Chromoblastomycosis (CBM) is a chronic human subcutaneous mycosis caused by various aetiologic agents. CBM does not have an established treatment but may be managed using antifungal agents, surgical removal of the lesions, or cryotherapy. Kojic acid (KA), a known tyrosinase inhibitor with a variety of biological actions, including fungistatic action against the fungus Cryptococcus neoformans, mediated by inhibiting melanin production, seems to be an alternative to improve the treatment of CBM. The aim of the present study was to analyze the action of KA against the pathogenic fungus Fonsecaea sp., an aetiological agent of CBM. The fungal culture was incubated with KA, and the amount of melanin was assessed, followed by cytochemical detection. Subsequently, the samples were analyzed by light microscopy, transmission and scanning electron microscopy. Culture analysis revealed that 100 g/mL KA significantly decreased the melanization of the fungus and the exocytosis of melanin into the culture supernatant. Additionally, KA induced less growth of biofilm formation and intense disruption of the cell wall, and decreased the number of melanin-containing vesicles in the culture supernatant. Finally, KA inhibited fungal filamentation in culture and the subsequent phagocytosis process. Thus, KA may be a promising substance to help in the treatment of CBM. Fonsecaea sp. In injured tissues, these fungal elements transform into muriform cells with multiplanar septae and are responsible for the establishment of chronic infections [Chromoblastomycosis (CBM) is a subcutaneous fungal infection that primarily affects human hosts, occurring primarily in tropical and subtropical regions ,2,3. Thifections ,6.One of the main virulence factors of the CBM agent is melanin, a polymer that has been widely described as an important virulence factor in several fungi ,8,9,10. Schistosoma mansoni [Leishmania (Leishmania) amazonensis [CBM does not have an established treatment but may be addressed through the use of antifungal agents, surgical removal of the lesions, or cryotherapy ,20,21,22 mansoni , as wellzonensis . Furtherzonensis . Thus, tFonsecaea sp. used in this study was obtained in 2006 from a human case with a desquamative lesion and long-standing chromoblastomycosis. The culture was kept by the Mycology Laboratory of the Evandro Chagas Institute  and maintained on Sabourad dextrose agar for a continuous period of 21 days. Each culture containing a 1 cm2 fragment was observed and identified following the microculture method in slides [Fonsecaea sp. hyphae containing conidia, the mycelial form was inoculated in broth for seven days at 30 °C. To separate hyphae from conidia, the cell suspension was placed in a tube with 10 mL of 0.45% NaCl, vortexed for one min, filtered on filter paper and centrifuged at 1500 rpm for one min to release the conidia to be used in the experiments, as shown in The clinical isolate of n slides . To obtaKojic acid (KA) and tricyclazole (TZL) were obtained from Sigma-Aldrich Co. . A stock solution was prepared at a final concentration of 1 mg/mL in distilled water, and further dilutions were made from this solution.6 conidia were added to 1 mL of glucose yeast peptone medium  containing KA  or medium alone as a control. The conidia were incubated at room temperature, and each experimental group was treated once (Day 0), twice (Days 0 and 7), or thrice  and analyzed after 21 days of treatment. To determine if the fungal culture recovered growth after the treatment period, aliquots of cultures in the filamentous phase were collected and placed in Sabouraud broth without KA and maintained under the same conditions as used before.To test the antifungal activity of KA, the methods were performed as described previously with some modifications ,42. In b2-5 mM; KCl-70 mM; EGTA-10 mM; HEPES-20 mM; and PIPES-60 mM), pH 7.2, for 1 h at room temperature. The cells were washed to identify hyphal spreading during examination with an Axio scope A1 Zeiss microscope. For SEM, cells were fixed with 1% glutaraldehyde, 4% paraformaldehyde and 2.5% saccharose in 0.1 M PHEM buffer, pH 7.2, for 1 h at room temperature, and then postfixed in 2.5% glutaraldehyde, 4% paraformaldehyde, and 2.5 M calcium chloride in 0.1 M cacodylate buffer, pH 7.2, for 1 h. The cells were washed and postfixed again in 1% osmium tetroxide and 1% ferrocyanide for 1 h, dehydrated in graded ethanol, critical point dried (CO2 in air), coated with gold, and examined with an LEO 1450 VP SEM. For TEM, the cells were fixed with glutaraldehyde (2.5%) and paraformaldehyde (4%) in cacodylate buffer (0.1 M) for 1 h at room temperature, postfixed in osmium tetroxide solution (1%) and ferrocyanide (0.8%), dehydrated in graded acetone, and embedded in epoxy resin. Ultrathin sections were obtained with an ultramicrotome , stained with uranyl acetate/lead citrate, and examined with a TEM .The 21-day KA-treated and untreated fungal cultures (control group) were processed for light microscopy (LM), scanning electron microscopy (SEM) and transmission electron microscopy (TEM). For LM, the cells were fixed with 4% paraformaldehyde in 0.1 M PHEM buffer  and the supernatant. The supernatant was ultracentrifuged at 15,000 g  to obtain vesicles according to a previously published procedure . The celTo quantify and analyze the morphology of extracellular vesicles, 150 mL culture-conditioned medium of 21-day liquid-treated culture with KA was used. To obtain cell-free vesicles, the medium was centrifuged  to obtain the final precipitate. Each precipitated sample was fixed with 1% glutaraldehyde in 0.1 M PHEM buffer, pH 7.2, and processed with Fontana–Masson stain as described previously. The vesicles were analyzed with a Zeiss EM900 TEM and quantified using ImageJ software 1.52a. Untreated cultures were used as the control group.6 conidia were added to the coverslip to be cultured in 1 mL of DMEM containing 100 µg/mL KA or medium alone. After 24 h of incubation at 37 °C and 5% CO2, the cells were stained with 10% Giemsa, and the filamentous forms were quantified from 100 total conidia cells. The size of the cells was measured by ImageJ software. To analyze the intracellular fungal filamentation in infected KA-treated macrophages following phagocytosis, murine macrophages were obtained from peritoneal cavities of Mus musculus Balb/c mice with DMEM, pH 7.2. After one hour of incubation at 37 °C and 5% CO2, the nonadherent cells were washed away with PBS, pH 7.2, and adherent macrophages were incubated overnight in DMEM supplemented with 10% heated-inactivated fetal bovine serum (FBS). The animals were euthanized in accordance with the committee of animal research and ethics of the Federal University of Pará N°. 8482280916. After that, the interaction of conid cells with macrophages was performed for 3 h of incubation (MOI of 5:1), and infected cells were washed three times with PBS, pH 7.2, and treated with 100 µg/mL KA for 24 h. After that, the cells were fixed with 4% paraformaldehyde and stained with 10% Giemsa.To test the activity of KA on the differentiation of fungal cultures, 10p-value of less than 0.05 was considered statistically significant.All experiments were performed in triplicate. The mean and standard deviation of the three independent experiments were determined, and the data were analyzed using GraphPad Prism 6.0 , followed by an analysis of variance (ANOVA) and the Tukey test. A The cultures treated with different concentrations of KA  showed aTo analyze the possible recovered growth and melanization after KA treatment, aliquots of each culture were removed and maintained under the same conditions but without KA treatment. The once-treated cultures were able to recover their dark color at all the concentrations evaluated, whilst the cultures that received two or three treatments did not recover their growth or dark color B. To detLight microscopy analysis of untreated A,C and 1To verify whether the decrease in melanization in the culture supernatant was related to the number of externalized vesicles, quantification of these supernatant vesicles was carried out . InteresUltrastructural analyses were performed to determine possible cell-wall alterations that occurred after treatment with 100 μg/mL KA. The treatment induced an intense disruption of the fibrillar portion of the cell wall B as compTo verify the possible relationship between cell-wall disruption after KA treatment and the development of hyphae, a temporal analysis was performed during 24 h of culture. We observed that treatment with 100 μL/mL KA significantly reduced the number A and sizWe also analyzed intracellular fungal filamentation following phagocytosis of conidia by the host cell. As shown in Fonsecaea pedrosoi, which is the primary etiological agent of CBM, melanin is deposited in the cell wall and is directly related to the protection of the fungal cell against stressful environments and the host immune response [Fonsecaea sp., a potent inhibitor of the enzyme tyrosinase, which is involved in the synthesis of melanin, are not well known [Fonsecaea sp., an aetiologic agent of CBM.Chromoblastomycosis (CBM) is a disease caused by pigmented yeast-like fungi (melanin producers) that are involved in fungal pathogenesis . In Fonsresponse ,48,49. Hll known ,51. ThusFonsecaea sp, but we also tested another isolate with similar results. Initially, the clinical isolate of Fonsecaea sp. was grown in three KA exposure groups and compared with a control group. Each KA-treated group received 25, 50 and 100 μL/mL KA once, twice, or thrice (every seven days for 21 days). Our results demonstrated a reduction in mycelial growth and dark staining in the KA-treated groups compared to in the control group. Additionally, fungal growth was not able to recover after two or three treatments with KA. These data reveal that KA was able to inhibit fungal growth and suggest that melanin production and/or other melanin-dependent properties of Fonsecaea sp. might also be defective.As the basis for the experimental design of this study, we have used only one clinical isolate of Filamentous fungi grow by hyphal extension through the exocytosis of vesicles, which are carried by microtubules to the apical part of the hyphae (polarized exocytosis), delivering growth supplies, including melanin, membranes, and cell wall synthase proteins . This hyAfter spectrophotometry, quantification of intracellular and extracellular melanin confirmed that KA treatment inhibited the production of melanin. The observed decrease in melanin production may be related to the action of KA on vesicle traffic since there are no reports that this substance has any action on polyketide synthase, a group of enzymes responsible for the production of melanin in CBM agents ,55. HoweCryptococcus neoformans revealed that sizes of extracellular vesicles are heterogeneous and also related to melanization. Smaller diameter vesicles are associated with melanization and larger diameters are associated with non-melanization [Fonsecaea sp. hyphae modulate the host immune response, and this factor may be involved in fungal survival [A study on nization ; i.e., tnization ,54. It isurvival . Anothersurvival . Our SEMThe hypothesis that vesicle traffic may be affected by KA treatment may also explain the disruption of the cell wall since the constituents of this structure, such as chitin and β-glucans, are synthesized in the cytosol of fungal cells and then transported to the surface, restructuring the cell wall . MelaninFurthermore, it has been reported that melanin is an important factor in virulence due to its antioxidative and metal-binding properties . It appeC. neoformans and Candida albicans [Another important finding of our research was that KA treatment also inhibited cellular filamentation in fungal culture and during macrophage infection. These data suggest that KA also acts as a fungistatic drug. Not only is cell-wall melanin known to be an evasion mechanism but so too is fungal filamentation. The internalization of pathogenic fungi by macrophages induces the transition to filament forms that promote macrophage death to save the fungus from killing by immune cells ,13,63. Falbicans ,66. Melaalbicans ,67.In conclusion, our results demonstrate for the first time that KA has an important action in vitro on a clinical isolate of a chromoblastomycosis agent, promoting inhibition of fungal growth, intense disruption of the cell wall with vesicle externalization, reducing biofilm formation, decreasing melanization, and affecting fungal filamentation in culture and during phagocyte interaction. Thus, considering the crucial role of the cell wall and the production of melanin for fungal survival, KA may have potential therapeutic application in the treatment of chromoblastomycosis.


