Adipokines are cytokines secreted by adipose tissue that play a crucial role in several biological processes, including energy balance, food intake, immune status, and reproduction. Research has shown that there is a close correlation between energy balance, metabolism, and reproductive function in mammals. Among these factors, ovarian physiology has been found to have its own local regulation. In this study, we aimed to gain insight into the local production of novel adipokines and their receptors in the corpus luteum of cycling and pregnant cows. We examined corpora lutea at various stages in cycling and pregnant cows to investigate the involvement of locally produced adipokines and their receptors in ovarian physiology. Our findings reveal significant differences in the expression levels of adipokines throughout the estrous cycle and pregnancy, indicating their potential role in corpus luteum lysis and/or resumption of cyclicity.This study aimed to determine the gene expression of different local novel adipokines, such as vaspin, adiponectin, visfatin, and resistin, and their known receptors, namely, heat shock 70 protein 5, adiponectin receptor 1, and adiponectin receptor 2, in the bovine corpus luteum (CL) during different phases of the estrous cycle  and pregnancy . The mRNA expression was measured by reverse transcription polymerase chain reaction (RT-qPCR). The mRNA expression levels were normalized to the geometric mean of all three constantly expressed reference genes . Our findings suggest that adipokines are expressed and present in all investigated groups, and are specifically up- or downregulated during the estrus cycle and during pregnancy. Vaspin and adiponectin levels were upregulated in the middle and late cycle stages. Resistin was abundant during the CL regression stage and in the first months of pregnancy. The specific expression of adipokine receptors indicates their involvement in the local mechanisms that regulate CL function. Further investigations are required to elucidate the regulative mechanisms underlying the different local effects of adipokines on the ovarian physiology of cows. The female reproductive system in domestic ruminants is regulated by a complex system of hormones produced by the hypothalamus, pituitary gland, and ovaries. This interaction of protein hormones  and steroid hormones  results in ovarian cyclicity in females, which, in consequence, leads to fertilization, pregnancy, and parturition ,2. This No other organs in the body, when compared to the ovaries, are subject to dramatic changes in function and structure in such short intervals. These changes include cell proliferation, differentiation, and transformation, resulting in an ovulatory follicle, and hence, the formation, function, and regression of the CL. Nevertheless, cow fertility is much more complex than the interactions between these well-known reproductive hormones. Fertility is also tightly related to other components, such as locally secreted mediators, including growth factors, peptides, cytokines, steroids, prostaglandins, and many more ,6,7,8,9.More recently, the involvement of adipokines in the regulation of fertility and the development of some reproductive disorders has been suggested ,23,24. DAdipokines have been shown to play a functional role in mammalian ovarian physiology ,34. MoreHowever, further research is needed to fully elucidate their functions and their associations with other biochemical pathways, particularly in cattle. To address this knowledge gap, our study aimed to investigate the ovarian expression levels and potential regulatory effects of adipokines at different time points in the corpus luteum during the estrous cycle and pregnancy. Specifically, we focused on the local adipokines mentioned above. Through our research, we hope to contribute to a better understanding of the role of adipokines in ovarian physiology, which could have important implications for the reproductive performance of cattle.n = 10), Group II , Group III , Group IV , Group V , Group VI . In addition, four groups of pregnancy stages were formed: Group VII , Group VIII , Group IX , Group X .The CL from dairy cows (German Fleckvieh) were collected from the local slaughterhouses, first frozen in liquid nitrogen, and then frozen at −80 °C until further processing for RNA isolation techniques ,37. Afte® Lysis Reagent . The total RNA pellet was dissolved in 100 µL nuclease-free water. The RNA concentration was determined by measuring the absorbance at 260 nm and a ratio of 260/280 nm using a NanoDrop® ND-1000 Spectrophotometer . All samples showed high RNA purity and a 260/280 ratio of >2. Additionally, RNA integrity was assessed using an Agilent 2100 Bioanalyzer , which classifies RNA integrity into a score called the RNA Integrity Number (RIN). The automatically calculated RNA Integrity Number (RIN), using the ratio of 28S to 18S rRNA, ranks RNA integrity on a scoring system from 1 to 10, with 1 being the most degraded total RNA profile and 10 being the most intact total RNA extract. In our experiments, we depicted samples in which RIN was always higher than 5.Total RNA was extracted from 50 mg tissue of the dissected corpora lutea using a liquid–liquid extraction protocol (acid guanidinium thiocyanate–phenol–chloroform extraction) with QIAzolPrimers and oligonucleotide probes (hydrolysis) for housekeeping genes, i.e., ubiquitin, ubiquitin C, cyclophilin A, and target genes, i.e., vaspin, heat shock 70 kDa protein 5 (HSPA5), adiponectin, adipoR1, adipoR2, visfatin, and resistin, were designed using the Primer3 program (version 4.1.0) and the databases from Ensembl (EMBL-EBI) . Moreove® Universal Probe One-PCR) in a 10 µL volume reaction containing 5 µL Luna Universal Probe One-Step Reaction Mix , 0.5 µL Luna WarmStart RT Enzyme Mix, 0.4 µL each of forward and reverse primer of the targeted sequence (10 µM), 0.2 µL hydrolysis probe of the corresponding sequence, 3.0 µL of sample RNA, and 0.5 µL of nuclease-free water. The following cycling protocol was applied in a thermal cycler : one cycle of reverse transcription at 55 °C for 10 min, one cycle of initial denaturation at 95 °C, forty-five cycles of denaturation at 95 °C for 10 s, and extension at 60 °C for 30 s. RT-qPCR products were checked in 2% agarose gel via electrophoresis  to see if the RT-qPCR product length corresponded with the calculated and expected target sequence lengths. The complete RT-qPCR workflow complied with the MIQE guidelines [The total extracted RNA was diluted to the desired concentration of 30 ng/µL for mRNA transcript quantification via RT-qPCR. We applied a one-step real-time quantification using hydrolysis probes  were obtained via Rotor-Gene Rotor Q Software 2.3.1  using the comparative quantitation method. The mRNA expression levels were normalized to the geometric mean of three constantly expressed reference genes: cyclophilin A (PPIA), ubiquitin, and ubiquitin C. The geometric mean, when checked in the geNorm and NormFinder algorithms, on GenEX software (version 7)was always the most stable and constantly expressed normalizer , Group II , and Group III , Group IV , Group V , Group VI . Samples from pregnant cows were divided into the following groups: Group VII , Group VIII , Group IX , and Group X . All the data are shown as ΔCq means ± SEM (standard error of the mean). Statistical significance was assessed by one way ANOVA followed by the Tukey’s HSD and LSD for multiple comparison analysis. Changes were considered significant if they exhibited a p-value < 0.05.In this study, we used corpora lutea from cycling cows divided into six groups and pregnant cows into four groups. The cycling cow group consists of the following stages: Group I  followed by a continuous increase, with the highest expression in the regression stage (D > 18) of the estrous cycle a. MeanwhDifferent studies have shown that various metabolism-related factors and hormones can affect and regulate ovarian function ,46. RemeCurrently, there are limited data available regarding the expression and function of vaspin in reproductive physiology, particularly in the CL or bovine