Skip to main content
PMC home page
PLOS ONE logoLink to PLOS ONE
. 2024 Dec 10;19(12):e0315376. doi: 10.1371/journal.pone.0315376

Clinical efficacy analysis of the Chinese medicine Paiteling applied to human papillomavirus infection: A retrospective study

Na He 1,#, Lin Song 2,#, Zhaoxia Lu 2,#, Qingsong Zeng 2, Wumei Jin 3, Wenrong He 2, Cunjian Yi 2,4,*
Editor: Kazunori Nagasaka5
PMCID: PMC11630571  PMID: 39656663

Abstract

Aim

To investigate the clinical efficacy of population-based treatment of human papillomavirus (HPV) infections with Paiteling.

Methods

Between 1 June 2024 and 31 August 2024, 575 HPV-infected patients attending The First People’s Hospital of Jingzhou gynecology outpatient clinic from October 2020 to December 2023 were retrospectively collected, all of whom were analyzed for HPV subtype infection and the presence or absence of cytomorphological abnormality using HPV-DNA testing and TCT; they were divided into 319 cases in the Paiteling group and 256 cases in the Interferon group, and the patients of both groups were subjected to TCT 1 month after the end of the administration of the medication and HPV review.

Results

1. The three most frequent subtypes of HPV in this data are HPV 16, HPV 52, and HPV 58, all of which are high-risk types; 2. The results of the post-treatment review of HPV infection showed that the overall effective rate of the Paiteling group was better than that of the Interferon group, and the difference in the cumulative effective rate between the two groups was statistically significant (P < 0.001); 3. Comparative analysis of patients with 14 high-risk types of human papillomavirus in a single infection showed that the overall conversion rate in the Paiteling group was 76.3%, higher than that of the Interferon group, which was 36.7%. The difference was statistically significant (P < 0.001).

Conclusion

The overall efficacy of Paiteling for cervical HPV infection is significantly better than that of Interferon, and it is worth promoting its use in the clinic.

1. Introduction

Persistent human papillomavirus infection is the main cause of cervical cancer development. According to the Global Cancer Statistics Report 2020, cervical cancer is considered one of the fourth leading causes of cancer in women in terms of both morbidity and mortality [1]. According to the latest update of the World Health Organisation (WHO) carcinogens, some HR-HPVs are classified as Class I carcinogens, including HPV types 16, 18, 33, 31, 35, 39, 45, 51, 52, 56, 58, and 59 [2]. Generally speaking, HPV infection usually disappears naturally within a few months, and about 90% disappear within 2 years. However, a small number of people will continue to be infected with HPV, which will transform into cervical intraepithelial neoplasia and even develop into invasive cervical cancer [3]. In recent years, with the increasing incidence of cervical cancer and the trend towards younger age groups, early clearance of persistent HPV infection has become the primary goal of clinicians. Some patients with persistent HPV may develop cervical intraepithelial neoplasia, and interventions such as physiotherapy or electrosurgery may lead to structural damage to the cervix or increase psychological stress in young patients with reproductive needs. Therefore, it is particularly urgent to explore an effective drug treatment option. Because of its unique efficacy in antiviral therapy, the proprietary Chinese medicine Paiteling has been increasingly widely used in anti-HPV treatment.

Paiteling is a pure Chinese medicine preparation, developed by the Chinese Academy of Sciences in 1993, and its main ingredients are several Chinese herbs such as Da Qing Ye, Honeysuckle, Bitter Ginseng, Crow’s Nest, and Snake Bed Seed. Da Qing Ye, Bitter Ginseng, and Honeysuckle can interfere with and block the synthesis of HPV-DNA and inhibit viral replication, at the same time, they have the effects of clearing heat and removing toxins, activating blood circulation and removing blood stasis, and improving and stimulating autoimmunity [4]; Both Serratia marcescens [5] and Crowberry [6] have the ability to exfoliate keratinocytes while removing and inhibiting HPV pathogens from proliferating cells; in other words, Paiteling allows the virus to be exfoliated along with the host cell before the epithelial cell completes the reproduction of the release, thus effectively removing the virus. Internationally recognized studies have shown that the action of Paiteling is limited to the basal layer of the skin and does not enter the dermis, causing no damage to the dermis or subcutaneous tissues, thus unifying its high potency and low toxicity [7]. At present, there is no clear drug or treatment to eradicate HPV infection in either the international guidelines or the domestic consensus of the relevant experts, so the search for drugs with good efficacy and low toxicity and side effects in clinical work is what clinicians have been exploring. This study aims to investigate the clinical efficacy analysis of the Chinese medicinal Paiteling and the traditional drug Interferon in the treatment of HPV infection.

2. Methods

2.1 Study subjects

Between 1 June 2024 and 31 August 2024, we retrospectively collected patients who attended the gynecology outpatient clinic of The First People’s Hospital of Jingzhou from 1 October 2020 to 1 December 2023, all of whom underwent both thin-layer cytology (TCT) and human papillomavirus (HPV) DNA genotyping. Colposcopy was performed on patients who had medical indications for undergoing a colonoscopy, and biopsies were taken from abnormal sites under colposcopy for histopathological examination. Five hundred and seventy-five patients who met the inclusion criteria were screened and divided into 319 cases in the Paiteling group and 256 cases in the Interferon group. This study was approved by the Ethics Committee of the First People’s Hospital of Jingzhou (Approval No. KY202434), which allowed access to the data used for this study.

2.2 Inclusion and exclusion criteria

Inclusion criteria: (1) Persistent HPV positivity and no cancer in colposcopic cervical biopsy; (2) history of sexual life; (3) no important organs and oncological diseases; (4) no gynecological examination, vaginal medication, vaginal douche within two weeks; (5) no recent oral antiviral medication and HPV vaccine; (6) negative infectious disease examination.

