NCIN87-DR cells were seeded into a 6-well plate and cultured in DMEM-F12 medium at 37 °C with 5% COCell apoptosis and cell cycle were analyzed as a former study  describe5 NCIN87 cells or NCIN87-DR cells were transfected with siRNA-encoding lentivirus  in presence of polybrene at a concentration of 1 μg/mL overnight. Subsequently, NCIN87 cells or NCIN87-DR cells were cultured in a medium containing 10% FBS for 24 h and transfected with pLVshRGS1 viral vector.The pLVshRAN-EGFP(2A)-Puro lentiviral vector was used to generate pLVshRGS1 vector. shRNA nucleotide sequences targeting RGS1 were listed as the followings: sense: 5’-GATCCACTTCCGCACTCGAG AATCTATCAAGAGTAGATTCTCGAGTGCGGAAG TTTTTG-3’;antisense:5’-AATTCAAAAACTTCCGCA CTCGAGAATCTACTCT TGATAGAT TCTC GAGTGCGGAAGTG-3’. In brief, CD47 shRNA sequence was cloned into pLVshRAN-EGFP(2A)-Puro vector for generating pLVshRGS1 vector. Then, the synthesized pLVshRGS1 vector was packaged by mixing with psPAX2 and pMD2.G. Total of 1 × 10−ΔΔCT method, with the GAPDH as a reference gene.Total RNA was extracted using a Trizol kit and cDNA was synthesized from the extracted RNA using Hifair II 1st strand cDNA synthesis kit  in accordance with the protocol of the manufacturer. The specific primers were synthesized and sequences are listed in 6 cells/mouse) suspended in DMEM-F12 medium were subcutaneously injected into right axilla of mice. When tumor size achieved to 300 mm3 (assigned as 0 week), T-mab (5 μg/g body weight) was administrated weekly to each mouse for NCIN87+Tmab group, NCIN87-DR+T-mab group, and NCIN87-DR+pLVshRGS1+T-mab group. While saline was administrated weekly for mice in NCIN87 and NCIN87-DR group. For mice in NCIN87-DR+pLVshRGS1 and NCIN87-DR+pLVshRGS1+T-mab group, NCIN87-DR cells were transfected with pLVshRGS1 virus followed by cell injection into mice. Tumor size (volume) and body weight of mice were recorded each week post the above treatments (from 1st week to 6th week). Tumor volume was calculated as the following formula illustrated: tumor volume (mm3) = (long diameter × short diameter2) × 0.52. All above mice were euthanized at 6 weeks posttreatments, and the tumors were isolated and measured.Mice were randomly divided into 6 groups, including NCIN87 group, NCIN87+T-mab group, NCIN87-DR group, NCIN87-DR+T-mab group, NCIN87-DR+pLVshRGS1 group, NCIN87-DR+pLVshRGS1+Tmab group (n = 6 per group). NCIN87 cells or NCIN87-DR cells , dehydrated using graded ethanol , treated with xylene, embedded in paraffin, and sectioned into slices (5 μm thickness). Then, paraffin tumor sections were stained using rabbit antimouse Ki-67 antibody , followed by staining with HRP-labeled goat antirabbit IgG (Beyotime Biotech.). Finally, sections were sealed with neutral gum, and pictures were captured with a microscope .Total proteins were separated from NCIN87/NCIN87-DR cells or tumor tissues using 1 mL of radio immune precipitation assay (RIPA) buffer. The above samples were then immediately sonicated for 2 min to break cell membranes and were centrifuged at 12000 r/min for 5 min at 4 °C. Supernatants containing targeting proteins were collected for western blotting analyses. Concentrations of isolated proteins were examined using a BCA Protein Detection kit (Beyotime Biotech.) as described by the manufacturer. Then, proteins were separated using 10% SDS-PAGE and electro-transferred onto a PVDF membrane. Proteins on PVDF membranes were washed using TBST, blocked using 5% nonfat milk for 1 h at room temperature, and incubated using rabbit antimouse RGS1 , mouse antimouse E-cadherin (ZEN Bio.), rabbit antimouse N-cadherin (ZEN Bio.), rabbit antimouse Slug (ZEN Bio.), mouse antimouse Vimentin (ZEN Bio.) and rabbit antimouse β-actin antibody  at 4 °C overnight. Next, PVDF membranes were washed using PBST and incubated using HRP-conjugated goat antirabbit IgG (Beyotime Biotech.) or HRP-conjugated goat antimouse IgG (Beyotime Biotech.) at room temperature for 1 h. Finally, the immunoblot bands were visualized with the enhanced chemiluminescence (ECL) kit (Beyotime Biotech.) according to the manufacturer’s instructions.Statistical analyses were carried out using SPSS 21.0 software . Data are