The diagnosis of brucellosis largely relies on tiger red plate agglutination test (RBPT). However, it is difficult to distinguish between natural infection antibody positive and vaccination antibody positive, nevertheless, the identification of specific Brucella species natural infection.Brucella ovis (B. ovis) and Brucella melitensis (B. melitensis), which are the main pathogens of sheep brucellosis, and found the OMP25 and OMP31 could be used as the differential antigens for B. ovis and B. melitensis antibody. Then we expressed the OMP25 from B. ovis (OMP25o) and OMP31 from B. melitensis (OMP31m).Here, we analyzed the structure of main outer membrane proteins (OMPs), OMP25 and OMP31 from B. ovis and B. melitensis specific primers based PCR detection, and all these samples were B. melitensis negative. However, four out of six samples are B. ovis positive. These results showed that we could use the OMP25o and OMP31m to diagnose sheep brucellosis antibody, especially to discriminate the infection of the B. ovis.They have equally efficiency in antibody detection of vaccinated sheep serum, consistent with the RBPT results. However, through epidemiological investigations, we found some RBPT positive samples were negative by the OMP31m based serum antibody detection, but these samples gave positive results by the OMP25o. We verified these OMP31m negative but OMP25o positive samples by B. ovis and B. ovis positive samples should be naturally infected. There should be some implicit transmission of B. ovis in Jilin province. Further epidemiological investigation should be conducted to monitor the B. ovis natural infection.Currently, China has not yet approved a vaccine based on  Brucells (dogs) . Brucells (dogs) . B. ovis in ewes . Once in in ewes . Most ra 4 years . In Chinnfection . The immBacterial isolation and PCR based diagnosis method is the gold standard for the diagnosis of brucellosis , howeverB. ovis infection , group 2 (40 KDa) and group 3 (30 KDa) proteins according to their apparent molecular mass . Two pronfection . Althoug abortus , the vacnfection . OMP31 anfection . OMP25 w abortus . Amino aBrucella . OMP25 iBrucella . The DNAepitopes .B. ovis and B. melitensis, we speculate that sheep should generate some special antibody repertoires against B. ovis OMP25(OMP25o) different from B. ovis OMP31, which is almost similar with B. melitensis OMP31(OMP31m). This property can be used for discrimination of B. melitensis antibody (including vaccine stimulated antibody) and B. ovis antibody. In China, there is no B. ovis based vaccine, the B. ovis related antibody positive individuals should be the result of natural infection with B.ovis. This strategy can at least be used in screening for the B. ovis natural infection, providing guidance for farmers to handle their breeding sheep.Through structural analysis of OMP25 and OMP31 of 22.1https://www.tiangen.com).The DH5α, BL21 competent cells are purchased from TIANGEN BIOTECH (https://colab.research.google.com/github/sokrypton/ColabFold/blob/main/AlphaFold2.ipynb).Structural analysis of OMP25 and OMP31 is based on the Alfa fold online instruction (2.2www.sangon.com), and then refolded by dialysis against 20 mM Tris-HCl buffer containing 0.1 mM DTT with β-ME, 1 mM reduced glutathione and 0.2 mM oxidized glutathione. Aliquots were run on SDS to check the recombinant protein OMP25o and OMP31m. Purified soluble OMP25o and OMP31m were used for serological tests.The sequence of omp25 gene (642 bp) was download from Genebank (AAB06702.1). It was cloned into the pET-28a expression vector and designated as pET-28a-omp25. The sequence of omp31 gene (723 bp) was download from Genebank (AAB36693.1). It was cloned into the pET-28a expression vector and designated as pET-28a-omp31. Recombinant OMP25o and OMP31m were expressed as inclusion bodies in Escherichia coli (BL21) by induction with 1.25 mM isopropyl thiogalactoside (IPTG). OMP25o and OMP31m extracts were denatured by 8 M urea and purified by Ni-NTA agarose  and lysed using TGyrate Basic Vortex mixer (TIANGEN). The cell debris was removed by centrifugation at 8000g for 30min. Filtered the supernatant using a Millipore cartridge (0.22 μm pore size) and loaded it onto a gravity flow column containing Ni-NTA resin. The target protein was eluted with elution buffer . Peak fractions were analyzed by SDS-PAGE to determine whether the target protein was collected. After confirming the purity and yield of the protein, the fractions were pooled, concentrated, and stored at 4°C.2.3All samples are sheep originated. The samples are detected by Rose Bengal test and 100 samples are identified as positive samples, 33 as negative samples. There are 100 samples that are not tested. . All serum samples are treated with 60°C water bath for 30 min before use. The blood samples are freshly used to extract nucleic acids.2.4OMP25o and OMP31m were electrophoresed on SDS-PAGE and transferred to Polyvinylidene Fluoride membranes . The blotted membrane was incubated in 1:1,000 diluted monoclonal antibody for 2 h at room temperature. The strip was washed in TBS containing 0.05% Tween 20 (TBST) and incubated with 1:5,000 dilution of goat anti-mouse IgG and IgM HRP-conjugated antibodies. The blot was visualized by adding immuno-chemiluminescence reagent .2.5https://www.abcam.cn) to bind the specific antibodies in serums. Incubate for 40 min at 37°C. Wash the plates three times with PBST. Add chromogenic substrate TMB and after 10 min incubation has elapsed, stop the reaction with 2 M H2SO4. Finally, the optical densities at 450 nm wavelengths were measured on Microplate Reader.Coat the antigen onto the ELISA plates by adding 100 μl of the antigen solution to each well. Incubate overnight (about 12 h) at 4°C. Wash the wells three times with PBST (0.05% Tween 20 in PBS). Block the rest of the protein binding sites with 200 μl/well blocking buffer (3% BSA in PBS), and put the plates in 37°C oven for 2 h. After washing the plates three times with PBST, dilute the serums in an appropriate ratio with PBST containing 3% BSA and dispense it to the wells. Incubate at 37°C for 1 h. Wash the plates three times with PBST. Adding the donkey anti sheep IgG HRP-conjugated antibody solution  and incubated on ice for 4 to 5 min with occasional shaking. White blood cells were collected by centrifugation at 500g for 5 min and used for DNA extraction by silica column (MolPure® Blood DNA Kit) according to manufacturer instructions. The PCR primer for B. ovis is previously validated species-specific PCR primer for B. ovis detection (Forward 5′-GCCTACGCTGAAACTTGCTTTTG-3′ and Reverse 5′-ATCCCCCCATCACCATAACCGAAG-3′), which corresponding to a 228 pb amplicon.Bloods were collected using vacuum tubes treated with heparin and 0.5 ml of blood was used to extract DNA. The blood was centrifuged at 500g for 7 min and the supernatant discharged. The pellets were suspended in 1 ml red blood cell lysis buffer (155 mM NH33.1B. ovis and B. melitensis separately. OMP31 of B. melitensis (OMP31m) is a 31 kDa pore-forming protein with 240 amino acid residues, having a β-barrel structure based on eight β-strands with flexible N-terminal of 48 residues, which is the linker of peptidoglycan (B. ovis (OMP31o) also has 240 amino acids with 9 residues sporadically spread along the sequence. The identical Tm-score is 0.97. They are very similar to each other, which maybe the reason why immunity based on B. melitensis can also give protection against B. ovis infection. On the other hand, OMP25 of B. melitensis (OMP25m) is a 23 kDa protein consisting of 213 residues, having similar three-dimensional structure with OMP31 (B. ovis (OMP25o) is short of 12 amino acid residues on the C terminal corresponding to the fourth loop of seventh and eighth strands. This could cause antigenic shift in both linear and non-linear epitopes, which could be used in the identification of B. ovis infection  cells. The optimization of expression conditions showed that under the condition of 1.25 mM ITPG, the target protein could express very well as inclusion body Figure 23.3To determine the ability of our recombinant proteins in serum screening, indirect ELISA was chosen with Omp25o and Omp31m as coating antigens. The optimal coating conditions were determined by checkerboard experiment. The results showed that the optimal coating concentration of Omp25o is 8 μg/ml and the optimal dilution ratio is1:10 Table S13.4B. melitensis negative, but B. ovis positive. So, we decided to verify the sample by nucleic acids PCR test.To evaluate the prevalence of brucellosis infection in these areas (as mentioned above), we randomly selected 100 sheep serum samples and tested them using our established indirect ELISA method. According to the cut off value, the results showed that the positive detection rate is 82/100 when the antigen is OMP25o (3.5B.ovis specific primers were designed and synthesized according to previous research results (B.ovis specific primers PCR (B. ovis antibody positive samples with PCR, because this bacterium is not always detected in the blood. This result indicated that there might be undetected B. ovis natural infection in Jilin Province. Our indirect ELISA strategy based on OMP31m and OMP25o recombinant antigens could easily screen for natural infection of B. ovis. Epidemiological survey should be conducted in Jilin province on B. ovis natural infection.PCR is the most sensitive method for causative agent detection. So, blood DNA was extracted and purified from OMP25o positive and OMP31m negative samples.  results . The PCRmers PCR Figure 54B. ovis is one of the main pathogens of sheep brucellosis. Since it can produce subclinical asymptomatic infections, it will have long-term latent transmission in sheep flocks and cause serious economic losses to sheep industry. So, the diagnosis of B. ovis infection is very important for the clearance of B. ovis infection in sheep flock. However, there is currently no suitable strategy to screen for natural infections of B. ovis. We first compared the structural characteristics of OMP25 and OMP31, all of them are barrel shaped proteins. OMP31m and OMP31o are highly similar, with only 9 amino acids substituted. However, OMP25o lacks 12 amino acids in the carbon terminal, which corresponds to the fourth loop of the beta barrel protein, means that OMP25o will produce some special antibodies completely different from that of OMP25m. Therefore, OMP25o and OMP31m were selected as candidate antigens to distinguish B. ovis induced antibody from B. melitensis induced antibody. Since OMP25 and OMP31 are beta barrel structure, their expression takes the form of inclusion body. After purification and renaturation of our target proteins, we first tested their ability to detect serum antibodies after inoculation. We found that these two proteins were equal in detection of vaccinated serum antibodies and the results were consistent with traditional RBPT method. However, when we applied these two proteins in epidemiological surveys, the results showed that OMP25o was more sensitive than OMP31m, and the result of OMP25o was consistent with that of RBPT. So, we reasoned that our epidemiological samples should have B. ovis antibody positive samples. PCR confirmed that our samples indeed contained B. ovis. Four out of six samples tested positive. Our indirect ELISA based on two antigens is an effective serum screening strategy that can overcome the drawback of false negative in PCR. If this strategy can combine with PCR detection, the diagnosis of brucellosis will be more accurate. It will be realizable to find a sheep flock without brucellosis.The original contributions presented in the study are included in the article/The animal study was reviewed and approved by Institutional Animal Care and Use Committee of Jilin University. Written informed consent was obtained from the owners for the participation of their animals in this study.TZ and YW conduct the experiment. TQ, YL, and ZY calculate and statistic the data. BZ and HJ designed the experiment and written the manuscript. LC analyzed data and interpretation. All authors contributed to the article and approved the submitted version.


