Genetic factors may influence the susceptibility to high-risk (hr) human papillomavirus (HPV) infection and persistence. We conducted the first genome-wide association study (GWAS) to identify variants associated with cervical hrHPV infection and persistence.10/LiPA25. hrHPV infection was positive if at least one carcinogenic HPV genotype was detected in a sample provided at the baseline visit and persistent if at least one carcinogenic HPV genotype was detected in each of the samples provided at the baseline and follow-up visits. Genotyping was done using the Illumina Multi-Ethnic Genotyping Array (MEGA) and imputation was done using the African Genome Resources Haplotype Reference Panel. Association analysis was done for hrHPV infection (125 cases/392 controls) and for persistent hrHPV infection (51 cases/355 controls) under additive genetic models adjusted for age, HIV status and the first principal component (PC) of the genotypes.Participants were 517 Nigerian women evaluated at baseline and 6 months follow-up visits for HPV. HPV was characterized using SPFp < 5 X 10− 8). The top three variants associated with hrHPV infections were intronic variants clustered in KLF12 . The top variants associated with cervical hrHPV persistence were in DAP , NR5A2  and MIR365–2  gene regions.The mean (±SD) age of the study participants was 38 (±8) years, 48% were HIV negative, 24% were hrHPV positive and 10% had persistent hrHPV infections. No single variant reached genome-wide significance (This exploratory GWAS yielded suggestive candidate risk loci for cervical hrHPV infection and persistence. The identified loci have biological annotation and functional data supporting their role in hrHPV infection and persistence. Given our limited sample size, larger discovery and replication studies are warranted to further characterize the reported associations.The online version contains supplementary material available at 10.1186/s12881-020-01156-1. Human papillomavirus (HPV) is a highly conserved double-stranded DNA virus that has coevolved with human populations for millennia . Over 15et. al evaluated a panel of 7140 candidate single nucleotide polymorphisms (SNP) in 305 candidate genes/regions selected based on a priori hypotheses of their association with HPV infection and cervical cancer, within the population-based Guanacaste cohort in Costa Rica. They reported that SNPs in Deoxyuridine Triphosphatase (DUT), General Transcription Factor IIH Subunit 4 (GTF2H4), 2′-5′-Oligoadenylate Synthetase 3 (OAS3) and Sulfatase 1 (SULF1) gene regions were associated with HPV persistence, while SNPs in the Transmembrane Channel Like (TMC) 6 and TMC8 gene regions were associated with progression to cervical intraepithelial neoplasia (CIN) 3 and cervical cancer [PRDX3 and RPS19 were associated with HPV persistence and progression from persistent HPV infection to CIN3+ [RPS19:rs2305809 and TYMS:rs2342700 [Wang l cancer . In a suto CIN3+ . We exams2342700 .While the previous candidate gene studies have provided insight into the genetic risk of HPV infection and persistence, agnostic approaches such as genome-wide association studies (GWAS), which interrogate the entire genome would be more useful to uncover novel susceptibility loci for cervical hrHPV infections. A GWAS of cervical hrHPV infection, can also identify novel biomarkers and potential therapeutic targets in cervical cancer, however, none have been conducted to date. We therefore conducted this GWAS of cervical hrHPV infections and tested previously reported associations between genes/regions and prevalent and persistent cervical hrHPV infections.We studied 544 women participating in a cohort study of cervical HPV infection and cervical cancer at National Hospital, Abuja and University of Abuja Teaching Hospital, Nigeria, and enrolled between 2012 and 2014, as previously described [10 amplimers to a mixture of general HPV probes recognizing a broad range of high-risk, low-risk, and possible hrHPV genotypes in a microtiter plate format, as described previously [10 DNA Enzyme Immunoassay (DEIA) were genotyped using the LiPA25 version 1. The LiPA25 assay provides type-specific information for 25 different HPV genotypes simultaneously and identifies infection by one or more of 13 hrHPV genotypes: 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, and 68 [We extracted DNA from the cervical exfoliated cells as previously described . Sampleseviously . All sam, and 68 . Howevern = 78,713), variant missingness < 0.05 , Hardy-Weinberg equilibrium (HWE) p > 1 × 10–6 (n = 7692) and minor allele frequency (MAF) > = 0.01 . The resulting 958,363 SNPs that passed these quality control filters had a SNP success rate of 0.9985 and were used as the basis for imputation.Samples from the study participants were genotyped using the Illumina Multi-Ethnic Global Array (MEGA) which has ~ 1.7 million markers. Sample-level genotype call rate was at least 0.95 for all the study participants. We filtered out from the genotyped dataset SNPs that did not meet the following criteria: autosomal SNPs (https://imputation.sanger.ac.uk/) [Imputation was performed using the Sanger Imputation Service (.ac.uk/) . Pre-pha.ac.uk/)  and impu.ac.uk/) . The ref.ac.uk/)  and the .ac.uk/) . The IMPn = 9), those with missing HPV results (n = 35) and included the remaining 473 women in the analyses for persistent hrHPV infections. For the prevalent hrHPV analysis, we compared 125 women with cervical hrHPV infections (cases) to 392 women without cervical hrHPV infections at baseline (controls). For the persistent hrHPV analysis, we compared 51 women with hrHPV infection at both the baseline and follow-up visits (cases) to 355 women without hrHPV infections at either the baseline or follow-up visits (controls). Using LD-pruned SNP genotype data available on the same women, we computed principal components based on the variance-standardized relationship matrix with PLINK 1.9 [“--indep 50 5 2” , namely with a window size of 50 SNPs, 5 SNPs to shift the window at each step and a variance inflation factor of 2. We found that the first principal component was significant in the test for population differentiation and included it in downstream association analyses. The association between the genetic variants and prevalent or persistent hrHPV infection was estimated using unconditional multivariate logistic regression, assuming an additive genetic model adjusted for age, HIV status and the first principal component. Genome-wide significance was set at p-value < 5 × 10− 8. We used an additive genetic model adjusted for HIV status to test for replication of SNPs associated with HPV and cervical neoplasia in other populations and considered p-values < 0.05 as statistically significant evidence for replication. The analyses were conducted using PLINK.From the original set of 544 women, we excluded 27 women from the baseline analyses because of incomplete data , leaving only 517 women in the baseline analyses. Of the 517 women, we excluded those who did not return for the follow-up visit  was 27 (±6). About half of the participants were HIV positive , 24% (125/517) had prevalent cervical hrHPV infections at baseline and 11% (51/473) had persistent hrHPV infections. The distribution of type-specific prevalent and persistent cervical hrHPV infections is shown in Table The mean (±SD) age of the participants was 38 (±8) years while their mean (±SD) body mass index  located on chromosome 13, rs149473200, rs147344426 and rs151071053 , had the strongest association with cervical prevalent hrHPV. The regional plot for rs149473200 in Fig. KLF12) and shows the surrounding markers. SNPs near Long Intergenic Non-Protein Coding RNA 290 gene (NCRNA00290) also had a borderline genome-wide significant association with prevalent hrHPV.The Manhattan plot, Fig. 1p = 7.15 × 10− 8, Table DAP) and Catenin Delta 2 (CTNND2) genes. Figure (MIR365–2), OR: 7.71, p = 2.63 × 10− 7; variants clustered upstream of Nuclear Receptor Subfamily 5 Group A Member 2 gene (NR5A2) and Junctophilin Type 2 gene (JPH2). Next, we conducted a replication study by identifying all SNPs associated with HPV and cervical neoplasia in other studies  and rs2299187  in our dataset but they were not significantly associated with prevalent or persistent cervical hrHPV infections , a protein coding gene which plays an essential role in T-cell development and its defects cause immunodeficiency. KLF12, a protein coding gene, is overexpressed in human B and T lymphocytes, CD8 T cells and natural killer cells [KLF12 has been linked to several cancers [KLF5 and KLF12 in HPV-positive SiHa cells [KLF12 was one of the top three integration sites for HPV [KLF12 may play a major role in the underlying mechanisms that lead to hrHPV infection, persistence and cervical carcinogenesis.The associated SNPs in er cells . These cer cells . This cr cancers –32, incl cancers , 34, whiHa cells . Recentl for HPV . Thus, KCTNND2 and DAP in the short arm of chromosome 5, had the strongest association with persistent cervical hrHPV infections in the present study. CTNND2 gene encodes an adhesive junction associated protein and is overexpressed in the cervix [DAP encodes a basic, proline-rich protein which acts as a positive mediator of programmed cell death that is induced by interferon-gamma [DAP is associated with digestive disorders, gut microbiota, height and obesity [et. al. showed that hypermethylation of the CpG islands located in the promoter region of DAP leads to transcriptional silencing thereby enabling malignant growth [A locus between e cervix . It has e cervix –39. DAP on-gamma . It negaon-gamma , which r obesity –45. Ther obesity –48. Estet growth .MIR365–2 and NR5A2 (LRH-1), respectively, were also associated with persistent cervical hrHPV infections. Like CTNND2 and DAP, MIR365–2 has also been linked to breast and cervical cancers [POU5F1) gene. Aberrant expression of this gene in adult tissues is associated with tumorigenesis [NR5A2, an orphan receptor recently identified as a negative modulator of hepatic inflammatory processes [rs200516199 and rs143668247 near  cancers , 51. It  cancers , 53 and  cancers –57. Bioi cancers , 59. rs1igenesis . rs14366rocesses . It encorocesses  and severocesses –69. AlthTMC6/TMC8:rs9893818 which was reported to be associated with CIN3/cervical cancer [CACNA2D1:rs2299187, which was associated with survival of head and neck squamous cell carcinoma in a recent GWAS [PRDX3 and rs2305809 variant in RPS19, which were shown to be associated with HPV persistence in a candidate gene study conducted within Guanacaste cohort in Costa Rica, were not associated with hrHPV in our study. This may be due to inadequate sample size, variability in the types of hrHPV or population differences. Unlike our study population which was comprised of only African women, the population of Guanacaste is heavily admixed and has been described as being composed mainly of European (42.5%) and Native American (38.3%) ancestries, with considerable African influence (15.2%) and a small influence from Asians (4%) [Our study is limited by its exploratory nature. Given the small sample size of this study the power of the study was limited. Thus, we may have missed associations with smaller effect sizes and we could not examine the relationship between variants and type-specific hrHPV and by HIV status. Our replication study yielded two SNPs, ent GWAS . Howeverans (4%) . The freans (4%) , our stuans (4%) , suggestKLF12, CTNND2 and DAP genes may provide insight into mechanisms of susceptibility to hrHPV infection and persistence. Larger discovery and replication studies are warranted to confirm these findings.In conclusion, our study yielded suggestive genetic risk factors for prevalent and persistent cervical hrHPV infections. Further investigations of genetic variation in the Additional file 1: Supplemental Table S1.Additional file 2: Supplemental Table S2. Replication of SNPs Associated with Cervical high-risk Infections.Additional file 3: Supplemental Table S3. Associations of the Top SNPS with Cervical High-risk Infections in HIV-Negative Women.Additional file 4: Supplemental Table S4. Associations of the Top SNPS with Cervical High-risk Infections in HIV-Positive Women.Additional file 5: Supplementary Figure S1. Principal components (PC) plot of the genotypes of the study participants.