presented as mean ± SD. Comparisons between 2 groups were done using Student’s t-test, while comparisons among multiple groups were done with one-way ANOVA followed by Tukey’s post hoc test. The threshold for statistical significance was set as p < 0.05.In this study, we verified and compared proliferation, migration, and invasion between NCIN87 cells and NCIN87-DR cells. CCK-8 assay findings showed that cell viability of NCIN87-DR cells was significantly lower compared to that of NCIN87 cells at 24 h, 48 h, and 72 h, respectively  and invaCell cycle results indicated that there were more G1 phase cells and fewer S phase cells in NCIN87-DR cells compared to those in NCIN87 cells  also exhibited lower migration capability and invasion capability. Meanwhile, there were fewer clones formed in NCIN87-DR cells compared with that of NCIN87 cells. Therefore, the proliferation, migration, invasion, and colony formation ability of drug-resistant NCIN87 cells seemed to be low, which is consistent with the findings of a previous study . In addiIn addition to migration and invasion, the EMT process of cancer cells is also a key factor in the distant-metastatic cascade of cancer cells . In factIn order to determine the role of RGS1 in drug-resistance of NCIN87-DR cells, RGS1-silence vector pLVshRGS1 was generated and transfected into HCIN87-DR cells. CCK-8 assay findings showed that tumor-specific antibody T-mab could obviously decrease cell viability of NCIN87 cells, but had relatively little effect on NCIN87-DR cells. pLVshRGS1 transfection significantly decreased the cell viability of NCIN87-DR cells. Compared with NCIN87-DR cells treated with T-mab, NCIN87-DR cells treated with T-mab combined with pLVshRGS1 demonstrated lower cell viability. These results suggest that pLVshRGS1 transfection enhanced the inhibitive effect of T-mab on the proliferation of drug-resistant NCIN87-DR cells. According to these findings, we found that RGS1 is a target to block the proliferation of cancer cells, which may be beneficial to the function of antitumor drugs (such as T-mab).We also immunized animals with NCIN87-DR cells to generate a Xenograft tumor mouse model. As the findings show, the tumor size of Xenograft mice immunized with NCIN87 cells treated with T-mab reduced obviously, while the tumor size of Xenograft mice immunized with NCIN87-DR cells treated with T-mab decreased less, showing obvious drug-resistance in vivo. However, RGS1 gene-silenced NCIN87-DR cell immunization obviously decreased tumor size of Xenograft mice compared to that of solely NCIN87-DR cell immunized Xenograft mice. RGS1 gene-silenced NCIN87-DR cell immunization could also strengthen inhibitive effect of T-mab on tumor growth. Thus, RGS1 gene-silenced NCIN87-DR cell immunization could obviously inhibit tumor growth of Xenograft tumor mice. Ki67, as a constitutively expressed molecule in cycling mammalian cells, is widely used to be a cell proliferation biomarker of cancer cells . TherefoThis study also demonstrated a few limitations. First, this study silenced the RGS1 gene expression only by treating it with shRGS1 plasmid. In fact, RGS1 gene knock-out mice might be better to illustrate the silence of RGS1 gene. Second, the sample size (mice) was small in this study. Third, the correlation between RGS1 and EMT associated molecules has not been fully clarified. Fourth, this study only conducted PCR assay for determining the silencing effects of pLVshRGS1 on RGS1 expression in NCIN87-DR cells. It is better to confirm these silence effects by western blotting analysis. Fifth, the expression of RGS1 in tumor tissues of Xenograft tumor mice has not been quantified and its correlation with Ki67 has not been analyzed in this study.We evaluated the proliferation, migration, and invasion of gastric cancer cells, and determined the expression of RGS1 in NCIN87-DR cells. We also evaluated the antitumor effect of RGS1 gene silence on NCIN87-DR cells in vivo and in vitro. It was found that RGS1 gene silence reduced the proliferation of NCIN87-DR cells and inhibited tumor growth. Overall, this study showed that RGS1 might be an antitumor target for the treatment of gastric cancer.