The purpose of this study is to explore the association of P300 components with clinical characteristics and efficacy of pharmacotherapy in alcohol use disorder (AUD).One hundred fifty-one AUD patients and 96 healthy controls were recruited and evaluated for the symptoms of depression, anxiety, sleep, and cognitive function by the Alcohol Use Disorders Identification Test (AUDIT), the 9-item Patient Health Questionnaire (PHQ-9), the 7-item Generalized Anxiety Disorder scale (GAD-7), the Pittsburgh Sleep Quality Index (PSQI), Digit Symbol Substitution test (DSST), and event-related potential P300, which is one of the averaged scalp electroencephalography responses time-locked to specific events. Among the AUD group, 101 patients finished an 8-week pharmacotherapy and were evaluated for the above data at post-intervention.1. At baseline, AUD patients had higher scores of AUDIT, PHQ-9, GAD-7, PSQI, and P300 latency at Cz, Pz, and Fz and lower DSST score and smaller P300 amplitudes at Fz, Cz, and Pz compared with controls. P300 components correlated significantly with alcohol dose and score of AUDIT, PHQ-9, GAD-7, PSQI, and DSST. 2. After 8 weeks' treatment, there were significant changes for the P300 components; alcohol dose; and score of AUDIT, PHQ-9, GAD-7, PSQI, and DSST. Variables at baseline, including P300 amplitudes at Fz, Cz, and Pz; latency of Fz and Pz; alcohol dose; and scores of PHQ-9, GAD-7, PSQI, and DSST, were significantly associated with changes of reduction rate of AUDIT scores. However, P300 amplitudes at Fz, Cz, and Pz in AUD patients after 8-week treatment were still significantly shorter than healthy controls (HCs), and P300 latencies at Fz, Cz, and Pz were significantly longer than HCs. 3. When validated area under the receiver operating characteristic curve (AUC) was over 0.80, the baseline variables including amplitudes at Cz and Pz, alcohol dose, and scores of PSQI could predict the changes of reduction rate of AUDIT score.P300 amplitudes and latencies at Fz, Cz, and Pz could be used as biological markers for evaluating the clinical characters and severity of AUD. P300 amplitudes at Cz and Pz, sleep condition, and cognitive function at baseline could predict the efficacy of pharmacotherapy for AUD patients. About 31 million people suffer from substance use disorders (SUD) worldwide  and now AUD is frequently accompanied by co-occurring psychiatric disorders or somatic disorders, such as drug use disorders, major depressive disorder, bipolar disorder I, and anxiety disorders . In a crElectrophysiological variables may represent sensitive biomarkers of vulnerability to, or endophenotypes for, AUD . Event-rA previous study found that the relationship of prolonged P300 latency and reduced P3 amplitude with impairment of auditory information processing in schizophrenia was not influenced by neuroleptic medication . In anotA cohort of 151 subjects of male AUD was recruited from the Second Affiliated Hospital to Kunming Medical University, Mental Health Hospital of Qujing, and Mental Health Hospital of Yunnan Province. All patients met the criteria for Diagnosis and Statistics of Mental Disorder 5th edition (DSM-V) for AUD with normal vision and hearing or within the normal range after correction and were right handed. The exclusion criteria were (1) diagnosis of other substance use disorders; (2) history of head injury, neurological disorders, or loss of consciousness; (3) history of diabetes, stroke, or hypertension that required medical intervention; (4) clinical evidence of Wernicke–Korsakoff syndrome; (5) having evidence of mental retardation and any pervasive developmental disorder; (6) having comorbid diagnoses of schizophrenia, obsessive compulsive disorder, and post-traumatic stress disorder because comorbid AUD and PTSD or OCD could lead to a high rate of treatment dropout , 22; (7)A group of 96 male healthy controls (HC) were recruited from the Health Management Center of the Second Affiliated Hospital to Kunming Medical University or local community. For HC, the exclusion criteria included (1) current substance abuse or dependence; (2) history of substance dependence; (3) a current or previous mental illness (or/and treatment); (4) history of head injury, neurological disorders, or loss of consciousness; (5) without normal vision or hearing or out of range after correction; (6) history of diabetes, stroke, or hypertension that required medical intervention; and (7) left handed.The study was carried out in accordance with the latest version of the Declaration of Helsinki and was approved by the Ethics Committee of the Second Affiliated Hospital to Kunming Medical University. Informed consent of the participants was obtained after the nature of the procedures had been fully explained. The registration number of this study is NTC 03910686.The Alcohol Use Disorders Identification Test (AUDIT) , 24 is aChinese versions of the 9-item Patient Health Questionnaire (PHQ-9), 7-item Generalized Anxiety Disorder scale (GAD-7), and Pittsburgh Sleep Quality Index (PSQI) with established reliability and validity were used to assess the severity of depression, anxiety, and insomnia. Subjects completed three self-administered scales: PHQ-9 , GAD-7 , and PSQSymptom severity was defined as mild, moderate, or severe using the following cutoffs: scores of 6, 12, and 15 on the PHQ-9 for depression  and 4, 9The Digit Symbol Substitution Test (DSST) is a valid measure of cognitive dysfunction impacted by many domains, including motor speed, attention, processing speed, executive functioning, and working memory, and is sensitive to the presence of cognitive dysfunction as well as to change in cognitive function across a wide range of clinical populations , 33. DSSP300 was detected by the same methods as our previous reports .An auditory oddball paradigm with 80% non-target stimuli  and 20% target stimuli  presented binaurally through headphones in a pseudo randomized order was used . Subjects were seated with their eyes closed in a reclining chair and had to press a button with their dominant hand after target stimuli. P300 recordings were measured automatically, and the researcher of P300 was blind to disease status and genotype status.x-axis) and amplitude (y-axis). The P300 component was identified as the most positive component within the latency window of 250–600 ms. For artifact suppression, an amplitude criterion has been used (77 mV) involving three channels at any time point during the averaging period. Only wave shapes based on at least 50 averages were accepted. The P300 amplitude and latency at all electrodes for the target stimulus were determined automatically after detection by the computerized program.Recording took place in a sound-attenuated and electrically shielded room adjacent to the recording apparatus (Niclolet MEGA). Subjects were seated with closed eyes in a slightly reclined chair with a head rest. Evoked potentials were recorded with electrodes Fz, Cz, and Pz. The reference electrodes were A1 and A2. A1 and A2 were linked. The electrodes were positioned according to the International 10/20 system. Fpz served as ground. Electrode impedance was <10 kΩ. Data were collected with a sampling rate of 250 Hz and an analogous band pass filter (0.16–50 Hz). After channels were selected , data were averaged per condition (target vs. non-target) in which only segments with correct behavioral responses were included in the average and represented graphically in terms of latency ” , benzodiAccording to the Guidelines for the Diagnosis and Treatment of Mental Disorders in China (2020), all AUD patients were prescribed benzodiazepine when they finished the initial assessment. Titration was allowed for the first week, and all subjects were treated from doses in the lower end of the recommended range, 10 mg/day, to the highest end of the recommended range, 30 mg/day. The benzodiazepine dose was allowed to decrease in response to emergence of side effects, such as excessive sedation and difficulty breathing. The titrated dose was then kept constant for 2 weeks. From the fourth week to the end of the fifth week, in order to avoid dependence on benzodiazepine, the dose was decreased from the titrated dose to withdrawal.Antidepressant drugs were prescribed for AUD patients with comorbid major depressive disorder (MDD) or GAD according to local best practice. Titration was allowed for the first 2 weeks, and all subjects were initially treated with doses in the lower end of the recommended ranges . The dose was increased after the first week. In exceptional cases , the dose could then be increased further at the second weekend, then up to a maximum daily dose at the higher end of recommended ranges . The dose was then kept constant for 8 weeks.Statistical analyses were performed by SPSS 25.0  and MedCalc Statistics v19.6.3 . Continuous data were presented as mean ± standard deviation (SD) or median (interquartile range). Categorical data were presented as absolute numbers and percentages. The expectation maximization (EM) method was used in missing data imputation. There were 19 random missing data of PHQ-9, GAD-7, PSQI, and DSST from drop-outs (38%), which were filled by the EM method.A multi-level model was used to compare the outcome variables between pre-treatment and post-treatment as the outcome variable at level 1 and the participant at level 2.Associations between changes in ERP data and symptoms were analyzed by Spearman correlation analysis. Univariate and multivariate linear regressions were analyzed using the reduction rate of AUDIT as the dependent variable, while the pre-intervention ERP data and psychometric scales as the independent variables.n = 53, 52.5%) and the ineffective group . Binary logistic regression analysis was used to explore if changes in ERP data and psychometric scales could predict a better therapeutic effect on alcohol dependence. We used a receiver operating characteristic (ROC) curve to compare the overall accuracy of the variables associated with better therapeutic effect. The area under the ROC curve (AUC) and 95% confidence interval (CI) were calculated. The larger the AUC is, the better the overall diagnostic accuracy is. The comparisons between ROC curves were performed by the DeLong method. We used a two-sided α of 0.05 for statistical significance.Based on the frequencies and distributions of the reduction rate of AUDIT scores [reduction rate = (pre-treatment score – post-treatment score) / pre-treatment score × 100%], a better therapeutic effect on alcohol dependence in this research was defined as the reduction rate of AUDIT score of ≥20%, which was around the second quartile, and accordingly, the patients were classified into the effective group , 36 cases with moderate depression (23.8 %), 14 cases with mild depression (9%), and 16 cases without symptoms of depression (10.9%). According to symptom severity from GAD-7, there were 82 cases comorbid with anxiety symptoms to a severe degree (54.3%), 28 cases with moderate anxiety (18.5%), 15 cases with mild anxiety (9.9%), and 26 cases without symptoms of anxiety (17.3%). The score of PSQI in AUD was significantly higher than that of HCs. The score of DSST in the AUD group was significantly lower than that of the HC group.Also shown in As shown in In