Exclusion criteria: (1) immunocompromised; (2) received local or systemic immune enhancer treatment in the past six months; (3) acute inflammation of the reproductive tract; (4) pregnancy and breastfeeding; (5) long-term use of immunosuppressants; (6) suffering from severe cardiac, pulmonary, hepatic and renal dysfunction; (7) received local or systemic antiviral treatment in the past two months; (8) do not accept the full treatment and follow-up.

2.3 Methods of drug administration

(1) Paiteling Group: Patients in the Paiteling Group were given vaginal medication by specially trained staff, using 3 days and then stopping for 4 days, stopping use during menstruation, with 7 days being a cycle, and a total of 6 cycles of use constituting a whole course of treatment. During the treatment period, patients were urged to strictly avoid sexual intercourse, tub baths, and other phenomena. (2) Interferon Group (Jinshuxi): Starting on the 3rd day after the patient’s menstrual period, the drug was placed in the posterior fornix of the vagina every night before bedtime, 1 tablet each time, every other day, avoiding the menstrual period, and the treatment was carried out for three consecutive months. Follow-up with TCT and HPV was conducted 1 month after the end of the medication.

2.4 Evaluation of efficacy

(1) Ineffective: re-infection in which the original HPV subtype remains positive or is different from the previous subtype; (2) Partial conversion: reduction in the number of subtype species in multiple-mixed individuals; (3) Total conversion: negative results for the original HPV subtype.

2.5 Statistical methods

In this study, the data were analyzed and processed using the statistical software SPSS version 25.0. The Mann-Whitney U test was used to assess the age-related variance in the measurement data, and the chi-square test was used to compare the rates of categorical data. Results were considered statistically significant if P < 0.05.

3. Results

3.1 Comparison of the general conditions of the two groups

There were a total of 319 patients in the Paiteling group, aged 44 (34–53) years, of whom 186 were single HPV infected and 133 were multiple HPV infected, with no cancerous tissue further confirmed on examination. In the Interferon group, there were 256 cases, aged 49 (38–56.5) years, including 184 cases of single HPV infection and 72 cases of multiple HPV infection; no cancer was found in the pathological examination.

3.2 The prevalence of the HPV genotypes

In the 575 samples, the total frequency of infection for each subtype of the infected persons was 887 times (the frequency of infection for double infected persons was recorded as 2 times, and so on), of which 84.7% (751/887) were high-risk types and 15.3% (136/887) were low-risk types. The three most frequently infected subtypes were HPV 16, HPV 52, and HPV 58, with 13.4% (119/887), 13.4% (119/887) and 10.4% (92/887) infections, respectively, as shown in Table 1.

Table 1. Distribution of infection subtypes in HPV positive patients.

HPV genotypes Person-time of infection Constituent ratio*
High-risk type
16 119 13.4
18 55 6.2
31 13 1.5
33 28 3.2
35 16 1.8
39 56 6.3
45 7 0.8
51 50 5.6
52 119 13.4
53 70 7.9
56 29 3.3
58 92 10.4
59 24 2.7
66 34 3.8
67 6 0.7
68 24 2.7
73 5 0.6
82 3 0.3
83 1 0.1
Low-risk type
6 15 1.7
11 9 1.0
40 15 1.7
42 24 2.7
43 10 1.1
44 16 1.8
54 15 1.7
55 12 1.4
61 8 0.9
81 12 1.4
Open in a new tab

HPV: human papillomavirus.

3.3 Analysis of the efficacy of the two groups of drugs on HPV infection

Of the 575 patients with HPV infection, they were categorized as mono-infected and multi-infected according to the type of infection. In a single infection, the conversion rate in the Paiteling group was 76.3% (142/186), with significantly better efficacy than that in the Interferon group of 36.4% (67/184), and the difference was statistically significant (P<0.001). Among the multiple infections, they were further divided into partial conversion and total conversion according to the review results, and the difference between the two groups of total conversion of multiple infections was statistically significant (P = 0.001), and the conversion rate in the Paiteling group (52.6%) was higher than that in the Interferon group (29.2%); Among them, patients with partial conversion of multiple infections were slightly higher in the Paiteling group (42.1%) than in the Interferon group (25.0%, 17/69), and the difference in efficacy between the two groups was statistically significant (P< 0.05). In terms of cumulative effective rate, the Paiteling group (84%) was significantly higher than the Interferon group (41.4%), and the difference in efficacy was statistically significant (P < 0.001) (Table 2).

Table 2. Comparison of treatment efficacy between the two groups [n (%)].

Groups Total cases single infection multiple infection cumulative effective rate
Partial conversion Total conversion
Paiteling 319 142(76.3) 56(42.1) 70(52.6) 268(84.0)
Interferon 256 67(36.4) 18(25.0) 21(29.2) 106(41.4)
P-value a <0.001 <0.05 0.001 <0.001
X 2 60.004 5.925 10.419 113.391
Open in a new tab

N: number of cases; %: rate.

aP-value was calculated by chi-square test.

3.4 Analysis of the efficacy of the two groups of drugs in the rate of conversion to 14 HPV mono-infections

Nucleic acid testing for 14 high-risk HPV subtypes (HPV 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, and 68) is recommended in the WHO guidelines for cervical cancer screening and pre-cancerous lesions issued in 2021, as well as in the Recommended Methods for China’s National Health and Wellness Cervical Cancer Screening Programme [8]. Fourteen high-risk HPV subtypes were classified from 318 patients with mono-infection in the Paiteling group and 182 patients with mono-infection in the Interferon group, and the conversion rates of the 2 drugs for each HPV subtype were compared and analyzed. Eight HPV subtypes converted ≥80.0% in the treatment of the Paiteling group, whereas only two HPV33 and 45 converted ≥80.0% in the Interferon. The top 3 subtypes of highly prevalent HPV in this study were 16, 52, and 58, and the conversion rates were 75.5%, 80.6%, and 52.9% in the Paiteling group, and 24.0%, 38.1%, and 23.1% in the Interferon group, respectively, with statistically significant differences in the efficacy of the three groups of HPV 16, 18, and 52 (P < 0.05). In terms of the overall efficacy of the 2 groups, the conversion rate was 76.3% in the Paiteling group and 36.7% in the Interferon group, p<0.001, which is statistically significant, indicating that the overall efficacy of the Paiteling group was significantly better than that of the Interferon group in the treatment of the 14 high-risk types of HPV infections. Currently, HPV is classified into more than 200 subtypes by molecular biology technology, of which HPV16 and 18 are the most common high-risk types of cervical cancer, and the efficacy of Patulin against HPV16 and 18 is significantly higher than that of interferon. See Table 3.