ovary. As a result, our interpretation and understanding of its role is insufficient. However, studies have shown that vaspin and HSPA5, both in terms of mRNA and protein expression, are predominantly found in porcine ovary structures, such as ovarian follicles, oocytes, and the CL . In thesResearch has shown that adiponectin plays a crucial role in oocyte maturation, granulosa cell proliferation, and steroid secretion in the ovaries . AdditioNumerous studies have demonstrated a strong correlation between resistin and female reproductive function . A studyIn cattle, visfatin has been shown to play a role in the activation of IGF1R and MAPK3/1, resulting in a greater abundance of steroidogenic acute regulatory protein (StAR) and HSD3B activity . A recenHowever, it is important to note that the detection of mature proteins and histological localization of the studied adipokines and their receptors in bovine species is impossible, due to the lack of commercial and stabilized antibodies. The development of specific and reliable antibodies is crucial to gain a better understanding of adipokines at different molecular levels and facilitate their expression strength and exact tissue localization. This will help us speculate about the potential of adipokines in reproductive function and provide valuable insight into their underlying mechanisms. Hence, further research is needed to identify and develop stable antibodies that can accurately measure the expression and localization of adipokines and their receptors in bovine tissues.Through our investigation, we provide data that contribute towards advancing our understanding of the complex mechanisms that govern dairy cattle reproduction. Our findings give valuable insight into the local regulation of adipokines within the corpus luteum of dairy cattle, offering a deeper understanding of the intricate interplay between adipokines and reproductive physiology. By delving into the local regulation of adipokines within the corpus luteum, we contribute to the existing knowledge base, and highlight the importance of continued research efforts in this domain and the exploration of additional factors that may influence the interplay between adipokines and reproductive processes in dairy cattle.Our findings demonstrate that adipokines are present in the CL during all cyclic and pregnancy stages, suggesting their important role in regulating CL function. Moreover, the up- or downregulation of adipokine mRNA levels varied among different stages of the estrous cycle and pregnancy, indicating their potential regulatory effects. The specific expression of adipokines and their receptors in the CL suggests their participation in the local mechanisms that regulate CL activity. In conclusion, our present study suggests that all investigated adipokines are expressed in the bovine CL mRNA during the estrous cycle and pregnancy, and are regulated independently and differently. However, further investigations are required to elucidate the detailed regulation and mechanisms involved in different local actions of adipokines in CL tissue during the estrous cycle and pregnancy. Understanding the role of adipokines in CL function may lead to the development of targeted therapies that can improve fertility and reproductive function in both humans and animals.


Despite its effectiveness in preventing invasive meningococcal disease (IMD), pediatric uptake of recombinant meningococcal vaccination for serogroup B meningitis (MenB) is low in Italy. This study aimed to investigate knowledge, attitudes, and practice (KAP) about IMD and the vaccine uptake for MenB from July to December 2019, in a sample collected from a series of local Facebook discussion groups from the provinces of Parma and Reggio Emilia . A self-administered anonymous web-based questionnaire was used to collect demographics, knowledge status, perceived risk for contracting meningitis, attitude towards the utility of meningococcal vaccine, and willingness to receive/perform MenB vaccine in their offspring. In total, 541 parents returned a fully completed questionnaire , with a mean age of 39.2 years ± 6.3 . Meningococcal infection was identified as severe or highly severe by most participants (88.9%), while it was recognized as being frequent/highly frequent in the general population by 18.6% of respondents. The overall knowledge status was unsatisfactory (57.6% ± 33.6 of correct answers to the knowledge test). Even though 63.4% of participants were somewhat favorable to MenB/MenC vaccines, offspring’s vaccination towards MenB was reported by only 38.7% of participants. In a binary logistic regression model, the male gender of respondents , living in a municipality >15,000 inhabitants , reporting a favorable attitude on meningococcus B vaccine , having been vaccinated against serogroup B  and/or serogroup C , and having previously vaccinated their offspring against serogroup C meningococcus  were characterized as positive effectors of offspring’s vaccination. On the contrary, having a higher risk perception on vaccines was identified as the only negative effector . Our results hint towards extensive knowledge gaps on IMD and preventive interventions in the general population, suggesting that a positive attitude towards vaccines and vaccinations could be identified as the main effector also for MenB acceptance. Interventions in the general population aimed at improving confidence, compliance, and acknowledgment of the collective responsibility, as well as preventing actual constraints and the sharing of false beliefs on infectious diseases and their preventive measures, could therefore increase vaccination acceptance in both targeted individuals and their offspring. Neisseria meningitidis or meningococcus, a Gram-negative diplococcus, which colonizes the pharynx and upper respiratory tract [Invasive meningococcal disease (IMD) is a condition caused by the bacterium ry tract ,2. IMD iry tract ,4,5. Incry tract ,7,8,9.To date, 12 serogroups of meningococcus have been identified based on bacterial capsular polysaccharide ,10,11,12Since 2014, incidence rates of serogroup B IMD have slowly but steadily declined ,15,16, pWith official notification rates ranging between 0.52 cases per 100,000 in 2004 and 0.28 cases in 2018 , Italy hIn this regard, the SARS-CoV-2 pandemic has represented a substantial game-changer in both the epidemiology and prevention of IMD . On the Shortly before the inception of the SARS-CoV-2 pandemic, we designed a cross-sectional study targeting parents of children aged 14 years or less on their knowledge , attitudes , and practices  on MenB. Our primary objective was to investigate their adherence to the official schedule for MenB, investigating their respective KAP, and specifically focusing on vaccine hesitancy and its main drivers. By providing a sort of “historical” picture of the acceptance of vaccination policies, as perceived shortly before an unprecedented health event , our study could share a valuable contribution in the design of appropriate interventions for improving vaccine acceptance for MenB.2. Group pages had approximately 132,784 (Parma) and 205,330 (Reggio Emilia) unique members, equal to 34.3% of the target population , but no information could be obtained regarding cross-inscriptions, nor on how many of these members were actively using Facebook.The present study was designed as a cross-sectional questionnaire-based study  and power of 95%, the minimum sample size for each province was calculated as follows:Therefore, by assuming a minimum sample size of 246 respondents for each province, a total of 492 respondents were targeted for the present study.In order to post the study invitation, the chief researcher (MR) contacted the administrators and requested their preventive authorization to post a link to the questionnaire. The link included a short description of the aims of the survey and led to a web page including the full study information and the informed consent . IndividSubjects who gave their consent received the link to a structured Google Forms survey including three preliminary questions corresponding to