total, there were 101 patients who finished the 8-week pharmacotherapy intervention. In the pharmacotherapy intervention, the average dose of benzodiazepine each day was 20.72 ± 8.64 mg/day, and the average daily dose for each antidepressant was consistent with usual clinical prescribing practices .Except for the latencies of Fz and Cz, there were no significant differences for age; education; marriage status; drinking dose; and symptom duration of PHQ-9, GAD-7, and PSQI; scores of DSST; amplitudes of Fz, Cz, and Pz; and latency of Pz between completers and dropouts of the AUD group, as shown in n = 101) as well as the entire sample (n = 151).As shown in As shown in When validated AUC was over 0.80, the variants of baseline, namely, amplitudes at Cz and Pz and scores of PSQI and DSST, could predict the reduction rate of AUDIT scores after pharmacotherapy intervention, as shown in In the present study, all AUD patients had depressive or anxiety symptoms and sleep disturbances, such as insomnia. Among them, 89.1% patients were comorbid with depression, and 80.1% of them could be rated as having a moderate or severe degree of depressive symptoms. Furthermore, 82.7% patients were comorbid with anxiety, and 72.8% of them could be rated as having a moderate or severe degree of anxiety symptoms. There is considerable comorbidity between AUD and MDD or GAD . ResultsAfter excluding the effect of age on cognitive function, the score of DSST in the AUD group was significantly lower than that of HCs, suggesting that AUD patients had cognitive impairment. The cognitive impairment indicated by the DSST test in AUD patients was confirmed also by P300 amplitudes and latency. Both P300 amplitudes and latencies of AUD patients at Fz, Cz, and Pz were attenuated below healthy controls. The clinical factors such as depression, anxiety, sleep disturbance, and cognitive impairments found in AUD in this study were consistent with other research , 44.Only a few pharmacological treatments are formally available for treating AUDs. Disulfiram, naltrexone, and acamprosate are Food and Drug Administration (FDA) approved, and nalmefene is approved in European Union , 46. OffIn the “Guidelines for the Diagnosis and Treatment of Mental Disorders in China (2020)” , benzodiAfter the 8-week pharmacotherapy, P300 amplitudes at Fz, Cz, and Pz and the score of DSST increased significantly, and P300 latencies at Fz, Cz, and Pz were significantly shorter. High reliabilities, including test–retest reliability , were foBefore the pharmacotherapy intervention, both P300 amplitudes and latencies of AUD patients at Fz, Cz, and Pz correlated with average alcohol dose; drinking duration; and scores of AUDIT, PHQ-9, GAD-7, PSQI, and DSST, suggesting that the P300 amplitudes and latencies at Fz, Cz, and Pz could be used as biological markers for evaluating the clinical character and severity of AUD. After the 8-week treatment, the changes of the severity of AUD demonstrated by AUDIT scores could be predicted significantly by variables at baseline, including P300 amplitudes at Cz and Pz and scores of GAD-7, PSQI, and DSST. Jaworska et al.  found thInterpretations from this study are limited by the sample size. Although there were 151 AUD patients recruited at baseline, only 101 patients finished the 8-week intervention. Therefore, comparisons for therapeutic effects of pharmacotherapy intervention were made between the total subjects including drop-outs and completers by completer subsample analysis and ITT analysis, which showed no difference. Secondly, because of limited sample, we did not compare the effects of different antidepressants. Thirdly, in this study, most patients were comorbid with depression, anxiety symptoms, or insomnia, so these results could not be applied to AUD patients without such comorbidities. In addition, clinical characteristics such as depression, anxiety, sleep condition, and cognitive dysfunction were assessed by using self-rating scales by patients themselves; thus, there might be some subjective bias or recall error. The last limitation was the detection of P300. The P300 amplitude and latency at all electrodes for the target stimulus were determined automatically by the computerized program. However, it cannot demonstrate the data of non-target stimulus. So, the different score between P3 target and non-target could not be analyzed in this study.In summary, the current study found that the P300 amplitudes and latencies at Fz, Cz, and Pz could be used as biological markers for evaluating the clinical characteristics and severity of AUD. P300 amplitudes at Cz and Pz, sleep condition, and cognitive function at baseline could be used as biological markers for predicting the efficacy of pharmacotherapy for AUD patients.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by NTC 03910686. The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.CK, YP, and JYa performed data collection, data analysis, data interpretation, and manuscript preparation. JYu, CW, LW, TZ, LX, YW, and HW collected the data. XF conducted statistical analyses. All authors contributed to the article and approved the submitted version.This work was supported by the National Key R&D Program of China (Grants 2018YFC 1314400 and 2018YFC 1314405). The grant had no further role in study design, collection, analysis, interpretation of data, writing of the report, and decision to submit the paper for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Obstructive sleep apnea (OSA) severity is based on the apnea-hypopnea index (AHI). The AHI is a simplistic measure that is inadequate for capturing disease severity and its consequences in cardiovascular diseases (CVDs). Deleterious effects of OSA have been suggested to influence the prognosis of specific endotypes of patients with acute coronary syndrome (ACS). We aim to identify respiratory polygraphy (RP) patterns that contribute to identifying the risk of recurrent cardiovascular events in patients with ACS.Post hoc analysis of the ISAACC study, including 723 patients admitted for a first ACS (NCT01335087) in which RP was performed. To identify specific RP patterns, a principal component analysis (PCA) was performed using six RP parameters: AHI, oxygen desaturation index, mean and minimum oxygen saturation (SaO2), average duration of events and percentage of time with SaO2 < 90%. An independent HypnoLaus population-based cohort was used to validate the RP components.2 and obstructive respiratory events with severe desaturation, and the second component (component 2) was characterized by high mean SaO2 and long-duration obstructive respiratory events without severe desaturation. In the ISAACC cohort, component 2 was associated with an increased risk of recurrent cardiovascular events in the third tertile with an adjusted hazard ratio (95% CI) of 2.44  compared to first tertile. For component 1, no significant association was found for the risk of recurrent cardiovascular events.From the ISAACC study, PCA showed that two RP components accounted for 70% of the variance in the RP data. These components were validated in the HypnoLaus cohort, with two similar RP components that explained 71.3% of the variance in the RP data. The first component (component 1) was mainly characterized by low mean SaOA RP component, mainly characterized by intermittent hypoxemia, is associated with a high risk of recurrent cardiovascular events in patients without previous CVD who have suffered a first ACS. Cardiovascular diseases (CVDs) are one of the leading causes of death worldwide, and more than half are consequences of coronary heart disease, which is often manifested for the first time as acute coronary syndrome (ACS). Ranging from unstable angina to myocardial infarction, ACS is the main cause of morbidity and mortality worldwide , 2.post hoc study from the ISAACC study reported that the effect of OSA is heterogeneous and it was identified a specific endotype of patients with ACS where OSA was associated with an increased risk of recurrent cardiovascular events. The results of this post hoc study suggested that patients with OSA admitted by a first ACS without previous CVD present an increased risk of recurrent cardiovascular events (Obstructive sleep apnea (OSA) is a prevalent and chronic disease that affects more than 20% of the adult population  and is cr events . ISAACC r events , 10, 11 Recent study  reportedAvailable evidence supports that the indicators of cardiovascular risk in patients with OSA, mainly based on AHI, are insufficient. In the present study, we aimed to evaluate the RP patterns that could contribute to identifying the risk of recurrent cardiovascular events in patients with a first ACS and without previous CVD.post hoc study, we analyzed the data from 723 ISAACC patients with a first ACS and without CVD (This is an ancillary study of the ISAACC (Impact of Sleep Apnea syndrome in the evolution of ACS. Effect of intervention with CPAP) study, a multicenter, open-label, parallel, prospective, randomized, controlled trial . Full details of the ISAACC study’s methods, including inclusion and exclusion criteria, have been previously reported . Brieflyhout CVD  and in wAcute coronary syndrome was defined as the acute presentation of coronary disease with or without ST elevation infarction, unstable angina, or type 1 myocardial infarction.The ethics committee of each participating center approved the study  and patients provided written informed consent.The RP components in the ISAACC cohort was externally validated in the HypnoLaus population-based cohort , a nesteQuestionnaires to record demographic and anthropometric characteristics, medical history and usual pharmacological treatment were administered the day before the sleep study along with questionnaires associated with quality of life (EuroQol-5D questionnaire) and the degree of daytime sleepiness . All patients were evaluated at baseline and 1 month, 3 months, 6 months, 12 months, 18 months, 24 months, 30 months, 36 months, and annually thereafter. All patients were monitored and followed up for a minimum of 1 year. At each visit, sociodemographic and anthropometric variables previously related to increased cardiovascular risk were recorded. Each follow-up visit included assessments of the rate of a composite of cardiovascular events [cardiovascular death or non-fatal events ].2), average duration of events and percentage of time with SaO2 < 90%. We explored the contribution of RP components to the risk of recurrent cardiovascular events.For the present study, we explored RP parameters to identify specific components, including the AHI, oxygen desaturation index , mean and minimum oxygen saturation . Moreover, on the basis of cardiovascular risk prediction models , 18, we Participants underwent full polysomnography at home. Details of the sampling and procedure methodologies have been described elsewhere , 15. ForP value for trend was evaluated using Spearman’s rank correlation coefficient when data were continuous and non-normally distributed and the chi-square test for trend when they were categorical (The main characteristics were described using medians (25th percentile and 75th percentile) or percentages. The egorical .Principal component analysis (PCA) was used to avoid collinearity between the RP