The recommendation for cervical screening is that it should be based on human papillomavirus (HPV) molecular testing. For all screening programs, attention to quality assurance is required to fully realize the benefits. Internationally recognized quality assurance recommendations for HPV-based screening are needed that are ideally applicable for a variety of settings, including in low- and middle-income countries. We summarize the main points of quality assurance for HPV screening, with a focus on the selection, implementation, and use of an HPV screening test, quality assurance systems , and staff competence. While we recognize that it might not be possible to fulfill all points in all settings, an awareness of the issues is essential. Understanding that persistent infection with human papillomavirus (HPV) is a necessary factor for the development of most cervical cancers has informed key developments for prevention. The World Health Organization's (WHO) strategy to eliminate cervical cancer as a public health problem, considers that screening with a high-performance test is one of the three key pillars to support elimination—along with HPV vaccination and treatment—and should benefit all women.Evidence shows that screening using assays to detect HPV nucleic acids is more effective to reduce the incidence of, and mortality from cervical cancer than screening with cytology.This said, we should remember that the interpretation and application of quality assurance criteria is somewhat heterogeneous worldwide. Additioanlly, the number of tests and indeed laboratory services required to fulfill WHO 2030The Global HPV Laboratory Network (HPV LabNet) was created by WHO in 2006 to support the worldwide development and implementation of HPV vaccines through improved laboratory standardization and quality assurance of HPV genotyping for research, evaluation of HPV vaccines, and HPV surveillance.The current HPV LabNet comprises national HPV reference laboratories appointed by their respective countries and led by the International HPV Reference Center.In line with the remit of HPV LabNet to support the international community, particularly in view of the increased use of HPV testing for screening and disease management, this review summarizes the main points to consider when adopting quality assurance for HPV testing in primary cervical screening . In addiHPV tests are based on the detection of viral nucleic acids in varied formats, including DNA-based and mRNA-based, with and without polymerase chain reaction (PCR) amplification. These target several different HPVs, including those most clinically relevant given their oncogenic potential. Of these, 12 types are classified as carcinogenic (group 1) by the International Agency for Research on Cancer (IARC) ; most tests also include HPV68 (group 2A ‘probably oncogenic’) and some HPV66 (group 2B ‘possibly oncogenic’).The main differences between the screening tests relate to technology, including throughput level and availability of automation. Generally, screening tests can be divided into four groupsHPV DNA tests that screen clinically the most oncogenic HPV types without distinguishing the individual genotype/s.HPV DNA tests with concurrent partial/extended, or reflex partial genotyping for the main genotypes.HPV DNA tests with full individual identification of the 12 oncogenic genotypes (or more).HPV mRNA tests that screen clinically the most oncogenic HPV types without distinguishing the individual genotype.Speculation exists that HPV assays targeting the E6/E7 genes are more sensitive than those targeting the L1 gene because the latter may be disrupted in the viral integration process; however, there is little evidence from large-scale studies that L1 disruption affects sensitivity. In the meta-analysis by Arbyn et al, the relative sensitivity for CIN2/3+ compared with standard comparator HPV tests was very similar for either L1 or E6/7-targeted assays.The key issue for HPV molecular testing in cervical screening is its ability to detect viral infections associated with cervical intra-epithelial neoplasia (CIN) grade 2 or higher (CIN2+), and to  delineate significant infections from transient infections that only require follow-up. Thus, unlike other molecular microbial tests, high-analytical sensitivity is not the aspiration, rather, it is the qualitative ascertainment of clinically relevant levels of HPV that makes a test fit for purpose in screening.Meijer et alA complementary approach to assay validation is being undertaken by an international initiative, VALGENT (VALidation of HPV GENotyping Tests), created to support evaluation of HPV tests’ clinical performance, including those with genotyping capabilities.While the Meijer 2009 criteria have been fundamentally important in setting a benchmark for suitable performance, future update and development will be welcome. The current guidance does not, for example, comment on suitable pre-analytical and operational aspects that would affect potential scalability. Laboratory professionals, clinicians, and public health decision-makers should be careful to choose assays associated with robust clinical validation and performance data. Kits approved by the US Food and Drug Administration and/or the European Medicines Agency (EMA) provide additional reassurance.Likewise, it is important that the chosen HPV test(s) are clinically validated for their particular application such as cervical cancer screening and that they are used on appropriate biospecimens. To date, the most frequently used biospecimens for HPV testing are clinician-taken samples in cytology preservation media. All manufacturers of the commercial HPV tests that meet Meijer 2009 criteria include a claim for this type of sample within the instructions for use. A smaller number of tests include a formal claim for use on self-taken samples, although this is likely to change given the increasing demand for self-sampling.The implementation of a new assay methodology has to undergo appropriate verification in each laboratory prior to routine use, even for commercially available HPV assays.The manufacturer is responsible for providing the analytical performance characteristics, as well as expected clinical performance data; this should reflect performance assessment relative to internationally accepted criteria for screening tests, as described earlier. Ongoing verification is also recommended, at least annually.Currently, most HPV assays contain an endogenous control; it frequently involves amplification of a housekeeping gene present in all human cells, such as β-globin, as a control of extraction and inhibition.In each run, the clinical samples are processed along with the kit’s own controls and internal quality controls . After control checks, the results obtained for the clinical samples analyzed may be interpreted. Whatever the test, its results should be interpreted according to manufacturer’s instructions. Control results help to validate the run, and if the control result is not as expected, the run should be considered void.In screening, HPV assays are generally