the inclusion criteria: (1) living in the province of Parma or Reggio Emilia; (2) being aged 18 years or older; (3) having any child aged 14 years or less. Participants fulfilling criteria 1 and 2 were allowed to complete the questionnaire, with the exclusion of the section specifically dealing with vaccination in offspring. On the contrary, if a potential participant was found not to match inclusion criteria 1 and/or 2, the survey was stopped, with the potential participant unable to provide answers to the following items of the questionnaire. The survey was anonymous and no personal data, such as name, IP address, email address, or personal information unnecessary to the survey, was requested, saved, or tracked. No monetary or other compensation was offered to the participants. Demographic characteristics of the participants. Age, sex, professional qualifications, education level, household characteristics, whether they had any background  in healthcare settings.Knowledge Test. Participants received a knowledge test, containing a total of 18 true–false statements, such as “Measles vaccine may elicit autism” , covering some typical misconceptions on vaccines and immunizations (items Q6 to Q18) and, more specifically, targeting IMD and meningococcal vaccines (items Q1 to Q5) ,47,48,49inf), (b) vaccine-related adverse effects (Evac), and whether they perceived the severity of the (c) natural infection (Cinf) and (d) vaccine-related adverse effects (Cvac). In order to summarize the results, we used a fully labelled 5-point scale . Two risk perception scores (RPS) were eventually obtained through the formulas:Risk Perception. Risk perception is a significant component of attitude and has been defined as a function of the perceived probability of an event and its expected consequences, being assessed as the mathematical product of subjective probability and disease severity ,50,51,52The questionnaire included a series of items previously developed for KAP inquiries ,46,47,48inf = Risk Perception Score for natural infections;RPSvac = Risk Perception Score for vaccinations;RPSinf = perceived probability of contracting a meningococcal infection;Evac = perceived probability of developing complications after the delivery of vaccine;Einf = perceived severity of meningococcal infection;Cvac = perceived severity of vaccine side effects.4.Attitudes toward vaccinations. Participants’ attitude towards vaccines and immunizations was asked both in general and more specifically towards MenB/MenC, through a 5-point Likert scale . In the analyses, the results were dichotomized as somehow favorable (“strongly favorable” and “favorable”) vs. somehow against/neutral : in both cases, a selected set of declarative sentences was presented to the participants regarding their reason to respectively accept immunizations and more specifically meningococcal vaccines ”, “to avoid transmitting VPDs”, “to avoid complications of VPDs”, “to avoid VPDs in subjects who cannot be vaccinated”) or instead refuse them . Eventually, participants were asked to summarize their perceived trust towards vaccines and healthcare providers through a 5-point Likert scale .5.Practices. All participants were asked whether they had been previously vaccinated for serogroup B meningitis. Participants having children 14 years old or younger were then asked whether their offspring had previously received MenB vaccine, or whether immunization was planned to be performed in the next six months.EThis study was conducted according to the guidelines of the Declaration of Helsinki. We opted for an anonymous, observational design, and deliberately limited the extent of retrieved information. As some participants could develop stress, anxiety, and even panic about this disease through an inappropriate understanding of its features, we provided the correct answer for all items of the knowledge test as a plain text, which was made available to participants after the completion of the questionnaire. As stated in the informed consent, we specifically guaranteed the confidentiality of all information reported by study participants. Moreover, the design of the questionnaire deliberately avoided the recall of clinical data, and limited the collection of personal data to quite general information. In this regard, participants were also guaranteed that retrieved data would be stored only for the time required by the data analysis. As participants cannot be individually identified through the presented material and retrieved demographic data, and the present survey did not include clinical data about participants, the present study reasonably caused no harm or stigma to participants. Therefore, this study did not configure itself as a clinical trial and no preliminary evaluation by an Ethical Committee was statutorily required, according to Italian law  .p value > 0.100), or through a Mann–Whitney or Kruskal–Wallis test when not normally distributed . The correlation between continuous variables was assessed by the calculation of Pearson’s correlation coefficient or through Spearman’s rank test according to the distribution of the data. Next, categorical variables were reported as percentage values, and their distribution in respect of the outcome variable represented by a somewhat positive attitude towards MenB was initially analyzed through a chi-squared test. Eventually, all variables during univariate analysis that were significantly (p < 0.05) associated with having vaccinated offspring against serogroup B meningococcus were included in a stepwise binary logistic regression analysis model in order to calculate their multivariate odds ratios (aOR) and their respective 95% confidence intervals (95%CI). All statistical analyses were performed by means of IBM SPSS Statistics 26.0 for Macintosh .As a preliminary step, two independent researchers preventively checked the accuracy of collected data, with incomplete questionnaires excluded from the analyses. Cumulative scores  were then normalized to percentage values, with the latter also dichotomized by median value as “high” and “low” groups. All continuous variables were expressed as mean ± standard deviation. Their distributions were preventively assessed by means of the D’Agostino–Pearson K2 test, and were compared through a Student’s t-test for unpaired data or ANOVA when normally distributed . Of them, 245 were excluded from further analyses as they lacked some demographic features. Of the 1010 completed questionnaires, 558 (55.2%) fulfilled all inclusion criteria as they reported at least one child <14 years old, compared to 452 (44.8%) participants not reporting any children . Of thesDetailed characteristics of the sample as a whole are reported in p < 0.001), a substantially higher number of individuals holding a university-level degree , and a quite different composition of their household. Not only did this sub-group include 3 or 4 persons more often than those participants not reporting children < 14 years , but a lower proportion of respondents acknowledged living with individuals aged 65 years of more . Interestingly, the share of participants with an occupational background in healthcare settings was higher among individuals not parenting children < 14 years than among those who were included in further analyses .In fact, the sub-group of participants that had parented at least one child aged < 14 years, and were therefore included in further analyses, was characterized by a higher proportion of individuals of the female gender  , whose distribution of the cumulative score did not pass the normality check  . SimilarDetailed results of the knowledge test are reported in As reported in When focusing on the risk perception for vaccines against meningococcus, 28.5% of all respondents acknowledged meningococcal vaccines as being associated with either severe or very severe side effects, while 26.3% reported side effects as either severe or highly severe. The corresponding RPS accounted for 41.6% ± 22.3 for meningococcal natural infection and 26.2% ± 25.8 for meningococcal vaccines . The majority of respondents exhibited high or very high confidence