parameters and to identify relational patterns that reflect sleep apnea patterns. Six RP standardized parameters previously mentioned were used in the PCA. RP parameters that were not normally distributed were log-transformed and then included in the PCA (ODI and AHI). The magnitude of the eigenvalues > 1  and varip-values were reported, and statistical significance was set at 0.05.Statistical analyses were conducted using R, version 3.6 . Two-sidFrom a total of 1,851 patients with ACS enrolled in the ISAACC cohort, we included 948 patients without CPAP treatment and without previous CVD. Finally, 723 patients with available data for the variables explored were included in the present study . The medThe external validation cohort was 2,168 individuals from the HypnoLaus population-based cohort. Finally, 1941 individuals were selected without previous CVD and available data. The median age was 56.9 years, 47% were males, and the median AHI was 9.8 events per hour . The mea2, average duration of events and percentage of time with SaO2 <90%. The first two components were selected to characterize the RP patterns. In the ISAACC study, these two components, which contributed significantly to explaining the relationships among the six RP parameters , accounted for 70% of the variability of the RP data (2 <90% and inversely correlated with the mean and minimum SaO2. Component 1 accounted for 42.2% of the variability of the RP data. The second component (Component 2) was highly correlated with the AHI, ODI, mean SaO2, and average duration of events and inversely correlated with the percentage of time with SaO2 <90% .In the present study, from the ISAACC study, we explored specific RP parameters and components  in the sIn the subgroup of patients without previous ACS, OSA severity (measured by AHI) showed a trend toward statistical association [HR (95% CI) of 1.62 (0.98–2.66)] with an increased risk of recurrent cardiovascular events .In the analysis of RP components and the risk of recurrent cardiovascular events, it was observed that component 2 showed a significant independent association with the risk of recurrent cardiovascular events in patients with the highest adherence (3rd tertile) of component 2 with an adjusted HR (95% CI) of 2.44 (1.07 to 5.56). For component 1, no significant contribution was found to the risk of recurrent cardiovascular events . The disIn the HypnoLaus cohort the risk of recurrent cardiovascular event in patients with first ACS could not be assessed due to its population-based design.In the present study, we explored the relationship between specific components of sleep-disordered breathing and the risk of recurrent cardiovascular events in a cohort of patients with a first ACS and without previous CVD. Recently, it has been reported that patients with OSA admitted by a first ACS without previous CVD present an increased risk of recurrent cardiovascular events . The resCurrently, OSA severity is characterized by the AHI, which captures only one aspect of this heterogeneous disease. The ability to dissect OSA heterogeneity using additional features is necessary for incorporating personalized approaches in disease management. In our study, we observed that the effect of OSA severity, assessed only by the AHI, showed a trend toward a statistical association (with an HR of 1.62) with the risk of recurrent cardiovascular events in the group of patients without previous CVD. When considering the RP components, we observed an HR of 2.44 for component 2, indicating an increase in the risk of recurrent cardiovascular events. Based on the results, we suggest that the analysis of other parameters from RP could contribute to the determination of RP components and their relationship with the development of recurrent cardiovascular events in patients who have suffered an ACS.2 and longer event duration. This tertile would suggest an intermittent hypoxemia component. In contrast, the lowest adherence to this component was characterized by lower AHI, ODI and mean SaO2, which would suggest a sustained hypoxemia component.The ISAACC study  and otheThe results of the present study suggest that from available variables from RP, it is possible to improve the evaluation of the risk of recurrent cardiovascular events with an HR of 1.61 exclusively with AHI to 2.44 considering additional variables. The patients with the highest adherence to component 2 (3rd tertile), which represents an intermittent hypoxemia component, strengthen the hypothesis that OSA exerts a risk in specific subgroups of patients with ACS. In contrast, the patients with the lowest adherence to this component, characterized by sustained hypoxemia, would have a lower risk of recurrence of a cardiovascular event. Notably, the same RP components were found in the HypnoLaus cohort suggesting that these components are not specific to the ISAACC population. However, it was not possible to estimate the predictive nature of the identified RP components for recurrent cardiovascular events in this cohort. Since, the low number of available cardiovascular events due to its population-based design.The existence of specific RP components that could be associated with detrimental effects in specific phenotypes of patients with ACS invites us to reconsider the design strategies of new interventional studies to demonstrate the possible beneficial effect of CPAP treatment on secondary CVD prevention. These preliminary results raise the possibility that, in studies such as the ISAACC study , no bene2, average duration of events and percentage of time with SaO2 < 90%. The usefulness of other variables such as the mean respiratory rate as a predictor of cardiovascular recurrence was previously reported. This variable was not available in the ISAACC study, and future studies exploring the contribution of this specific variable as a predictor of cardiovascular outcomes should be performed. Second, the results of this study indicate the possibility of identifying RP components associated with different risks of recurrent cardiovascular events in patients who have suffered a first ACS and without previous CVD. However, these exploratory results should be validated in future independent cohorts. Third, in our study, we determined RP components using RP parameters that do not include information about sleep phases. Some studies have suggested that rapid eye movement-related respiratory disorders could be informative regarding cardiovascular risk associations with respiratory sleep disorders  and patients provided written informed consent. The patients/participants provided their written informed consent to participate in this study.Laura Abad, Aida Munϸoz, Elisabet Zamora, Ignacio Vicente, Sandra Ingleìs, Carlos Egea, Jaime Marcos, Almudena Fernaìndez, Valentin Cabriada-Nuño, Sonia Castro, Leyre Serrano, Marina Floreìs, Anna Mas, Maricel Arboneìs, Silvia Ortega, Alicia Martiìn, Jose Miguel Romaìn-Saìnchez, Ma Isabel Valiente-Diaz, Ma Esther Viejo-Ayuso, Concepcioìn Rodriìguez-Garciìa, Laura Vigil, Enriqueta Ramiìrez, Mariìa Pinϸar, Elisabet Martiìnez, Blanca Barriuso, Jaime Corral, Francisco Javier Goìmez de Terreros Caro, Antonia Barceloì, Paloma Gimeìnez, Ana Ma Fortuna, Patricia Penñacoba, Abel Jesuìs Martiìnez-Garciìa, Sergio Garciìa-Castillo, Lara Navas, Onintza Garmendia, Joseì Sancho, Salvador Perelloì, Gemma Rubinoìs, and Rocío Gallego.AZ, GS, AS-d-l-T, EG-L, IB, FB, RH, and MS-d-l-T contributed to the study concept and design. GS, AS-d-l-T, GT, JD, JA, JD-C, AU, OMe, MJM, EO-C, JFM, MDP, MM, RC, JMM, EC, OMí, LP, AC, DM, RM, and RH contributed to the data acquisition. AZ, GS, AS-d-l-T, EG-L, IB, GT, FB, RH, and MS-d-l-T contributed to the data analysis and interpretation. All authors contributed to the drafting of the manuscript, critically revised the manuscript for important intellectual content and approved the final version. MS-d-l-T is the guarantor of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Theobroma cacao pod husk (TCPH) in this work, the developed catalyst was tested for the production of fatty acid ethyl ester (FAEE) using the blends of beef tallow (BTO) - waste use oil (WUO) in the ratios of 10:90 (BTO10), 20:80 (BTO20), 30:70 (BTO30)….., 90:10 (BTO90), respectively. To determine the optimum FAEE yield with variable effects , a hybrid design from response surface was adopted with coefficient of determination (R2) and Adjusted coefficient of determination (R2-adj.). Furthermore, the catalytic efficiency was tested by catalyst recycle, refining, and reusability test.A new base catalyst was derived from submerged fermented 60:WUO40 was adequate to produced low viscous FAEE. Catalysts' analysis and characterization revealed the catalyst produced high CaO-base of 87.65 (%wt.), which accounted for the high yield of FAEE. Mathematical optimization via hybrid design showed that the catalyst amount with high F-value = 3063.24 and P-value = 0.0115, played the most significant role in the conversion of blended oil to FAEE among the variable factors considered. Furthermore, based on Box-Cox transformation, the lambda indicated a normal data in normal function of Y3 for polynomial model accuracy. Optimum validated FAEE yields of 99.64 (%wt.) with high coefficient of determination (R2) was established. The qualities of the FAEE were within the standard specification for biodiesel, and the produced catalysts can serve as feedstocks for industrial application.Data revealed the oil blend ratio of BTO The tab2 TPD. Data plot on catalyst recycle, refining, reusability test are plotted and displayed in D6751 and EN 14214). Based on dataset on comparative study of this work with other research earlier reported data, The graphical interactions between the responses (FAEE3) data and the linear constraint interactions  was employed to design the experiment with consideration of four factors namely; reaction time, catalyst amount, reaction temperature and ethanol to oil molar ratio, respectively, was used to study the effects of variables on the response (FAEE) in a single batch reaction.Theobroma cacao pod husk).Materials used in this work are Ethanol, Methanol, Hydrochloric acid, Sulphuric acid, Sodium thiosulphate, Sodium hydroxide, Starch solution, Wij's solution, and phenolphthalein etc., obtained from ChemiSciences Nig. Ltd.  Further material also include waste used oil (WUVO), beef tallow oil (BTO), and Cocoa pod husk  to study the high spatial resolution (surface morphology) of the catalyst, XRD fortified thru Kά and Cu radiation source, enhanced at 20 mA and 40 kV, to institute the angular scanning electron implemented in the range of 1010), 20:80 (BTO20), 30:70 (BTO30), 40:60 (BTO40), 50:50 (BTO50), 60:40 (BTO60), 70:30 (BTO70), 80:20 (BTO80), and 90:10 (BTO90), respectively, to obtain low viscous oil, low acid value and accurate density required for transesterification of oil to biodiesel. The mixed oil in different ratios was properly was heated at 35 oC on a hot plate for proper mixing owing to the uncertainty in the nature of fat. The viscosity, the acid value, and the specific gravity of the resulting mixed oil were examined.The method used for oil blend/mix BTO:WUVO in volumetric ratios as; 10:90 (BTOoC until a constant weight was achieved (bone dried). The dried fermented sample was milled and sieved into powder of 0.30 mm particle size before calcined at 750 oC for 4 h in a furnace. The calcined sample (SFCTCPH) after calcination was left in the furnace for 24 h for proper cooling, and then placed in cleaned container for further analysis.Cocoa pod husk obtained from Cocoa processing factory in Ondo State, Nigeria. The pod husk was cleaned by washing with ionized water, and was decanted, kept overnight to allow proper draining. The drained-cleaned Cocoa pod was fermented in distilled water anaerobically (submerged) for 10 days. After which the fermented sample was separated from fermented water by decantation, dried in an oven at 120 oC for 60 min using a hot plate equipped with a magnetic stirrer. 