The development of cervical cancer has been shown to involve both viral and host factors. The host factors are those that determine the specific response to human papillomavirus (HPV) infection by the patient's immune system. The immune responses to vaccines have been shown to be influenced by polymorphisms in genes involved in innate and adaptive immunity. The specific genetic variants that may influence the immune responses to HPV vaccine which may contribute to persistence of immunity (POI) have not been widely studied yet. In order to address the question as to “is it right to vaccinate all children, and all with equal dose?” we have critically examined the knowledge of common immunogenetic and immunogenomic variations that may influence the HPV vaccine POI across various populations. We have also identified a number of specific research questions that need to be addressed in future research into host molecular genetic variations and HPV vaccine POI in order to afford life-long protection against the development of cervical cancer. This work informs future insights for improved HPV vaccine designs based on common host molecular genetic variations. Haemophilus influenzae type b (Hib) and Neisseria meningitidis alone, are estimated to cause 340,000 episodes of severe Hib in the year 2015, and there are about 500,000–1,200,000 invasive meningococcal diseases occur each year worldwide  molecules, cytokines, and cytokine receptors, have been associated with heterogeneity of immune responses to a wide range of vaccines , who do not develop cervical neoplasia can help to assess individual genetic factors for natural immunity to HPV persistent infection .Older women with a persistent oncogenic HPV infection who do not develop cervical neoplasia can be examined to assess individual genetic factors for natural immunity to HPV persistent infection .Given the complexity in molecular genetic variations of the host and immune responses to HPV vaccine, future efforts will likely require the use of high-throughput genetic technologies, such as WES, to assess the polymorphisms of numerous immune response genes simultaneously, in a timely and accurate manner. This will enable comprehensive assessment of personalized host immune gene pathways rather than a limited number of candidate genes or markers.Molecular genetic variations exert distinct influences on antigen-specific immune responses , 32. The*15/HLA-DQB1*0602/HLA-DQA1*0102,HLA-B*0702/HLA-C*0702, and HLA-DRB1*0401/HLA-DQA1*0301, were associated with increased risk for cervical neoplasia” after HPV infection.However, the identification of causal variants within the HLA region is intrinsically difficult due to the complex polymorphisms found in this region. During HPV vaccination, the early immune response signals originate from differing abilities of classical HLA alleles to bind virus-like particles (VLPs). The HLA genes, through innate immunity, play an important role in the initiation process of producing antibodies against viral infection . HLA-assHLA class I and HLA class II) as endogenous or exogenous antigens, respectively (In innate immunity antigen-presenting cells (APCs), such as dendritic cells, internalize the HPV vaccine VLPs and display them on their surfaces with the help of major histocompatibility complex (MHC) genes  above, it is unclear how this would relate to other ethnic groups in Sub-Saharan Africa , and worm infestations may affect the effectiveness of vaccines  above, the genetic differences between populations may change the incidence and severity of vaccine adverse events (What are the acute and chronic adverse events of HPV vaccination according to different HPV vaccine dosage regimens in different populations? (Common vs. uncommon adverse events). e events .Rationale: Host molecular genetic variations in the same population or between different populations may have a profound effect on the vaccine effectiveness  of women developed persistence of oncogenic HPV infection and later cervical precancerous lesions , 65. AppAlthough several environmental risk factors have been demonstrated to influence the immune responses to vaccines, genetic factors are the major determinants . For exaHLA restrictions. To quote Mentzer et al. (Identification of the non-HLA genes influencing HPV antibody responses in vaccinated women should aid the development of novel and, improved HPV vaccine, and its adjuvants that act independently of the r et al. ; “if a gHLA alleles (It is therefore important that individuals who have experienced primary or secondary HPV vaccine failures should be well-examined in order to determine whether they also possess different allele frequencies of the risk or protective  alleles . If suchImplementing molecular genetic profiling or WGS at a national level may or may not be practical or economical for now, but it may certainly become ethically compelling to target at-risk individuals or population groups in the future in order to bring about the prospect of personalized HPV vaccination. The preventative healthcare strategies may involve universal genotyping of new-borns on a national scale and this may become a reality in the future in an effort to predict disease genetic risk , 59. SucNovel methods of creating vaccine adjuvants with personalized vaccination based on molecular genetic variations, may become useful strategies in settings, where vaccine immune responses are suboptimal resulting in a raised incidence of HPV vaccine failure. A previous study carried out in the UK and the Netherlands by O'Connor et al. , on threHPV vaccine failures can be studied further by genotyping via WGS or WES. As suggested by O'Connor et al. ; “NGS apHLA, would benefit from scientific approaches that move beyond individual allele–disease associations to investigate biologically relevant groups. It is hoped that the identification of genetic markers for HPV vaccine immune responses and the POI could soon prove their clinical utility because the costs for WGS and WES are progressively decreasing.Longer-term surveillance in a vaccinated population is needed to identify waning immunity, and to evaluate requirements for booster immunizations to improve HPV vaccine effectiveness. Future genetic studies with respect to Host molecular genetic variations undoubtedly play a major role in HPV vaccine immune responses and the POI. Assessment of an individual's immunogenetic and immunogenomic backgrounds is crucial for the evaluation of HPV vaccine long-term immunogenicity, effectiveness, and safety. Molecular genetic profiling for variations in common immune response genes will improve HPV vaccine POI by enabling targeted vaccination according to individual molecular genetics in a more cost-effective manner. However, it is essential that studies investigating the contribution of host molecular genetic variations to HPV vaccine POI are; carefully planned, interpreted with caution, and account for known and unknown environmental factors. The results of these studies should help us to understand how we can design an improved HPV vaccine that protects every child individually, and only administered to those children who are at higher risk. The ability of current HPV vaccine to generate effective lifetime vaccine-induced immunity requires further research in different populations. Our work adds novel insights to the future of HPV vaccine designs based on individualized genetic risk, common host molecular genetic variations, and HPV vaccine POI in different populations.RC drafted the manuscript, EK and GR contributed equally to the editing and completion of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


There is a lack of quantitative evidence concerning UK (United Kingdom) Armed Forces (AF) veterans who access secondary mental health care services—specialist care often delivered in high intensity therapeutic clinics or hospitals—for their mental health difficulties. The current study aimed to investigate the utility and feasibility of identifying veterans accessing secondary mental health care services using National Health Service (NHS) electronic health records (EHRs) in the UK. Veterans were manually identified using the Clinical Record Interactive Search (CRIS) system—a database holding secondary mental health care EHRs for an NHS Trust in the UK. We systematically and manually searched CRIS for veterans, by applying a military-related key word search strategy to the free-text clinical notes completed by clinicians. Relevant data on veterans’ socio-demographic characteristics, mental disorder diagnoses and treatment pathways through care were extracted for analysis. This study showed that it is feasible, although time consuming, to identify veterans through CRIS. Using the military-related key word search strategy identified 1600 potential veteran records. Following manual review, 693 (43.3%) of these records were verified as “probable” veterans and used for analysis. They had a median age of 74 years (interquartile range (IQR): 53–86); the majority were male (90.8%) and lived alone (38.0%). The most common mental diagnoses overall were depressive disorders (22.9%), followed by alcohol use disorders (10.5%). Differences in care pathways were observed between pre and post national service (NS) era veterans. This feasibility study represents a first step in showing that it is possible to identify veterans through free-text clinical notes. It is also the first to compare veterans from pre and post NS era. The UK’s veteran population, defined by the British government as those who have been in military service for at least one day , is estiRecent research suggests that 93% of veterans who reported having a mental health difficulty seek some form of help for their problems, with 86% endorsing informal support through family and friends and 46% endorsing formal non-medical (or welfare) support ,11. HoweWhile it is useful to know the profile of those who take the first step in tackling their problem through primary care, we know little about veterans who access secondary mental health care—more specialist care, often delivered in higher intensity therapeutic clinics or hospitals. This is partly because veteran status is not routinely collected for those accessing primary or secondary care . As a reEHR-based systems function as single, complete and integrated electronic versions of traditional paper health records . EHRs haThere is currently no flag or indicator for identifying veterans in the UK within EHRs ,17. To tprobable veterans from a clinical database and extracting and comparing data related to these veterans.In contrast, the current study investigated the utility and feasibility of manually identifying veterans accessing secondary mental health care services through a psychiatric database of a large NHS Foundation Trust in the UK. It is unique in attempting to detect members of the AF who have sought treatment for their mental health difficulties. We discuss utility and feasibility in relation to manually identifying and verifying The CRIS system was set up in 2006 as a novel data resource, derived directly from the routine EHRs of the South London and Maudsley (SLaM) NHS Foundation Trust . The datThe CRIS system is composed of: (a) pre-set, structured fields, made up of dates and numeric records—for example, dates of birth and scores on psychological tests such as the Alcohol Use Disorders Identification Test ; and (b)Ethical approval for the use of CRIS as an anonymised database for secondary analysis was granted by the Oxford Research Ethics Committee (reference 08/H0606/71+5). The current study described here has been approved by the CRIS Patient Data Oversight Committee of the National Institute of Health Research Biomedical Research Centre.Veterans who had accessed secondary mental health care services within a ten-year