Breast cancer is the leading cancer in women in developed and developing countries. Treatment strategies can affect sexuality in the short or long term.The aim of our study was to assess sexuality and martial satisfaction in patients followed for breast cancer.Cross-sectional descriptive study including patients followed for breast cancer at the outpatient medical oncology consultation of Hadj Ali Soua regional hospital from January to March 2021. We passed the Female Sexual Function Index (FSFI) and the martial adjustment test (MAT).Fifteen patients were included with a mean age of 49.87 ± 8.48 years and a mean age at diagnosis of 46.73 ± 7.55 years. At the TNM classification, 66.6% of the patients had a T1 or T2 at the time of diagnosis and 80% had an N0. All patients received a surgical intervention, which was conservative in 53.3% of cases. No patient underwent breast reconstruction. Chemotherapy and hormone therapy were prescribed in 86.7% of patients. Radiotherapy and targeted therapy were prescribed in 12 and 2 case, respectively. Amenorrhea, hot flushes and vaginal dryness were noted in 98.7%, 26.7% and 7.6% of patients, respectively. Sexual disorders were found in 53.3% of cases, which settled in a chronic mode in 75% of cases and progressed in a continuous mode in half of cases. The assessment of physical and erotic life was revealed to be neat in 73.3% of the patients. The mean score of the FSFI questionnaire was 17.25 [2.6-31.9]. Eleven patients (73.3%) had sexual dysfunction. A low marital satisfaction was found in 34% of cases.The medical consultation to identify sexuality disorders in correlation with the martial dissatisfaction in women followed for new breast cancer is crucial allowing a better management of this pathology.None Declared


In the published article, there was an error in In the published article, there was an error. Values for peak force were off by a decimal point.26.5 should have read 266.4; 26.09 should have read 260.9; 28.29 should have read 282.9; 27.81 should have read 278.1; 24.83 should have read 248.3; and 24.11 should have read 241.1.Results, paragraph 2. The sentences previously stated:A correction has been made to ′′ jump height and 26.09 (%BW) for the preferred jump height (p = 0.4228). When evaluating the peak force of the trailing forelimb, the mean peak force was 28.29 (%BW) for the 20′′ jump height and 27.81 (%BW) for the preferred jump height (p = 0.7081). When evaluating the peak force of the leading forelimb, the mean peak force was 24.83 (%BW) for the 20′′ jump height and 24.11 (%BW) for the preferred jump height (Mean peak force when averaging the forelimbs was 26.5 (%BW) for the 20p height . The meap height . The meap height .The corrected sentence appears below:′′ jump height and 260.9 (%BW) for the preferred jump height (p = 0.4228). When evaluating the peak force of the trailing forelimb, the mean peak force was 282.9 (%BW) for the 20′′ jump height and 278.1 (%BW) for the preferred jump height (p = 0.7081). When evaluating the peak force of the leading forelimb, the mean peak force was 248.3 (%BW) for the 20′′ jump height and 241.1 (%BW) for the preferred jump height (Mean peak force when averaging the forelimbs was 266.4 (%BW) for the 20p height . The meap height . The meap height .The authors apologize for this error and state that this does not change the scientific conclusions of the article in any way. The original article has been updated.


Chenopodium quinoa Willd.) is a highly nutritious food product with a comprehensive development prospect. Here, we discussed the effect of Bacillus amyloliquefaciens 11B91 on the growth, development and salt tolerance  of quinoa and highlighted a positive role for the application of plant growth-promoting rhizobacteria bacteria in quinoa. In this artical, the growth-promoting effect of Bacillus amyloliquefaciens 11B91 on quinoa (Longli No.1) and the changes in biomass, chlorophyll content, root activity and total phosphorus content under salt stress were measured. The results revealed that plants inoculated with 11B91 exhibited increased maximum shoot fresh weight (73.95%), root fresh weight (75.36%), root dry weight (136%), chlorophyll a (65.32%) contents and chlorophyll b (58.5%) contents, root activity (54.44%) and total phosphorus content (16.66%). Additionally, plants inoculated with 11B91 under salt stress plants showed significantly improved, fresh weight (107%), dry weight (133%), chlorophyll a (162%) contents and chlorophyll b (76.37%) contents, root activity (33.07%), and total phosphorus content (42.73%).Quinoa ( In the Bacillus amyloliquefaciens 11B91 was obtained from the Northwest Institute of Eco-Environmental and Resources, Quinoa seed (Longli No. 1) was obtained from the Animal Husbandry, Pasture and Green Agriculture Institute .4 for 10 min and rinsing in sterile water until it was colorless. For the seed soaking treatment, Luria-Bertani (LB) liquid medium was first prepared by mixing of distilled water (1 L) with tryptone (10 g), yeast extract (5 g), and sodium chloride (10 g) according to the recipe at pH 7.2 ± 0.2, and then sterilizing it at 121 °C for 20 min; the LB liquid medium was inoculated with strain Bacillus amyloliquefaciens 11B91 and incubated at 28 °C and 180 r/min to facilitate rapid culture (Bacillus amyloliquefaciens 11B91 (treatment group) for 5 min, ensuring that the seeds were completely submerged (The seeds were disinfected by soaking quinoa seed in 0.5% KMnOately 1) . Quinoa ubmerged .3, 0.5 mM NH4H2PO4, 0.5 mM Ca(NO3)2, 0.5 mM MgSO4, 0.5 mM Fe-citrate, 92 µM H3BO3, 18 µM MnCl2·4H2O, 1.6 µM ZnSO4·7H2O, 0.6 µM CuSO4·5H2O, and 0.7 µM (NH4)6Mo7O24·4H2O) (2 L). Relevant physiological data were measured at 2, 3 and 4 weeks of quinoa growth  and chlorophyll b (Chl b) were calculated as follows:Fresh leaves (0.05 g) were weighed and recorded by a specific weight (G). After crushing, they were placed in 10 mL centrifuge tubes, and 10 mL ethanol acetone (1:1) mixed solution was added. Samples were stored in the light for 48 h, and the absorbance value was determined with UV-spectrophotometer  at 663 and 645 nm wavelengths (using solution as a blank control) . The conW: veight of fresh leaves; V: volume of ethanol acetone (1:1) mixed solution; A663 and A645: the absorbance value was determined with a spectrophotometer at 663 and 645 nm wavelengths, respectively.Note: The triphenyl tetrazolium chloride (TTC) colorimetric method was used to determine root activity in quinoa. Quinoa roots (0.5 g) were mixed with 10 mL of 0.4% TTC solution, succinic acid and phosphoric acid buffer in equal amounts. A TTC standard curve was obtained, and the TTC reduction was calculated against the standard curve .C: TTC (μg), w: root weight (g), h: time (h).Note: 2O2) and concentrated H2SO4, allowed to cool and then fixed in ultrapure water. Then, the total phosphorus content of the quinoa was determined using the molybdenum blue colorimetric method. Total P (mg·g−1 DW) was measured at 420 nm with a UV-spectrophotometer using potassium dihydrogen phosphate as the calibration standard.For the determination of the total phosphorus content, a method described by p ≤ 0.05. The Duncan multi-interval test was used for one-way analysis of variance (ANOVA). The results of the growth and physiological data are presented as the mean ± standard error. The data were plotted using ORIGIN software  was used to identify differences between means at a significance level of software .p < 0.05). In the second and third weeks of the 11B91 treatment, the fresh weight of the aboveground parts was 59.54% and 73.95% higher than that of the blank group (p < 0.05) between the first and second weeks of 11B91-treated seedlings, and the fresh root weight of 11B91—treated seedlings was 49.66% higher than the blank group in the third week . The dry root weight of the 11B91-treated seedlings was 1.36 times higher than that of the blank group. In the first and third weeks, there was no significant difference in root dry weight of 11B91-treated seedlings (p < 0.05). At the third week of 11B91 treatment, the dry root weight was 49.56% higher than that of the blank group  (a content in the first and third weeks of the 11B91 treatment was 65.32% and 23.48% higher than that in the blank group. There was no significant difference in chlorophyll a content in the second week of 11B91-treated seedlings (p < 0.05), and the content of chlorophyll a in seedlings treated with 11B91 was 11.23% higher than in the blank group (The content of chlorophyll  < 0.05) . The chlnk group .b in the first week of quinoa seedlings treated with B. amyloliquefaciens 11B91 was significantly higher than that in the blank group (p < 0.05); the content of chlorophyll b in the first week of seedlings treated with 11B91 was 58.50% higher than that in the blank group (b content in the second and third weeks of 11B91-treated seedlings (p > 0.05); the content of chlorophyll b in 11B91-treated quinoa seedlings was 45.42% higher than that in the blank group in the third week  than that of the blank group in the first week . The fresh weight of quinoa treated with 11B91 was 63.99% and 83.55% higher than that of the blank group in the first and second weeks of 0 mM salt treatment (p < 0.05). The fresh weight in the 11B91 treatment was 23.98% higher than that of the blank group in the third week of 0 mM salt treatment and 54.99% higher in the second week of 300 mM salt treatment than in the blank group  . No significant difference was found in dry weight in the 0 mM treatment at three weeks or the treatment during the first and third weeks of salt treatment.The dry weight of 11B91-treated quinoa seedlings treated with 150 mM salt in the second week and 300 mM salt in the first week was significantly higher than that of the blank group ( < 0.05)  and 5D. The dry weight in the 11B91 treatment was 21.07% and 11.26% higher than that of the blank group in the 0 mM salt treatment in the first and third weeks, respectively. In the 150 mM salt treatment in the first and third weeks, the dry weight was 20.54% and 10.85% higher than that in the blank group  and 5F.a in quinoa treated with 11B91 was significantly higher than that in the blank group (p < 0.05) in the 0 mM salt treatment at 2 and 3 weeks, 150 mM salt treatment in the first week, and 300 mM salt treatment in the first, second and third weeks . The chlorophyll a content in the first week with 11B91 in the 0 mM salt treatment was 11.23% higher than that in the blank group  . The chlorophyll b content in the third week of the 0 mM salt treatment was 24.82% higher than that in the blank group, and in the first and third weeks of the 300 mM salt treatment, it was 109% and 20.53% higher than that in the blank group, respectively (The content of chlorophyll rd weeks  and 6E. nk group  and 6E.  < 0.05) . The chlectively .p < 0.05). The root activity of the 11B91-treated seedlings was 5.45% higher than that of the blank group in the first week of 0 mM salt treatment . In the second week, the total phosphorus content of the 11B91 treatment was 7.40% higher under 150 mM salt treatment than that in the blank group and 42.73% higher under 300 mM salt treatment than that in the blank group . However, the root activity was higher in the control group than in the group treated with 11B91 in the third week. The total phosphorus content of quinoa seedlings inoculated with 11B91 began to decline after the second week. This is because Bacillus can quickly occupy a dominant position in the root, but over time, the relative abundance gradually decreases, while strains of the genus Myxococcus continue to exist and dominate in the root (The root is an organ that absorbs water and nutrients and plays an important role in the growth and development of plants. The PGPR microbial inoculants increased the dry weight, plant height, root length, root average diameter, root surface area, and root volume of eedlings . Similarthe root .Pseudomonas sp., Bacillus sp. and Enterobacter sp with different salt concentrations can promote the germination of inebrians seeds and promotes the growth of rice and millet (Low salt stress slows the growth rate of plants, and high salt stress causes the growth and development of plants to be in a state of obvious stagnation. Inoculation of rhizosphere growth-promoting bacteria d millet . In thisd millet .Medicago sativa L. under salt stress (a content of quinoa seedlings inoculated with 11B91 was significantly increased in the second and third weeks of 0 mM salt treatment, the second week of 150 mM salt treatment, and the first and second weeks of 300 mM salt treatment. The chlorophyll b content was significantly increased in the second week of 0 mM, and in the first and second weeks of 300 mM salt treatment, it was higher than that of the LB blank control group. The same results were noted in white clover and ryegrass (Chlorophyll content is an important indicator of plant photosynthesis. However, the chlorophyll content will still decrease under salt, drought and other abiotic stressors. Studies have demonstrated that the chlorophyll content of plants with weak stress resistance decreases faster than that of plants with strong stress resistance . Studiest stress . The chlryegrass .Phosphorus is associated with the formation of biomacromolecules and compounds in plants, photosynthesis, and stress resistance. Phosphorus is an indispensable element for plant growth and development. Studies have shown that some rhizosphere growth-promoting bacteria play a promoting role in phosphorus uptake by plants. PGPR bacterial fertilizer alone or in combination significantly increases the total phosphorus content of oats . The rooBacillus amyloliquefaciens 11B91 could be suitable for promoting plant growth in quinoa. Under salt stress, 11B91 promoted the growth of quinoa and increased the root and total biomass of quinoa seedlings. The chlorophyll a and chlorophyll b content in the 300 mM NaCl treatment was increased by 11B91 inoculation. 11B91 improved the root activity of seedlings under salinity in the third week; it also improved the total phosphorus content of seedlings under salinity. These data provide evidence that 11B91 inoculation can improve the salt tolerance of quinoa seedlings.Taken together, the findings of this study suggest that inoculation with 10.7717/peerj.15925/supp-1Supplemental Information 1Click here for additional data file.