2.5 (wt.%) of CaO catalyst was measured in a 250 ml dried-cleaned flask, and 50 ml of ethanol was measured and added to the ethanol flask to achieved EtOH/OMR of 1:4. The mix was placed on a shaker for 15 min, and then added to the heated oil in the reactor. The resulting mixed indicated two separated layers which contained the ethanol-catalyst layer and the oil layer. The reaction was carried out at 70 oC for 65 min to reach completion.Production of biodiesel was carried out through the use of derived heterogeneous based CaO-catalyst synthesized from samples. The reaction process took placed in a 1000 ml reactor with three-necked, 200 ml of the oil mixed was first heated at 100 2SO4), and was separated by liquid–solid separation (decantation) to obtain the pure FAEE as liquid. The solid residual catalyst purified and reused. The step by step reaction process was conducted based on number of experimental runs generated by design expert.At the end of reaction process, the non-soluble catalyst was removed by decanting, and the resultant product (ethanol-based-diesel) was distinguished through density separation. The biodiesel (fatty acid ethyl ester: FAEE) along with leached catalyst was separated by washing with warm mixture of 1.0 g sodium carbonate and 20 ml methanol. The washed mixed was separated by filtration, and the filtrate-diesel was washed with ionized water, and separated via gravity settling. The water wet-diesel was dried over anhydrous sodium sulphate  was adapted to elucidate the data while diagnostic was used to estimate the fit of the model, and model transformation, the graphical plots were used to interpret and evaluates the model. The p-value called the probability value, the f-value called the factor value, the df known as degree of freedom, and the VIF called the variance inflation factor, were used for model significance. The regression parameters such as the coefficient of determination: Three-dimensional plots was used as a geometric setting to express the relationship between three variables while the second-order differential equation that further elucidates the connection between FAEE yield and the four factors is expressed arithmetically in Where FAEE is the yield in percentage, oC for 60 min so as to make free of the alcohol before cooled temperature of 27 oC and then reused.The recovered catalyst was examined for its effectiveness by carried out the reusability tests. Catalyst purification of the recovered catalyst was carried out by the method used Properties of the FAEE such as density, viscosity, moisture content, mean molecular mass, acid, saponification, iodine, peroxide, higher heating value, cetane number, API gravity, and diesel index were determined so as to determine its aptness as a substitute for conventional fuel used in diesel engine. These qualities were compared with 1, X2, X3 and X4). The image of the SEM image and FTIR analysis of the calcined cocoa husk powder are displayed in The properties of mix oil ratio are displayed in This work does not involve the use animal or human subject.Adepoju T.F.: Conceptualization, Methodology, Software, Validation, Formal Analysis; Ukpong A.A.: Investigation, Resources, Data Curation, Writing – original draft, Supervision; Balogun T.A.: Validation, Formal Analysis, Investigation, Resources, Data curation; Emberru E.R.: Formal Analysis, Investigation, Resources, Data Curation, Provide Financial Support, Methodology, Software.The authors declare that they have no competing financial interests or personal relationships which have, or could be perceived to have, influenced the work reported in this article.Financial institution. This research work receives no financial support from either Institution or government organization.


Pure primary ovarian squamous cell carcinoma (oSCC) is very rare, with about 42 cases have been reported in the literature. Lacking effective treatment guidelines, the prognosis of oSCC is extremely poor. Here, we report a 52-year-old postmenopausal woman diagnosed with pure primary oSCC in our center. The patient received debulking surgery followed by chemotherapy with carboplatin, paclitaxel, and bevacizumab. The patient survived 11 months after surgery and died of tumor progression and multiple organ failure. We also present a review of the literature. Ovarian squamous cell carcinoma (oSCC) accounts for 1% of ovarian cancer . Here, wA 52-year-old postmenopausal woman, G1P1, presented with abdominal pain and abdominal distension for more than 1 month was transferred to West China Second University Hospital. Physical examination revealed the bilateral adnexal thickness and tenderness. Her vulva, vagina, and cervix appeared normal and a Papanicolaou smear showed no abnormal cells. Tumor markers showed CA199:43.3 U/ml (<30.9), CA125:41.2 U/ml (<35), CEA:1.1 ng/ml (<2.5), AFP:4.2 ng/ml (<8.1). On transvaginal ultrasonography, a 7.1 × 4.3 × 5.4 cm septal cystic, solid mass was detected on the left adnexal and the endometrium was thin and clear. Abdominal computed tomography (CT) identified that the solid components of the mass were enhanced and left hydronephrosis with dilation of the proximal ureter and the lymph nodes of bilateral obturator regions, iliac vessels, and para-aortic were noticed Figure 1The patient received laparoscopic evaluation. The pelvic mass was 8 cm in diameter origin from the left adnexa, densely aggregated with the surrounding sigmoid colon, omentum, and left pelvic peritoneal. A part of the left ureter was surrounded by the tumor in about 5-cm length. There was no ascitic fluid, and the right adnexa was normal. A frozen section of the left adnexal mass reported a poorly differentiated carcinoma of the ovary. A debulking surgery was performed, including total abdominal hysterectomy, bilateral salpingo-oophorectomy, pelvic and para-aortic lymph nodes dissection, omentectomy, appendectomy, and multiple peritoneal biopsies through a generous laparotomy, and there was no residual tumor. On grossly, the left adnexal mass section was grayish-white, solid, and crispy, and the fallopian tube and ovary were unremarkable. Her postoperative course was uneventful. Her postoperative pathology reported a poorly differentiated invasive SCC of the ovary without any other associated dermoid cysts, endometriosis, or Brenner tumors Figure 2The patient received adjuvant chemotherapy with carboplatin (450 mg) and paclitaxel (210 mg) at 4-week intervals for six courses. After completing six courses chemotherapy, abdominal CT revealed the thickening of the left pelvic peritoneal, and a solid, nodular mass occupied the left adnexal region. The mass involved the left iliac vessels, the left iliopsoas muscle, and the left lower ureter. Considering the possibility of tumor recurrence or metastasis, we combined the chemotherapy regimen with bevacizumab (400 mg) for two courses. However, 2 weeks after the treatment, the patient appeared bloody stool. Physical examination revealed a fixed mass with about 10 cm in diameter in the left pelvic cavity and an annular hollow about 1-cm long in the rectum. The patient chose to abandon the treatment and died of tumor progression and multiple organ failure 11 months after surgery.Ovarian cancer clinical appearances are atypical, with 70–80% of patients diagnosed at advanced stages, and it is the most common cause of gynecological cancer death . OvarianBecause SCC is the common histologic type of malignancy in the cervix, vulva, vagina, lung, head, and neck. We are of the view that thorough evaluation, including physical examination, cytologic tests if applicable, and/or imaging of these anatomic sites, is mandatory to make the primary diagnosis. Especially with the immunohistochemistry (IHC) site-specific markers . The oSCoSCC is rare but has poor prognosis; Cheng, based on the SEER database, selected patients with oSCC and serous carcinoma (SC) with 1:2 matching analysis and revealed that the median survival time of oSCC was 21 months. The 1-, 2-, and 5-year OS rates of oSCC were 61.6, 49.2, and 44.9%, respectively. The prognosis of SCC was significantly worse than that of patients with SC . Only a Pure primary oSCC is extremely rare; the adjuvant treatment has not been well established. Because this tumor is regarded as EOC, the adjuvant chemotherapy with paclitaxel and platinum should be suggested , 4, 6. OIn addition, treatments for other organs SCC may offer a clue for the treatment of pure primary oSCC. EGFR is overexpressed in cervical SCC. A phase II study of EGFR inhibition combined with radiotherapy and cisplatin in the treatment of locally advanced cervical cancer has shown a complete response rate of 94.4%. A patient with metastatic oSCC was treated with a combination of platinum, cetuximab, and radiotherapy, and the patient achieved an impressive 5-year disease-free survival . VasculaThe pure primary oSCC is extremely rare and most reported in case reports. The effective treatment has been not established. At present, debulking surgery followed by chemotherapy paclitaxel combined with platinum is recommended. However, due to the variable prognosis, the adjuvant therapy is still controversial. With the accumulation of more cases, drawing lessons from the existing treatment of primary SCC in other organs and other types of EOC, as well as the clarification of its pathological mechanism, a breakthrough in the treatment of pure primary oSCC will be achieved.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.YL: manuscript writing. CB: protocol development, manuscript revision, and final approval of the version to be published. All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