window—1 January 2007 to 31 December 2016. The CRIS register was implemented in 2007, so this was the earliest that EHRs could be accessed. This project commenced in 2018, so 2017 was the last full year that digital records were available.Veterans who had served in the UK AF—we retained records for those whose country of birth was noted as the UK or was left as blank .This study was focused on veterans who had accessed secondary mental health care services through SLaM. They were identified using a detailed search strategy  era veteran. However, it is important to consider that those who carried out NS may not have voluntarily entered the AF, as it was a legal requirement to serve in the military of the UK between 1949 and 1963. Veterans were determined to be of NS era if they were of legal age to be conscripted into the AF between these dates. It was also hypothesised that there may be differences in care needs older veterans .Identifying: As there is no structured field for flagging (or denoting) probable veterans within CRIS, our objective was to identify this group by applying a military-related keyword search strategy to the unstructured free-text notes filled in for each patient by clinicians. All EHRs identified as potential veteran records were manually checked by a member of the research team , to ensure they indicated that the patient had served in the military. It must be noted that, although military terms and phrases were used, we were unable to confirm whether patients had served in the AF. In this study, we use the term “probable veteran” from this point onwards. Percentage agreement between KMM, DL and DP was 100% for a random 10% of the 1600 possible veteran records.Extracting: Three members of the research team  identified probable veterans in CRIS and extracted relevant data. Data fields were exported from CRIS and imported into a comma separated values file. Structured fields relating to the veterans’ socio-demographic characteristics, mental disorders and treatment pathways through care were extracted. The details were transferred to a bespoke study database. The 11 specific variables of interest extracted are shown in Analysing: Our utility and feasibility investigation used qualitative methods. This allowed us to discuss the practicality of the approach used. We focused on the utility and feasibility of identifying probable veterans and of extracting veteran data. In addition to the descriptive results, this paper also reports on the socio-demographic profiles, mental disorders and treatment pathways of the identified probable veterans.p-value of less than 0.05. Percentages, frequencies and IQRs are presented, alongside chi-square or t-test statistics.All analyses were undertaken using the statistical software package Stata . Statistical significance was defined as a The identification process took place in two steps. First, a list of relevant military-related words was compiled by the research team, drawing on their extensive expertise of the AF. Second, similar, and frequently used, military-related terms that appeared in probable veterans’ records were derived during an initial search of veteran EHRs within CRIS. Together, these two methodologies resulted in a large list of military-related words, of which 19, including “Royal Navy”, “Army”, “Royal Air Force” and “Armed Forces” see , proved When considering the individual word searches used to identify probable veterans, the term “Army” returned the highest number of potential veteran records, followed by “Royal Navy” and then “Royal Air Force”. However, sheer numbers returned are not reflective of the hit rate of each term. We tested a random batch of 457 of the potential veteran records returned, to determine individual identification rates for each of the three key military terms used. “Royal Air Force” had the highest hit rate for correctly identifying veterans out of all 19 military-related words, followed by “Royal Navy” and then “Army” see .The key word searches, combined with the exclusion limits, returned 6039 potential veterans. The research team randomly selected 1600 of these probable veterans to inspect in more detail, considering time and manpower restrictions. This sample size was determined based on the maximum time allowable for the research team to review each potential veteran. After a member of the research team  manually scrutinised each of these 1600 EHR records, 693 were identified as being probable veterans and were included in the final sample.Identifying veterans through CRIS in this way was labour intensive and time consuming. Manually verifying each potential veteran record involved reading through, often, a vast number of free-text notes, written by the clinician who had seen the patient. We manually worked through 1600 probable veteran records for this project, which equated to 400 h of reading time or approximately 11 weeks’ worth of work. This time frame did not include creating the search strategies for identifying potential veterans, extracting and cleaning their data or carrying out data analyses.Following the identification of veterans, we were able to successfully extract data on 693 probable veterans who had accessed secondary mental health care services through the SLaM see . HoweverThe sample had a median age of 74 years (IQR = 53–86) and the majority were male (90.76%). Probable veterans of both NS era and post NS era groups reported living alone most frequently (37.95%). The most common disorders diagnosed overall were depressive disorders (22.87%) and alcohol misuse disorders (10.46%). The sample had booked a median of 2 (IQR = 1–5), and attended a median of 2 (IQR = 1–4), outpatient secondary mental health care appointments through SLaM. The median number of inpatient secondary mental health care stays within SLaM across the full sample was 1 (IQR = 1–2) and the median duration of these inpatient stays was 28.5 days (IQR = 12–73.5).The most common diagnosis for NS era probable veterans was depressive disorders and then anxiety disorders. The most common diagnosis for post NS era veterans was depressive disorders and then alcohol misuse disorders. A total of 233 (33.62%) veterans had a diagnosis unrelated to mental health. Differences were observed in the duration of inpatient mental health care stays, with NS era veterans experiencing a median stay of 60.5 days (IQR = 31–120) and post NS era veterans experiencing a median stay of 15 days (IQR = 7–35).This research showed that it is feasible to identify two groups of probable veterans who accessed secondary mental health care services through SLaM using CRIS. The hit rate for correctly detecting veterans from these EHRs was 43.3% and our final sample consisted of 693 veterans. We were able to identify probable veterans from pre and post NS era, but the procedure for doing so was far from straightforward. This study is the first to identify differences in mental disorder diagnoses and treatment duration between NS era veterans and post NS era veterans. Further, as far as we are aware, it is also the first to identify veterans and non-veterans accessing the same secondary mental health service. This study identified differences in prevalence rates between pre and post NS era and healthcare utilisation. This could be due to older veterans having more complex healthcare needs coupled with higher levels of comorbidity resulting in longer and more frequent inpatient stays.An important strength of the study was the exploitation of EHRs, which are advantageous for investigating subgroups within the wider population. For example, we found that NS era veterans had longer inpatient stays within SLaM than post NS era veterans. Future research is required to investigate the drivers behind this observation and why differences may exist between two groups of individuals that had the same occupation. Another strength was that we tested the utility and feasibility of identifying UK veterans accessing NHS secondary mental health care for the first time. The study was unique in describing and evaluating how to use secondary health care records to undertake research on veteran’s secondary mental health care utilisation.true veterans; nor can we be confident of the integrity of the underlying primary data source. However, this is also the case for other EHR datasets, such as the Adult Psychiatric Morbidity Survey (APMS); for cohort studies, which require completers to self-report their veteran status [false negatives , but it was not possible to evaluate this due to the large volumes of data used. It is worth noting, however, that protocol requires clinicians to talk through a patient’s previous occupations when they first enter mental health care services [It must be noted that there was no way to confirm our identified CRIS veterans, verified by the research team using clinical notes, were n status ; and forservices .Along the same lines, there was no way to confirm that our verified non-veterans had not served in the AF. Some veterans may not have volunteered the fact that they had belonged to the military to their health care provider. In this case, there would be no mention of these individuals’ veteran statuses in their clinical notes. We can acknowledge that certain demographic and military factors, such as age and time since leaving the service, might impact on disclosure —perhaps While we have shown that the process is feasible, the manual identification of probable veterans from CRIS was labour and resource intensive and time consuming. We recommend trying to improve the accuracy and efficiency of identifying veterans from EHR databases, such as CRIS, where possible. For example, as is already the case in NHS Scotland , the impA more immediate solution to accelerating veteran identification is the creation of digitalised tools, such as natural language processing (NLP) methods, to automatically detect these individuals using keywords and rules. Of great importance is its utility in being applied automatically to EHR and free-text clinical notes ,29. NLP Because of time and resource constraints, we were only able to include 693 probable veterans. While this sample is large enough to show proof of concept, it is lacking in statistical power for more complex analyses, such as those involving subgroups of women or ethnic minority veterans. We have already detected approximately 6000 potential veterans from our current research. Based on this work, we expect that 30–40% could be verified as actual veterans using NLP, suggesting an anticipated sample size of 2000 veterans could easily be reached from CRIS. It would also be possible to match this veteran group to non-veterans accessing mental health services through SLaM. Using these data, we could establish whether there are similarities in socio-demographic, mental health, medication, suicide and treatment characteristics present between veterans and non-veterans, as well as between NS and post NS era veterans.Data within EHRs are not collected primarily for research purposes and therefore often have large amounts of missing values —as was tThis study showed that it is feasible, although time consuming, to identify veterans accessing NHS secondary mental health care in the UK using CRIS and our manual approach. Our feasibility study contributes to the growing base of knowledge with regards to the mental health and needs of veterans and informs the development of digitalised approaches. Further, it is the first to identify differences between NS era and post NS era veterans. Despite our success in the current study, difficulties with the methodological procedure for identifying veterans have recognised a need for further work—including creating an automated NLP tool for detecting veterans more efficiently; increasing the pool of participants derived from CRIS; and addressing missing data.