Cases were microbiologically confirmed COVID-19 patients who died in the hospital during the period of study and controls were microbiologically confirmed COVID-19 patients who were discharged from the same hospital after recovery. Cases were recruited sequentially from March 2020 until December–March 2021. All information regarding cases and controls was extracted retrospectively from the medical records of patients by trained physicians. Univariable and multivariable logistic regression was done to assess the association between various predictor variables and deaths due to COVID-19. A total of 2,431 patients  were included in the study. The mean age of patients was 52.8 years (SD: 16.5 years), and 32.1% were females. Breathlessness was the most common symptom at the time of admission (53.2%). Increasing age ; preexisting diabetes mellitus (aOR: 1.9 [95% CI: 1.2–2.9]); malignancy (aOR: 3.1 [95% CI: 1.3–7.8]); pulmonary tuberculosis (aOR: 3.3 [95% CI: 1.2–8.8]); breathlessness at the time of admission (aOR: 2.2 [95% CI: 1.4–3.5]); high quick Sequential Organ Failure Assessment score at the time of admission (aOR: 5.6 [95% CI: 2.7–11.4]); and oxygen saturation < 94% at the time of admission (aOR: 2.5 [95% CI: 1.6–3.9]) were associated with mortality due to COVID-19. These results can be used to prioritize patients who are at increased risk of death and to rationalize therapy to reduce mortality due to COVID-19.Severe acute respiratory syndrome coronavirus 2 disease (COVID-19) has caused more than 6 million deaths globally. Understanding predictors of mortality will help in prioritizing patient care and preventive approaches. This was a multicentric, unmatched, hospital-based case-control study conducted in nine teaching hospitals in India.  The pandemic of novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), first reported in the Wuhan province in China in December 2019, caused at least 3 million deaths globally in 2020 by the WHO’s preliminary estimates.The mortality observed in the Indian and South Asian subcontinent has reportedly been lower than in the West, and multiple reasons have been ascribed for this differential mortality as described in the literature.2) and dyspnea at admission, and preexisting morbidities as predictors of in-hospital mortality due to COVID-19.–,,Various studies have reported higher age, male sex, low oxygen saturation /rapid antigen test (RAT) during the hospital stay or within 28 days before hospital admission and death in the hospital during the study period. Controls were patients with infection with SARS CoV-2 diagnosed by RT-PCR/RAT who were discharged from the hospital after recovery and were recruited from the same hospital. Although we initially planned to have two controls per case, this was later changed to one control per case when the sample size planned for the study (660 cases) was exceeded. This sample size was adequate for estimation of an odds ratio of 1.5 for a population exposure level of 15% with 1% alpha error and 85% power. Cases were consecutively selected from hospital records by date of admission. Cases and controls were selected at a ratio of 1:1. Controls were not matched to cases except by day of admission in the same hospital and were selected randomly from hospital records.2, and pulse rate), was extracted. The quick Sequential Organ Failure Assessment (qSOFA) score was calculated by assigning a score of 1 each for altered mental status, respiratory rate ≥ 22, and systolic blood pressure ≥ 100 mm Hg. Information on administration of antivirals, steroids, hydroxychloroquine, convalescent plasma, or immunoglobulins was collected; however, data on type of antiviral or duration of drug treatment were not extracted. In addition, information on type of respiratory support , complications during the hospital stay , and admission to the intensive care unit (ICU) was extracted.All information regarding cases and controls was extracted retrospectively from the medical records of patients. A standardized data extraction sheet was developed, and data were extracted by trained physicians. In addition to age and sex, information on preexisting morbidities  was extracted. Missing information on preexisting morbidities was treated as absence of morbidity, as it was assumed that it is a routine practice to record those morbidities in hospital case sheets. Information on the clinical status of a patient at the time of admission, that is, presenting symptoms  and signs  in the bivariate analysis. Adjustments were done in the multivariable logistic regression for age, sex, preexisting morbidities, presenting symptoms at the time of admission, qSOFA score and SpO2 at the time of admission, admission in the ICU, invasive mechanical ventilation, and associated complications in the hospital. Adjustment for clustering by site was done in all analyses. P < 0.05 was considered significant. Ethical approval for the analysis was obtained from the Ethics Committee of the All India Institute of Medical Sciences, New Delhi, and all participating institutes.Data were entered in an Excel sheet and imported in Stata version 15  for further analysis. No imputation was done for missing data. Various study characteristics were presented either as proportion or means and compared between cases and controls using the χA total of 2,431 patients were included in the study; 1,137 were cases, and 1,294 were controls. The least number of cases contributed by a site was 27, and the maximum was 334. The participating hospitals showed considerable variations in patient severity profile (comorbidity and qSOFA score) and treatment practices, especially the use of antivirals and hydroxychloroquine .The mean age of patients was 52.8 years (SD: 16.5 years), and 32.1% were females. In addition, 6.1% of patients had a history of ischemic heart disease, one-third had a history of hypertension, approximately one-third had a history of diabetes mellitus, 10.0% had a history of chronic respiratory disease, and 12.2% were current smokers . Only ha2 than controls (86.7% versus 96.2%) at the time of admission. Cases were more likely than controls to receive antivirals (25.2% versus 8.4%) and steroids (70.4% versus 26.8%) but less likely to receive hydroxychloroquine (21.3% versus 27.9%), more likely to be put on invasive (78.2% versus 3.9%) or noninvasive (47.6% versus 1.3%) ventilation, and more likely to be admitted to the ICU (78.2% versus 10.1%). During treatment, cases were more likely than controls to develop sepsis (35.2% versus 0.7%), coagulopathy (8.7% versus 3.6%), acute renal injury (29.6% versus 0.9%), stroke (3.5% versus 0), and myocarditis (2.0% versus 0)  and male (71.4% versus 64.8%) and to have comorbidities . Cases were less likely than controls to have been admitted with confirmed COVID-19 (32.4% versus 61.5%) and more likely to have a fever (53.7% versus 40.7%), and breathlessness (77.5% versus 31.7%). Cases also had a lower mean SpOersus 0) .2 < 94% at the time of admission (aOR: 2.5 [95% CI: 1.6–3.9]).On multivariable analysis, the following variables were associated with mortality due to COVID-19: increasing age (adjusted odds ratio [aOR]: 46–59 years: 3.4 [95% CI: 1.5–7.7]), 60–74 years: (4.1 [95% CI: 1.7–9.5]), ≥ 75 years: (11.0 [95% CI: 4.0–30.6]); preexisting diabetes mellitus (aOR: 1.9 [95% CI: 1.2–2.9]); malignancy (aOR: 3.1 [95% CI: 1.3–7.8]); pulmonary tuberculosis (aOR: 3.3 [95% CI: 1.2–8.8]); breathlessness at the time of admission (aOR: 2.2 [95% CI: 1.4–3.5]); high qSOFA score at the time of admission (aOR: 5.6 [95% CI: 2.7–11.4]); and SpOThere was no difference in mortality by sex after adjustment for other variables. Administration of convalescent plasma or hydroxychloroquine during hospitalization did not affect the odds of mortality . People 2 and high qSOFA score at time of admission were associated with higher odds of death. Patients with COVID-19 who were 75 years or older were 11 times more likely to die than those younger than 30 years. To the best of our knowledge, this is one of the first multicentric studies to estimate predictors of COVID-19 death in India with a robust sample size.In this hospital-based case-control study of predictors of mortality due to COVID-19, we found that older age, preexisting diabetes mellitus, pulmonary tuberculosis or malignancy, difficulty in breathing at admission, and low SpO,,,–,,,,,We found that increasing age was associated with increased odds of mortality due to COVID-19. This is consistent with evidence from elsewhere. A multicentric cohort study among adults 18 years or older in 10 countries of Africa found that every increasing year increased the odds of death due to COVID-19 by 3%.,2 value ≤ 94% at the time of admission was also associated with higher odds of mortality; similar results were found in other studies as well.,,,,,,,,We found that poor clinical status at the time of hospital admission was associated with increased odds of mortality. The qSOFA score, which combines low systolic blood pressure, altered mental status, and raised respiratory rate, was a strong predictor of mortality due to COVID-19 in our study. We found that those with a qSOFA score of 2 and above were five times more likely to die as a result of COVID-19, which was consistent with other studies.,,,,,,,Among the preexisting morbidities that we examined, diabetes mellitus, malignancy, and pulmonary tuberculosis were found to be independent predictors of mortality due to COVID-19. Studies have found an association between multi-morbidity and deaths due to COVID-19.,,,We found that use of hydroxychloroquine was not associated with reduced odds of mortality due to COVID-19. Although some observational studies have reported protection with use of hydroxychloroquine,2 < 95%: 2; age ≥ 50 years: 2.52; pulse rate ≥ 100/minute: 2.02; and coexisting diabetes mellitus: 1.73, with hypertension and gender not retaining their significance. These results are similar to those of the current study in relation to the variables SpO2 (95/94%), age, and preexisting diabetes mellitus.A similar study conducted in Tamil Nadu (South India) found a higher mortality rate among patients aged 40–70 years, with the highest rate among diabetic patients with elevated urea levels.This study was conducted in multiple hospital settings with a robust sample size. However, there are some limitations. As is true for any study based on retrospective extraction of patient case records, completeness was a major limitation. The study did not capture risk factors such as day of illness at admission, severity of illness (moderate/severe), or laboratory parameters, as well as details of treatment such as dose and duration. However, we used indicators for severity both at the time of admission  and during the period of hospitalization  to adjust our analyses. We did not impute any data on signs and symptoms, but preexisting morbidities or treatment modalities during hospitalization were considered positive only when they were explicitly mentioned in the case record. The ratio of cases to controls in the study institutions was variable. The emergence of newer data during the study period led to a change in standard practice at the institutions in the study period, which may have affected the comparisons.2 and general condition as determined by qSOFA score at the time of admission, and admission to the ICU were significant predictors of mortality among hospitalized patients with COVID-19. Prioritizing patients at increased risk of death and rationalizing therapy will help reduce mortality due to COVID-19 during the ongoing pandemic.In this hospital-based case-control study, we found that older age, preexisting diabetes mellitus, pulmonary tuberculosis or malignancy, difficulty in breathing, low SpO