in vaccines , and particularly on MenB (64.2%) , while tWhen focusing on the perceived drivers for vaccinating themselves and their offspring against serogroup B meningococcus , followed by the fear of neurological syndromes following the vaccine (36.9%), and more generally, the fear of side effects (36.0%), as well as those elicited by vaccine adjuvants (30.5%) and by heavy metals allegedly included in the vaccine formulate (30.2%). Similarly, 8.9% of respondents reported side effects after previous immunizations. Approximately 16.9% of participants reported a fear of autism, while 9.5% had a greater trust in alternative therapies, in preventive measures (7.7%), or in antimicrobial treatment (5.5%). Moreover, 5.5% of respondents aimed to reduce their number of injections. Interestingly, only 5.2% of participants were reportedly “against” vaccination practice and 3.4% identified meningococcus vaccines as scarcely affordable, while in 1.2% of cases, the vaccine was either not recommended by the competent general practitioner/pediatrician or not possible due to a previous condition of the respondents of their offspring.p < 0.001) and negatively correlated with RPS on vaccine side effects , while RPS on vaccines and natural infection were negatively correlated . Similar estimates for the sample as a whole are reported in As shown in p < 0.001; see p < 0.001), while RPS was conversely lower among the vaccinated than the unvaccinated  (p < 0.001), with higher GKS and RPS for natural infections among individuals without offspring , while higher RPS on vaccine was scored by participants with any children aged less than 14 years than among those without offspring   a,b. Intectively) .Neisseria meningitidis serogroup B. As a total of 17 participants did not share the vaccine status of their offspring, estimates were calculated for 541 out of 558 potential respondents.p < 0.001), living in a municipality with more than 15,000 inhabitants , and reporting a better knowledge score , while it was negatively associated with reporting a higher RPS score . Nonetheless, offspring vaccination was more frequently reported among individuals reporting a positive attitude on vaccines, in general , as well as regarding serogroup B meningococcus ; among subjects with higher confidence in vaccination services ; and among respondents reporting higher confidence in vaccines, both in general , as well as regarding vaccines for meningococcus of serogroup B . Finally, vaccination of offspring was more frequently reported among participants having been vaccinated against meningococcus B  and meningococcus C , and having reportedly vaccinated their offspring against meningococcus C . Data on the sample as a whole are reported in As shown in Regression analysis  includedBriefly, the male gender , living in a municipality >15,000 inhabitants , reporting a favorable attitude on meningococcus B vaccine , having been vaccinated against serogroup B  and/or serogroup C , and having previously vaccinated their offspring against serogroup C meningococcus  were characterized as positive effectors. On the contrary, having a higher risk perception on vaccines was identified as the only negative effector .To date, IMD cases in Italy are quite uncommon events. According to the national surveillance system for bacterial meningitis, a total of 26 cases of IMD were reported in 2021 in the whole of the Italian population , compared to 74 in 2020 , with a stark and sustained decline from the notification estimates of 2019 , but also for 2018 and 2017 . The corresponding incidence rates ranged from 0.33 cases/100,000 population in 2017, 0.28 cases/100,000 population in 2018, and 0.31 cases/100,000 population in 2019, to eventually 0.12 cases/100,000 population in 2020 and 0.04 cases/100,000 population in 2021 . Even thIn other words, reaching and maintaining high vaccination rates for MenB and MenC still represent a main public health objective ,23,28. IIndeed, our survey was somewhat consistent with previous studies performed on the determinants of meningococcus vaccination ,68,69, ap < 0.001). In fact, not only is Italy usually acknowledged as geographically quite heterogenous in terms of health literacy [In comparison to other Italian reports, we specifically did not inquire whether respondents had any knowledge of MenB , but simliteracy ,79,80, bliteracy  or parenliteracy . As a coDespite its potential interest, the present article is unfortunately affected by several limitations ,91,92,93http://dati.istat.it/, accessed on 20 December 2022). A similar quantification of individuals with a documented background in healthcare settings, by 31 December 2018 , by the Regional Health Service of Emilia Romagna accounted for a total of 61,854 professionals  . As a consequence, we reasonably collected a substantial share of individuals who were particularly willing to contribute to our study because of a series of factors, including and not limited to their better literacy or younger age, an increased attitude to sharing personal information through Internet access, greater knowledge and/or interest about the assessed topic, and a stronger will to contribute to health-care-related research because of their healthcare background [Second, our data are reasonably affected by some degree of self-selection bias, an issue substantially shared by all web-based studies ,81,82. Dckground ,71, and ckground ,91,92,93Similarly, as the questionnaire was not externally validated, we cannot rule out some degree of declarative bias. In other words, some of the respondents could not truly adhere to our inclusion criteria, particularly when dealing with the geographical recruitment of study participants. Moreover, in analogy with the items of the knowledge test, some participants may have reported “socially desirable” attitudes instead of their actual ones, inflating the actual acceptance of vaccines and preventive interventions ,72. In tThird, even though our sample fulfilled the sample size requirements, it may be acknowledged as relatively small compared to the whole of the Italian population, particularly when stressing the distinctive Italian regional patterns of healthcare settings. On the one hand, our sample was substantially in line with estimates from other Italian studies, and its geographical settings may contribute to the overall understanding of the heterogenous acceptance of this vaccination in Italy shortly before the inception of the SARS-CoV-2 pandemic ,71. In this regard, the very same timeframe of our inquiry may represent both a substantial limit and also a potential strength of the present study, as the provinces of Parma and Reggio Emilia were extensively affected by the SARS-CoV-2 pandemic ,100,101,TM is an open online tool [p < 0.001) and a positive correlation with RPS on vaccines  [Last but not least, we cannot rule out that our results may have been influenced by background factors, such as the coverage by conventional and social media of meningococcal infections. An extensive representation of certain topics in the media may reasonably lead to overstating the true significance of this pathogen from a public health point of view . While tine tool ,108,109,Despite some substantial shortcomings associated with its design and timeframe, our study suggests that in the few months before the inception of the SARS-CoV-2 pandemic, the acceptance of MenB vaccination among parents of children aged less than 14 years in the provinces of Parma and Reggio Emilia was far from optimal. In fact, a positive attitude towards vaccines and vaccinations was identified as the main effector of MenB acceptance, while the usual effectors of vaccine hesitancy/propensity seemingly had a more limited role. Interventions on the general population aimed to improve confidence , compliance , and acknowledgment of the collective responsibility associated with vaccine interventions, as well as preventing actual constraints and the sharing of false beliefs on infectious diseases and their preventive measures, could therefore increase vaccination acceptance in both targeted individuals and their offspring.