Table 3. Analysis of the efficacy of the two groups of drugs on the rate of conversion to 14 HPVs [n (%)].

Subtype Paiteling Group Interferon Group X 2 P-value a
Total cases Conversion rate Total cases Conversion rate
HPV
16 53 40(75.5) 25 6(24.0) 18.601 <0.001
18 18 11(61.1) 13 3(23.1) 4.409 0.036
31 5 4(80.0) 2 2(100.0) 0.467 1
33 8 6(75.0) 3 0(0.00) 4.950 0.061
35 - - 5 3(60.0) - -
39 11 9(81.8) 11 7(63.6) 0.917 0.635
45 1 1(100) 1 1(100) - -
51 5 5(100) 15 7(46.7) 4.444 0.055
52 31 25(80.6) 21 8(38.1) 9.775 0.002
56 5 5(100) 5 1(20.0) 6.667 0.048
58 17 9(52.9) 25 7(28.0) 2.669 0.102
59 6 5(83.3) 4 3(75.0) 0.104 1
66 6 5(83.3) 5 2(40.0) 2.213 0.242
68 7 7(100) 4 1(25.0) 7.219 0.024
Total 173 132(76.3) 139 51(36.7) 9.864 <0.001
Open in a new tab

HPV: human papillomavirus.

aP-value was calculated either by chi-square test or Fisher’s exact test.

3.5 Adverse reactions

The incidence of adverse reactions was higher in the Paiteling group than in the Interferon group, and several different side effects may occur during the same patient’s dosing period. For example, patients may experience symptoms such as localized burning sensation and Shedding of cervical epidermal cells simultaneously. In contrast, only 18 patients in the interferon group reported an increase in conscious vaginal discharge. The specific data are detailed in Table 4.

Table 4. Comparison of the occurrence of adverse reactions in the two groups [n (%)].

Groups Total cases Increased vaginal secretions Shedding of cervical epidermal cells Localized burning sensation Lower abdominal cramping Drug induced hypothermia
Paiteling 319 113(35.4) 268(84.0) 248(77.7) 179(56.1) 4(1.0)
Interferon 256 18(7.0) 0 0 0 0
X 2 65.078 - - - -
P-value a <0.001 - - - -
Open in a new tab

aP-value was calculated by chi-square test.

4. Discussion

In this retrospective study, our epidemiologic research found that the top three HPV incidence rates were for HPV types 16, 52, and 58, all of which are high-risk types. This finding is largely consistent with the large-sample epidemiologic survey conducted in Northwest Eurasia, China [9]. In this study, from the analysis of the cumulative effective rate situation, the cumulative effective rate of HPV mono-infection and multi-infection patients using Paiteling was 84.0%, much higher than the cumulative effective rate of Interferon 41.4%. The results of this study also showed that the difference in the conversion rate of HR-HPV in 14 mono-infections between the two groups of drugs was statistically significant (p-value <0.001), with the conversion rate in the Paiteling group being significantly higher than that in the Interferon group. In HPV16, 18, 52, 56, and 68, the conversion rate of the Paiteling group was significantly better than that of the Interferon group, with P value <0.05, which suggests that Paiteling has better clinical efficacy against HPV.

A systematic review and Bayesian network meta-analysis study have shown that the application of various forms of vaginal administration, except for individual use of Lactobacilli vaginal capsules, is more efficacious than no treatment in patients with cervical persistent HR-HPV infection after excisional treatment [10]. A retrospective study aims to evaluate the therapeutic outcomes of Paiteling and CO2 laser therapy on high-risk human papillomavirus. The results of the study show that the percentage of persistent HR-HPV clearance rate for Paiteling patients was higher than carbon dioxide laser vaporization [11]. In addition, the results of a 2-year follow-up comparing HPV-positive with HPV-negative patients with Urothelial Carcinoma of the Bladder showed that the presence of HPV DNA was associated with a trend toward a higher recurrence rate [12]. During early HPV infection, HPV virus particles infect basal cells, the epidermis, through the broken epidermal mucosal cell layer, rarely involving the dermis of the skin. Clinical methods used to try to clear HPV include a variety of methods, such as antiviral gels, interferon, herbal preparations, physiotherapy, etc., of which interferon is commonly used in the treatment of HPV infection, its mechanism of action is to inhibit viral division and proliferation, in addition to stimulating the activity of T-cells as well as natural killer cells, inhibit the proliferation of epidermal cells, and enhance the phagocytosis of patients’ macrophage cells, but previous studies showed that However, previous studies have shown that the effect of interferon therapy is not satisfactory [4]. In recent years, we have found that Paiteling inhibits and removes HPV infection mainly through its exfoliative effect on cervical epithelial cells, the metabolism rate of cervical epithelial cells in patients is significantly accelerated after the use of Paiteling. Yunhua Liu’s team, by integrating LC-MS/MS, network pharmacology, and pharmacological experiments, has found that Paiteling can induce cervical cancer cell apoptosis by inhibiting the E6/E7-Pi3k/Akt signaling pathway [13]. This may provide an effective alternative strategy for traditional Chinese medicine in the treatment of epithelial neoplasias caused by HPV infection.