Patients with an SPPB score > 5 had a Barthel index < 60 in only 4% (n = 4) of cases; the remainder of the patients  had a Barthel index > 60. Patients with an SPPB > 5 showed a higher probability of survival at 30 days (p = 0.029), 6 months (p = 0.031), and 1 year (p = 0.007) with ; OR: 3.9; 95%CI (1.30–11.60); OR: 6.01; 95%CI (1.90–18.30)), respectively. No statistically significant differences were obtained in the probability of readmission at 30 days, 6 months, and 1 year (p > 0.05). Conclusions: Patients admitted with acute heart failure showed a high frequency of frailty as assessed by the SPPB. Patients with an SPPB ≤ 5 had greater comorbidities and greater functional limitations than patients with an SPPB > 5. Patients with heart failure and a Barthel index > 60 frequently presented an SPPB < 5. In daily clinical practice, priority should be given to performing the SPPB in patients with a Barthel index > 60 to assess frailty. Patients with an SPPB ≤ 5 had a higher risk of mortality at 30 days, 6 months, and 1 year than patients with an SPPB ≤ 5. The SPPB is a valid tool for identifying frailty in acute heart failure patients and predicting 30-day, 6-month, and 1-year mortality.Background: Most patients diagnosed with heart failure (HF) are older adults with multiple comorbidities. Multipathological patients constitute a population with common characteristics: greater clinical complexity and vulnerability, frailty, mortality, functional deterioration, polypharmacy, and poorer health-related quality of life with more dependency. Objectives: To evaluate the clinical characteristics of hospitalized patients with acute heart failure and to determine the prognosis of patients with acute heart failure according to the Short Physical Performance Battery (SPPB) scale. Methods: Observational, prospective, and multicenter cohort study conducted from September 2020 to May 2022 in patients with acute heart failure as the main diagnosis and NT-ProBNP > 300 pg. The cohort included patients admitted to internal medicine departments in 18 hospitals in Spain. Epidemiological variables, comorbidities, cardiovascular risk factors, cardiovascular history, analytical parameters, and treatment during admission and discharge of the patients were collected. Level of frailty was assessed by the SPPB scale, and dependence, through the Barthel index. A descriptive analysis of all the variables was carried out, expressed as frequencies and percentages. A bivariate analysis of the SPPB was performed based on the score obtained (SPPB ≤ 5 and SPPB > 5). For the overall analysis of mortality, HF mortality, and readmission of patients at 30 days, 6 months, and 1 year, Kaplan–Meier survival curves were used, in which the survival experience among patients with an SPPB > 5 and SPPB ≤ 5 was compared. Results: A total of 482 patients were divided into two groups according to the SPPB with a cut-off point of an SPPB < 5. In the sample, 349 patients (77.7%) had an SPPB ≤ 5 and 100 patients (22.30%) had an SPPB > 5. Females (61%) predominated in the group with an SPPB ≤ 5 and males (61%) in those with an SPPB > 5. The mean age was higher in patients with an SPPB ≤ 5 (85.63 years). Anemia was more frequent in patients with an SPPB ≤ 5 (39.5%) than in patients with an SPPB ≥ 5 (29%). This was also seen with osteoarthritis (32.7%,  Most patients diagnosed with heart failure (HF) are older adults with multiple comorbidities . PatientHF patients usually have several associated comorbidities, and in fact, the absence of these is exceptional. However, most HF registries tend to collect comorbidities associated only with a cardiovascular etiology such as arterial hypertension, diabetes mellitus, hypercholesterolemia, smoking, and atrial fibrillation. These registries ignore other comorbid processes which, although apparently unrelated to the HF process, can have a direct influence on the prognosis of these patients and are often the cause of hospital admission . In the In the hospital setting, frailty is a clinical syndrome that is defined as “a state of increased vulnerability as a result of decreased physiologic reserve and function in multiple systems, with consequent compromise in the ability to cope with any stressful situation” ,8. FrailA recent study evaluating the prevalence of frailty in patients with heart failure concluded that 50% of hospitalized older patients with HF were frail. Frailty is associated with higher rates of adverse events, increased risk of hospitalization, and poor long-term survival ,13,14,15A frailty scale that has become one of the most promising tools for the assessment of functional capacity is the Short Physical Performance Battery (SPPB) ,17. The The aim of this study was to determine the clinical characteristics of patients admitted for acute HF and their prognosis according to the SPPB.We conducted a prospective observational multicenter cohort study based on the PROFUND-IC registry of the Spanish Society of Internal Medicine (SEMI). We selected patients admitted for acute heart failure as the main diagnosis in the internal medicine services of 18 hospitals in Spain between September 2020 and May 2022. Inclusion criteria were age > 18 years, main diagnosis of acute HF, and NT-proBNP on admission > 300 pg/mL. Patients with active COVID-19 infection were excluded.The data were collected prospectively in the internal medicine and cardiology departments from one of the 18 hospitals that collaborated in the admission of the patients (first 24–48 h). Demographic variables were recorded such as sex and age and clinical variables such as HF etiology , comorbidities, toxic habits , and Barthel index were recorded. Analytical variables included pro-BNP, hemoglobin, lymphocyte count, creatinine, serum sodium, serum potassium, total cholesterol, LDL cholesterol, albumin, urinary sodium, and potassium. The treatments received during admission were collected, including intravenous iron, red blood cell transfusion, antibiotics, bronchodilators, corticoids, hypertonic saline solution, maximum dose of furosemide during, protein supplements, and treatment at discharge.three balancing positions with increasing difficulty, each held for 10 s;walking 4 m at the usual pace to assess walking speed;getting up from a chair without assistance and time to perform five repetitions.Frailty is the main variable to be measured in this study. The tool selected to measure frailty in patients with acute heart failure is the SPPB which consists of three tests:Each test is scored from 0 to 4 points, using previously defined and validated cut-off points, after which a final score of between 0 and 12 points is obtained, with the total score indicating overall physical function. The SPPB was categorized according to the latest studies for analysis into very low (0–3 points), low (4–6 points), moderate (7–9 points), and high (10–12 points) . FrailtyFeet together: less than 10 s (0 points) or 10 s (1 point);Semi-tandem: less than 10 s (0 points) or 10 s (1 point);Tandem: less than 3 s (0 points), 3 < 10 s (1 point), or 10 s (2 points);Time spent walking 4 m at normal pace: cannot (0 points), more than 8.7 s (1 point), 6.2–8.7 s (2 points), 4.8–6.2 (3 points), or less than 4.8 (4 points);Crossing arms across chest and rising from chair: unable (0 points) or able (1 point);Five repetitions of previous tests: more than 60 s or cannot (0 points), more than 16.7 s (1 point), 13.7 to less than 16.7 (2 points), 11.2 to less than 13.7 (3 points), or 11.19 s or less (4 points).Clinical assessment on admission by the SPPB consisted of the following:The patients were divided into two groups according to an SPPB ≥ 5 and SPPB < 5. All patients were followed up at 30 days, 6 months, and 1 year after hospital discharge and the following variables were collected: readmission, cause of readmission (heart failure/other), exits, or death due to cardiovascular causes.A descriptive analysis of the variables was performed, and an analysis of the frequencies and percentages is presented. Continuous variables are expressed as means with standard deviation or medians with interquartile ranges (25th to 75th percentiles). A bivariate analysis of the SPPB was performed and, depending on the score obtained, patients were stratified according to an SPPB > 5 and SPPB ≤ 5. After stratification, a description of the variables for each of the groups was made and presented by frequency distribution, mean, and median.t-test and Mann–Whitney U test were used for quantitative variables for distributions that did not meet the normality criteria. For qualitative variables, the Chi-square test (χ2) or Fisher’s test was used. Kaplan–Meier analysis was performed for 30-day, 6-month, and 1-year mortality among patients with an SPPB > 5 and ≤ 5. A binary logistic regression analysis adjusted for comorbidities was performed.To obtain the possible differences between groups, the Student’s Data analysis was performed using the Statistical Package for Social Sciences (SPSS) version 25.0 for Mac OS.A total of 482 patients were included with a main diagnosis of acute heart failure, including 269 women (55.8%). The mean age was 82.8 ± 9.3 years, and women were older (83.9 ± 8.5) compared to men. Among the most frequent comorbidities were arterial hypertension (91.1%), atrial fibrillation (62.2%), dyslipidemia (67.9%), chronic kidney disease (52.7%), diabetes mellitus (46.9%), chronic anemia (36.9%), ischemic heart disease (34.9%), chronic osteoarticular disease (27.6%), COPD (22%), diabetes mellitus with retinopathy and symptomatic neuropathy (18.7%), and previous stroke (17.8%). Smoking was reported in 33.7% and alcohol intake in 9%. More than half of the patients (55%) were NYHA II, followed by NYHA III (35.5%), NYHA I (6.8%), and NYHA IV (2.3%). The mean daily dose of furosemide was 113.9 ± 95.7 mg/day .Of the 482 patients in the sample, the SPPB was assessed in 449 patients. A total of 77.7% of the patients obtained an SPPB score ≤ 5, while 22.3% of the patients obtained an SPPB score > 5. The categorized SPPB results showed that 60.6% of the patients obtained a very low score (0–3), 22.1% of the patients obtained a low score (4–6), 11.1%, a medium score (7–9), and 6%, a high score (10–12) .n = 349, 77.7%) and SPPB > 5 . Most patients (61%) with an SPPB ≤ 5 were female and most patients (61%) with an SPPB > 5 were male. The mean age of the patients was higher in patients with an SPPB ≤ 5 (85.6 years). Of note, a higher frequency of certain comorbidities was identified in patients with an SPPB ≤ 5 (p < 0.05). Neurological disease with motor deficit and cognitive deficit was found in 8.6% and 13.2% in patients with an SPPB > 5 and SPPB ≤ 5, respectively (p = 0.000). Anemia was more common in patients with an SPPB ≤ 5 (39.5%) than in patients with an SPPB > 5 (29%). Similarly, osteoarticular disease was more frequently described in patients with an SPPB ≤ 5 (32.7%) than in patients with an SPPB > 5 (14%) (p = 0.000). Diabetes and dyslipidemia were more common in patients with an SPPB ≤ 5  . In contrast, patients with an SPPB > 5 showed higher frequency in variable smoking and alcohol intake than patients with an SPPB ≤ 5, and 51% smoking and 20% alcohol intake were described in patients with SPPB ≥ 5 (p = 0.000) (Patients were divided into two groups according to the SPPB with a cut-off