applied at a qualitative level (presence or absence of HPV types at a manufacturer defined cut-off point) to make management decisions. The clinical usefulness and application of the semiquantitative read-out of the assay has not yet been demonstrated. As described earlier, detection of very small amounts of HPV using assays that have not been calibrated to disease endpoints is not helpful for screening purposes.Laboratory operators should be aware of the ‘uncertainty of measurement’ of a test, which is the margin of doubt that exists about the result of any measurement, and also be aware of the critical factors that may affect this. The use of established, clinically validated tests supported by appropriately trained staff, and well-maintained equipment can mitigate uncertainty but not remove it completely. The core challenge/concern around HPV molecular screening tests  will be uncertainty around the cut-off value resulting in false-negative results. However, as validated screening tests are tuned to achieve a high clinical sensitivity and are interpreted at a qualitative level, the level of acceptable ‘uncertainty’ for HPV tests may be greater than for other tests where a quantitative read-out would influence specific decision-making.Quality in healthcare is closely connected to the level of excellence in knowledge, and technical development. High quality molecular testing helps to ensure an accurate result is delivered to the right individual. The International Organization for Standardization (ISO)Accreditation is a good way to demonstrate the competence of a laboratory; to be accredited a laboratory undertakes a process whereby an authoritative body gives a formal recognition of technical competence for specific tests, based on third party assessment and following international standards. In diagnostics laboratories, the ISO 15189Internal quality control involves daily monitoring of the reproducibility or precision of the assay to detect errors in the analytical procedure.Although commercial tests may include their own controls, internal quality control requires control materials, independent of those provided with the test kit, which can help evaluate variations between kit batches. The control materials should ideally resemble the biomatrix of samples, be prepared in sufficient quantity to last ideally at least 1 year, be stable for the period of use, be aliquoted for convenient use, and preferably be subjected to the whole procedure, from extraction to detection. Controls may be purchased from a commercial source, obtained from reference laboratories, or prepared in-house. Positive and negative HPV control materials can be generated in different ways, such as pooled from residual positive and negative HPV cervical samples, dilutions of HPV positive and negative cervical cancer cell lines in cytological media, and liquid, lyophilized, or freeze-dried specimens representing individual HPV types.Since HPV testing is applied at qualitative level, the internal quality control needs to involve both negative and positive HPV control materials, the latter optimally close to the test’s cut-off point. However, the possibility to register a numerical or semiquantitative measure, depending on the assay, permits the operator to analyze the trend in behavior of the assay. Therefore, the internal quality control is useful to check each run , kit batch, and process over time. It is advisable to include an internal quality control in each run/sample batch or at least every 24 hours or with a new kit batch, in cases of continuous platform instruments.Laboratories should monitor and log internal quality control performance, and acceptability criteria should be previously established. At the qualitative level, the match between expected and observed results must be analyzed. Additionally, in assays that provide a numerical read-out, recording values allows the creation of control charts (Levin-Jennings).A control chart allows identification of a random error (deviation from an expected result) and provides information as to whether a particular run is acceptable. Additionally, systematic errors can drive a change in the mean value of the quality control material, either gradual or sudden, which may trigger the test procedure review, equipment calibration, and reagent performance. All laboratories should have their rejection rules and corrective actions documented.Internal quality assessment is the repeat testing of a percentage  of routine test samples to determine the laboratory’s ability to obtain reproducible results. Consistency is an important measure of quality assurance, repeat tests continually giving the same results as the original test provide evidence that a system is in control.There are no specific recommendations for the number and/or frequency of internal quality assessment that should be implemen. For monitoring, the internal quality assessment result is compared with the original result and registered. Discrepancies may be noted and are normally classified as minor (a variation which would not affect the result/management) or major (lead to a different result/management). All discrepancies should be investigated. Factors that could affect the internal quality assessment result should be taken into account, like potential specimen degradation during storage and (if available) the semi-quantitiave value of the original result t.External quality assessment, sometimes used interchangeably with proficiency testing, is defined as a system that allows comparison of a laboratory’s testing performance with a source outside the laboratory.Interlaboratory schemes involve reciprocal exchange of material of known quantity or may involve the creation of a pool of often ‘blind’ material(s) by a central laboratory that are then disseminated to participating laboratories. In both scenarios, observed versus expected results are assessed, with discrepancies noted and investigated. Interlaboratory exchange schemes can complement formal external quality assessment schemes and can help to build robust relationships and communications between laboratories, particularly within a particular country/service. They may also be particularly valuable at the initiation of a new service—for example, in England, prior to the national introduction of HPV testing for triage and test of cure, the relevant service laboratories were sent a panel of centrally collated and annotated samples suitable for testing on the varied HPV platforms approved for use within the program.Additionally, interlaboratory exchange schemes can add value if existing external quality assessment schemes do not reflect the biomatrix of the sample routinely used for testing. If a laboratory is looking for accreditation by an external agency, then interlaboratory exchange schemes is not generally mandated provided participation in a recognized external quality assessment scheme is demonstrated.External quality assessment schemes have commonalities with interlaboratory schemes, although they operate independently of a setting, are often  associated with external accreditation, and