In conclusion, Paiteling, as a purely traditional Chinese medicine, has been observed to be efficacious against HR-HPV infection, reducing the risk of progression to cervical cancer in patients with HR-HPV, and the associated adverse effects are relatively few, most of which can gradually disappear after stopping the drug, making it a better therapeutic choice. However, Paiteling, as a pure Chinese medicine preparation, has not yet been included in the scope of medical insurance, and its cost is higher than that of interferon, which may increase the economic burden for patients who use it. The use of Paiteling treatment can avoid cervical physiotherapy and electrocution and other cervical damage operations, related side effects are small, operation repeatability is strong, at the same time, for the reproductive needs of patients can avoid the cervical structure of the cervix damage, reduce the patient’s psychological and surgical costs, and thus, promoting the clinical application of these findings is highly recommended.

At the same time, this study also has certain shortcomings, such as the observation time is still short, whether the therapeutic effect of Paiteling on HPV infection is temporary, whether HPV will recur after treatment, and whether the long-term efficacy is not yet certain. This study was conducted on a single-center basis, so the conclusions may be unconvincing, and it is expected that large-sample, multi-center studies can be conducted in the future to increase the persuasiveness of the findings.

Supporting information

S1 Dataset

(XLS)

pone.0315376.s001.xls (76.5KB, xls)

Data Availability

All relevant data are within the paper and its Supporting information files.

Funding Statement

This study was supported by the Hubei Provincial Medical Leaders Cultivation Project Special Funding Program (E Health Planning and Health Development (2013) No. 4) to Cun-jian Yi. And supported by Jingzhou Joint Research Fund Project, Project No. 2024LHY22 to Qing-song Zeng.

References

  • 1.Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mor tality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin. 2021;71(3):209–49. doi: 10.3322/caac.21660 [DOI] [PubMed] [Google Scholar]
  • 2.IARC MONOGRAPHS ON THE IDENTIFICATION OF CARCINOGENIC HAZARDS TO HUMANS 2024 [2024]. https://monographs.iarc.who.int/list-of-classifications.
  • 3.Crosbie EJ, Einstein MH, Franceschi S, Kitchener HC. Human papillomavirus and cervical cancer. The Lancet. 2013;382(9895):889–99. doi: 10.1016/s0140-6736(13)60022-7 [DOI] [PubMed] [Google Scholar]
  • 4.Liu Lian-hui, Qin Wen-min, Zhang Ying-xue, Liu Jie. Meta-analysis on effect of Paiteling on high-risk HPV infection. Chinese Herbal Medicines. 2021;52(22):6928–38. doi: 10.7501/j.issn.0253-2670.2021.22.019 [DOI] [Google Scholar]
  • 5.Li Yaguang, Zhang Weiyue, Wang Weijie, Wei Jingwen, Liu E. Effect of Paiteling on the treatment of persistent HR-HPV infection. Journal of North China University of Science and Technology Health Sciences Edition. 2020;22(06):436–40. doi: 10.19539/j.cnki.2095-2694.2020.06.004 [DOI] [Google Scholar]
  • 6.Rui Chen, Jian Zhao, Qin* L. The clinical observation report of paiteling on treatment of CIN1, 2. Chinese Journals of Practical Gynecology and Obstetrics. 2011;27(09):703–5. [Google Scholar]
  • 7.Zhi Xiongli, Chen Haixia, Hu Zhijun, Zhang Fanfan, Li Ning, Duan Chunmei, et al. Comparison of the efficacy of Baofukang suppository combined with Paiteling in the treatment of HR-HPV infection. HEBEI MEDICAL JOURNAL. 2016;38(16):2468–70. doi: 10.3969/j.issn.1002-7386.2016.16.020 [DOI] [Google Scholar]
  • 8.Li M, Wei L, Sui L, Martin, Kong B, Wu X, et al. Guidelines for cervical cancer screening in China. Chinese Journal of Clinical Obstetrics and Gynecology. 2023;24(04):437–42. doi: 10.13390/j.issn.1672-1861.2023.04.029 [DOI] [Google Scholar]
  • 9.Lu Jian, Ying-hua H. Current status and genotype distribution of human papilloma virus in 20532 cases in northwest Hubei. CHINA TROPICAL MEDICINE. 2023:1–6. [Google Scholar]
  • 10.Tang Y, Tong Q, Dai N, Xu C. Evaluation of the clinical efficacy of vaginal treatment options for p ersistent high-risk human papillomavirus infection after excisional tr eatment of cervical high-grade squamous intraepithelial lesions: a sys tematic review and Bayesian network meta-analysis. Virol J. 2023;20(1):47. doi: 10.1186/s12985-023-02001-6 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 11.Cobbinah P, Zheng Zheng S, Oklah F, Yuyang Z. Comparative analysis of Paiteling a traditional Chinese medicine (TCM) and CO2 laser therapy for high-risk HPV-associated with LSIL (CIN1) lesions. Eur J Obstet Gynecol Reprod Biol. 2024;302:81–6. doi: 10.1016/j.ejogrb.2024.08.042 [DOI] [PubMed] [Google Scholar]
  • 12.Sarier M, Usta SS, Turgut H, Öztürk SA, Soylu A, Emek M, et al. Prognostic value of HPV DNA in Urothelial Carcinoma of the Bladder: A Preliminary Report of 2-Year Follow-up Results. Urol J. 2021;19(1):45–9. doi: 10.22037/uj.v18i.6429 [DOI] [PubMed] [Google Scholar]
  • 13.Liu Y, Zheng P, Jiao T, Zhang M, Wu Y, Zhang X, et al. Paiteling induces apoptosis of cervical cancer cells by down-regulatio n of the E6/E7-Pi3k/Akt pathway: A network pharmacology. J Ethnopharmacol. 2023;305:116062. doi: 10.1016/j.jep.2022.116062 [DOI] [PubMed] [Google Scholar]

Decision Letter 0

Kazunori Nagasaka

15 Oct 2024

PONE-D-24-38433Clinical efficacy analysis of the Chinese medicine Paiteling applied to human papillomavirus infection: a retrospective studyPLOS ONE

Dear Dr. Yi,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Nov 29 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

  • A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

  • A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

  • An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Kazunori Nagasaka

Academic Editor

PLOS ONE

Journal Requirements:

1. When submitting your revision, we need you to address these additional requirements.

Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at 

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and 

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. In the online submission form, you indicated that Data are available from the corresponding author for researchers who meet the criteria for access to confidential data.