To evaluate the capacity of fetal Doppler, maternal, and obstetriccharacteristics for the prediction of cesarean section due to intrapartumfetal compromise (IFC), a 5-min Apgar score < 7, and an adverse perinataloutcome (APO), in a high-risk population.This was a prospective cohort study involving 613 singleton pregnant women,admitted for labor induction or at the beginning of spontaneous labor, whounderwent Doppler ultrasound within the last 72 h before delivery. Theoutcome measures were cesarean section due to IFC, a 5-min Apgar score <7, and any APO.p = 0.03 andp < 0.0001, respectively). A UA RI > the 95thpercentile and a cerebroplacental ratio (CPR) < 0.98 were also found tobe predictors of cesarean section due to IFC. Gestational age and a UA RI> 0.84 were found to be predictors of a 5-min Apgar score < 7 fornewborns at < 29 and ≥ 29 weeks, respectively. The UA RI and CPRpresented moderate accuracy in predicting an APO, with areas under the ROCcurve of 0.76 and 0.72, respectively.We found that maternal characteristics were neither associated with norpredictors of an APO. Abnormal umbilical artery (UA) resistance index (RI)and the need for intrauterine resuscitation were found to be significantrisk factors for cesarean section due to IFC (A high UA RI appears to be a significant predictor of an APO. The CPR seemsto be predictive of cesarean section due to IFC and of an APO in latepreterm and term newborns. In most cases, IFC occurs in low-risk pregnancies, makingadverse perinatal outcomes (APOs) difficult to predict.Acute fetal compromise is one of the leading causes of perinatal morbidity andmortality worldwide. As well as being a major cause of fetal death, a reduction inthe oxygen supply for the conceptus can lead to relevant neonatalcomplications,5. Technologiescomplementary to CTG were developed to reduce false-positive rates and avoidunnecessary interventions in cases of suspected fetal compromise, although there arestill many uncertainties regarding the benefits of such technologies and technicaldifficulties related to their use, which hinder their introduction into clinicalpractice-10. When acute fetal compromise becomes established,various physiological changes, including the redistribution of the fetoplacentalblood flow, occur and behave as defense mechanisms; that is, attempts to maintainadequate oxygen levels in vital organs for fetal survival (the “brain sparing”effect). This phenomenon can be evidenced by cerebral blood flow Doppler,12, which can show a reduction in the resistance index (RI)of the fetal middle cerebral artery (MCA).Although electronic monitoring of the fetal heart rate (FHR), known ascardiotocography (CTG), is widely used in screening for IFC, its use has not reducedthe incidence of hypoxic-ischemic encephalopathy, probably due to its low positivepredictive value in diagnosing fetal hypoxia-16. Studies have shown that, in cases of in late-onset fetalgrowth restriction (FGR), there is an association between the brain sparing effectand the occurrence of an APO-19. However, this phenomenon is alate manifestation of fetal compromise, and, given its potentially harmfulconsequences, there is a need for methods that can detect signs of fetal blood flowredistribution earlier.Despite the seemingly beneficial role of the fetal brain sparing effect, some recentstudies have produced results that call into question its protective effect, whichcan be greater or lesser depending on the gestational age (GA) at which it occursand whether other hemodynamic parameters are normal or abnormal-25. Because it represents the ratiobetween the RI of the MCA and that of the umbilical artery (UA), the CPR can beabnormal even before the brain sparing effect has been identified. Nevertheless, studies evaluatingthe CPR and its association with the occurrence of an APO vary widely in terms ofmethodology and outcome measures. There is therefore insufficient evidence torecommend its introduction into clinical practice as a predictor of poor obstetricoutcomes and neonatal complications.For normal and FGR fetuses, the cerebroplacental ratio (CPR) has emerged as predictorof cesarean section due to IFC, an APO, and long-term neurologicalimpairmentThe objective of this study was to evaluate the capacity of fetal Doppler, as well asof maternal and obstetric characteristics, to predict, in a high-risk population,cesarean section due to IFC, a 5-min Apgar score < 7, and the occurrence of anAPO.This was a prospective cohort study that included high-risk pregnant women admittedfor labor induction due to maternal conditions or pregnant women admitted at thebeginning of spontaneous labor . All patients wererecruited from the University Hospital of the Ribeirão Preto Medical Schoolof University of São Paulo (FMRP-USP), in the city of Ribeirão Preto,Brazil, in 2018. The facility serves approximately 1,800 high-risk pregnant womenevery year. The inclusion criteria were GA > 26 weeks at delivery; singletonpregnancy; fetus without congenital anomalies; and obstetric ultrasound within thelast 72 h before delivery. The following exclusion criteria were applied: structuralor chromosomal anomalies diagnosed in the newborn; transfer of the newborn toanother hospital; and failure to acquire data from the medical records. The studywas approved by the FMRP-USP Research Ethics Committee (Reference no. 14366/2009).All participating patients gave written informed consent.Of 1,167 eligible pregnant women, 554 did not meet the study criteria and wereexcluded, leaving 613 for analysis. The GA was determined on the basis of the lastmenstrual period and confirmed by a first trimester scan using the crown-rumplength, or by the head circumference measured in a second trimester scan, performedbetween weeks 14 and 20 of pregnancy.; single deepest vertical pocket (SDVP) of amnioticfluid; and the RIs ofthe UA and MCA on Doppler ultrasound. The UA was assessed at the level of umbilicalcord insertion into the placenta, and the RI was considered abnormal if the valuewas above the 95th percentile.The RI of the fetal MCA was assessed in a cross-sectional view of the fetal head atthe level of the origin of the MCA from the circle of Willis and was consideredabnormal if the value was below the 5th percentile. Flow velocity waveforms were obtained withoututerine contractions, fetal body movements, or maternal respiratory movements, whenthe FHR was normal. The UA and MCA were evaluated with color Doppler. The pulsedDoppler sample volume was < 3.0 mm, the insonation angle was < 30°, and thefilter was set at < 50 Hz. The CPR was calculated by dividing the RI of the MCAby that of the UA, and the resulting value was considered abnormal if <1.0.All ultrasound examinations performed before admission were conductedtransabdominally with a 4-8 MHz probe  by consultants with considerable experience in fetal medicine.The following parameters were measured: fetal biometry and estimated fetal weight(EFW), as described previously and the American College ofObstetricians and Gynecologists (ACOG) guidelines. If IFC was suspected, the pregnancies weremanaged in accordance with the ACOG guidelines. Indeterminate (category II) or abnormal (category III) FHRtracings, even after 10-15 min of intrauterine resuscitation, corresponded toIFC.Intrapartum electronic FHR analysis was carried out in accordance with the NationalInstitute of Child Health and Human Development guidelines. It is noteworthy that patients with absent or reversedend-diastolic velocity in the fetal UA or increased fetal ductus venosus pulsatilityindex undergo cesarean section at our institution. In addition, IFC was defined,according to International Federation of Gynecology and Obstetricscriteria, as a fetalbiophysical profile score ≤ 4 before delivery or a CTG result classified aspathological after delivery. However, the following were not considered indicationsfor preterm delivery or cesarean section: a CPR or MCA RI < the 5th percentile; aUA RI > the 95th percentile