GDPD genotypes in infants with G6PDd detected by newborn screening and later studied in a single follow-up center. G6PDd newborns were categorized into three groups: group 1: hospitalized with or without neonatal jaundice (NNJ); group 2: non-hospitalized with NNJ; and group 3: asymptomatic. Frequencies of homozygous UGT1A1*28 (rs34983651) genotypes among G6PDd patients with or without NNJ were also explored.Glucose-6-phosphate dehydrogenase deficiency (G6PDd) newborn screening is still a matter of debate due to its highly heterogeneous birth prevalence and clinical expression, as well as, the lack of enough knowledge on its natural history. Herein, we describe the early natural clinical course and the underlying −202A/376G genotype was the most frequent (60.5%), followed by the G6PD A−376G/968C (22.2%) and the Union-Maewo  genotypes. These genotypes produce a wide range of clinical and biochemical phenotypes with significant overlapping residual enzymatic activity values among class I, II or III variants. Some G6PD A−202A/376G individuals had enzymatic values that were close to the cutoff value , while others showed extremely low enzymatic values . Homozygosity for UGT1A1*28 among G6PDd patients with  or without  NNJ did not shown significant statistical difference (p = 0.611).A total of 81 newborns  were included. Most individuals (46.9%) had NNJ without other symptoms, followed by asymptomatic (42.0%) and hospitalized (11.1%) patients, although the hospitalization of only 3 of these patients was related to G6PDd, including NNJ or acute hemolytic anemia (AHA). Nine different G6PDd genotypes were found; the G6PD A−376G/968C and G6PD A−202A/376G haplotypes.Wide variability in residual enzymatic activity was noted in G6PDd individuals with the same G6PD genotype. This feature, along with a documented heterogeneous mutational spectrum, makes it difficult to categorize G6PD variants according to current WHO classification and precludes the prediction of complications such as AHA, which can occur even with > 10% of residual enzymatic activity and/or be associated with the common and mild G6PD A G6PD gene  ), which was found in 7.4% of the deficient patients. The mean enzymatic activity of each variant and its geographical origin are shown in Table Across the studied population, we found 9 different ed Table . The mosys) rs39823546), wOf the 81 individuals, 9/81 (11.1%) patients, in accordance with the Luzzato 2016 classification [p = 0.376).The G6PD activity of the different clinical groups are shown in Table G6PD genotypes, enzymatic activity, and geographical origin of each of 81 patients are shown in Additional file In four families, one or more siblings were G6PDd, and their results are presented in Table G6PDd is widely heterogeneous in terms of biochemical, clinical, and molecular manifestations . In the G6PD variants. In class II newborns, the residual activity ranged from 0.56% to 12.36%, while in class III newborns, the residual activity ranged from 5.6 to 43.82%, and in a significant number of individuals, there was an overlap of the values , while other individuals showed extremely low enzymatic values . In fact, we identified four G6PDd families with more than one affected patient (Table −202A/376G genotype (class III)  and A(TA)7TAA allele, or for the “G71R” (rs4148323) variant highly prevalent in Asian-derived populations [p = 0.051). Nevertheless, one limitation of this study design is that it does not allow us to know the severe cases of kernicterus that could have occurred, which is to be expected in such patients that would be hospitalized or even deceased and not come to our newborn screening follow-up center.Several studies have revealed that the prevalence of G6PDd is higher in jaundiced newborns than in the control population, ranging from 8.9 to 28.1% –33. Badetability . Recentltability  describeG6PD spectrum, the most frequently identified hypomorphic variants come from Africa (82.7% comprised by G6PD A−202A/376G and G6PD A−376G/968C), followed by the class II Union-Maewo or p.(Arg454Cys) allele (7.4%)  Table , whose oectively –41. To tectively .G6PD variant can lead to highly variable enzymatic residual activity as well as a wide phenotypic spectrum in the first month of life, which is in accordance with previously reported results [In summary, the present work shows that the same  results . The abs results . Our worG6PD genotype. This feature, along with a documented heterogeneous mutational spectrum, hinders the categorization of G6PD variants according to the current WHO classification and, importantly, precludes the prediction of complications such as AHA, which can occur even with > 10% of residual G6PD activity and/or associated with the common and mild G6PD A−376G/968C and G6PD A−202A/376G variants.There is wide variability in the enzymatic activity in G6PDd individuals, even in those with the same Additional file 1: Table 1. Individual genotypes, geographic origin, residual enzymatic activity and concordance classification; Table 2. Proportion of patients with or without symptoms related to G6PDd, according to their genotype.