are disseminated, as panels, through defined and specific cycles. Although many are not-for-profit, a charge is usually levied, and sometimes international distribution can be restricted; this can be a reason for pursuing an interlaboratory exchange schemes approach. External quality assessment schemes should ideally be amenable to a variety of HPV tests to reflect the international diversity and availability of HPV tests, with their respective chemistries and targets; any doubt may be discussed with the scheme coordinator. Ideally, the external quality assessment schemes used should challenge the end-to-end process of a test, including any pre-analytics and extraction as well as detection.overall report provided by the scheme provider as well as the individual laboratory report, as this can help contextualize individual laboratory performance with that of the wider community experience and may help to highlight issues with a particular platform. Recourse to the scheme provider can be helpful during the investigation process for gaining advice and, potentially, for provision of additional residual material should retesting be of value for troubleshooting purposesThe results of external quality assessment should be clearly documented and made available internally and to users of the service, where required. A (minimum) yearly review of external quality assessment performance is advised, although any non-conformance should be managed in real time with a documented root cause investigation and suggested corrective and preventative actions. It is important during the investigation (of discrepant results) to reflect on the Annual review of quality assurance is intended to provide an update and overview of the whole process of the HPV molecular test repertoire,. It should include the profound assessment of the following topics:Results of the internal quality controls as well as of external quality assessment should be assessed with a focus on exceptions that may indicate quality problems. Comparison of results with those of previous years, together with a check on existing performance trends, should be in place.A review of supplier activities should include an assessment of (a) suppliers of laboratory materials , (b) suppliers (organizers) of external quality assessment schemes, and (c) suppliers of analytical results when subcontractors are used.Relevant issues/findings from internal and external audits should be described. including installing corrective actionsReflection on the user’s perception of the services provided by the laboratory should be performed. The laboratory should also formulate an action plan informed by user feedback.Deviations from procedures (or non-conformities) must be documented throughout the year, and these records are the basis for the annual overview, including the observed trends and evolutions within previous years as well as the corrective actions applied.Improvement proposals by the technical staff as well as evaluations of current technical needs, including improvement of laboratory infrastructure, should be performed. The training needs of technical staff, including effectiveness of existing training plans, should be evaluated.time interval from sample reception to the availability of the test result. The TAT should be established in accordance with practical capacities of the individual laboratory as well as actual clinical needs and will strongly depend on the global positioning of HPV testing in the particular country/laboratory .Quality indicators should be monitored to evaluate critical aspects of the pre-analytical, analytical and post-analytical phases. If feasible, parameters should be quantifiable to evaluate the nature and magnitude of corrective actions applied, eg. number of corrected reports. The most used measurable quality indicator is turnaround time (TAT) i.e. the The impact of the work processes, and if applicable the implications of their disruption/ failure on patient safety should be evaluated. Identified risks should be reduced or eliminated and all decisions about the corrective actions should be documented.We accept that access to a bespoke laboratory space which has been configured with molecular testing in mind may be a luxury. Additionally, how rapidly a new platform can be integrated will depend on various factors. including the extent of any overarching laboratory quality management system. In Most HPV tests in use for screening and clinical management are based on molecular amplification. The enemy of molecular testing is contamination and having systems and protocols in place to manage this is important; some HPV assays integrate digestion of amplified products, but this alone is not a solution. Should the assay require, in-house preparation of primers and master-mixes restricted ‘clean’ preparation areas that contain dedicated laboratory coats, small equipment , and a local standard operating procedure for appropriate use are needed. Records that detail preparation of primer and master-mix batches should be completed to ensure traceability and support troubleshooting in the event of downstream problems. The higher throughput, clinically validated, HPV assays are increasingly less reliant on manual preparation steps. Additionally, detection of PCR products in real time obviates the need for exposing ‘open’ PCR products to the environment.To summarize, the extent of molecular demarcation will be affected by the nature of the assay used. However, even with automated analyzers, introduction of a cleaning and decontamination schedule(s) appropriate to a chosen test (cleaning products that can destroy nucleic acid safely but will not interfere with the specific reaction chemistry) will support good laboratory practice, as will the creation of a policy and practice for waste management. Standard operating procedures should include such aspects on decontamination.Even with well-established, commercial, clinically validated HPV assays, it is important that the impact of changing reagent-lots on test performance is monitored and that particular lots are confirmed as fit for purpose through acceptance testing. A gradual trend in the growth of use of commercial tests for HPV in European Union countries by 2028 is expected.Small and large equipment used to deliver a particular test, whether provided by the test manufacturer, or required but not supplied (such as pipettes and cold storage), need to be well maintained. Maintenance schedules can be created to support timely organization of preventative maintenance by external or internal personnel. Documentation of maintenance and repair should be detailed and include dates, activities, and personnel involved. A daily, operational user log associated with a particular piece of equipment can support team communication about problems, particularly if the equipment is multi-user. Additionally, environmental records of ambient temperature and the temperature of any associated equipment used for storing reagents or controls relevant to the equipment/test should be documented daily, with lower and upper tolerances specified, exceptions