point of an SPPB ≤ 5 (= 0.000) .p = 0.017). In contrast, a higher frequency of dilated cardiomyopathy HF was observed in patients with an SPPB > 5, described in 5.1% (p = 0.016). The presence of valvulopathies and the number of admissions recorded in the last year were similar in both groups, with no statistically significant differences. In relation to the assessment of functional class according to the NYHA, although no differences were found between groups in the initial stages  (p > 0.05), differences were found between both groups (SPPB ≤ 5 and SPPB > 5) when the functional limitation was moderate (NYHA III) (p = 0.001) , showing significant differences with patients with an SBPP > 5 (33.3%) (= 0.001) .p > 0.05) except for the administration of hypertonic saline, for which its use was described in the patients with an SPPB ≤ 5 (2.33%) (p = 0.002). With respect to the administration of morphine, differences between groups were also identified, with its application being more frequent in patients with an SPPB ≤ 5 (15.36%) than in patients with an SPPB > 5 (4.12%) (p = 0.001)  .p > 0.05). There were differences (p = 0.048) in the use of new anticoagulants, with less administration in patients with an SPPB ≤ 5 (23.2%) than in patients with an SPPB > 5 (33%)  .n = 152) of the patients with an SPPB ≤ 5 had a Barthel index < 60, which shows dependence for daily life activities, and 56.4% of patients with an SPPB ≤ 5  had a Barthel index > 60, correlating with independence for basic activities of daily living. Patients with an SPPB > 5 score had a Barthel index < 60 in only 4% (n = 4) of the cases; the remaining patients were rated as independent. Statistically significant differences between groups were seen (p = 0.000).In this cohort, nearly half . In-hospital mortality in our total sample of patients was 6.33% (n = 28). All deceased patients had an SPPB score ≤ 5 (p = 0.000) and 4.98% (n = 22) died from HF (p = 0.000).Spearman’s correlation analysis showed a positive correlation (0.728) between the SPPB and Barthel index variables (n = 61). A total of 5.16% were readmitted for HF exacerbation. In patients with an SPPB > 5, hospital readmission for all diagnoses was 3.65% (n = 12) and 1.21% (n = 4) readmission for HF. At the 6-month follow-up, readmission of patients with an SPPB ≤ 5 was 21.16% (n = 102) and 7.08% (n = 34) were readmitted for HF exacerbation. At the 1-year follow-up after hospital discharge, 25.52% (n = 123) of patients with an SPPB ≤ 5 were readmitted to the hospital and 8.08% (n = 39) were readmitted for HF exacerbation (p = 0.000). In patients with an SPPB > 5 score, we noted a hospital readmission of 5.8% (n = 28) of patients with readmission for HF in 2.90% (n = 14).At the 30-day follow-up after hospital discharge, readmission of patients with an SPPB ≤ 5 occurred in 18.54% (p = 0.000). Mortality for patients with an SPPB ≤ 5 was 14.85% (n = 54) and 7.9% (n = 30) died from HF. Mortality for patients with an SPPB > 5 was 0.55% (n = 2); both cases were due to HF. The 6-month mortality observed according to the SPPB also showed differences in the patient cohorts (p = 0.000). Mortality in patients with an SPPB ≤ 5 was 14.33% (n = 69), with 9.55% (n = 46) mortality related to HF. The percentage of patients with an SPPB > 5 who died was 0.83% (n = 4), all due to HF (p = 0.000). The 1-year mortality observed according to the SPPB also shows differences in the patient cohorts (p = 0.000). Patients with an SPPB ≤ 5 died in 16.3% (n = 79) and 11.5% died from HF (n = 55). The percentage of patients with an SPPB ≥ 5 who died was 0.83% due to HF , 6 months (p = 0.031), and 1 year (p = 0.007) with an OR = 7.07; 95%CI (1.60–29.80); OR: 3.9; 95%CI (1.30–11.60); and OR: 6.01; 95%CI (1.90–18.30), respectively, compared to patients with an SPPB ≤ 5 (p > 0.05).The results of our study showed that patients with an SPPB > 5 had a higher probability of survival at 30 days  of patients hospitalized for acute HF. This was higher than the scores published by other authors. For example, Sze et al. reported frailty rates from 30 to 52% in HF patients, perhaps because of a different tool used [In our study, we identified the frailty in 77.7% , in which a score of less than five (SPPB ≤ 5) classified frail patients and a score of more than five (SPPB > 5) classified non-frail patients.p = 0.000), consistent with other authors who concluded that frailty is a state associated with aging [The mean age was higher in patients with an SPPB ≤ 5 (85.6 years) . The percentage of patients with neurological disease with motor and cognitive deficits in frail patients was higher than that observed in patients with an SPPB score > 5. These results are similar to those described by other studies showing an association between frailty, cognitive impairment, and motor deficit [In the analysis of comorbidities according to the score obtained by the SPPB, we identified a higher frequency of certain comorbidities in patients with an SPPB ≤ 5 . The development of anemia has been identified as a contributing factor to frailty syndrome. In the FRADEA study  conducteIn our study, we found differences between subgroups in which the use of the new anticoagulants was lower in the group of frail patients. It is common in published studies to find benefits derived from treatment with direct-acting anticoagulants versus vitamin K antagonists without consideration of frailty, dependence, or other associated comorbidities that influence the physician when initiating or not initiating anticoagulant treatment .Considering the etiology of HF, we found that patients with an SPPB score ≤ 5 presented a higher proportion of HF of hypertensive etiology than patients with an SPPB > 5. Since the Framingham Study, published by Mahmood et al. in 2014, antihypertensive treatment in these patients has not been discussed. However, the diagnosis, treatment, and control of blood pressure has undergone many changes and controversies in the last decades. Still, it is common that some patients are neither diagnosed nor treated given that hypertension is a totally silent entity. This results in HF of hypertensive origin being more common in older patients .In the functional assessment of HF, we found statistically significant differences between groups (NYHA III), with greater limitation for basic activities of daily living in the SPPB ≤ 5 subgroup. This result agrees with what has been reported in other studies, in which a moderate activity limitation leads to a lack of physical activity and a loss of muscle mass and function. These concepts define sarcopenia, key in the cycle of frailty itself, in which the patient becomes increasingly frail ,37,38. IDuring patient admission, the treatments received by both groups did not result in statistically significant differences. No differences in diuretic treatment were found between groups, with the dose of furosemide administered being similar in the frail and non-frail patients, despite the finding that the etiology of HF in a patient with an SPPB ≤ 5 tends to be more congestive. As for the administration of hypertonic saline, in this study, it was only described in patients with an SPPB ≤ 5, showing differences with the SPPB > 5 group. According to the latest experiences published in the JACC-HF regarding the use of hypertonic saline in patients with HF, the authors concluded that it is an effective and safe strategy in patients with advanced HF with diuretic resistance . The useIn our cohort of patients, dyspnea (NYHA III) was more common in the frail patient. This association between the SPPB and the NYHA functional class has been evaluated in some recent studies. A meta-analysis published by Fuentes et al. in 2020 showed that loss of walking function or reduced walking speed was associated with a higher risk of all-cause mortality compared to patients with heart failure who maintained an adequate walking speed. That study further concluded that for each unit improvement in SPPB, the combined risk of hospitalization and mortality could be reduced .Currently, the use of morphine in patients with HF is controversial; according to a recent study published by Domínguez et al. in 2022, the use of opioids should only be used in palliative care situations and not in the usual treatment of acute heart failure ,42. HoweOur results show a positive correlation between the SPPB and Barthel index variables. However, despite the positive correlation between variables, it should not be assumed that a normal Barthel index score rules out frailty in the patient. The Barthel index discriminates very well against dependence, but not against frailty. As can be seen in the results, more than half of the patients with an SPPB ≤ 5 are considered independent, but they are still frail with all that this entails at the prognostic level. This aspect of our study seems clinically relevant, since we can recommend from the results that patients with HF and a Barthel index greater than 60 who are admitted to the hospital should undergo a frailty assessment by SPPB.Patients with an SPPB ≤ 5 presented higher mortality during follow-up and higher readmission. We believe that the difference observed in hospital readmission between patients with an SPPB ≤ 5 and SPPB ≥ 5 is considerable and that comorbidities play an important role, since, as has been described, they are more frequent in frail patients. The survival and mortality risk function analysis of our study showed that patients with an SPPB > 5 had longer survival and that patients with an SPPB ≤ 5 had a higher risk of mortality at 30 days, 6 months, and 1 year compared to patients with an SPPB > 5. HF mortality observed by Martinez Santos et al. in 2019 in Spain was 9.2% and increased to 14.5% at the 1-year follow-up. Volpato et al. reached the same conclusion in a multivariable analysis of survival of patients with low SPPB scores upon hospital discharge. These patients had an increased risk of hospitalization and death compared to those with better SPPB scores . In thisIn contrast, no differences were found in the probability of readmission at 30 days, 6 months, and 1 year. Readmission is a variable influenced after hospital discharge by many factors such as follow-up, early visit, or whether they are referred to an HF unit, internal medicine, or cardiology.This study has some limitations. The frailty assessment was performed during admission, this being the time of greatest risk, and we did not further evaluate the SPPB during follow-up after patient discharge. In addition, we did not compare the SPPB with other simpler scales such as the Frail scale. Finally, we do not know the impact of the interventions performed in frail patients from a rehabilitatitive point of view because they were not evaluated, and we do not know how they may have influenced prognoses. More research is needed in this regard.Patients admitted with acute heart failure showed a high frequency of frailty as assessed by the SPPB. Patients with an SPPB ≤ 5 had greater comorbidities and greater functional limitations than patients with an SPPB > 5. Patients with heart failure and a Barthel index > 60 frequently presented an SPPB < 5. In daily clinical practice, priority should be given to performing the SPPB in patients with Barthel index > 60 to assess frailty. Patients with an SPPB ≤ 5 had a higher risk of mortality at 30 days, 6 months, and 1 year than patients with an SPPB ≤ 5. The SPPB is a valid tool for identifying frailty in acute heart failure patients and predicting mortality at 30 days, 6 months, and 1 year.