All PLOS journals now require all data underlying the findings described in their manuscript to be freely available to other researchers, either a. In a public repository, b. Within the manuscript itself, or c. Uploaded as supplementary information.

This policy applies to all data except where public deposition would breach compliance with the protocol approved by your research ethics board. If your data cannot be made publicly available for ethical or legal reasons (e.g., public availability would compromise patient privacy), please explain your reasons on resubmission and your exemption request will be escalated for approval. 

3. PLOS requires an ORCID iD for the corresponding author in Editorial Manager on papers submitted after December 6th, 2016. Please ensure that you have an ORCID iD and that it is validated in Editorial Manager. To do this, go to ‘Update my Information’ (in the upper left-hand corner of the main menu), and click on the Fetch/Validate link next to the ORCID field. This will take you to the ORCID site and allow you to create a new iD or authenticate a pre-existing iD in Editorial Manager.

4. Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please delete it from any other section. 

5. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information. 

Additional Editor Comments:

Dear Authors,

Thank you very much for your submission to PLOS ONE. As both reviewers noted, the manuscript is intriguing. I recommend that you revise the manuscript in accordance with their comments.

I look forward to receiving your revised version.

Sincerely,

Kazunori Nagasaka

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Partly

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Both in the interferon group and in the paiteling group, the complications related to use should be mentioned in more detail.

Especially the place of interferon therapy today is controversial.

Viral clearance occurs in 90% of these patients within 2 years. In this case, the effectiveness of treatment is questionable.

It would have been more effective if the authors had conducted this study in symptomatic HPV infection cases.

It is debatable how accurate it is only in HPV-DNA+ cases.

Nevertheless, it should be evaluated because it is an original study.

The authors can add the study below as a reference to increase the value of manuscript.

Sarier M, Usta SS, Turgut H, et al. Prognostic value of HPV DNA in Urothelial Carcinoma of the Bladder: A Preliminary Report of 2-Year Follow-up Results. Urol J. 2021;19(1):45-49. doi:10.22037/uj.v18i.6429

Reviewer #2: 1. Data completeness: the article states that no datasets were generated or analysed, which could mean that the study results were based solely on existing medical records without additional data collection to validate those records.

2. Sample size: Although the study included 575 patients with HPV infection, this number may still not be large enough for some subgroups to be analysed, especially when multiple HPV subtypes are considered.

3. Confounding factors: studies may not adequately consider or control for all the confounding factors that may affect the results, such as the patient's age, lifestyle, and allergies to the drug's ingredients。

4. Failure to mention the control group: The article did not mention whether there was a control group using placebo or other treatments, which is crucial for assessing the efficacy of Patulin.

5. Reporting of side effects: The article mentions that some patients in the PATLIN group experienced mild side effects, but these were mostly tolerable and may have disappeared on their own at the end of treatment. However, the reporting of side effects may not be comprehensive enough, as only serious or persistent side effects are more likely to be reported.

6. Statistical analysis: Although statistical software was used to analyse the data, the article does not detail whether the statistical tests used were best suited to the type of data or whether they were adjusted for all possible confounders.

7. Standardisation of treatment: The study mentions the treatment modalities of Patulin and Interferon, but does not detail whether the treatment was administered in exactly the same way in all patients, which may have affected the consistency of the results.

8. Failure to discuss economic costs: The article did not discuss the economic costs of the treatment with PATRIN, which is important for assessing its feasibility in the real world.

Reviewer #3: The study by He et al., titled “Clinical Efficacy Analysis of the Chinese Medicine Paiteling Applied to Human Papillomavirus Infection: A Retrospective Study,” evaluates the effectiveness of Paiteling in treating HPV infections on a population level. This retrospective study included 575 HPV-infected patients from the First People’s Hospital of Jingzhou Gynecology Outpatient Clinic, covering the period from October 2020 to December 2023. The patients were divided into two groups: 319 received Paiteling, while 256 were treated with interferon.

A key strength of this study is the large sample size in both treatment groups. However, a significant limitation is the absence of a clearly defined or sufficiently long post-treatment follow-up period to assess the efficacy of Paiteling compared to interferon. Although the study appears to combine both retrospective (HPV infection) and prospective (treatment and efficacy evaluation) elements, it is classified as a retrospective study. Furthermore, the authors did not clearly explain how this study differs from previous similar studies conducted in China, nor did they adequately compare their findings with earlier research, leading to a somewhat brief discussion.

Major and general comments:

-The authors did not evaluate factors influencing the effectiveness of Paiteling treatment, such as age, baseline viral load, HPV type, single versus multiple HPV infections, immunological and nutritional status, obesity, and other comorbidities.

-Additionally, details on the duration and number of post-treatment follow-ups, as well as the number of patients lost to follow-up, are missing.

-The discussion section is superficial and could benefit from comparisons with previous studies on the clinical efficacy of Paiteling treatment for cervical cancer and the clearance of persistent HPV infections. It is important to determine whether the current findings align with or differ from existing evidence on the effectiveness of Paiteling treatment, to highlight the significance of this study.

-The strengths and limitations of the study should also be addressed. Although the sample size is relatively large, the subcluster analysis of treatment outcomes by HPV types in the two intervention groups is limited by small sample sizes and lacks statistical power. Except for HPV types 16, 18, 52, and 58, the sample sizes for other high and low-risk HPV types are extremely low, which is a common limitation of retrospective study designs in clinical research.