recorded, and associated corrective actions documented. A system/method to ensure that the temperatures are accurate within the required range through external calibration is also required. Additionally, prior to receipt of reagents by a laboratory, the appropriate transport of commercial reagents should be secured by the manufacturer.A check to see that the assay is performing as expected should occur after preventative maintenance. The process used to provide evidence for this—sometimes referred to as a ‘back to service’ exercise—should be documented and available for view. Additionally, for significant ‘changes’ such as a physical movement of the equipment within the laboratory, after a critical repair, or after a software update, reverification of the assay is advised.Good relationships and communications between the commercial supplier of the HPV platform and the operating laboratory are important; initial training on a particular assay should ideally be supported by the supplier, and documentation of this training made available. The obligations for service and maintenance of any test equipment should be honored according to the maintenance contract. As described earlier, an annual documented review of any problems with suppliers (including response times) is important to identify particularly areas of pressure and challenge and to inform subsequent improvements.Frequently, in cases of high-throughput analyzers, automatic interface of the machine output with the laboratory information management system occurs, which supports rapid generation of results and can obviate transcription errors associated with manual input. However, if an interface is created, clear demonstration of its accuracy should be trialed and documented before it is put into live practice.Competence is the demonstrated ability to apply knowledge and skills that allow staff to perform in specific work situations in accordance with the occupational area standards.Staff should have clearly defined lines of responsibility and job descriptions. Likewise, it is important to ensure that the personnel are aware of the relevance of their activities, and their contribution to meeting quality objectives.If a laboratory decides to adopt more than one HPV testing method, the personnel must be trained for each of the tests used.The aim of this work was to provide laboratories with an overview of core quality control measures that can help to ensure robust laboratory-based HPV testing. Quality monitoring of HPV testing is an evolving field, and developments in (1) the tests themselves, (2) the associated automation, (3) international validation metrics, and (4) regulatory requirements will probably influence and inform the approach to quality monitoring over time. We also accept that globally, laboratory infrastructure and remit varies widely and that the implementation of some of the items described above may be challenging. Nevertheless, we hope that this piece introduces some of the key concepts on quality assurance of HPV testing and its importance. Given the high negative predictive value of HPV testing which lends itself to extended screening intervals of 5 years, accuracy, supported by quality, is clearly fundamental. We would also argue that quality assurance should be a prime consideration of any laboratory looking to undertake HPV testing and that creation and maintenance of a core local policy to support this must be implemented according to each environment.Certainly, the requirement for increased HPV testing globally is indisputable; as one of the three pillars of cervical cancer elimination described by WHO, it is estimated that around 1.5 billion tests over a period of 5 years will be required to reach the 70% ‘target’ of screening women twice in their life time. Ensuring these tests are delivered accurately to the right person at the right time is not a trivial undertaking and quality frameworks to support this will continue to be essential.


Dear Friends and Colleagues,Warm welcome to the 2023 Annual Meeting of the Belgian Society of Radiology. It is a distinct pleasure to gather again with everyone dedicated to the ever-evolving realm of radiology.This year, the focus is on a topic of vital significance: vascular imaging throughout the entire body. The vasculature, intricate and essential, is not just a network of vessels but a testimony to the marvel of human anatomy and physiology. Rapid progress in imaging technologies now enables us to capture and analyze this system with unprecedented detail and reality, leading to improved diagnosis and treatment strategies, as well as, ultimately, improved prognosis and patient outcome.Given the overwhelming range of topics in this field, it has been challenging to select appropriate lectures for a one-day event. Thanks to the huge efforts of the Scientific Section of Non-Invasive Cardiovascular Imaging and the invaluable contribution from the Young Radiologists Section (YRS), an attractive program has been composed, promising to be both insightful and inspiring.The goal of the sessions is to share the latest techniques, with innovative applications of vascular imaging. Active participation is encouraged to get the most of it for your routine practice. Indeed, the annual meeting is as much about the exchange of ideas as it is about learning.I sincerely hope this meeting serves as a fruitful platform for teaching and learning, as well as for networking, and hopefully even sparks the flame of new ideas or collaboration.Thank you for joining and enjoy an enlightening meeting!Piet VanhoenackerChair Scientific Board BSR


Code blue is one of the important practices for preventing mortality and morbidity and increasing the quality of care in hospitals. The aim of this study was to evaluate the blue code notifications and their results, emphasise their importance, and determine the effectiveness and deficiencies of the application.In this study, all code blue notification forms recorded between January 1 and December 31, 2019, were examined retrospectively.It was determined that code blue calls were made for 108 cases, including 61 females and 47 males, and the mean age of the patients was 56.47 ± 20.73. The accuracy rate of the code blue calls was determined as 42.6%, and 57.4% of them were made during non-working hours. Also, 15.2% of the correct code blue calls were made from dialysis and radiology units. The mean time for the teams to reach the scene was 2.83 ± 1.30 minutes, and the mean time to respond to correctly made code blue calls was 33.97 ± 17.95 minutes. It was found that 15.7% of the patients in correctly made code blue calls were exitus after the intervention.Early diagnosis of cardiac or respiratory arrest cases and quick and correct intervention are very important in achieving patient and employee safety. For this reason, it is necessary to continuously evaluate code blue practices, educate the staff, and organise improvement activities constantly. Code blue practices are an important indicator of quality service in terms of patient and employee safety.In terms of patient and employee