with positive end-diastolic velocity; the fetus beingcategorized as small for gestational age (SGA), with an EFW < the 3rd percentileor < the 10th percentile plus abnormal Doppler findings; and GA < 37weeks.Obstetric care was provided in accordance with the local guidelines, which are basedon the best available evidence.Variables of interest related to maternal characteristics, maternal history,ultrasound findings, intrapartum interventions, and newborn characteristics wereobtained from each pregnant woman at enrollment in the study and from medicalrecords. The following outcomes were considered: cesarean section due to IFC; a5-min Apgar score < 7; and any APO. The occurrence of an APO was defined as oneor more of the following: intraventricular hemorrhage; periventricular leukomalacia;hypoxic-ischemic encephalopathy; necrotizing enterocolitis; bronchopulmonarydysplasia; sepsis; admission of the newborn to the neonatal intensive care unit; andneonatal death. The local neonatology unit is a member of the Vermont Oxford Networkand therefore applies the diagnostic criteria established by the network for eachneonatal complicationp < 0.05 were considered statistically significant.The sample calculation was performed using Proc Power procedure in theStatistical Analysis System, version 9.3 .Continuous variables are presented as mean and standard deviation, whereascategorical variables are expressed as absolute and relative frequencies. Thechi-square test was employed to detect associations between qualitativevariables and outcomes. A binomial log regression model  was used in order to estimatethe crude and adjusted relative risks (RRs) for each variable in relation to theoutcomes. A conditional inference tree model was employed to determine the mostsignificant predictors for the outcomes, which allowed the use of quantitativeand qualitative variables, with R software, version 3.6.1. . Receiver operating characteristic (ROC)curves were constructed to evaluate the individual accuracy of each parameterfor predicting outcomes by calculating the area under the curve (AUC). Values ofThe final study sample comprised 613 singleton pregnant women: 542 (88.4%) admittedfor labor induction; and 71 (11.6%) admitted at the beginning of labor. The meanmaternal age was 28.4 ± 6.97 years , 319 (54.3%) of thepregnant women were obese, and the mean maternal weight was 90.3 ± 22.2 kg. The mean GA at delivery was 38 ± 3.2 weeks , the mean birth weight was 2,914 ± 813 g , and 179(29.2%) of the newborns were classified as SGA. The mean RI for the UA and the MCAwas 0.58 ± 0.10  and 0.73 ± 0.07 ,respectively. The mean CPR was 1.27 ± 0.27 , and the meanSDVP was 3.91 ± 1.81 cm .p = 0.004). During the study period, the overall rate ofcesarean section in our high-risk neonatology unit was 42.0%.p = 0.03; and RR = 3.77, 95%CI: 2.53-5.62, p < 0.0001, respectively). For a 5-min Apgarscore < 7, the risk factors were oligohydramnios  and prematurity . The variables considered significant risk factorsfor an APO were oligohydramnios , prematurity ,and cesarean section . TheEFW was not found to affect those results.In the multivariate analysis, an abnormal UA RI and the need for intrauterineresuscitation retained their significance as risk factors for cesarean section dueto IFC . For a 5-min Apgarscore < 7, the most relevant predictor was low GA at delivery. A 5-min Apgarscore < 7 was seen in 45% of the newborns at a GA < 29 weeks. It is essentialto highlight that in that group (n = 26), the pregnancies ended in labor inductionin four cases, spontaneous labor in four, and elective cesarean section due tochronic maternal disease in 19. However, for newborns at a GA ≥ 29 weeks, themost significant predictor of a 5-min Apgar score < 7 was a UA RI > 0.84. Inthe group with a fetal UA RI < 0.84 before delivery, the prevalence of thatoutcome was near zero.The conditional inference tree model showed that a GA < 34 weeks at delivery wasthe most significant predictor of an APO, which occurred in 85% of the newborns at aGA < 34 weeks, compared with 30% of those born at a GA of 34-36 weeks and 5% ofthose born at a GA > 36 weeks. The prevalence of an APO was 25% among thenewborns at a GA > 34 weeks with an abnormal CPR. Among the newborns with anormal CPR, oligohydramnios was a relevant predictor of an APO, which occurred in12% of those with oligohydramnios, compared with 2% of those with normal amnioticfluid volume. Among the newborns at a GA > 37 weeks, the prevalence of an APO wasnear zero. Two other factors were significant predictors of an APO among thenewborns at a GA < 37 weeks: an MCA RI < the 5th percentile; and cesareansection due to IFC. Among the preterm newborns with the brain sparing effect, theprevalence of an APO was 75% for those delivered by cesarean section, compared withonly 25% for those delivered vaginally. Among the preterm newborns without the brainsparing effect, the prevalence of an APO was 30% regardless of the mode ofdelivery.In the ROC curve analysis, all of the ultrasound variables presented poor performancein the prediction of cesarean section due to IFC and of a 5-min Apgar score < 7.However, an abnormal UA RI and an abnormal CPR presented moderate accuracy inpredicting an APO, with AUCs of 0.76 (95% CI: 0.69-0.81) and 0.72 (95% CI:0.65-0.77), respectively, whereas the other ultrasound variables all performedpoorly in the prediction of an APO.-23,36,37. In the presentstudy, a CPR ≤ 0.98 proved to be a significant predictor of cesarean sectiondue to IFC, regardless of the GA at delivery, and a CPR < 1.0 proved to be asignificant predictor of APO in newborns at > 34 weeks. Our results also showthat maternal characteristics were not predictors of any APO. In a prospective studyof women who gave birth to full-term fetuses, Fiolna et al. demonstrated that combiningmaternal characteristics with GA increased the accuracy of the prediction ofcesarean section due to IFC. However, the addition of the CPR did not improve thataccuracy. However, the features of our sample and the GAs at delivery are verydifferent from those of the Fiolna et al. sample.Our study was motivated by recent publications that showed an association between anabnormally reduced CPR and the occurrence of APOs, Valiño et al., and Stumpfe et al. in samples of FGR fetuses.However, it differs from those of Vollgraff Heidweiller-Schreurs et al., who demonstrated the superiorityof the CPR over UA Doppler in predicting cesarean section due to IFC. However, aspreviously mentioned, a CPR < 0.98 might also be a relevant predictor of thatoutcome, as demonstrated by other authors,24,42. Nevertheless, it is crucial to highlight thedifferences among the studies. In addition, our study has a major limitation, whichis the absence of pH results confirming neonatal acidosis. Furthermore, in theconditional inference tree model in which abnormal UA was shown to be a betterpredictor than the CPR, the ultrasound parameters were qualitative. Therefore, theuse of a CPR cutoff of 0.98 could have influenced the findings.Despite the potential associations of ultrasound variables with cesarean section dueto IFC, only an abnormal UA RI remained a significant risk factor in themultivariate analysis, cesarean section due to IFC having occurred in 55% of thecases in which the UA RI was abnormal, compared with only 10% of those in which itwas normal. That is in agreement with the findings of DeVore,43. However, this finding underscores the importance of the CPRas a predictor of the outcome, given that many of the pregnant women in whom IFC wassuspected had previously been pregnant with a fetus with an abnormal CPR.Although the fact that the need for intrauterine resuscitation was an importantpredictor of cesarean section due to IFC seems like an obvious finding, only 55% ofthe cases in which intrauterine resuscitation was performed ended in cesareansection because the FHR pattern of IFC persisted thereafter,44. Oligohydramnios was a risk factor for a 5-min Apgar