In this narrative review, we summarize the main findings of all NHRVS studies (n = 82) published as of June 2020, and discuss the clinical implications, limitations, and future directions of this study. Review of these articles was organized into six major topic areas: post-traumatic stress disorder, suicidality, aging, resilience and post-traumatic growth, special topics relevant to veterans, and genetics and epigenetics. Collectively, results of these studies suggest that while a significant minority of veterans screen positive for mental disorders, the majority are psychologically resilient. They further suggest that prevention and treatment efforts designed to promote protective psychosocial characteristics , and social connectedness  help mitigate risk for mental disorders, and promote psychological resilience and post-traumatic growth in this population.United States (U.S.) veterans are substantially older than their non-veteran counterparts. However, nationally representative, population-based data on the unique health needs of this population are lacking. Such data are critical to informing the design of large-scale outreach initiatives, and to ensure the effectiveness of service care delivery both within and outside of the Veterans Affairs healthcare system. The National Health and Resilience in Veterans Study (NHRVS) is a contemporary, nationally representative, prospective study of two independent cohorts ( Nationally representative epidemiological studies of United States (U.S.) military veterans conducted outside of the Veterans Affairs (VA) healthcare system are sparse, yet highly valuable, given that only about half (48%) of veterans utilize any VA healthcare services , and eveFurther, while a substantial body of research on veterans has focused on risk factors for prevalent mental and physical health conditions, few studies have assessed potentially modifiable factors that may help mitigate risk for these conditions, such as gratitude, social support, optimism, community integration, and purpose in life , 4. AccoSince the NHRVS began in 2011, it has yielded a total of 82 publications. In this review, we summarize the main findings of all NHRVS studies published as of June 2020, and discuss the broader clinical implications, limitations and future directions of this study. To thematically organize the content, the 82 articles were sorted into six major topic areas: post-traumatic stress disorder, suicidality, aging, resilience and post-traumatic growth, special topics relevant to veterans, and genetics.The NHRVS cohorts were recruited to complete a 60-min online survey from a research panel of over 50,000 households that was developed and maintained by GfK Knowledge Networks, Inc. (now Ipsos). GfK Knowledge Networks, Inc. recruited panel members through national random samples by telephone and postal mail. Internet and computer hardware access are provided if needed. GfK Knowledge Networks, Inc. uses dual sampling frames to recruit participants and offers coverage of ~98% of U.S. households. These sampling procedures are different from Internet convenience panels  as it included listed and unlisted telephone numbers, telephone and non-telephone households, cell-phone-only households, and households with and without Internet access. Only individuals sampled through these probability-based techniques are eligible to participate in the survey. To promote generalizability of results to the entire population of U.S. veterans, post-stratification weights based on demographic distributions of US veterans from concurrent US Census data  data were collected in 2013, Wave 3  in 2015, and Wave 4  in 2018. Additional saliva samples were collected from 500 veterans in Wave 3 for epigenetic and telomere length assays. At baseline, C1 was 90.6% male, 76.2% White, 9.6% Black, 8.2% Hispanic, 1.5% mixed races, and the mean age was 60.3 , with 57.3% aged 60 years or older. Two-thirds of participants (66.7%) had completed at least some college education, 75.6% were married/cohabitating, 44.0% reported a household income of $60,000 or greater, 43.5% were retired, and 40.7% reported working part-time and/or full-time. The majority of did not serve in a combat or war zone (65.2%), and 19.3% reported using VA healthcare as their main source of health care.C1 completed a baseline survey in 2011, which included comprehensive measures of demographics and military history, medical and psychiatric status, and psychosocial functioning. Following the baseline survey, 2-, 4-, and 7-year follow-ups were conducted. Wave 2  at baseline. The majority of C2 veterans were married/cohabitating (70.1%), 44.2% were retired, and 41.6% were working part-time and/or full-time, and had household incomes of $60,000 or greater (43.4%); two-thirds (66.9%) had completed at least some college education. The majority of C2 veterans did not serve in a combat or war zone (61.6%), and 21.3% reported using VA as their main source of healthcare. Saliva samples were also obtained from both NHRVS cohorts, with genetic data (PsychChip) available for 2,827 veterans.Cohort 2 (C2) completed a baseline survey in 2013 and a follow-up survey 3 years later. A total of 1,602 individuals responded “Yes” to an initial screening question that confirmed veteran status and 1,484 participated, resulting in a response rate of 92.6%. C2 consists of 1,484 veterans who completed a baseline survey and 713 (48.0%) who completed a 3-year follow-up survey. Veterans in C2 were demographically similar to C1, with 89.7% male, 75.4% White, 9.7% Black, 9.1% Hispanic, and 1.4% mixed races, with a mean age of 60.4  and International Classification of Diseases (ICD) are the two major diagnostic systems commonly used worldwide and, historically, the two have defined PTSD using similar criteria. However, in the recent publication of the ICD-11  and/or derealization . Tsai ePTSD deleteriously affects various aspects of functioning, including physical health, quality of life (QOL), and psychosocial functioning. Given that there is considerable variability in PTSD symptom presentation among trauma survivors, analysis of individual symptoms that are associated with measures functioning may provide more nuanced insight into how this heterogeneous syndrome may impact these outcomes. Using NHRVS data, Kachadourian et al.  employedThe DSM-5 criteria for PTSD include four symptom clusters of intrusions, avoidance, negative alterations in cognitions and mood, and alterations in arousal and reactivity . Tsai etEvaluating the underlying structure of PTSD symptoms allows researchers to determine specific sets of symptoms that account for comorbidity of PTSD with other disorders and aspects of functioning. Using NHRVS data, Pietrzak et al.  examinedData from the NHRVS have also been used to examine latent profiles of DSM-5 PTSD symptoms. One study  found a Exposure to traumatic events in veterans often involves life-threatening combat, injuries, accidents, loss, or interpersonal violence, such as sexual trauma . While iTo address this gap, a network analysis of DSM-5 PTSD symptoms was conducted in participants from C2 of the NHRVS with subthreshold or greater PTSD symptoms. Results revealed that negative emotions related to the trauma, detachment, flashbacks, and physiological reactivity were most central and interconnected within the PTSD symptom network . Strong Results of NHRVS studies focused on PTSD suggest that veterans report exposure to a wide range of potentially traumatic events from military and non-military experiences, and a strikingly high proportion of veterans—approximately one in three—experience clinically significant PTSD symptoms in their lifetime, with a significant minority screening positive for PTSD , 13, 14.Suicide has been a significant public health problem among veterans for over a decade and is a top clinical priority for the VA. In 2016, the rate of deaths by suicide was 1.5 times greater for veterans than for non-veteran adults, after adjusting for age and gender . NumerouSuicidal ideation (SI) is often a precursor to a suicide attempt or death by suicide. Thus, there is a great need to systematically understand the nature and prevalence of SI over time among veterans. This may provide insight into the predominant patterns and causes of SI, which can help determine targets for prevention and treatment. In 2017, Smith et al.  analyzedThe risk of suicide is even greater in veterans who have been diagnosed with PTSD and/or major depressive disorder (MDD). A recently published NHRVS study  found thAnother military-related stressor that has been associated with elevated risk for suicide is moral injury. Moral injury is defined as “the psychological, biological, spiritual, behavioral, and social impact of perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations” Effectively responding to suicide risk among veterans involves further understanding reactions to military-related stressors, including military sexual trauma (MST). Veterans with a history of MST  are at elevated risk for suicide. Accordingly, Monteith et al.  sought tCollectively, results of NHRVS studies on suicidality conducted to date indicate that a considerable proportion of U.S. veterans experience SI, and that SI courses may fluctuate over time. These findings underscore the importance of periodic monitoring of suicidal thoughts and behaviors in this population . FurtherMore than half (65%) of veterans are currently aged 55 or older  and it iUsing data from C1 of the NHRVS, Pietrzak et al.  found thPhysical disability is an important aspect of aging that may negatively affect functioning and quality of life in older veterans. Accordingly, elucidation of modifiable factors that may help buffer against the development of physical disability are critical to further understanding determinants of successful aging. Mota et al.  found thEmployment may play a role in fostering a greater sense of purpose in life, and with the aging veteran population reaching retirement age, understanding the roles that veterans maintain later in life could be a useful mechanism for promoting successful aging. Indeed, older veterans may transition to providing care to their family members as they reach retirement or face other challenges, as it is estimated that one in 10 of all caregivers in the U.S. have served in the military . Monin eSocial connectedness recurrently appears as an important factor in successful aging and resilience among older veterans who participated in the NHRVS. Fanning and Pietrzak  found thSignificant changes and losses are common in older adulthood and include retirement, erosion of social networks, and reductions in functioning and mobility. It has been proposed that experiencing trauma and stressors before late adulthood may “inoculate” and help enhance coping skills in older adults , 64. It Negative age stereotypes, defined as deprecating beliefs about older people as a category, have been linked to a broad range of negative health outcomes, including cardiovascular disease, cognitive decline, and mortality . Using NBetween 41 and 79% of older persons with psychiatric disorders do not receive mental health care , 68. PerA majority of veterans with a high lifetime trauma burden are psychologically resilient in later life . HoweverTwenty-five see  studies Certain trauma exposures are unique to veterans, including military sexual trauma and combat exposure. While the prevalence of MST is highest in female veterans, the VA reports that almost half of VA users who screen positive for MST are men . FurtherSimilar to MST, combat exposure is linked to increased risk for mental health problems, including psychiatric disorders such as PTSD, generalized anxiety disorder, MDD, and substance use , 95. A NIn addition to combat exposure, other military-related factors, such as perceived threat during deployment, and difficult living and working environments, have been linked to depression, anxiety, and PTSD . Using NMDD is prevalent disorder that often co-occurs with PTSD. Using data from the NHRVS, Nichter et al.  estimateAlthough PTSD is one of the most prevalent and intensively studied psychiatric disorders among veterans, other disorders are also prevalent among veterans. With regard to alcohol use disorder (AUD), Fuehrlein et al.  found thBuilding on these cross-sectional findings of AUD in veterans, a 4-year