Minor and specific comments:

-Line 90-91: What does the term “information” mean? It might refer to detailed patient information, including demographics, medical history, and clinical outcomes. If this was the case, of course, it was, the authors should delete information in “Information and Methods” and Replace “1.1 General Information” with “1.1 Study Subjects”.

-Line 96: The phrase “those who met the indications for colonoscopy” is unclear. It likely means patients who had medical reasons or criteria that warranted a colonoscopy. You could rephrase it to: “patients who had medical indications for undergoing a colonoscopy.”

-Line 98-99: This sentence “Five hundred and seventy-five patients who met the inclusion and exclusion criteria were screened …” appears incorrect. If the 575 subjects were enrolled because they met the inclusion criteria, you should delete “and exclusion”. The revised sentence would be: “Five hundred and seventy-five patients who met the inclusion criteria were screened.”

-Line 115: “1.3 Methods of Administration” appeared to me unclear. If it refers to how drugs were administered, you should specify this. You could rephrase it to: “1.3 Methods of Drug Administration”. Also, since this section was written as a proposal or protocol, and needs to be rewritten in the past tense. For example: “The drugs were administered according to the following methods…”

-Line 144: Including a figure that demonstrates the flow of participants through the study is a great idea. A figure titled “A flow chart illustrating the number of participants enrolled in different intervention groups, dropouts, and the number of individuals who cleared the virus versus those who did not” needs to be provided in the methods or result section for clarity of the manuscript.

-Line 177: Replace “see Table 2 for details” with “(Table 2)”.

-Line 209: The section on adverse reactions should be more detailed. I suggest generating a table that summarises the findings on adverse reactions. The table provides figures on the number of study participants who developed adverse reactions in the two intervention groups, along with the most commonly observed adverse reactions.

-Line 247: The term “scholars” is vague. It could be referring to researchers or experts. You might want to clarify this based on the context.

-Lines 263-264: The sentence “reduce the patient’s psychological and economic burden, it is worth to promote the clinical” seems incomplete. You could rephrase it to: “ ..reduce the patient’s psychological and economic, and thus, promoting the clinical application of these findings is highly recommended.”

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: Yes: Shuguang Zhou

Reviewer #3: Yes: Tesfaye Gelanew

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

PLoS One. 2024 Dec 10;19(12):e0315376. doi: 10.1371/journal.pone.0315376.r002

Author response to Decision Letter 0

9 Nov 2024

Point-by-Point Response to the comments by Reviewers

Journal: PLOS ONE

Manuscript ID: PONE-D-24-38433

Title: Clinical efficacy analysis of the Chinese medicine Paiteling applied to human papillomavirus infection: a retrospective study

Author(s): Na He, Lin Song, Zhaoxia Lu, Qingsong Zeng, Wumei Jin, Wenrong He, Cunjian Yi.

Corresponding authors:

Name: Cunjian Yi, e-mail: 2022721105@yangtzeu.edu.cn

Wenrong He, e-mail: hewenrong@126.com

Dear editors and reviewers:

Thank you for offering us an opportunity to improve the quality of our submitted

manuscript entitled “Clinical efficacy analysis of the Chinese medicine Paiteling applied to human papillomavirus infection: a retrospective study ” (ID: PONE-D-24-38433 ). We appreciated very much the reviewers’ constructive and insightful comments. We have studied comments carefully and have made corrections which we hope meet with approval. Revise portions are marked in red in the revised manuscript. If there are any incorrect answers or questions in the manuscript, please do not hesitate to let us know.

A Point-by-Point Response to the reviewer’s comments is given below.

The detailed explanation is given as follows:

Reviewer #1 Summary of the revision:

1.Both in the interferon group and in the paiteling group, the complications related to use should be mentioned in more detail.

2. Especially the place of interferon therapy today is controversial.

3. Viral clearance occurs in 90% of these patients within 2 years. In this case, the effectiveness of treatment is questionable. It would have been more effective if the authors had conducted this study in symptomatic HPV infection cases. It is debatable how accurate it is only in HPV-DNA+ cases.

4. Nevertheless, it should be evaluated because it is an original study.

5. The authors can add the study below as a reference to increase the value of manuscript.

Sarier M, Usta SS, Turgut H, et al. Prognostic value of HPV DNA in Urothelial Carcinoma of the Bladder: A Preliminary Report of 2-Year Follow-up Results. Urol J. 2021;19(1):45-49. doi:10.22037/uj.v18i.6429

Responses to a reviewer’s comments.

Thanks very much for your approval of this study, below are the replies to your

constructive questions：

1. Comment: Both in the interferon group and in the paiteling group, the complications related to use should be mentioned in more detail.

1. Reply: We feel great thanks for your professional review work on our article. As you are concerned, we believe that the adverse effects of both drug groups merit a more detailed discussion. According to your nice suggestions, we have made extensive corrections to our previous manuscript, the detailed corrections are listed below.

Key points added in Section 2.5: “ The incidence of adverse reactions was higher in the Paiteling group than in the Interferon group, and several different side effects may occur during the same patient's dosing period. For example, patients may experience symptoms such as localized burning sensation and Shedding of cervical epidermal cells simultaneously. In contrast, only 18 patients in the interferon group reported an increase in conscious vaginal discharge. The specific data are detailed in Table 4.” Please check out sections 2.5 on line 205-212 for specific modifications, tks.