BRCA1/2 and all six high-penetrance genes , respectively. Applying the updated criteria for genetic investigation would increase the number of positive detection, leading to potentially more patients. However, the balance between the resource and benefits requires further consideration.The NCCN Clinical Practice Guidelines are testing criteria used to identify high-risk individuals associated with an increased risk of breast, ovarian, pancreatic, and prostate cancer. The testing criteria have been recently modified in early 2023. In this study, we provided a real-world application of the updated criteria and their effect on germline mutation rates in Chinese high-risk breast cancer patients. An additional 6.4% (242/3797) of the patients were included after the revision; the mutation rates in these newly included patients were 2.1% and 2.5% for BRCA1, BRCA2, CDH1, PALB2, PTEN, and TP53, have been recently modified in 2023 to 2023 v.1. The following criteria have been changed: (1) from a person diagnosed with breast cancer at ≤45 to ≤50; (2) from aged 45–50 of personal breast diagnosis to any age of diagnosis with multiple breast cancers; and (3) from aged ≥51 of personal breast diagnosis to any age of diagnosis with family history listed in NCCN 2022 v.2. Methods: High-risk breast cancer patients (n = 3797) were recruited from the Hong Kong Hereditary Breast Cancer Family Registry between 2007 and 2022. Patients were grouped according to NCCN testing criteria 2023 v.1 and 2022 v.2. A 30-gene panel for hereditary breast cancer was performed. The mutation rates on high-penetrance breast cancer susceptibility genes were compared. Results: About 91.2% of the patients met the 2022 v.2 criteria, while 97.5% of the patients met the 2023 v.1 criteria. An extra 6.4% of the patients were included after the revision of the criteria, and 2.5% of the patients did not meet both testing criteria. The germline BRCA1/2 mutation rates for patients meeting the 2022 v.2 and 2023 v.1 criteria were 10.1% and 9.6%, respectively. The germline mutation rates of all 6 high-penetrance genes in these two groups were 12.2% and 11.6%, respectively. Among the additional 242 patients who were included using the new selection criteria, the mutation rates were 2.1% and 2.5% for BRCA1/2 and all 6 high-penetrance genes, respectively. Patients who did not meet both testing criteria were those with multiple personal cancers, a strong family history of cancers not listed in the NCCN, unclear pathology information, or the patient’s voluntary intention to be tested. The mutation rates of BRCA1/2 and the 6 high-penetrance genes in these patients were 5.3% and 6.4%, respectively. Conclusion: This study provided a real-world application of the revision of NCCN guidelines and its effect on the germline mutation rate in the Chinese population. Applying the updated criteria for further genetic investigation would increase the positive detection rate, and potentially more patients would benefit. The balance between the resource and outcome requires careful consideration.Background: The National Comprehensive Cancer Network (NCCN) testing criteria for the high-penetrance breast cancer susceptibility genes, specifically  BRCA1, BRCA2, CDH1, PALB2, PTEN, and TP53) [BRCA1, BRCA2, CDH1, PALB2, PTEN, and TP53. This guideline helped select patients with the highest likelihood of mutation carriers and increased the cost–benefit ratio of genetic testing and subsequent clinical management [BRCA1/2 screening for all women in 2014 [BRCA1, BRCA2, CDH1, PALB2, PTEN, and TP53 genes only instead of a universal testing on all patients with breast cancer. The NCCN panel favored a confined approach due to the low positive detection rate when a large screening panel of genes was tested on all breast cancer patients. There was also a lack of evidence-based input for rarer genes to support risk management. Appropriate use of resources is another consideration. There was a shortage of well-trained genetics counselor and health professionals to provide genetic counseling and the subsequence spinout procedures, such as surveillance cancer screenings, prophylactic surgeries and caring, genetics counseling on related family members, and reproductive planning supports. These situations were not just locally happening in Hong Kong. There were, in fact, a worldwide issue applicable to any country providing or planning to provide such a genetic service. Here, we provided a review and re-examination in our Hong Kong high-risk breast cohort, evaluating the increase in the number of tested patients and the expansions on the spectrum of mutation carriers in the additional actionable genetic variants found by multigene panel testing after compliance with the most current NCCN guideline when compared with the previous version of the NCCN eligibility criteria.Hereditary cancers are often caused by pathogenic or likely pathogenic (P/LP) variants in genes involved in regulating cell growth and/or DNA repair ,2,3. P/Lnd TP53) ,7,8. Thend TP53) ,10. Currnagement . With th in 2014 , but it  in 2014 . The AmeA total of 3797 Asian individuals were recruited through the Hong Kong Hereditary Breast Cancer Family Registry from March 2007 to August 2022 for germline mutation screening. Patients were eligible to participate if they fulfilled the following selection criteria: (1) diagnosed with breast cancer with at least one first- or second-degree relative with breast and/or ovarian cancer, regardless of age; (2) diagnosed with breast cancer ≤50 years; (3) had bilateral breast cancer; (4) had triple-negative breast cancer; (5) male breast cancer; and (6) had personal breast cancer and other cancer. Informed consent was obtained from all recruited participants, and the research was conducted according to the Declaration of Helsinki.Genomic DNA extraction from peripheral blood was performed using a QIAamp DNA Blood Mini Kit  or a QIAsymphony DNA Mini Kit  according to the manufacturer’s instructions. Qualified DNA was pooled and sequenced with a 30-gene panel  or a 93-gene DHS-001Z human breast cancer panel  on MiSeq or NextSeq  instruments. The minimum sequencing depth and median coverage were typically 50-fold of 200–300×. All detected pathogenic variants were further validated by conventional Sanger bi-directional DNA sequencing.http://varnomen.hgvs.org/, accessed on 1 February 2023). The variant descriptions were further cross-checked with a Mutalyzer Name Checker .Variant calling bioinformatics was performed as previously described ,16. Pairp-value of <0.05. Data analyses were performed using the statistical software R (version 3.4.2) [Fisher’s exact test was used to study the relationship between selection variables and the mutation status. The limit of significance for all analyses was defined as a n 3.4.2) .Our testing cohort included 3797 patients with breast cancer. All patients underwent germline genetic testing with a panel of at least 30 genes . The medThere were recent modifications to the NCCN testing criteria for the high-penetrance breast cancer susceptibility genes. Testing was recommended to patients with a personal history of breast cancer at below 45 in 2022 and was amended to below 50. The testing criteria used for patients with a family history of breast, ovarian, pancreatic, or prostate cancer have been relaxed from personal diagnosis at the age 46–50 to any age. Families with more than two family members having breast or prostate cancers at any age were advised for genetic tests without considering the proband’s age of diagnosis in the updated testing criteria. In patients with multiple breast cancers, the testing age was also changed from 46–50 to any age. The details on the changes of testing criteria are listed in BRCA1/2 mutation rate for patients meeting the 2022 v.2 criteria was 10.1% (351/3461), and the rate for those meeting the 2023 v.1 criteria was 9.6% (356/3703). Of these additional patients who met the 2023 v.1 criteria, the germline BRCA1/2 mutation rate was 2.1% (5/242). However, the difference in the percentage of the BRCA1/2 positive rate in these two groups (who met the NCCN testing guideline 2022 v.2 or 2023 v.1 criteria) did not reach statistical significance (p = 0.476). The germline mutation rate of the 6 high-penetrance genes  in patients meeting the 2022 v.2 criteria was 12.2% (423/3461), and the rate of those meeting the 2023 v.1 criteria was 11.6% (429/3703); the difference in positive cases between these two groups was not statistically significant (p = 0.4218). The mutation rates for patients who did not meet both testing criteria were 5.3% for BRCA1/2 and 6.4% for all 6 high-penetrance genes. These patients were those with multiple personal cancers, with a strong family history of cancers not listed in the NCCN, with unclear pathology information, or in which tested because of their own intentions. On a 30-gene panel with an elevated risk of hereditary cancers, including breast, ovarian, uterine/endometrial, colorectal, melanoma, pancreatic, prostate, and stomach [p = 0.4136) and with an extra 3.7% (9/242) detection rate on pathogenic or likely pathogenic mutation variants with the new 2023 NCCN testing guideline. Details of the mutation rate are listed in A total of 514 (13.5%) out of 3797 patients had a P/LP mutation variant in 30 genes. By analyzing the pedigrees and respective personal breast cancer clinicopathological characteristics from these patients, they were classified according to the NCCN testing guideline 2022 v.2 and 2023 v.1 criteria. Of these, 3461 (91.2%) of them met the 2022 v.2 criteria, and 3703 (97.5%) met the 2023 v.1 testing criteria. An additional 242 patients (6.4%) met the 2023 v.1 criteria but would be excluded from genetic testing using the 2022 v.2 criteria. Lastly, 94 patients (2.5%) did not meet both testing criteria. The germline BRCA1/2 mutation rate was 3.6%, and it was 4.8% in all six high-penetrance genes. The 30-gene mutation rate of this group was 7.1%. One hundred fifty bilateral breast cancer patients with a diagnosis age over 50 were also included in these new criteria. The mutation rate was 1.3% for both BRCA1/2 and all 6 high-penetrance genes, and the mutation rate for 30 genes was 2%. None of these patients had a family history of breast, ovarian, prostate, or pancreatic cancer. Detailed clinicopathological characteristics of these patients are shown in Among 242 patients who met the 2023 v.1 criteria only, most of these breast cancer patients were diagnosed at 45–50 (37.4%) and 62% had bilateral breast cancers. A total of 84 patients met the new testing criteria because of their diagnosis age (45–50); the BRCA1/2 mutation rates for patients meeting the 2022 v.2 and 2023 v.1 criteria were 10.1% and 9.6%, respectively. The germline mutation rates of all 6 high-penetrance genes in these two groups were 12.2% and 11.6%, respectively. The mutation rates for 30 hereditary-cancer-associated genes in these two groups were 14.4% and 13.7%, respectively. With the revision of the NCCN testing criteria, a total of 9 out of 242 (3.7%) mutation carriers were detected. The positive detection rates for BRCA1/2, 6 high-penetrance genes, and 30 hereditary-cancer-associated genes were 2.1%, 2.5%, and 3.7%, respectively. This shows that the update is also applicable for the Chinese population. In the old days, when the NCCN testing guideline included BRCA1/2 only, there was a study from