To systematically assess the clinical effect and survival time of immune checkpoint inhibitor (ICIs) in advanced gastric cancer (GC) and adverse reactions to provide evidence-based medicine for its enhancement and adoption.  PubMed, EMBASE, ScienceDirect, Cochrane Library, China Knowledge Network database (CNKI), China VIP database, Wanfang database, and China Biomedical Literature Database (CBM) online database were searched for randomized controlled trials (RCT) of immuno-checkpoint inhibitors in advanced GC therapy. Retrieval time was limited to the period from the date the database was established to present. Separately, two researchers gathered the data. Statistical software RevMan5.4 was used to estimate bias risk according to the Cochrane Handbook 5.3 standard. P < 0.05). The immune function indexes after treatment were compared, suggesting that the improvement of immune function indexes in the study group was notably better, and the difference was statistically significant (P < 0.05). Three clinical trials reported the median progression-free survival (PFS). The PFS of the study group was notably longer after treatment, and the difference was statistically significant (P < 0.05). The occurrence of adverse reactions after treatment was analyzed by meat, and all the literatures were analyzed. No notable differences were observed in the incidence of adverse reactions.  The computer database retrieved 1723 articles, and 465 articles were eliminated when repeated studies were removed. After screening the titles and abstracts of 287 articles, 124 articles were contained after eliminating irrelevant studies, reviews, case reports, and no control literature. After carefully reading 108 studies with insufficient data and no major outcome markers, 6 RCTs were eventually contained. 4 articles compared the levels of carcinoembryonic antigen (CEA) and carbohydrate antigen 199 (CA199) after treatment. The result indicated that the levels of serum CEA and CA199 in the study group were notably lower, and the difference was statistically significant ( ICIs associated with chemotherapy is effective when treating GC, which can effectively promote the disease control rate of patients, enhance immune function, reduce the level of tumor markers, and prolong survival time. The safety is controllable, which is worth popularizing in clinical practice. However, more studies and follow-up with higher methodological quality and longer intervention time are needed to further verify it. The most common malignant tumor of the digestive tract in China is gastric cancer (GC), which is highly prevalent and has a poor prognosis. GC ranked second in incidence and mortality among malignant tumors in China, right behind lung cancer, according to the results of a tumor epidemiological survey. GC is a type of malignant tumor of the digestive tract that is highly morbid and highly lethal. With the application of new treatment methods, like surgery, neoadjuvant radiotherapy, neoadjuvant chemotherapy, and targeted therapy, the treatment of GC has changed to individualized and comprehensive treatment. The short-term survival rate of patients has been improved, but the 5-year survival rate is still low . East AsTo treat advanced GC, the first-line treatment is platinum and 5-fluorouracil-based chemotherapy . A firstThe antitumor mechanism of traditional chemotherapeutic drugs may regulate the immune model. In combination with PD-1, PD-L1 inhibits T cell function, inhibiting tumor immunity and promoting tumor growth. In light of the study of this mechanism, blocking the PD-1/PD-L1 signal pathway makes sense for treating patients with GC. For example, chemotherapeutic drugs such as cyclophosphamide, platinum, and paclitaxel can enhance the antigenicity of tumor cells, while paclitaxel, cisplatin, and doxorubicin enhance the sensitivity of tumor cells to immune effector cells , 9. PD-1The occurrence of GC is related to unhealthy diet, Helicobacter pylori infection and Epstein-Barr virus infection. Cancerous cells evade host immune defense and attack through high expression of immune checkpoint proteins to facilitate tumor growth. ICIs block the immunosuppressive signal pathway activated by cancer cells through antibodies, to enhance the body's antitumor immunity and kill tumor cells , 13. CheSearch PubMed, EMBASE, ScienceDirect, CochraneLibrary, China Journal Full-Text Database (CNKI), VIP full-text Database (VIP), Wanfang Database and Chinese Biomedical Literature data (CBM), related journals, conference papers, and degree papers were searched and collected relevant data about the use of immuno-checkpoint inhibitors when treating patients with advanced GC. Searching literatures were conducted with free words + subject words, with the key words of ICIs; GC; progression; survival time; therapeutic effect; adverse reactions; meta-analysis, from January 2010 to May 2022.(1) Type of study: all controlled trials (CT) using immunosuppressive agents to treat patients with advanced GC. (2) Participants: all patients with advanced GC were diagnosed as GC by gastroscopy/laparoscopy. The diagnostic criteria were referred to the relevant literature . The TNM(1) The data report was incomplete and the data could not be used; (2) the research was repeated to select the most recent studies; (3) the evaluation of the curative effect of the study was not notable.Bias risk assessment contained in the study: for the evaluation, a bias risk assessment tool recommended by Cochrane System Review Manual 5.4 was usedLiterature screening and data extraction: independently, two researchers screened literature, gathered data, assessed quality, and cross-checked results. A disagreement should be discussed and resolved, or a third researcher should be invited to contribute to the judgement. Note: Express document management software and Excel office software were used to manage and extract research data. If the data contained in the literature was incomplete, the author of this article would be contacted to supplement it. The content of data extraction contained (1) basic information: author, publication time, and number of cases; (2) intervention: plan, course of treatment; and (3) outcome indexχ2 test is used to determine whether there is heterogeneity between the studies, if P > 0.05 and I2 < 50%, it is considered that the included study is homogeneous, and the modified impact model can be collected for meta-analysis; if P < 0.05 and I2 ≥ 50%, when judging the homogeneity of the included study, the combined effect is needed, then choose the random effect model; if P < 0.05, and the source of heterogeneity could not be judged, meta-analysis was not performed, and descriptive analysis was used.The RevMan5.4 software originated from Cochrane collaboration network for meta-analysis. The mean and standard deviation of the net change difference of serum albumin, prealbumin, and hemoglobin in the experiment, and the control cohorts were input into RevMan5 for analysis. Because the index is a continuous variable, the weighted mean difference (WMD) is used as the effect scale, and 95% confidence interval is selected. First, The computer database retrieved 1723 articles, and 465 articles were eliminated when repeated studies were removed. After screening the titles and abstracts of 287 articles, 124 articles were contained after eliminating irrelevant studies, reviews, case reports, and no control literature. After carefully reading 108 studies with insufficient data and no major outcome markers, 6 RCTs were eventually contained –21. The The six CT articles contained in this meta-analysis reported the baseline health status of the patients. The six studies contained all gave detailed intervention measures and treatment time. None of the 6 articles described in detail the number and reasons of the blind method and those who lost follow-up or withdrew. According to the Jadad scale, all the 6 articles were less than 2 points Figures .2 = 5.46, df = 4, P = 0.24, and I2 = 27%, without obvious heterogeneity among the contained data. The analysis of random effect model (P < 0.05). It is suggested that the use of ICIs when treating patients with advanced GC can notably enhance the disease control rate.There were 492 samples from 6 studies contained in this study. The disease control rates were analyzed by meta. The results of heterogeneity test indicated that the research data contained in the study showed distinct heterogeneity. Chict model  indicate2 = 76.60, df = 2, P < 0.00001, I2 = 97%; CA199: chi2 = 72.37, df = 2, P < 0.00001, I2 = 97%. Based on the summary analysis of all the literatures, the heterogeneity test results indicated that chi2 = 278.10, df = 5, P < 0.00001, I2 = 98%, indicating that the research data contained in the study showed distinct heterogeneity. The analysis of random effect model (P < 0.05). It has suggested that the treatment of patients with advanced GC with ICIs can better inhibit tumor progression and alleviate the disease.Four of them compared the levels of CEA and CA199 after treatment. The results of heterogeneity test indicated that: CEA: chict model  indicate2 = 45.60, df = 1, P < 0.00001, I2 = 98%; CD4+: chi2 = 112.66, df = 2, P < 0.00001, I2 = 98%; CD8+: chi2 = 34.93, df = 2, P < 0.00001, I2 = 94%. It indicated that the research data contained in the study showed distinct heterogeneity. The analysis of random effect model (P < 0.05). It has suggested that ICIs therapy can protect and enhance the immune function and reshape the antitumor immune system.There were 492 samples from 6 studies contained in this study. The immune function indexes after treatment were compared. The results of heterogeneity test indicated that CD3+: chict model  indicate2 = 17.29, df = 2, P = 0.0002, I2 = 88%). The analysis of random effect model (P < 0.05). It has suggested that immuno-checkpoint inhibitor therapy can notably prolong the survival time of patients with advanced GC.This study contained 6 studies with a total of 492 samples, of which 3 clinical trials reported postoperative median PFS. The results of heterogeneity test indicated that the research data contained in the study showed distinct heterogeneity . It has suggested that routine chemotherapy associated with immuno-checkpoint inhibitor therapy would not notably increase the adverse reactions of patients with advanced GC.The common adverse reactions contained liver function injury, myelosuppression, gastrointestinal reactions, anemia, hypothyroidism, and reactive capillary hyperplasia. The results of heterogeneity test indicated that chict model  indicateThe ICIs can restore the immune response by blocking the process of immune escape. At present, immunotherapy has been successfully applied in solid cancers such as advanced head and neck squamous cell carcinoma, non-small-cell lung cancer, and malignant melanoma, and gratifying results have been obtained in the early study of GC . For patTumor cells mainly escape the monitoring of immune response through the coinhibitory signal pathway mediated by immune checkpoint . It has At present, clinical trials of camrelizumab when treating many kinds of tumors have been carried out. The results show that camrelizumab can increase the CR rate of relapsed/refractory classical Hodgkin's lymphoma and the objective remission rate of advanced non-small-cell lung cancer, advanced esophageal squamous cell carcinoma, and advanced GC. Clinical studies have confirmed that the immune system can enhance the immune response to tumor, to enhance the ability of autoimmune system to clear tumor cells by strengthening the inhibition of PD-1/PD-L1 pathway to achieve the purpose of antitumor. The improvement of immune function indexes in the study group was notably better after treatment. It is fully proved that immunotherapy associated with chemotherapy can improve the synergism. On the one hand, chemotherapy can obviously damage the normal cell function of the body while killing tumor cells, resulting in low immunity of patients. Immunotherapy can protect and improve the immune function of the body, reshape the antitumor immune system, enhance the antitumor effect, prolong the survival time, and improve the quality of life. Therefore, the