Table 4 Comparison of the occurrence of adverse reactions in the two groups [n (%)]

Groups Total cases Increased vaginal secretions Shedding of cervical epidermal cells Localized burning sensation Lower abdominal cramping Drug induced hypothermia

Paiteling 319 113(35.4) 268(84.0) 248(77.7) 179(56.1) 4(1.0)

Interferon 256 18(7.0) 0 0 0 0

X² 65.078 - - - -

P-value ＜0.001 - - - -

2. Comment: Especially the place of interferon therapy today is controversial.

2. Reply: Thank you for this valuable comment. Yes, There is currently some controversy in the international medical community regarding the efficacy and applicability of the use of interferon for the treatment of HPV infection. In the field of HPV treatment, neither international guidelines nor domestic expert consensus currently recommends any specific drug or treatment to completely cure HPV infection. Interferon, as a broad-spectrum antiviral drug, is still used by many doctors and patients in the clinic due to its advantages of low cost and broad applicability. Based on these considerations, our team chose interferon as a control group to evaluate its actual effect on HPV treatment.

3. Comment: Viral clearance occurs in 90% of these patients within 2 years. In this case, the effectiveness of treatment is questionable. It would have been more effective if the authors had conducted this study in symptomatic HPV infection cases. It is debatable how accurate it is only in HPV-DNA+ cases.

3. Reply: We were really sorry for our careless mistake. Thank you for your reminder. In response to your inquiry regarding the natural clearance rate of HPV within two years, we regret to acknowledge an oversight in our article that failed to clearly communicate that our study subjects were all patients with persistent infections. Specifically, the majority of patients in the Paiteling group were included in the study because their infections persisted despite conventional antiviral therapy. Key points added in Section 1.2: “Persistent HPV positivity and no cancer in colposcopic cervical biopsy...” Please check out sections 1.2 on line 104-105 for specific modifications, tks.

4. Comment: Nevertheless, it should be evaluated because it is an original study.

4. Reply: We appreciate your summary of the manuscript and encouraging comment.

5. Comment: The authors can add the study below as a reference to increase the value of manuscript.

Sarier M, Usta SS, Turgut H, et al. Prognostic value of HPV DNA in Urothelial Carcinoma of the Bladder: A Preliminary Report of 2-Year Follow-up Results. Urol J. 2021;19(1):45-49. doi:10.22037/uj.v18i.6429

Reply: We sincerely appreciate the valuable comments. We have checked the literature carefully and added reference on “Prognostic value of HPV DNA in Urothelial Carcinoma of the Bladder: A Preliminary Report of 2-Year Follow-up Results.” into the DISCUSSION part in the revised manuscript. Please check out sections 3 on line 235-238 for specific modifications, tks.

Reviewer #2 Summary of the revision:

1. Data completeness: the article states that no datasets were generated or analysed, which could mean that the study results were based solely on existing medical records without additional data collection to validate those records.

2. Sample size: Although the study included 575 patients with HPV infection, this number may still not be large enough for some subgroups to be analysed, especially when multiple HPV subtypes are considered.

3. Confounding factors: studies may not adequately consider or control for all the confounding factors that may affect the results, such as the patient's age, lifestyle, and allergies to the drug's ingredients.

4. Failure to mention the control group: The article did not mention whether there was a control group using placebo or other treatments, which is crucial for assessing the efficacy of Patulin.

5. Reporting of side effects: The article mentions that some patients in the PATLIN group experienced mild side effects, but these were mostly tolerable and may have disappeared on their own at the end of treatment. However, the reporting of side effects may not be comprehensive enough, as only serious or persistent side effects are more likely to be reported.

6. Statistical analysis: Although statistical software was used to analyse the data, the article does not detail whether the statistical tests used were best suited to the type of data or whether they were adjusted for all possible confounders.

7. Standardisation of treatment: The study mentions the treatment modalities of Patulin and Interferon, but does not detail whether the treatment was administered in exactly the same way in all patients, which may have affected the consistency of the results.

8. Failure to discuss economic costs: The article did not discuss the economic costs of the treatment with PATRIN, which is important for assessing its feasibility in the real world.

Responses to a reviewer’s comments.

Thanks very much for your approval of this study, below are the replies to your

constructive questions：

1. Comment: Data completeness: the article states that no datasets were generated or analysed, which could mean that the study results were based solely on existing medical records without additional data collection to validate those records.

1. Reply: I agree with you, thanks very much for your advice. Our data were primarily derived from existing medical records and follow-up information, and we have not yet performed additional validation with external data. However, the points you raised are indeed very pertinent, and we strongly believe that incorporating your suggestions into future studies will greatly enhance the credibility of our findings.

2. Comment: Sample size: Although the study included 575 patients with HPV infection, this number may still not be large enough for some subgroups to be analysed, especially when multiple HPV subtypes are considered.

2. Reply: We gratefully appreciate for your valuable comment. Currently, our data collection is retrospective, and as such, we have been able to gather limited patient information. Some patients who were lost to follow-up or failed to undergo timely reviews were not included in our study. To enhance the credibility of our findings, we are considering conducting a multicenter study with a large sample size in the future. We believe that by expanding our research scope and deepening our data analysis, we can significantly increase the reliability and persuasiveness of our results. Your suggestions are greatly appreciated, and we are committed to striving for higher research standards.

3. Comment: Confounding factors: studies may not adequately consider or control for all the confounding factors that may affect the results, such as the patient's age, lifestyle, and allergies to the drug's ingredients.

3. Reply: We value your professional comments on our article. In response to your question about confounders, we did face some challenges in our study. Our study was based on a retrospective collection of data from patients who attended the gynecology outpatient clinic of the First People's Hospital of Jingzhou City between October 1, 2020, and December 1, 2023, retrospectively. Due to the nature of retrospective studies, our study had some limitations, especially in the absence of detailed information about patients' lifestyles and drug allergy histories, among others, which limited our ability to control for relevant confounders. We recognize this and will strive to overcome these limitations in future studies to provide a more comprehensive and precise analysis. Thank you again for your valuable input, which is essential for us to improve our research methods.

4. Comment: Failure to mention the control group: The article did not mention whether there was a control group using placebo or other treatments, which is crucial for assessing the efficacy of Patulin.