score< 7 but was not found to be a significant predictor of that outcome in theconditional inference tree model. The comparison of these findings with those ofother studies was limited, because many authors have evaluated the associationbetween the amniotic fluid index and APOs considering only term or post-termpregnancies.There were difficulties in comparing our findings related to a 5-min Apgar score <7 with those of other studies because, in many of those studies, that outcome wasincluded as composite neonatal morbidity, APO, or a similar term. In addition, oursample of pregnant women was quite diverse, with fetuses of various GAs and growthpatterns. The variables considered risk factors for a 5-min Apgar score < 7 wereoligohydramnios and a GA < 37 weeks at delivery. The latter was a relevantpredictor of that outcome, which occurred in 45% of the newborns at a GA < 29weeks, regardless of the ultrasound findings. However, among the newborns at a GA≥ 29 weeks, the GA seemed to have a lesser effect and a UA RI > 0.84 was abetter predictor of a 5-min Apgar score < 7. Therefore, GA at delivery was thefactor that most influenced the neonatal outcome, especially when it was < 29weeks, as has also been shown in other high-quality studies,44, prematuritymight be predictive of an APO because of fetal organ immaturity. After week 34 ofgestation, the gain in survival and reduction in neonatal morbidity isminimal. Among allpreterm newborns (GA < 37 weeks) in the present study, the brain sparing effect(MCA RI < the 5th percentile) was a predictor of an APO and acquired greaterrelevance when the newborn was delivered by cesarean section. Although this findingseems inconsistent, it should be borne in mind that the brain sparing effect is,initially, a protective event in a fetus with hypoxemia. Fetuses with cerebral vasodilation are at lowerrisk of an APO in the early stages of hypoxia. In addition, our findings indicatethat, for fetuses with the brain sparing effect, the risks of performing a vaginaldelivery are outweighed by the benefits of that type of delivery in comparison withcesarean section.A GA < 37 weeks at delivery was confirmed as the most critical predictor of anAPO, especially for the newborns at a GA < 34 weeks, 85% of whom experienced anAPO, compared with 30% and 5% for those born at 34-36 and > 36 weeks,respectively. As previously discussed,41,47-49.However, there were major limitations to comparing our results with those of otherstudies of the topic. In many such studies, the reference values and CPR cutoffpoints were unclear, the GA limits were not stated, the features of the women andtheir pregnancies were not correctly presented, and the number of cases wasinsufficient to analyze the outcomes. One possible explanation for our finding is the fact that thebrains of late preterm and term fetuses are more sensitive to hypoxia than are thoseof preterm fetuses. In a studyof newborns at a GA of 35-37 weeks, Akolekar et al. found an association between the CPR and theoccurrence of an APO, although they showed that the CPR had low accuracy andrecommended caution in its use to predict that outcome.In our analysis of the newborns at a GA > 34 weeks, an abnormal CPR was associatedwith the occurrence of an APO, as demonstrated in previous studies.Finally, as shown in our ROC curve analysis of the predictive power of the ultrasoundvariables , the UA RI and CPR presented moderateaccuracy in predicting the occurrence of an APO. That is in contrast with thefindings that have been presented and discussed in other studiesIn summary, GA is still a relevant variable that should be considered when proposinga delivery modality. An abnormal UA RI is a significant predictor of APO, especiallyin third-trimester, high-risk pregnancies. The CPR has emerged as a possible toolfor predicting an APO, and, in our sample, it was found to be a predictor ofcesarean section due to IFC and of an APO in late preterm and term pregnancies.However, when evaluated separately, the CPR presented moderate accuracy inpredicting an APO. Therefore, its introduction into clinical practice should stillbe evaluated with caution.


Chronic obstructive pulmonary disease (COPD) is a heterogeneous disease with distinct phenotypes, each having distinct treatment needs. Eosinophilic airway inflammation is present in a subset of COPD patients in whom it can act as a driver of exacerbations. Blood eosinophil counts are a reliable way to identify patients with an eosinophilic phenotype, and these measurements have proven to be successful in guiding the use of corticosteroids in moderate and severe COPD exacerbations. Antibiotic use in COPD patients induces a risk of Clostridium difficile infection, diarrhea, and antibiotic resistance. Procalcitonin could possibly guide antibiotic treatment in patients admitted with AECOPD. Current studies in COPD patients were successful in reducing exposure to antibiotics with no changes in mortality or length of stay. Daily monitoring of blood eosinophils is a safe and effective way to reduce oral corticosteroid exposure and side effects for acute exacerbations. No evidence on time-updated treatment guidance for stable COPD exists yet, but a current trial is testing an eosinophil-guided approach on inhaled corticosteroid use. Procalcitonin-guided antibiotic treatment in AECOPD shows promising results in safely and substantially reducing antibiotic exposure both in time-independent and time-updated algorithms. Chronic obstructive pulmonary disease (COPD) is a common disease worldwide with a substantial impact on quality of life and mortality, making it an important contributor to the global burden of disease ,2. It isCOPD is a heterogeneous disease in which the presence of emphysema, airway obstruction, excess mucus production, vascular dysfunction, and inflammation varies considerably among patients and none of these factors are particularly good predictors of symptom burden or disease development ,4,5. TheFurthermore, patient phenotypes are not necessarily constant ,9. Even The aim of this paper is to review current evidence for time-updated phenotypic guidance of corticosteroid therapy and antibiotic-guided therapy in COPD.The inflammatory response in COPD involves both the innate and adaptive immune system and is mediated by neutrophils, macrophages, and CD8+ T-cells (Tc1) as well as CD4+ T-cells (Th1 and Th17) ,19. The Eosinophilic inflammation is characterized by elevated eosinophil counts in the blood and sputum and the activation of Th2 T-cells. This inflammatory phenotype is associated with atopic diseases such as allergies and asthma  and tendn = 1787), OCS has been shown to reduce the rate of treatment failure and the rate of relapse and to improve lung function and breathlessness [In the treatment of acute exacerbations of COPD (AECOPD), oral corticosteroid (OCS) plays an important role. In a large meta-analysis of 16 studies , long-acting muscarine antagonists (LAMA), or both . For somWhile post hoc data from several large trials support the notion that ICS should be preferentially given to patients with high blood eosinophil counts ,34,56, tWhile eosinophil-guided treatment has been shown to be a safe way to reduce corticosteroid exposure, very few of the current studies consider the significant variability of blood eosinophils over time . Most haProcalcitonin (PCT) is a 116 amino acid peptide that was first discovered as the precursor to the peptide hormone calcitonin ,61. In iC-reactive protein (CRP) is a widely used biomarker for the detection and evaluation of treatment response during infections . HoweverAntibiotics are generously used for patients hospitalized with AECOPD, and often, antibiotic exposure exceeds guidelines . Antibion = 1656) used a similar design with the same thresholds for PCT, also measuring on days 1, 3, and 7 [The randomized controlled trial proHOSP included 1359 patients with acute lower respiratory tract infections, of which 533 (39.2%) had