the US that involved 959 patients on an 80-gene multicancer panel; of those patients who met the 2017 NCCN BRCA1/2 testing guidelines, 9.4% had a P/LP variant. Of those patients who did not meet the 2017 testing guidelines, 7.9% had a P/LP variant. The difference in positive results between these groups was not statistically significant (p = 0.424) [BRCA1 carriers and 44.9% of BRCA2 carriers did not meet the 2017 published NCCN testing guidelines [BRCA1/2. About 9.6% of their women met the NCCN testing criteria and had a mutation identified compared with 5.9% for those who did not meet the criteria. Another study by Susswein et al. [BRCA1/2. The results of a prospective study on postmenopausal women with breast cancer showed that 3.6% of them were harboring a P/LP variant on a panel of 28 breast-cancer-associated genes [ATM, BRCA1, BRCA2, CDH1, CHEK2, NF1, PALB2, PTEN and TP53) [BRCA1/2. Multiple gene panel testing on moderate- to low-penetrance genes identified those who have previously tested negative in genetic tests [With the revision of the NCCN testing criteria, an extra 242 (6.4%) patients were included after the revision of the criteria; 91.2% of the patients met the 2022 v.2 criteria, while 97.6% of the patients met the 2023 v.1 criteria, and 2.5% of the patients do not meet both testing criteria. The germline = 0.424) . Anotheridelines . In a stn et al.  reportednd TP53) . A similic tests . Currentic tests . Howeveric tests . This isBRCA1/2 and the 6 high-penetrance genes were 23.7% and 30.2%, respectively [BRCA1/2 mutation rates in this consecutive random cohort were 5.3% and 6.5% from 6 high-penetrance genes [BRCA1/2 mutations, and 19% from 6 high-penetrance genes (data from out rountine lab).We identified 242 patients who met the 2023 v.1 criteria only but not the 2022 v.2 criteria. The mutation pick-up rate on the 30-gene panel was 2% for patients with bilateral breast cancer. In another study on 139 bilateral breast cancer patients of unselected age, the overall mutation rate was 37.4%. The mutation rates on ectively . Over 67ce genes . Our latBRCA1/2, 6.4% in all 6 high-penetrance genes, and 8.5% for the 30-gene panel. In this cohort, 24 (25.5%) of these patients were recruited because of their personal history of multiple cancers, and 1 (4.2%) BRCA1 mutation carrier was identified. Three patients were tested because of patient intention; 2 out of 3 (66.7%) were BRCA1 mutation carriers. Other unclassified cases that met neither criteria were recruited at the startup of the registry with less stringent entry requirements or information only recorded by patient verbal descriptions.In our study cohort, 94 (2.5%) patients did not meet both testing criteria, and the mutation rates for these patients were 5.3% for The mutation detection rate after the relaxation of the NCCN testing criteria was reviewed in the Chinese population. An extra 3.7% (9 out of 242) of the patients with mutations in 30 hereditary-cancer-associated genes will benefit. Starting from early 2014, ACMG and individual research groups suggested that all patients with breast cancer should be evaluated for the need to have germline genetic testing for hereditary breast cancer ,13,14. IWe provided a review in our Hong Kong high-risk breast cancer cohort to evaluate the increase in allocated resources during the paths of expansions in mutation carriers identified by multigene panel testing compared with those included in the current risk-stratified approach NCCN eligibility criteria, before the test was performed on all breast cancer patients. Whether it is worth spending the resources on testing all patients depends on the clinical characteristics and resource limitations, such as providing surveillance cancer screenings, prophylactic surgeries and caring, genetics counseling, and reproductive planning support, not only to these patients but also to their family members.


Plasmodium vivax, primaquine is the sole potent drug against mature/infectious Plasmodium falciparum gametocytes. It may prevent onward transmission and help contain the spread of artemisinin resistance. However, higher dose of primaquine is associated with the risk of acute haemolytic anaemia in individuals with a deficiency in glucose-6-phosphate dehydrogenase. In many P. falciparum endemic areas there is paucity of information about the distribution of individuals at risk of primaquine-induced haemolysis at higher dose 45 mg of primaquine.The use of primaquine for mass drug administration (MDA) is being considered as a key strategy for malaria elimination. In addition to being the only drug active against the dormant and relapsing forms of A retrospective cross-sectional study was carried out using archived samples to establish the prevalence of G6PD deficiency in a malaria hotspot area in Misungwi district, located in Mwanza region, Tanzania. Blood samples collected from individuals recruited between August and November 2010 were genotyped for G6PD deficiency and submicroscopic parasites carriage using polymerase chain reaction.P. falciparum positive by PCR. G6PD heterozygous deficiency were associated with carriage of submicroscopic P. falciparum (p = 0.029).A total of 263 individuals aged between 0 and 87 were recruited. The overall prevalence of the X-linked G6PD A− mutation was 83.7% (220/263) wild type, 8% (21/263) heterozygous and 8.4% (22/263) homozygous or hemizygous. Although, assessment of the enzymatic activity to assign the phenotypes according to severity and clinical manifestation as per WHO was not carried out, the overall genotype and allele frequency for the G6PD deficiency was 16.4% and 13. 2%, respectively. There was no statistically significant difference in among the different G6PD genotypes (p > 0.05). Out of 248 samples analysed for submicroscopic parasites carriage, 58.1% (144/248) were This study showed that 16.4% of the population in this part of North-western Tanzania carry the G6PD A− mutation, within the range of 15–32% seen in other parts of Africa. G6PD gene mutation is widespread and heterogeneous across the study area where primaquine would be valuable for malaria control and elimination. The maps and population estimates presented here reflect potential risk of higher dose of primaquine being associated with the risk of acute haemolytic anaemia (AHA) in individuals with a deficiency in glucose-6-phosphate dehydrogenase and call further research on mapping of G6PD deficiency in Tanzania. Therefore, screening and education programmes for G6PD deficiency is warranted in a programme of malaria elimination using a higher primaquine dose. Plasmodium falciparum in areas approaching malaria elimination  years  was not independently assessed to assign individuals either deficient or normal. However, based on genotype, individuals were assigned as normal, heterozygous, homozygous and hemizygous. Hence, with the exception of individuals who were assigned as normal, the rest of the individuals were termed as deficient although not all individuals termed as heterozygous will be deficient./homozygous G6PD deficiency  of those tested were G6PD deficiency heterozygous and 8.4% (22/263) were hemi1/263 of p > 0.05). For males hemizygote frequency was highest (17.7%) among those in age group 0–4 years and the highest carriage of G6PD hemizygote frequency (12.9%) was observed at Budutu village but all these were not statistically significant (p > 0.05) (Table p = 0.007).Among heterozygous individuals observed were found at the highest frequency (15.5%) among 5–14 years age and the highest carriage of heterozygous (18.2%) was at Mwaholo village and the lowest 3.6%) at Budutu village. However, the result reveals that there was no statistically significant difference in heterozygous G6PD deficiency carriage between villages and age (.6% at Bup > 0.05)  Table .P. falciparum positive by PCR whereas a total of 25 samples (10.1%) and 3 samples (1.2%) were positive for P. malariae and P. ovale, respectively. None of the samples were positive for P. vivax. Furthermore, 16 (6.0%) samples were positive for both P. falciparum and P. malariae. Three samples (1.2%) were positive for both P. falciparum and P. ovale. None of the samples were positive for all P. falciparum, P. malariae and P. ovale.Out of 248 samples analysed for submicroscopic parasites carriage, a total of 144 (58.1%) individuals were P. falciparum carriage on G6PD homo/hemizygous deficiency and gender (p > 0.05). However, individuals with G6PD heterozygous deficiency were associated with carriage of submicroscopic P. falciparum (p = 0.029)  to assign individuals either deficient or normal was not independently assessed. However, based on genotype individuals were assigned as normal, heterozygous, homozygous and hemizygous. Therefore, with the exception of individuals who were assigned as normal, the rest of the individuals were referred to deficient although not all individuals termed as heterozygous will be deficient. The study reveals that the prevalence of the G6PD deficiency is 16.4%, in which genotype frequency was 8.0% and 8.4% for female heterozygous, and male hemizygous/female homozygous respectively. The overall prevalence is very similar to what has been found elsewhere in sub-Saharan Africa, where it ranged from 0 to 25% , 49 confUnlike to a study which was carried out in Nigeria where high prevalence of G6PD deficiency was particularly among children 2–5 years old , there wStudy in this area has indicated that over half of individuals have malaria in form of submicroscopic . The obsP. falciparum development is hindered in G6PD deficient red cells [P. falciparum carriage in children aged between 6 and 12 years [In this study, heterozygous G6PD deficiency was associated with carriage of submicroscopic parasites. It has already been reported in other studies that female heterozygotes are protected from severe malaria , 54, whied cells , slowinged cells . However12 years . From thPlasmodium, and also offers activity against P. falciparum gametocytes, thereby blocking transmission to mosquitoes should be considered [This high prevalence of G6PD deficiency in the area raises concern when planning for MDA for clearing of the malaria parasites in endemic areas using primaquine if a higher primaquine dose is considered , 57–60. nsidered , 61.Although studies in different malaria endemic countries including Tanzania , 62 haveTanzania is focusing on reducing malaria transmission and exploring the possibilities towards the malaria pre-elimination and elimination , the useThis study has some limitations. The enzymatic activity was not assessed, haemoglobin level and other polymorphisms in the study area, and this is a topic which warrants future research.G6PD deficiency is prevalent and spatially heterogeneous across in the study area. Likewise, submicroscopic infections, which are possible infectious reservoirs of parasites, are common in the area. The government of Tanzania is implementing recommended preventive and curative interventions to malaria with the possibility of moving towards the malaria elimination. One possibility is the use of primaquine, although SLDPQ is well tolerated and safe in G6PD deficiency, a higher PQ dosage may be needed. Higher dosage of PQ is associated with acute haemolytic anaemia in G6PD deficient individuals. Awareness is needed regarding the use of a higher dose of primaquine for G6PD deficiency individuals if required.