immunity of patients has been greatly improved after the application of ICIs, which is of positive significance to the treatment and rehabilitation of the disease. Four articles in this study compared the levels of CEA and CA199 after treatment. It is suggested that the use of ICIs when treating patients with advanced GC can better inhibit tumor progression and alleviate the disease. It is considered that PD-1 inhibitors can better reduce immunosuppression, enhance antitumor immune response, and effectively prevent the progression of disease. As important tumor markers, the levels of serum CEA and CA199 can accurately reflect the disease control of patients. In this study, the levels of serum CEA and CA199 in the study group decreased notably, indicating that ICIs have a good effect on advanced GC.No notable difference was discovered in the incidence of adverse reactions. It is suggested that routine chemotherapy associated with ICIs will not notably increase the adverse reactions of patients with advanced GC, indicating that immuno-checkpoint inhibitors are safe and suitable for patients with severe conditions. Patients are well tolerated and can be safely used. The limitations of the study are as follows: (1) the inclusion and exclusion criteria are relatively strict, and the final number of included literature is relatively small; (2) the source of heterogeneity cannot be found through subgroup analysis, which needs to be followed up by scholars, and the results of this study need to provide more support. More high-quality randomized controlled trials are needed to verify.To sum up, ICIs have high clinical application value in advanced GC. Combined chemotherapy can successfully enhance the level of T lymphocytes, regulate the function of immune system, and prolong the survival time of patients. In addition, the adverse reactions are within a controllable range.


Suicide is a leading cause of death in the United States, and suicidal ideation (SI) is a significant precursor and risk factor for suicide.This study aimed to examine the impact of a telepsychiatric care platform on changes in SI over time and remission, as well as to investigate the relationship between various demographic and medical factors on SI and SI remission.Participants included 8581 US-based adults (8366 in the treatment group and 215 in the control group) seeking treatment for depression, anxiety, or both. The treatment group included patients who had completed at least 12 weeks of treatment and had received a prescription for at least one psychiatric medication during the study period. Providers prescribed psychiatric medications for each patient during their first session and received regular data on participants. They also received decision support at treatment onset via the digital platform, which leveraged an empirically derived proprietary precision-prescribing algorithm to give providers real-time care guidelines. Participants in the control group consisted of individuals who completed the initial enrollment data and completed surveys at baseline and 12 weeks but did not receive care.r=0.24-0.37) with SI at baseline. Sleep issues and feeling tired or having low energy, although significant, had lower correlations with SI (r=0.13-0.14). In terms of demographic variables, advancing age and education were associated with less SI at baseline (r=−0.16) and 12 weeks (r=−0.10) but less improvement over time . Although not different at baseline, the SI expression was evident in 34.4% (74/215) of the participants in the control group and 12.32% (1031/8366) of the participants in the treatment group at 12 weeks. Although the participants in the treatment group improved over time regardless of various demographic variables, participants in the control group with less education worsened over time, after controlling for age and depression severity. A model incorporating the treatment group, age, sex, and 8-item Patient Health Questionnaire scores was 77% accurate in its classification of complete remission. Those in the treatment group were 4.3 times more likely  to have complete SI remission than those in the control group. Female participants and those with advanced education beyond high school were approximately 1.4 times more likely  to remit than their counterparts.Greater feelings of hopelessness, anhedonia, and feeling bad about oneself were most significantly correlated (The results highlight the efficacy of an antidepressant intervention in reducing SI, in this case administered via a telehealth platform and with decision support, as well as the importance of considering covariates, or subpopulations, when considering SI. Further research and refinement, ideally via randomized controlled trials, are needed. Suicide is a leading cause of death in the United States, claiming the lives of >47,000 people in 2019 [Amid the current global COVID-19 pandemic, concerns arose about increases in SI and suicide, with a study suggesting a particularly heightened risk at the intersection of patient vulnerability, risk, resources, and mental health status . AlthougAlthough 90% of those who commit suicide have a psychiatric diagnosis , predictSeveral studies have demonstrated that depression is the most common psychiatric disorder among people who die by suicide, with an estimated 50% to 75% diagnostic prevalence in suicide cases ,19. In aIn addition to the mental health conditions associated with an increased risk of suicide, certain physical health conditions such as chronic pain and chronic medical conditions have also been shown to be associated with increased SI and suicide attempts -31. ApprVarious demographic variables have been investigated as potential risk factors for SI and suicide. In general, factors such as sex , ethnicity , education level (high school or less), and economic factors (unemployment) are associated with higher rates of suicide -35. AlthIt has been relatively well established that suicide has a strong association with psychiatric disorders, especially major depressive disorder, and that pharmacological and nonpharmacological methods are often indicated for patients expressing SI as part of depressive symptomology. The course of treatment may commonly include prescribing antidepressants, such as selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, more modern antidepressants such as bupropion, older tricyclic antidepressants, and monoamine oxidase inhibitor antidepressants. Although antidepressants are a common treatment route, overall, there are conflicting findings regarding whether they reduce SI or suicide, or both ,36-40. TGiven the limited and inconsistent understanding of the effects of psychotropic treatment on SI, this study seeks to add to the literature by investigating the impact of psychiatric care, delivered via a telehealth platform, on SI. The objective of this study was, therefore, to examine the impact of this psychiatric care platform on SI, change in SI over time, and remission, as well as to investigate the relationship between various demographic and medical factors on SI and SI remission.Participant data used in this study were obtained from a national mental health telehealth company  and consisted of 8581 US-based patients receiving psychiatric care for depression or anxiety, or both between October 2018 and April 2021 . Participants were eligible if they (1) completed surveys at baseline and at 12 weeks; (2) denied any history of psychosis, schizophrenia, or bipolar I disorder; and (3) denied any history of chronic liver or kidney disease. Participants in the control group met the same criteria and signed up initially for Brightside but did not receive care. Brightside uses a free self-care product that sends emails requesting the completion of survey data over a period of 14 weeks even with no sign-up. The control group therefore consisted of individuals who completed the initial enrollment data and completed surveys at baseline and at 12 weeks. The treatment group included individuals who engaged in treatment with Brightside for at least 12 weeks. The demographic and clinical characteristics of the 2 groups are shown in During a patient’s first session, a licensed professional prescribed psychiatric medications for the patient in the treatment group. Enrolled Brightside patients completed an initial digital intake that included clinically validated measures of depression and anxiety, as well as questions about clinical presentation, medical history, and demographics. Brightside’s proprietary precision-prescribing platform analyzes these data points using an empirically derived algorithm to provide real-time care guidelines and clinical decision support to providers via the digital platform. Brightside platform provides this decision support via a computerized symptom cluster analysis at treatment intake. On the basis of the analysis of presenting symptom clusters, as well as decision support based on the empirical literature, treatment recommendations are provided . The algDiagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria. The PHQ-9 is a tool that is easy to use, but its validity remains widely confirmed [The Patient Health Questionnaire PHQ-9) is a 9-item self-report measure used to assess the severity of depressive symptoms present within the prior 2 weeks, as outlined by the onfirmed . Respondonfirmed . The PHQonfirmed . There ionfirmed . In this is a 9-ionfirmed . Item 9 onfirmed . For somDiagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria. Respondents rate items on a 4-point Likert scale (0-3), and total scores range from 1 to 21, with indications of 1 to 4 for minimal, 5 to 9 for mild, 10 to 14 for moderate, and 15 to 21 for severe symptoms [The Generalized Anxiety Disorder-7 (GAD-7) scale is a 7-item self-report instrument used to assess the severity of anxiety symptoms present within the prior 2 weeks as outlined by symptoms . The GADsymptoms .Basic demographic variables such as age, education, sex, and employment status were collected at baseline. In addition, individuals were asked if they had the following chronic health conditions: asthma, cancer, Crohn disease, irritable bowel syndrome, heart condition, obesity, or diabetes. A simple count variable was created with the number of chronic medical conditions endorsed. In addition, endorsement of either chronic pain or fibromyalgia was considered a variable representing chronic pain. Respondents were asked whether they used illicit substances and whether they currently experienced panic attacks. Finally, the patients were asked if they had ever attempted suicide in the past. Some participants  in the control group were missing the information about race, ethnicity, sex, and education level, whereas 1.28% (107/8366) of the participants in the treatment group were missing chronic pain status.Data analyses were performed using SPSS  to assemble the patient data sample, apply inclusion and exclusion criteria, and establish baseline versus follow-up survey outcomes. Brightside maintains deidentified databases for analytics that facilitate granular insights into clinical decisions, interactions, and outcomes. Assumptions for conducting regression models were assessed using visual inspection of distributions, a scatter plot of the residuals, and variance inflation