4. Reply: We sincerely appreciate the valuable feedback you provided on our article, and your suggestions are crucial in helping us improve the quality of our manuscript. Regarding your reference to the control group, we did not set up a blank group but added only the interferon group as a control. This decision was primarily due to the incomplete case data for some unmedicated patients and the difficulties encountered during follow-up. Nonetheless, we have introduced data from other research teams in the discussion section that included studies with blank control groups. The results showed that the HPV conversion rate was higher in both Paiteling and Interferon groups compared to the naturally observed group. We will continue to monitor the latest research in this area and consider a more comprehensive control group setup in our subsequent work. Thank you again for your valuable comments.

5. Comment: Reporting of side effects: The article mentions that some patients in the PATLIN group experienced mild side effects, but these were mostly tolerable and may have disappeared on their own at the end of treatment. However, the reporting of side effects may not be comprehensive enough, as only serious or persistent side effects are more likely to be reported.

5. Reply: Thank you very much for your valuable comments. According to your nice suggestions, we have made corrections to our previous manuscript, the detailed corrections are listed below. Key points added in Section 2.5: “ The incidence of adverse reactions was higher in the Paiteling group than in the Interferon group, and several different side effects may occur during the same patient's dosing period. For example, patients may experience symptoms such as localized burning sensation and Shedding of cervical epidermal cells simultaneously. In contrast, only 18 patients in the interferon group reported an increase in conscious vaginal discharge. The specific data are detailed in Table 4.” Please check out sections 2.5 on line 205-212 for specific modifications, tks.

We have not yet determined if there are serious or persistent side effects from using Paiteling during the observation period. We will extend the follow-up period and enhance the thoroughness of follow-up to ensure the safety of patients' use of the drug. However， no severe side effects were reported by the Paiteling patients. This is due to the fact that Paiteling, as a traditional Chinese medicine, is a topical, non-invasive medicine, thus preserving the integrity of the cervix.

6. Comment: Statistical analysis: Although statistical software was used to analyse the data, the article does not detail whether the statistical tests used were best suited to the type of data or whether they were adjusted for all possible confounders.

6. Reply: We thank the reviewer of pointing out this issue. We should indeed enhance the presentation of statistics with more detail. We have revised in the section 1.5: “In this study, the data were analyzed and processed using the statistical software SPSS version 25.0. The Mann-Whitney U test was used to assess the age-related variance in the measurement data, and the chi-square test was used to compare the rates of categorical data. Results were considered statistically significant if P < 0.05.” Thanks for your reminder. Please check section 1.5 on line 132-135, tks.

7. Comment: Standardisation of treatment: The study mentions the treatment modalities of Patulin and Interferon, but does not detail whether the treatment was administered in exactly the same way in all patients, which may have affected the consistency of the results.

7. Reply: Thanks to the review for this careful comment. Both groups of patients involved in this study received a standardized course of treatment based on hospital guidelines and medication recommendations, ensuring that each patient received the same treatment.

8. Comment: Failure to discuss economic costs: The article did not discuss the economic costs of the treatment with PATRIN, which is important for assessing its feasibility in the real world.

8. Reply: We agree with the reviewer’s suggestion and will incorporate the recommended changes into the manuscript. Key points added in Section 3:“However, Paiteling, as a pure Chinese medicine preparation, has not yet been included in the scope of medical insurance, and its cost is higher than that of interferon, which may increase the economic burden for patients who use it.” Thanks for your reminder. Please check section 3 on line 260-263, tks.

Reviewer #3 Summary of the revision:

Major and general comments:

1.The authors did not evaluate factors influencing the effectiveness of Paiteling treatment, such as age, baseline viral load, HPV type, single versus multiple HPV infections, immunological and nutritional status, obesity, and other comorbidities.

2.Additionally, details on the duration and number of post-treatment follow-ups, as well as the number of patients lost to follow-up, are missing.

3.The discussion section is superficial and co

Attachment

Submitted filename: Response to Reviewers.doc

pone.0315376.s002.doc (147.5KB, doc)

Decision Letter 1

Kazunori Nagasaka

26 Nov 2024

Clinical efficacy analysis of the Chinese medicine Paiteling applied to human papillomavirus infection: a retrospective study

PONE-D-24-38433R1

Dear Dr. Yi,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Kazunori Nagasaka

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Dear Authors,

Thank you for submitting your manuscript to Plos One.

Our reviewers have recommended that the manuscript is ready for publication. Congratulations on your work! We look forward to receiving your future studies.

Sincerely,

Kazunori Nagasaka

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #3: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Comments are addressed this paper is ready to publish

Reviewer #3: I have no more comments! However, authors need to meticulously revise to minimize grammatical errors here and there. They need to expand and discuss the limitations of the study, given it has several limitations.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #3: Yes: Tesfaye Gelanew

**********

Acceptance letter

Kazunori Nagasaka

29 Nov 2024

PONE-D-24-38433R1

PLOS ONE

Dear Dr. Yi,

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team.

At this stage, our production department will prepare your paper for publication. This includes ensuring the following:

* All references, tables, and figures are properly cited

* All relevant supporting information is included in the manuscript submission,

* There are no issues that prevent the paper from being properly typeset

If revisions are needed, the production department will contact you directly to resolve them. If no revisions are needed, you will receive an email when the publication date has been set. At this time, we do not offer pre-publication proofs to authors during production of the accepted work. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few weeks to review your paper and let you know the next and final steps.

Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

If we can help with anything else, please email us at customercare@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Professor Kazunori Nagasaka

Academic Editor

PLOS ONE

Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Supplementary Materials

    S1 Dataset

    (XLS)

    pone.0315376.s001.xls (76.5KB, xls)
    Attachment

    Submitted filename: Response to Reviewers.doc

    pone.0315376.s002.doc (147.5KB, doc)

    Data Availability Statement

    All relevant data are within the paper and its Supporting information files.

    Articles from PLOS ONE are provided here courtesy of PLOS

    RESOURCES