Occupational injuries in the construction sector constitute an important health problem affecting workers in their most productive years. The professional environment influences the outcomes of these accidents. The impact of social support among this vulnerable population may explain the difference in terms of outcomes of occupational injury.Evaluating the impact of social support in occupational injuries’ outcomes among construction workers.A cross-sectional analysis was conducted during 9 months among construction sector workers victim of an occupational injury consulting for an Impairment Rating Evaluation and working. Socio-professional data and the accident’ outcomes were collected. Social support was evaluated by the Social Support Scale. The pain was evaluated by a Visual Analogue Scale.± 10.79 years. The majority of accidents took place in 2020 (49%). Upper arm injuries represented 41.2% of injured sites. The mean pain scale was 6.98±1.69 and the mean length of absence was 227.88 days±292.23. A proportion of 9.8 % had Low social support. Twenty-three subjects (45.1%) had not returned to work. Low social support was associated with a perception of stigma and discrimination (p=0.000), negative outlook of the future (p=0.003), low job satisfaction (p=0.000) and non-return to work (p=0.009). No association was found with pain, length of absence and sleep disorders.Out of 51 injured workers, 96.1% were male. The mean age was 43.66 Social support may influence occupational injury outcomes. This finding highlights the need for further examination of social factors among this vulnerable population.None Declared


Due to the COVID-19 pandemic, our health system had to face new challenges such as Burnout (BO), particularly among healthcare workers (HCWs).Our study aimed to examine the prevalence of burnout among HCWs, as well as to identify the sociodemographic and professional factors associated to it.This was a cross-sectional descriptive and analytical survey, conducted during the fifth wave of COVID-19 between December 2021 and February 2022, among the healthcare workers of 3 hospitals in Djerba city. We used an online questionnaire to collect their sociodemographic and professional data. Maslach Burnout Inventory (MBI) was used to assess their burnout level.Our population consisted of 95 HCWs with a sex ratio of 0.46. Most of them (75%) had an age of less than 40 years. Among our participants, 56.8% were paramedics and 71.6% had a working experience of less than 10 years. A rate of 56.8% worked full-time with a minimum of 36 hours per week and more than 5 on-calls per month in 56.8%.In our study, 76% of the HCWs were affected by BO. The mean emotional exhaustion, depersonalization and professional accomplishment scores were 35.74 ±12.16, 11.84 ±8.08 and 27.32 ±6.95, respectively. A rate of 69% had a high level of emotional exhaustion, 42% had a high level of depersonalization and 41% had a low level of personal accomplishment.The subgroup analysis showed that BO was associated with: an age of less than 30 years (p=0.007); having no children (p=0.030); a work experience of less than 10 years (p=0.001); a number of working hours greater than 36 hours (p=0.030) and a number of on-call duties greater than 5 per month (p=0.007).Our study shows the burden of BO in the HCWs of Djerba, especially among the youngest ones, the least experienced and those with the highest workload. Thus, a special attention must be paid to this condition, and the implementation of a prevention strategy is essential.None Declared


The aim of the study was to evaluate the relationship between primary tumor type and the effectiveness of microwave ablation (MWA) therapy by comparing the technical and clinical outcomes of MWA in the treatment of colorectal liver metastases (CLM) and noncolorectal liver metastases (NCLM).Between January 2019 and March 2021, 47 consecutive patients  with a total of 63 unresectable hepatic metastases underwent MWA under ultrasound guidance. The patients were divided into CLM (n = 29) and NCLM (n = 18) groups. Patient demographics, procedural details, and complications were noted. The overall survival (OS) and disease-free survival (DFS) rates were also analyzed.Technical success was 100% in both groups. No major complication was observed. Three minor complications [fatigue (n = 2) and subcutaneous hematoma (n = 1)] were encountered. DFS rates were 88.9%, 71.9%, 64.9%, and 44.0% at 3, 6, 12, and 24-months, respectively, with a mean DFS of 17.4 months . Also, OS rates were 93.7%, 90.0%, 76.8%, and 64.3%, at 3, 6, 12, and 24-months, respectively, with a mean OS of 18.5 months . There was no significant difference in recurrence between the CLM and NCLM groups (p = 0.452). The recurrence rate in liver metastases > 3 cm in size was significantly higher than in metastases ≤ 3 cm in size (p < 0.001).MWA therapy is as effective in the NCLM group as in the CLM group, regardless of histologic type. Metastasis size (>3 cm) was correlated with the recurrence rate in the CLM and NCLM groups. Though metastatic liver tumors are associated with increased mortality and morbidity, clinical outcomes of patients with liver metastases improved greatly in recent years . After lMany physicians and patients also prefer interventional therapies due to the lower mortality and morbidity risks compared to surgery . The comPercutaneous MWA is a safe and effective method in the treatment of both primary and metastatic hepatic malignancies that are not suitable for surgery . Also, hThis retrospective study was conducted in compliance with the principles of the Helsinki declaration, and informed consent was obtained from each patient. Ethical approval for this retrospective study was obtained from the Institutional Review Board (2021-21460-217). Patients with metastatic liver disease who were referred to our clinic for thermal ablation between January 2019 and March 2021 were included in the study after obtaining their informed consent.An oncology committee consisting of radiologists, oncological surgeons, gastroenterologists, medical oncologists, radiation oncologists, and nuclear medicine specialists made all decisions about MWA therapy on a multidisciplinary. Inclusion criteria were as followed; (i) ineligible for surgery due to comorbidities, (ii) anatomical localization where surgical treatment is not feasible or safe, (iii) insufficient functional liver capacity after surgery , (iv) the patient’s refusal to undergo surgery. Exclusion criteria were; (i) presence of extrahepatic metastases, (ii) pregnancy, (iii) uncorrectable coagulopathy.A total of 47 patients with 63 lesions met the above criteria and were enrolled in this study. The patients were divided into two groups as CLM and NCLM. Therewithal, to determine how tumor size affected the recurrence rates, the lesions were classified into two groups: ≤3 cm lesions and >3 cm lesions. Also, the location of liver metastases was noted.One interventional radiologist with 7-years’ experience on interventional oncology performed all procedures. MWA was performed in all patients under deep sedoanalgesia under the supervision of an anesthesiologist. Under sterile conditions, local anesthesia was applied to the subcutaneous area and the liver capsule with 10 cc of prilocaine . Lesions were accessed under ultrasound guidance  with a convex probe. The Eco  device, which works with a frequency of 2.45 GHz, is shaft-cooled and continuous energy transferring, was used for MWA. Considering the location and size of the lesion, 14-16-17-gauge MWA antennas were used. Similarly, the ablation procedure was performed at varying power and duration depending on the size of the lesion. Successful treatment was defined as ablation of the tumor with a 10 mm margin, preserving intact parenchyma and nontarget tissues  Figure . In 21 pThe modified Response Evaluation Criteria in Solid Tumors (mRECIST) were used to evaluate the ablation procedure. Adverse events and complications after treatment are classified according to the SIR  adverse event classification . The locThe multiphasic computed tomography (CT)  examination was performed every three months for the first year and then every six months thereafter. The postprocedural ablation zone diameter ratio to preprocedural tumor diameter was calculated on CT images one day after the procedure. Follow-up imaging was performed with multiphasic CT or PET CT –3. If thStatistical analyzes were performed with the SPSS 13.0 Statistical Software . As statistical analysis, for descriptive statistics, categorical variables were presented with the number, percent, and continuous variables with mean ± standard deviation and median (minimum and maximum) values. Pearson’s chi-square test was used for the comparison of categorical variables. Continuous variables were compared with nonparametric (Mann-Whitney U test) and parametric (Student’s t-test) methods according to their conformity to normal distribution evaluated using the Kolmogorov-Smirnov tests. The Kaplan–Meier survival curves were used for survival analysis. The statistical significance level was accepted as p < 0.05.The data of 39 lesions in 29 patients  with CLM and 24 lesions in 18 patients  with NCLM were analyzed. The characteristics of the patients are shown in There were five (7.9%) lesions located near large vessels, three (4.8%) lesions located close to the gastrointestinal tract, six (9.5%) lesions adjacent to the diaphragm, five (7.9%) lesions located near the liver capsule and two (3.2%) lesions located near the gallbladder. The hydrodissection was performed on 21 lesions.A 16-G, 14-G, and 17-G antennas were used in 44 (69.8%), 12 (19.0%), and 7 (11.2%) lesions, respectively. The mean applied power was 40 ± 4.4 watts. The mean ablation time was 4 ± 1.6 min. The ratio of the diameter of the ablation zone to the tumor diameter was 1.72 ± 0.56 in lesions with no recurrence and 1.37 ± 0.45 in lesions with recurrence (p = 0.173).Three patients had grade A complications according to the SIR adverse event classification (6.4%). Two of these patients had fatigue for 2 days after the MWA procedure. A subcutaneous hematoma was encountered at the insertion site of the ablation probe, which did not require transfusion and resolved spontaneously.The mortality rate was 24.1% (7 of 29 patients) in the CLM group; the causes of death for patients were extrahepatic metastases (n = 4), cardiovascular events (n = 2), and local tumor progression (n = 1). Also, the mortality rate was 22.2% (4 of 18 patients) in the NCLM group; the causes of death for patients were extrahepatic metastases (n = 2), cerebrovascular event (n = 1), and local tumor progression (n = 1).The median follow-up time was 9 (range 3–24) months. The 3-, 6-, 12-, 24- months disease free survival (DFS) rates were 88.9%, 71.9%, 64.9% and 44.0%, respectively, with a mean DFS of 17.4 months . The 3-, 6-, 12-, 24- months overall survival (OS) rates were 93.7%, 90.0%, 76.8% and 64.3%, respectively, with a mean OS of 18.5 months  .Fifteen of the 39 CLM (38.5%) and 7 of the 24 NCLM (29.2%) had recurrence during follow-up. There was no significant difference in terms of recurrence between the two groups (p = 0.452). Moreover, 12 of the 46 liver metastasis with a tumor size of ≤3 cm (26%) and 10 of the 17 liver metastasis with a tumor size of >3 cm (58.8%) had recurrence after MWA. The recurrence rates were significantly higher in liver metastasis with a tumor size of >3 cm than in lesions with a tumor size of ≤3 cm (p < 0.001) .Parenchyma-preserving methods are increasingly adopted in the primary or metastatic cancers of the liver . AlthougTilborg et al. revealed that MWA was effective in the treatment of unresectable CLM . MoreoveMWA emerged after RFA as a new therapy, and it is a safe and effective treatment method in primary and metastatic cancers of the liver . It has In MWA, tumors located closer than 5 mm to critical organs, such as the intestinal system and great vessels, have a high risk for complications . On the In malignant liver tumors, the major complication rate of MWA therapy has been reported to be 2.6%–2.9% ,40. MajoThis study has several limitations. First, the retrospective nature of this study might have influenced the results. Second, the sample size was also relatively small. Third, long-term follow-up results were lacking. There is a need for larger, prospective, and longer follow-up studies on this subject.In conclusion, MWA therapy is as effective in the NCLM group as in the CLM group, regardless of histologic type. Metastasis size (>3 cm) was correlated with the recurrence rate in the CLM and NCLM groups.