safety, it is important to evaluate the causes of code blue and the time to reach the scene, in terms of planning the improvement studies for the cause.It is necessary to share the shortcomings of code blue practices with the staff, to plan improvement activities constantly, and to make assessments regularly1 These cases account for 50% of all cardiovascular deaths and can cause approximately 230 000-350 000 deaths annually.2 In the event of arrest, one of the basic conditions for preventing mortality and morbidity is to respond to the case as soon as possible.4 Early recognition of cardiac arrest and correct and quick intervention are very important for bringing patients back to life.5 For this reason, the importance of code blue in hospitals is gradually increasing.4 Code blue is a warning system used in cases of cardiac or respiratory arrest that may be encountered in the hospital and has been created for giving an effective and quick intervention.4 It is the only code in the world where the same colour is used for the same emergency situation,1 and it aims to create a common language and establish fast communication between healthcare professionals.6 Considering the size of hospitals and the variety of services provided, it is important to educate health professionals to determine the code blue teams, establish the call system, and run the system appropriately.4Cases of cardiopulmonary arrest are common in hospitals.7 As a clinical quality indicator, it is recommended to analyse data regularly and to determine the causes of false calls.6 It is expected that the performance of the code blue system should be evaluated regularly,8 the problems occurring during its practice should be determined, and the system should be improved.4 It has been determined that there is a need for research to evaluate the effectiveness and applications of code blue teams hospitals.1 The correct use of the blue code system by health professionals, the status of teams to reach the case in the appropriate time and the evaluation of the time to intervene in the case are extremely important in terms of quality improvement activities. The aim of this study is to evaluate the blue code notifications and their results, emphasize their importance, and determine the effectiveness and deficiencies of the application.Code blue is considered an important quality criterion for hospitals.The study was conducted in a University Hospital that has 1149 beds and admits 1 168 952 patients annually on average. Because the hospital consists of different blocks and bed capacities and the number of patients admitted is high, 2 code blue teams work there. The code blue system was established in the hospital in December 2018. As of this date, the employees and code blue teams throughout the hospital were given education on how and in which situations the calls would be made. The correct blue code covers calls made in cardiac or respiratory arrest situations. All calls except in cases of cardiac or respiratory arrest are incorrectly identified as code blue. The code blue teams consist of at least 1 anaesthesiology and emergency physician, 1 paramedic, and 1 staff member, and they provide service 24/7. The teams respond to the code blue calls made from the blocks and garden areas determined for them. Telephone/radio is used for the code blue call system in the hospital. When a code blue notification is required, all healthcare professionals call 2222 (switchboard) from the nearest extension phone.In this retrospective study, all code blue notification forms recorded between January 1 and December 31, 2019, after the instalment of the code blue system were examined. The forms included the citizenship number and name and surname of the person responding to the case, the name and surname/file number of the case (if applicable), age of the case, the place where the call came from, the date and time of the call, the time of arriving at the scene, the intervention, the time when the intervention finished, and the result of the intervention. All the data collection forms covering all age groups filled out completely by the 2 code blue teams were included in the study. Intensive care units, emergency service units, and operating rooms perform cardiopulmonary resuscitation (CPR) themselves, and therefore, code blue teams are not called by these units. Thus, these units were not included in the study. The sample of the study consisted of 108 calls made using the code blue system.Written approval of the Akdeniz Clinical Research Ethics Committee was obtained before starting the study (24.06.2020/428).U-test was used for the comparison of mean scores of 2 groups since parametric test assumptions were not met. The statistical significance level was accepted as .05 in the study.The Statistical Package for Social Sciences 23.0 software package  was used to evaluate the data obtained from the research. Conformity of continuous variables to normal distribution was examined by the Kolmogorov–Smirnov test. The categorical variables included in the study are presented as frequency (n) and percentage values (%), and continuous variables which met the parametric test assumptions are presented as mean ± SD values, while the variables that did not meet the assumptions are presented as median values (minimum–maximum). Pearson Chi-square and Fisher–Freeman–Halton exact test were used for the analysis of categorical variables. The Mann–Whitney In the study, code blue calls were made for 108 cases, including 61 females and 47 males. The mean age of the cases was 56.47 ± 20.73 years. The accuracy rate of the calls was 42.6%, and 42.6% of the calls were made during working hours. The teams were found to arrive at the scene in an average of 2.83 ± 1.30 minutes during code blue calls. It was determined that the average intervention time of the teams to correctly made code blue calls was 33.97 ± 17.95 minutes. As a result, 51.9% of the cases in code blue calls were taken to the emergency department, 15.7% were exitus, 25% were left in the scene, and 7.4% were taken to the intensive care unit .Correct code blue calls were mostly made from dialysis (15.2%) and radiology units (15.2%). The calls were most frequently made from the oncology clinic (8.7%). All units and the frequency of calls are shown in detail in In In The characteristics of patients who were exitus are shown in 9 and the performance of the system should be evaluated periodically.8 In our study, the data of 108 code blue cases were analysed, and the mean age was found to be 56.47 ± 20.73 years10 225 code blue patients were evaluated in a hospital with 250 beds, and the mean age was found to be 54.1 years. Incesu et al11 found that the mean age of patients for whom a code blue call was made in a hospital with a bed capacity of 137 was 58.46 ± 20.81 years.11 Monangi et al12 stated that a total of 694 code blue calls were analysed in their study.1 In another study, it was reported that the number of patients for whom a code blue call was made was 237.5 In the study conducted by Topeli and Cakir,8 the data of 155 code blue patients were