factor values, as well as by examining potential multicollinearity among predictors. For the logistic regression models, the Box-Tidwell test was used to test whether the logit transform was a linear function of the predictor. In univariate general linear modeling of baseline SI severity, checking the assumptions revealed heteroscedasticity. As such, models were run using Box-Cox transformations . The omnFirst, we examined zero-order correlations between item 9, the SI item, on the PHQ-9 and change over time, as well as with various demographic, clinical, and medical variables. We also examined the correlations between item 9 and the other PHQ items. Pearson or point biserial correlation coefficients were calculated based on the variables included. Univariate general linear modeling was used to explore the independent effects of demographic and clinical variables on the baseline SI severity.t tests. Mixed model analyses, controlling for age and PHQ-8 scores, were used to investigate the differences in SI over time by treatment group, education level, and employment status. These variables were chosen because they significantly differed between groups at baseline.We then examined the relative rates of SI at baseline and 12 weeks, as well as the percentage change over time. Chi-square analyses compared relative proportions between groups. An analysis of covariance examined the treatment effect by group, on changes in SI over time, controlling for baseline age and PHQ-8 scores. Bonferroni corrections were used in all follow-up 2-tailed remitted at 12 weeks  and then examined potential predictors of remission. Chi-square analyses compared relative proportions among groups. Using the control group as the reference group, logistic regression with 95% CIs was used to examine bivariate relationships between SI remission and all previously described demographic, clinical, and medical variables. We then implemented a forward stepwise regression procedure to identify the independent predictors of remission during the study period, considering all the variables that were significant in the bivariate models.Next, using only those who endorsed SI at baseline (a score of ≥1), we calculated the proportion of people who The WCG Institutional Review Board, Ethics Committee Panel 1, approved the retrospective research analysis of clinical data obtained by Brightside as part of routine clinical care (#1308524). The data were drawn from a deidentified clinical database.r=0.24-0.37) with SI at baseline. Sleep issues and feeling tired or having low energy, although significant, had lower correlations with SI (r=0.13-0.14). In terms of demographic variables, advancing age and education were associated with less SI at baseline (r=−0.16) and 12 weeks (r=−0.10), but less improvement over time . Although correlations between minority status (r=0.07) and employment status (r=0.05) and SI were significant, their magnitudes were small. Both the PHQ-8 and, to a lesser extent, the GAD-7 were significantly associated with SI  and with change over time . The number of chronic medical conditions was not significantly associated with SI or change over time. Endorsing either chronic pain or fibromyalgia was significantly associated with SI at baseline and week 12 but did not change over time, although the correlations were quite small (r=0.03-0.04). Having recent panic attacks and histories of illicit drug use or suicide attempt were significantly associated with SI at both time points, as well as change over time, although only correlations with baseline SI were of any magnitude (r=0.08-0.10).Correlations between the SI item on the PHQ-9 and all other items were examined . Greaterr=0.35; P<.001), it was not included in the model. Similarly, having a comorbid panic disorder was correlated with sex  and age , so it was also excluded. The overall model was significant  and accounted for 17% of the variance in the baseline SI. As shown in A univariate general linear modeling was used to explore the independent effects of these demographic and clinical variables on baseline SI severity . As GAD χ21=0.0; P=.89). At 12 weeks, 34.4% (74/215) of the participants in the control group and 12.32% (1031/8366) of the participants in the treatment group expressed SI . Similarly, the percent change in SI scores was greater in the treatment group  than that in the control group ; 41.73% (3491/8366) of the participants in the treatment group had lessening of SI over time, compared with 27% (58/215) of the participants in the control group. Among the control group, 13.5% (29/215) of the participants expressed more severe SI at 12 weeks than at baseline, whereas only 2.53% (212/8366) of the participants in the treatment group did .At baseline, 46.5% (100/215) of the participants in the control group and 47.12% (3942/8366) of the participants in the treatment group expressed SI . Analysis of covariance, controlling for age and PHQ-8 scores, demonstrated a significant effect for the treatment group  over time. In terms of emergence of SI in those who did not initially endorse it (n=4539), the control group had 15.6% (18/115) emergence, whereas the treatment group had only 2.98% , education level , and employment status . There were significant 2-way interactions, but these were further refined by a 3-way interaction among time, group, and education level . Mixed model analyses, controlling for age and PHQ-8, investigating differences in SI over time by treatment group, education level, and employment status revealed significant effects for the treatment group .Among those who endorsed SI at baseline but then endorsed none at 12 weeks, 76.37% (3087/4042) of the total sample manifested this complete remission. Complete remission was observed in 77.19% (3043/3942) of the treatment group and 44% (44/100) of the control group , obtaining education beyond high school, and lower depression severity (as measured by PHQ-8 scores) at baseline . Those iThe objective of this study was to examine the impact of psychiatric care on SI, change in SI over time, and remission, as well as to investigate the relationship between various demographic and medical factors on SI and SI remission.Greater feelings of hopelessness, anhedonia, and feeling bad about oneself were most significantly correlated with SI at baseline. Sleep issues and feeling tired or having low energy, although significant, had lower correlations with SI. These patterns of associations between the SI item and other items of the PHQ-9 mirror those found in other studies with primary care patients who had depression or chronic pain and had completed the PHQ-9 , with thAssociations between greater SI severity and younger age are consistent with national survey data finding that younger adults more frequently endorse SI than older adults . As mighNot surprisingly, both the PHQ-8 and, to a lesser extent, the GAD-7 were significantly associated with SI (much more so at baseline) and with change over time. The baseline PHQ-8 score was the most prominent independent predictor of SI, accounting for 12% of the variance. This reflects a consistent finding in the literature that depression severity is highly associated with SI  and withr=0.08-0.10). Again, these findings are in line with prior research [The number of chronic medical conditions was not significantly associated with SI or change over time. Endorsing either chronic pain or fibromyalgia was significantly associated with SI at baseline and week 12 but did not change over time, although the overall correlations were quite small. This is counter to prior research ,63 and mresearch ,64-66, aAlthough the groups were similar at baseline in terms of the presence of SI (47%) at baseline, after 12 weeks of treatment, only 12.32% (1031/8366) of the participants in the treatment group expressed any SI, compared with 34% (74/215) of the participants in the control group. These numbers are similar to a much smaller study investigating psychotherapy for depression , althougAlthough the treatment group improved over time regardless of various demographic variables, in the control group, after controlling for age and depression severity, those with less education worsened over time. Greater education levels are protective against many adverse outcomes, including SI -71. TeleThose in the treatment group were 4.3 times more likely to remit than those in the control group . Zisook et al  found siTreatment was clearly the biggest predictor of SI remission. Other factors found to be significantly associated with SI remission were older age, being female, being White, obtaining education beyond high school, and having lower depression severity at baseline. Women and those with advanced education beyond high school were about 1.4 times  more likely to remit than men and those without advanced education . In the STAR*D trial, remission of depressive symptoms was more likely in those who were White, female, employed, or had higher levels of education or income . AlthougThe primary limitation of this study is that there was no random assignment to treatment, and alternative explanations for any observed treatment effects are possible. Although comparison to a control group that completed assessments on the same schedule as the treatment group, and which was largely equivalent to the treatment group at baseline, reduced the likelihood that any effects were because of engagement on line or other Hawthorne effects, the control group did not engage with providers. As the participants were not randomized, there is potential for confounding. For example, participants in the control group were more likely to be unemployed and have no education beyond high school. As it is unclear why the control group participants did not pursue treatment, one possibility is that they had less scheduling flexibility or less ability to take time off to attend treatment.Another limitation is the inability to directly compare different medications, as this was a clinical sample with >400 different combinations of medications. Although this prevents generalizability to specific medication groups, it does speak to the ability of antidepressant treatment, as rendered in this novel virtual treatment regimen, to positively affect SI. An additional limitation, however, is that patients may have had other treatments such as psychotherapy that were not assessed. In addition, a specific measure of SI, such as the Beck Scale for Suicide Ideation or the Scale for Suicide Ideation , would hDepression severity is the primary driver of SI, relative to demographic and other clinical or medical factors. Certainly, many clinicians may be reluctant to prescribe antidepressants in those with SI because of the perceived risk of working with patients who are suicidal. These results address, at least to some degree, these concerns. The results of this study, as well as those of others, are consistent with the efficacy of psychiatric care administered via a telehealth platform with decision support. In antidepressant trials, depression severity mediates the effect of antidepressant medication on suicide risk ,77, so tFinally, these results align with a growing body of literature demonstrating the effectiveness of using a telehealth platform for providing mental health services -82. Clin