prospective cohort study  was condGiven that AUD and PTSD are among the most prevalent disorders in veterans and often co-occur, it is important to determine the burden associated with AUD/PTSD comorbidity relative to either disorder alone. Using NHRVS data, Norman et al.  found thAnother commonly used substance in veterans is nicotine. Baldassarri et al.  found thPTSD has also been associated with problem gambling  and 40% The relationship between trauma, PTSD, and physical health has been well-documented . Given tNHRVS investigators have also examined the prevalence and health burden of obesity in U.S. veterans. A recent study found that 32.7% of NHRVS veterans were obese, which is higher than previously reported estimates in the U.S. veteran population . The preGender differences have also been reported among veterans for specific health conditions. Risk for exposure to various types of traumatic events differs by gender  and the Understanding the burden and clinical features of hostility and anger is particularly relevant to veterans given evidence of elevated rates of hostility-related health issues such as PTSD, depression, and heart disease relative to non-veterans , 101. UsStudies from the NHRVS have also contributed to the literature on homelessness and employment, which may help inform allocation of governmental resources and services for veterans. A 2016 study by Tsai et al.  found thEfforts to support self-employment may help mitigate unemployment among veterans. Results from Heinz et al.  demonstrVeterans face a wide array of mental and physical health struggles, many of which commonly co-occur, and may result in functional difficulties, and chronicity and exacerbation of symptoms. Results of the NHRVS studies reviewed above help to characterize the population-based burden of a wide range of mental and physical health conditions that are prevalent among veterans, which may help inform outreach efforts, resource allocation, and program development within VA and non-VA settings to better serve this population. They also highlight the need for screening initiatives and specialty services targeting homelessness, employment, and PTSD and co-occurring health disorders. Specifically, veterans with histories of MST and combat-exposure, as well as common co-occurring physical and mental health conditions may have heightened need for screening, monitoring, and treatment efforts. Increasing access to information about mental health care, which may serve to decrease stigma, may also help veterans navigate barriers to initiation and engagement in care.Although most studies on trauma focus on psychopathology and other negative consequences, a new concentration in trauma literature is to characterize the prevalence and correlates of psychological resilience in veterans. Psychological resilience is defined as “the ability to adapt in the aftermath of trauma or extreme stress and maintain a high level of psychological functioning” . There aAs described above, studies from the NHRVS have found that the majority of veterans with a large number of traumatic experiences are psychologically resilient in later life and that prosocial behaviors and purpose in life may help promote psychological resilience . AlthougToward this end, Isaacs et al.  conducteA growing body of literature has found that individuals who experience a wide range of traumatic life events  often report experiencing PTG. However, the relationship between PTSD symptoms and PTG is less clear. In the first known nationally representative study of PTG in veterans, Tsai et al.  found thTo date, the vast majority of studies of PTG have been cross-sectional in nature, thus little is known about the longitudinal course or predictors of PTG. Consistent with the cross-sectional studies, a recent prospective study  of the dIn clinical settings, individuals with trauma-exposure generally receive treatments designed to reduce negative symptoms; however, a growing body of research suggests the potential importance of additionally considering interventions designed to foster resilience and PTG . SpecifiMany major psychiatric disorders have high heritability. To date, twelve studies see  have invIn addition to genetic and gene-by-environment studies, we examined how psychological factors may be linked to markers of biological aging, such as telomere length and DNA methylation age, in veterans. As with candidate gene findings, these findings should be interpreted with caution, as they may be tissue-specific .FKBP5) gene may interact with childhood abuse to increase risk of developing PTSD  were associated with lifetime severity of PTSD symptoms in veterans from C1 and C2 of the NHRVS. Results of this study further revealed that FKBP5 polymorphisms, directly and interactively with childhood abuse, predicted greater severity of lifetime PTSD symptoms, specifically hyperarousal symptoms.Examining the interactive effects of candidate genes and environmental factors on risk for mental disorders such as PTSD, rather than investigating independent genetic or environmental influences, may help advance understanding of the etiology of these conditions. Common single nucleotide polymorphisms (SNPs) in the FK506 Binding Protein 5  gene, which is expressed in a number of brain regions and plays a key role in the regulation of fear, stress, anxiety, learning, and memory  gene has also been implicated in PTSD risk. This gene is active in neuronal repair via cholesterol metabolism and transportation  may also interact with attachment style to predict PTSD, as the oxytocin system plays a key role in social behavior and stress regulation , which was then tested in the veteran NHRVS sample, and while the main effect was null, there was preliminary evidence that it also interacted with attachment style to predict PTSD. Taken together, results of this study indicated that polymorphisms in the OXTR gene and attachment style may contribute to vulnerability to PTSD in veterans.Polymorphisms in the oxytocin receptor gene  gene as a potential risk factor for PTSD  data sets, including C1 from the NHRVS, Andersen et al.  examinedIn addition to characterization of genetic risk factors for PTSD, alcohol dependence, and MDD, characterization of factors that may accelerate biological aging is important. Telomeres are nucleoprotein structures that cover the ends of chromosomes and protect from damage . ImportaAnother study  evaluateAging has also been associated with predictable changes in DNA methylation. Genome-wide methylation research has established algorithms that estimate chronological age and serve as an “epigenetic clock” . These eCollectively, results of NHRVS genetic and epigenetic studies underscore the utility of assessing, monitoring, and treating trauma-exposure, specifically childhood abuse and cumulative trauma burden, in veterans with certain genetic polymorphisms –120, 122This narrative review summarized results of 82 original research studies that have been published to date using data from the NHRVS. These studies have covered six major topic areas, including post-traumatic stress disorder, suicidality, aging, resilience and post-traumatic growth, special topics relevant to veterans, and genetics. Collectively, the results of these studies underscore the need to develop and test prevention and intervention strategies that aim to enhance modifiable protective factors in veterans. Just as risk factors may have additive and interactive effects, such that having multiple genetic, developmental, neurobiological, and/or psychosocial risk factors may increase allostatic load or stress vulnerability, having and enhancing multiple protective factors may help promote stress resilience . Prior rExtant research from the NHRVS has covered a broad range of health issues of relevance to U.S. military veterans. In future research in the NHRVS, including a new cohort of more than 4,000 veterans who completed a baseline NHRVS survey in 2019–2020, we plan to examine other conditions that may co-occur with PTSD, such as attention-deficit/hyperactivity disorder, traumatic brain injury, chronic pain, and dementia. Despite the inclusion of numerous potential correlates in the initial two NHRVS cohorts, there are other relevant factors, such as a broader range of potentially traumatic experiences that were not assessed in these cohorts, that may be differentially associated with PTSD and related disorders. Additionally, the assessment of substance use , as well as suicidality and non-suicidal self-harm behaviors has been expanded in this new cohort.Information on genetic, epigenetic, and modifiable protective factors, such as social connectedness, attachment style, physical exercise, have the potential to be combined to develop clinically useful risk-prediction models for PTSD and related disorders. Each of these factors alone may be weakly or moderately informative when considered individually, but a combination of these factors may provide more integrative approaches for assessment, monitoring, and treatment to mitigate risk for mental disorders that are prevalent in veterans, and promote better functioning and QOL in veterans. Accordingly, a goal for future NHRVS studies is to employ advanced data analytic approaches such as machine learning to identify key combinations of psychological, social, and biological  factors linked to key health outcomes in veterans.Longitudinal epigenome-wide association studies (EWAS) are also being planned to examine the stability and predictive utility of epigenetic  changes associated with PTSD and related disorders in the NHRVS genetics subcohorts. Although longitudinal EWAS are expensive and difficult to conduct, cross-sectional studies cannot detect the dynamic nature of epigenetic mechanisms impacting complex and evolving psychiatric disorders such as PTSD, making it difficult to ascertain whether the underlying causal effect is environmental or genetic . These sIn summary, NHRVS studies published to date have yielded several important new findings regarding the psychosocial and genetic epidemiology of mental disorders, suicidality, aging, resilience, and post-traumatic growth. Specifically, veterans report exposure to a wide range of potentially traumatic events and a considerable proportion of veterans report experiencing PTSD, MDD, AUD, and related symptoms in their lifetime. However, a majority of veterans were found to be psychologically resilient in later life. Results suggest that initiatives designed to promote protective psychosocial characteristics  and social connectedness  may help promote resilience and growth in veterans, and may help mitigate risk for prevalent mental disorders in this population.Given the nationally representative nature of the NHRVS, these findings can directly inform population-based prevention and treatment efforts in the broader U.S. veteran population. Many of the findings may also be applicable to the general U.S. adult population, as the majority of the NHRVS cohorts were comprised of non-combat-exposed veterans. Further research is needed to examine how demographic changes in the veteran population, including race and ethnic factors, older age, and a larger proportion of female veterans, may influence mental, physical, and cognitive health outcomes over time; and to translate findings from the NHRVS and other large-scale epidemiologic studies of veterans into novel and targeted prevention and treatment strategies to mitigating risk for major health conditions, and preserving functioning and overall quality of life in this population.BF was responsible for the formal analysis and writing, and original draft preparation. JT, NM, IH-R, JK, and SS contributed to writing, review, and editing of the manuscript. RP supervised and contributed to the conceptualization, investigation, analysis, data curation, writing, review and editing, and funding acquisition. All authors discussed the results, contributed to the writing, and approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