evaluated. When the result of our study is compared with the literature, it can be said that the number of code blue calls found in our study is relatively low and that the mean age is similar. We think that the sample size in our study was small possibly because the code blue system was newly established, the data were collected as of the date when the system was activated, and the awareness of the employees about the code blue application might not have been adequately developed.Code blue application is an indispensable standard of hospitals,13 Eroglu et al1 stated that 91.0% of the code blue activations in their study were incorrect.1 Çakırca and Kılcı14 reported the incorrect code blue rate as 67.1% in their study. When the literature is examined, it is seen that most code blue calls were made incorrectly, similar to our study. The communiqué on the code blue applications at the national level was published by the Ministry of Health in 2009.15 This shows that the code blue application process is new for hospitals. In addition, it is assumed in our study that the scope of the code blue application may not have been understood fully by the employees because the code blue system was established recently.It was found that 57.4% of the code blue calls in the data of our study were incorrect. In a study, 84.5% of the code blue calls were incorrect.10 Esen et al5 stated that code blue calls were made most frequently between 10:00 pm and 12:00 am.5 Tosyalı and Numanoğlu16 reported that the rate of code blue calls made during non-working hours was 59%. In another study, it was stated that 56% of code blue calls were made during non-working hours.17 Çakırca and Kılcı14 reported that calls were frequently made during working hours, but the number of arrests was statistically higher during non-working hours. As a result of another study, it was determined that the code blue calls were received mostly between 6 am and 7 am.18 In our study, similar to the literature, it is seen that most of the calls were made during non-working hours. We think that this was because the number of healthcare professionals who can respond to the patient during non-working hours in the hospital where the study was conducted was less than that during working hours. This result reveals the importance of the need for the 24/7 operation of the code blue system.It was determined that 57.4% of the calls in our study were made during non-working hours17 2.02 ± 0.92 minutes,18 1 minute 33 seconds, 1.10 minutes,10 and 40.77 ± 25.69 seconds,17 which are similar to the values in our study. The arrival of code blue teams at the scene within 3 minutes is considered a quality indicator.19 In our study, it is seen that the code blue teams reached the cases below the targeted time. This situation is extremely important in terms of patient and employee safety in the timely and rapid intervention to the arrest.In our study, it was determined that the mean time for the code blue teams to arrive at the scene was 2.83 ± 1.30 minutes 5 12.7 ± 12.7 minutes,14 27.5 ± 11.4 minutes,18 25.52 minutes,20 and 33.4 ± 19.6 minutes.21 The duration of CPR varies according to the condition of patients. Therefore, there may be differences in intervention times.In our study, it was determined that the mean intervention time of the teams to the cases in the correct code blue calls was 33.97 ± 17.95 minutes 22 stated that 2.6% of code blue calls were made from the dialysis unit. In another study by İncesu,11 it was determined that code blue calls were frequently made from polyclinics. In other studies, it was found that the code blue calls were mostly made from the clinics,21 and these calls were mostly made from palliative20 internal medicine20 and oncology clinics.20 A review of the literature indicated that the frequency of code blue calls varied according to departments/units. In our study, especially the data of correctly made code blue calls were examined. We think that the reason why correct code blue calls were made from the dialysis, radiology, and oncology clinics was that the healthcare professionals working in these fields showed more interest in the education provided and that they were more aware of the code blue issue.In our study, it was determined that correct code blue calls were mostly made from dialysis (15.2%) and radiology units and that 8.7% of them were made from oncology clinics14 In another study, it was reported that the most common causes of code blue calls were syncope (29.7%) and cardiopulmonary arrest (26.8%).21 In a study on the reasons for code blue calls, it was stated that 30 of the cases were cardiac arrest, 14 of them were convulsions, and 11 of them were syncope.23 In the study conducted by Topeli and Cakir,8 it was reported that 54.8% of the cases were exitus after the intervention. It is seen that our study result is similar to the literature.8In our study, it was determined that 42.6%  of code blue calls were made due to a cardiac arrest and that 27.8%  of them were due to worsening health16 In our study, most of the cases that were exitus in code blue calls were from the clinics, and we consider that this was because the patients hospitalized in the clinics were in a more critical condition. Rapid response systems used in hospitals are associated with lower rates of cardiopulmonary arrest and mortality in critically ill patients.24 For this reason, it is recommended to establish rapid response teams (rapid response system) to provide intervention before cardiac or respiratory arrest.In our study, 51.9% of code blue cases were found to be taken to the emergency department. Similarly, 58.6% of code blue cases in a study were taken to the emergency department. In our study, 15.7% of the correct code blue cases ended with exitus, and 52.9% of the code blue calls for patients who ended with exitus were made from the clinics. In a study, it was determined that 57.2% of the cases in the code blue application showed no return of spontaneous circulation.This study has some limitations. First, it is based on data obtained from the forms filled out by code blue teams. In addition, the code blue operation was newly established in the hospital where the study was conducted; therefore, this may have caused some shortcomings in practice. However, evaluation of the newly established system is also very valuable in terms of detecting problems and providing quick solutions.In conclusion, it was found in our study that code blue calls were mostly made for incorrect reasons. Since the code blue system was newly established and it was not fully understood, it is recommended to provide regular education for the personnel, increase practices that the personnel is involved in, and obtain opinions about code blue practices. It is necessary to share the shortcomings of code blue practices with the personnel, plan improvement activities constantly, and make assessments regularly. In addition, it is recommended to build a different team to respond to cases other than code blue. Code blue practices are an important indicator of quality service in terms of patient and employee safety.