An increasing number of studies have demonstrated that blue space can promote the recovery of the human body, as does green space. However, the influence of blue space on the color space has been studied much less. Based on research on color psychology and healthy cities, the current study takes Yijie District of Dujiangyan City as the research object. Logistic regression models and the semantic differential method was used to explore residents’ perceptions of color space and their restorative ratings of blue space. This study describes the characteristics of the people visiting blue space, investigates whether the benefits brought about by blue space are related to the color space, and studies whether the surrounding colors in the blue space have a positive effect in promoting residents’ perceptions of pleasure. Based on residents’ choices of environmental pictures containing various colors, a color tendency map was constructed. The results revealed strong correlations between residents’ perceived pleasure and color space color collocation. Socio-demographic factors were found to affect the frequency of visiting blue space. Reasonable color planning is necessary for human health. Based on the study findings, relevant planning suggestions are proposed as a reference basis for waterfront space color planning. Since ancient times, water has played a primary role in human existence, through irrigation and transportation, and has carried the rise and fall of cities . Blue spIn terms of the overall process, development of blue space generally follows a deterioration–suburbanization–decay–revival pattern . Since 1Water is at the center of a range of environments, and has an identifiable potential to promote human health. Like green space, it has the potential to improve human comfort and promote human resilience . The relIn general, at present, blue space has undergone commercialization, and can be considered part of an interdisciplinary research model. Based on the transformation of the original business model, more attention has been paid to satisfying residents’ environmental needs. This type of research is still in its infancy, and has not been extensively addressed in mainstream research literature. The research on this topic is obviously insufficient, but the potential of water for human promotion is indeed indisputable. There is still great potential for research in the future. Studies of waterfront space have penetrated deeply into various disciplines, including architecture and geology, and have become a hot topic of interest.Color psychology is a branch of psychology that assumes that color has a series of psychological or behavioral responses. Color psychology, like color therapy, is not accepted by mainstream medical science, but there are still a large number of research articles discussing the psychological, cognitive, biological, and behavioral effects of color . Ou cateAt present, there is little research evidence indicating that color can convey emotions; however, when inputting words such as “warm”, “cool”, and others into the retrieval system, corresponding pictures will be automatically retrieved. Based on the association between color and emotion, Solli and Lenz  designedMany studies have shown that there is an inherent correlation between color and geographic environment . DiffereTo date, research on urban color has typically focused on historical and cultural districts and areas. Unified color planning can only unify urban color; it is still impossible to prove whether it impacts on the inner perceptions of urban residents. There is little research on therapeutic and stimulative color planning and design. In recent years, studies of urban color planning and color psychology have been on the rise. In addition to their own fields, these studies have penetrated into fields such as the architecture and color therapy fields, which reflects their great research potential.This research combines psychology, planning, landscape science, and environmental behavior science to examine blue space from the perspectives of different fields. At the same time, it scientifically identifies color arrangements that can improve human mood to promote the happiness of urban residents and the overall image of the city. This research will attempt to achieve three objectives: (1) demonstrate that there is a relationship between residents’ cognition and color space, (2) demonstrate that reasonable color planning is necessary for human health, and (3) propose relevant planning suggestions as a reference for blue space color planning.For the purpose of this study, we defined waterfront space as “the terrestrial margin adjacent to the water”, which falls within the nine space types defined by Brand as waterfront squares . Color sThis research is based on the overall planning of Yijie District of Dujiangyan. The two main roads on this block, the south and west road of Shangshan and the east and west road of Baishui, were taken as the boundaries. The areas enclosed by the main roads, and water body was divided into five typical small-range study areas—A, B, C, D, and E—for map sampling . Area A The data collection methods included questionnaires, observations, and interviews. The questionnaire investigated residents’ or tourists’ perceptions of and preferences for color space in the blue space of Yijie District, the observation method involved the observation and recoding of the color collocation of buildings, landscapes, environmental waters, and other areas in the study area. The interview method was used to understand the needs and satisfaction of residents and tourists with respect to the environmental elements in the waterfront space. Because the geographical locations of different subdivisions are various distances from the central water body, zoning investigations were carried out according to the divisions depicted in the below figure.The purpose of this research was to examine the correlation between residents’ perceived pleasure and color space collocation, and to investigate the need for reasonable color planning for human health. SPSS 25  statistical software was used to test the reliability and validity of the questionnaire, in order to verify its scientific properties and preciseness. Logistic regression models were used to explore the key factors influencing the frequency that residents visited blue space. The semantic differential (SD) method and factor analysis method were used to evaluate residents’ perceptions from various angles.t-tests were performed to obtain the tendency results of different groups for different colors. The above analyses were completed using SPSS 25 software.Different analysis methods were adopted for different data: (1) multiple reliability and validity tests were conducted for all questionnaire items, and multiple pre-surveys were conducted after the exclusion of redundant items; (2) given that the adjectives and adverbs used to describe residents’ overall perceptions of color space and blue space in the questionnaire were divided into five levels, which met the scoring requirements of the SD method, the SD method was used to analyze the data; (3) in terms of the relationships between the frequency of visiting blue space and relevant factors, logistic regression was used to conduct one-to-many significance analysis and to obtain significance values; (4) finally, the color tendency analysis data for blue space and color space were obtained through the questionnaire, and one-sample See The questionnaire design was based on five dimensions: architecture, nature, landscape, city, and cognitive color. The questionnaire was divided into three parts: basic information , preference test (selection of pictures with difference scenes), and tendency test (selection of different colors in the scene pictures). The preference test involved 42 variables. Participants were asked to select as many adjectives with opposite meanings as possible in relation to six evaluation levels: aesthetics, relaxation, psychology, physiology, vision, and collocation. Five responses were then set between each pair of adjectives, and the respondent was to choose the response that best fit their perception: “very like”, “like”, “general”, “dislike”, and “very dislike” were used to distinguish participants’ preferences and tendencies for color. The values −2, −1, 0, 1, and 2 were assigned from left to right, respectively, for numerical processing in quantitative analysis. This was also used as the basis for obtaining the semantic difference scale .This research covered the whole Yijie District of Dujiangyan city. The sample was a random probability sample recruited from activity groups who entered the target area during the specified time periods, i.e., 9:00–11:00 a.m., 12:00–2:00 p.m., 4:00–6:00 p.m., and 8:00–10:00 p.m. These four sample periods were denoted as morning, noon, afternoon, evening; each sample period went for two hours.Trained interviewers administered questionnaires randomly to all residents visiting the blue space in one block, and interviewed some of these residents. They only looked for participants in selected areas, at least 2–3 times, during the four periods denoted above, in order to obtain data at different time points. During the investigation, the survey rate was usually between 85% and 90%. This investigation began on 15 September 2019; two pre-investigations were conducted between 15 September and 30 September 2019.We tested the reliability of the results obtained from two pre-investigations in sequence. The first investigation of the reliability of the valid questionnaire returned a reliability of 0.56. Based on this, two inefficient indicators were removed for the second pre-investigation. The reliability of the second valid questionnaire was 0.64. A low-efficiency index was removed, and the final formal questionnaire was finally established. The evaluation factor table is provided below .The formal survey was conducted from 4 October to 28 October 2019. A total of 500 questionnaires were issued, 100 for each region, and a total of 436 were returned; the return rate was 87.2%. In total, 427 of these were valid questionnaires, accounting for 85.4% of the distributed questionnaires.In terms of sampling structure, we first selected merchants, who accounted for 50% of the total research group . Secondly, we selected residents in residential areas , who accounted for 35% of the total research group. Third, we selected activity groups in the landscape area, accounting for 10% of the total research group. Finally, we selected government officials in the area, accounting for 5% of the total research group. Considering that some of the respondents were unlikely to respond to the questionnaire, we expanded the selection probability and scale to make the data more representative.In order to carry out targeted and in-depth research, we defined an expected color palette as a “pleasant, attractive combination”. This definition was used as the basis to further subdivide the five dimensions of architecture, nature, landscape, city, and cognitive color. The first factor was composed of the degree to which the landmark building was a representative color, the degree of coordination between the environment and architecture, the degree of color division in the block, and the degree of color coordination among key buildings and general buildings. this factor was denoted as building color (F1). The second factor was the landscape color (F2), composed of warm and cold tones and comfort level of the landscape. The third factor was natural color (F3), comprised of color matching of the water body, greenery, and landscape. The fourth factor was urban color (F4), comprised of the degree of contrast, degree of coherence, and degree of pleasure of the color. The fifth factor was comprised of perceived satisfaction, happiness, atmosphere, attractiveness, enthusiasm, and relaxation, and was denoted as cognitive color (F5). The data distribution of the five factors can be used for further research and analysis.K represents the total number of items, i2σ represents the variance in the questionnaire score, and T2σ represents the variance in the total score. In SPSS, this test was carried out as follows: Analyze–Scale–Reliability Analysis, select 24 variables to be analyzed under "Item, and analyze the data. The output showed that the alpha reliability coefficient was 0.784. After deleting an inefficient index, the reliability factor was increased to 0.802. Reliability refers to the degree of consistency and stability of the data obtained during repeated tests of the questionnaire. Reliability estimates range from 0~1; the larger the value, the higher the reliability. Cronbach alpha (referred to as α) is used to test reliability. The mathematical formula for the Cronbach alpha coefficient is Validity refers to whether a selected item can represent the measured subject; it reflects the accuracy of the measurement result. The validity of the questionnaire is more important than the reliability. After reliability analysis and the deletion of inefficient items, the items were analyzed for validity. The KMO (Kaiser-Meyer-Olkin) index was 0.903 , which iFactors were selected based on eigenvalues greater than 1, as proposed by Cliff . SpecifiIn The cumulative contribution rate of the first four factors was 81%, so the validity was high. Among them, the building color factor (F1) had the largest contribution, explaining 84.848% of variance, while the second factor, natural color (F3), explained 4.326% of variance, and the third, fourth, and fifth factors, denoting cognitive color (F5), landscape color (F2), and urban color (F4), respectively, explained 2.975%, 1.632%, and 1.197% of variance.Descriptive statistics for the sample data were generated, and the average score for each adjective and adverb was obtained. Based on these results, an SD curve of the evaluation of blue space in the One Street District was drawn . These sAccording to the residents’ cognitive results, the D area located in the center of the landscape water body in the Yijie District tends to the left of the words “integration” of architecture and nature, and scores higher than other areas, indicating that the area near the water has better color matching and fusion. In the general residential areas C and E, most of the residents interviewed were middle-aged males and females. For various reasons, the overall free time of these residents is less than the rest of the sample, and their sense of happiness is lower. Therefore, it is generally believed that the water body has a certain effect on eliminating fatigue. Area A, where public service facilities are concentrated, has a number of iconic buildings as well as public service buildings, and the architectural landscape caters to the surrounding environment. The residents in this area have the highest aesthetics and coordination indices from among the overall survey area. The overall blue color selection and landscape categorical evaluation are moderate, and in the SD curve, the average score of the five areas was located near the “0” value.Among the five districts, respondents generally believed that all blocks have a good degree of integration between architecture and natural colors: the aesthetics are well coordinated, the overall tone is soft, and the buildings represent the style of this area. The indicators for the psychological, relaxation, and physiological factors were to the left, indicating that with a reasonable color mix in the blue space, respondents tend to feel joy and happiness.n = 152), 59.3% of the residents had a low visitation frequency (n = 253), and 0.51% of the residents had never visited the blue space (n = 22). Because the dependent variable, visit frequency, was an ordered variable, and the independent variables were categorical variables, an ordered multi-class logistic regression model was used to explore the relationships between the frequency of visiting blue space and personal variables .In this study, 1–4 visits to the blue space daily or weekly was considered a higher frequency of visits, while 1–4 visits to the blue space in two weeks or a month was considered to be occasional visiting. As such, 35.6% of residents had a high blue space visitation frequency  occasionally visited waterfront spaces compared to ethnic minorities (22.2%), but among those who frequently visited waterfront spaces, there was a greater proportion of ethnic minorities (74.1%) than Han people (33.1%). More people with permanent jobs (91.3%) occasionally visited the blue space, compared to those without permanent jobs (8.7%).p value less than 0.05 was considered statistically significant. As can be seen from In the ordered logistic regression model, a t-tests were performed. The process was therefore (1) analyze, (2) compare means, (3) one-sample t-test.In order to conduct independent analysis of the differences in perceptions of residents after visiting blue space, we used the “occasional” and “frequent” responses to the visiting frequency measure to define the groups. The 12 independent measures of tendency  were thet-test companion probability p-values of the 12 items were all less than the significance level of 0.05. Thus, for all items, there was a significant difference between the high-visitation and low-visitation groups, indicating that each single item has a certain discriminative power. This demonstrates that the questionnaire responses tended to differ significantly.The Most respondents thought that the water body in the space has a positive effect on improving comfort (70.1%). At the same time, reasonable color matching (67.1%) and coherent color connections (68.2%) were also thought to promote physical and mental happiness.During the questionnaire, we presented the respondents with multiple color pictures, including pictures of the study area and other online pictures. Respondents had to choose their desired pictures according to their self-inclination. In the selection of residential buildings, 62.8% of people chose residential buildings with obvious color contrast . FurtherIn the SD psychological curve, respondents’ overall cognition in relation to visiting blue space was generally inclined to the left of the graph. This indicates that respondents were more likely to believe that visiting blue space is relaxing and pleasant, which is conducive to physical and mental health see .We analyzed the scores of respondents from five sub-regions that were different distances from the waterfront space (zone D). The curves in each area were basically the same. Most respondents (73.5%) said that although it takes time to get to the blue space, as it is some distance from their residence, the distance does not influence the purpose and motivation of respondents to “relax” and “eliminate fatigue” around the blue space. When we asked respondents to score the integration of buildings and nature in blue space and general areas, area D scored higher than other areas for many indicators. This indicates strong natural integration, with the water element playing a crucial role. The water environment is obviously the first choice for relaxation and leisure.People can have different perceptual experiences of nature and water environments, and for 90% of people, the perceptions are beneficial to the human body. Ulrich  comparedMost of the respondents visited blue space at least once or twice every two weeks during their activity time, but the frequency of visiting blue space was related to a combination of factors. Education level, occupation, and duration of residence were all predictors of the frequency of visiting blue space.Our research results show that socioeconomic status is one of the main factors that influences how often a resident visits blue space, and also determines how much benefit is gained from visiting blue space. Variation in socioeconomic status is associated with variation in binding forces, and as such, these waterfront areas may mitigate the health impacts of socioeconomic inequality . It is wThose of a higher social and economic status tend to visit blue space more frequently, and most believe that they feel “relaxed” and are “enjoying the joy of nature” in blue space; this is directly reflected in their higher education level and stationary profession condition. Due to the support of social factors, these people have greater capabilities and opportunities to “appreciate the beauty of nature”. For those with a low social status or lower economic level, visiting blue space may not bring many benefits. Some of these people have lived in the research area for more than five years without having visited the blue space. This appears to be related to low levels of education and occupational instability; these people experience life pressures greater than the energy they receive from nature. They may also have less opportunity to visit blue space, and thus, cannot obtain benefit from the water environment. In addition, blue space may be viewed negatively be these people, as an unhealthy place . It has Furthermore, the results revealed that older respondents and those who had lived in the area for a long time were more likely to visit the blue space as one of their basic activities. It was interesting to find that more than 90% of the people who visited the research area for the first time chose to visit the target water environment because of its tourist and leisure attraction. For these respondents, visiting blue space with a recreational pursuit can bring benefits .The results show that color is an important factor affecting the quality of visiting perceptions. In total, 67.1% of respondents thought that reasonable color collocation can promote physical and mental well-being. This result is reflected in their selection of relevant pictures. More interviewees tended to choose warm color environments with bright colors, believing that “1–2 prominent colors” in the environment is the most appropriate color combination.At the same time, we found that certain colors were considered appropriate for certain facilities in the space, such as access paths and benches; these facilities are key to obtaining benefits from blue space . Most reIt is worth noting that from the images that were presented to participants, 80% of respondents chose images that showed a picture of water. This indicates that these water environments are even more attractive to respondents, indicating that humans have a natural affinity for water environments . The ana“I’ve been retired for a long time and enjoy coming here to be active, where I can see water, trees and all kinds of flowers and plants, and lots of people my age, and everyone is a little happier together”(from a 67-year-old woman).“I like to take my kids to play on this side of the Red Bridge, sometimes the weather is bad and it’s grey everywhere I go, but it’s always brightly colored and the kids choose this place every time”(from a woman who has a son).“I’m busy at work and don’t get many opportunities to come out and relax, but when I’m free, I’ll still have tea by the river and be in a calmer mood”(from a middle-aged man).From an evolutionary perspective, the attraction to water and color makes sense. Early humans attracted to freshwater were more likely to survive than those attracted to non-aquatic environments . These pBlue space is an important type of living space, and has great importance for the emotional and mental health of residents. In our research, most people “occasionally” or “often” visited blue space, and almost all of these visitors had high levels of education and stable occupations. Therefore, the frequency of visiting blue space is determined by the social and economic status of the person. Blue space has strong natural attributes and plays a crucial role in emotion perception and psychological recovery. For disadvantaged people in society, the benefits of water environments cannot be accessed due to individual limitations. Most people believe that color choices in blue space are significant in creating a water environment atmosphere. Positive color collocation is conducive to eliminating negative impacts brought about by social pressures, while colors that contrast with natural colors are associated with increased visitation, due to increased attractiveness and visual stimulation. This suggests that the quality of colors in a blue space may be the basis for the relaxation effects of these spaces. However, there are also some limitations of this research. For example, we did not conduct a comparative study of people of different ages. Samples were also not collected from other cities in order to make comparisons between cities. In the future, researchers should focus on the above two key points. At the same time, city planners and managers should pay more attention to the planning of blue space, especially in relation to collocation and design of color. Future studies are needed to study different color collocations, in order to promote residents’ emotional and mental health through reasonable blue space color collocation.