COPD. They measured PCT on days 1, 3, and 7 of the admission and adjusted antibiotics based on whether PCT was above or below 0.25 μg/L. There were no differences in mortality, rehospitalization, or intensive care admissions, neither in the total population, nor in the subset of COPD patients. However, antibiotic prescriptions for COPD exacerbations were reduced from 69.9% to 48.7% and the mean duration of intravenous therapy was reduced from 1.9 to 1.3 days. The trial had high adherence to the protocol, which was overruled in only 10.4% of COPD exacerbations . The pro3, and 7 . It alson = 1062), including the aforementioned, found that PCT guidance reduced antibiotic exposure by 3.8 days (95% CI 4.32–3.35) with no differences in mortality, re-exacerbation, or readmission [p = 0.015, indicating that PCT guidance is less appropriate for severely ill patients [Several other trials have explored this type of design in COPD patients ,83,84,85dmission . Howeverpatients .n = 457) found no effect of antibiotics versus no antibiotics for patients with AECOPD and PCT < 0.1 μg/L, though the study excluded febrile patients and patients with pneumonia [n = 210) patients with suspected respiratory infections, 89 of which had COPD, used a threshold of 0.25 μg/L to decide whether or not to use antibiotics [Two randomized trials in COPD patients used a design in which PCT was assessed only at the beginning of the exacerbation. One trial  and a reduction in antibiotic exposure from 8.1 days to 5.7 days (95% CI: −2.71 to −2.15) with PCT-guided therapy .A limitation of PCT is that it, like CRP, can respond to non-infectious causes such as trauma, malignancy, or kidney disease. Consequently, some patients have higher baseline levels and respond differently to infections, making it difficult to create universal cut-off levels . This coThere is an increasing body of evidence that supports that time-updated phenotypical treatment guidance can carry some pronounced benefits for patients and societies. Procalcitonin is a promising candidate for guiding the antibiotic therapy of AECOPD with evidence from several large well-designed trials using a time-updated design. Blood eosinophil measurements have proven to be successful in guiding the use of oral corticosteroids in moderate and severe COPD exacerbations, and post hoc analyses from large trials indicate that it could be a viable biomarker to use to guide ICS treatment as well. However, unlike procalcitonin, few studies account for the temporal variability of eosinophils levels. The CORTICO-COP trial has shown that daily monitoring of blood eosinophils is a safe and effective way to reduce OCS exposure and side effects for acute exacerbations. No time-updated studies have been completed for treatment with ICS in the stable phase of COPD, but an ongoing trial is testing this approach.


In addition, alcohol drinking was found to partially mediate the association between depression and suicidal ideation . These results indicated that patients with mental illness who are concerned about drinking alcohol might be able to reduce suicidal thoughts by consulting with a healthcare professional or taking informed actions with the support of a counselor or support group.This study aimed to investigate the mediating effect of alcohol drinking on the relationship between depression and suicidal ideation inpatients with mental illness. A survey was conducted among 163 individuals with various major mental disorders using a self-reported questionnaire. Data were collected from July to September 2020. Subsequently, the data were analyzed using a t-test, one-way analysis of variance, Pearson’s correlation coefficients, hierarchical multiple linear regression, and a Sobel test. Significant relationships were found between alcohol depression and drinking (r = 0.26,  In South Korea, the suicide rate was 26 per 100,000 people in 2021, 1.1% higher than that reported in 2020 ,4. ThereSuicide attempts can often lead to death. Therefore, preventing suicidal behavior is important. In general, suicide begins with suicidal ideation, progresses to suicidal attempts, and ends up completing the suicide .Thus, unAlcohol drinking is another suicidal factor. It is persistently involved in suicidal behavior . MoreoveIn the case of patients with mental illness, depression is closely related to suicidal ideation and alcohol drinking. Accordingly, alcohol drinking can have mediating effects on the relationship between depression and suicide. In this aspect, conducting a direct empirical study on the effect of alcohol drinking on the association between depression and suicide is necessary. Therefore, this study attempted to investigate depression levels, suicidal ideation, and alcohol drinking among patients with mental illness. Moreover, the effects of alcohol drinking on suicidal ideation and the mediating effect of alcohol drinking on the relationship between these factors were also investigated. The findings of this study provide basic data to establish a strategy to reduce suicidal ideation in patients with mental illness.Understanding the role of alcohol drinking in patients with mental illness is essential for designing targeted interventions. By identifying alcohol drinking as a potential mediator, this study may aid in the development of more effective treatment strategies that consider cultural and social factors specific to South Korea. It can also contribute to the broader global understanding of how alcohol influences the complex relationship between depression and suicidal ideation.Depression and suicidal ideation are pressing concerns in South Korea, and the role of alcohol drinking in mediating these concerns needs to be thoroughly examined. This study seeks to shed light on the relationship between depression and suicide, thereby providing valuable insights for mental health professionals, policymakers, and researchers striving to improve the well-being of patients with mental illness in South Korea and worldwide.This study aimed to verify the levels of depression, alcohol drinking, and suicidal ideation among patients with mental illness, the correlations between the variables, and the factors influencing suicidal ideation. In particular, it explored whether alcohol drinking mediates the relationship between depression and suicidal ideation in this unique cultural setting.This study is a descriptive survey research to verify the degree of depression, alcohol drinking, and suicidal ideation in psychiatric patients, the correlations among these variables, and factors affecting suicidal ideation .Regarding the number of study subjects, the G-power 3.1.9 program was applied to calculate an appropriate number of samples. The minimum number of samples for multiple regression analysis was 147 when the significance level was 0.05, explanatory power was 0.90, medium effect size was 0.15, and the number of predictive factors was 12.From July to September 2020, a total of 280 individuals from five basic mental health welfare centers, two addiction management support centers, two rehabilitation facilities, and eight mental health medical centers were enrolled through convenient sampling. Prior to conducting the questionnaire survey, an official letter of cooperation was sent, and approval was received from the institutions. Among the individuals who volunteered to participate in the study, the ones suitable for participation in the survey were chosen. In particular, 141 members of mental health improvement centers and 99 inpatients from mental health medical centers responded to the questions in the questionnaire survey. Of them, those who chose multiple answers and did not respond honestly were excluded from the study. Of the 212 respondents, 30 with alcohol use disorders and 9 with anxiety disorders were excluded. Finally, data from 163 patients were analyzed. The inclusion criteria of the participants were as follows: (1) those aged 18–65 years; (2) those diagnosed with schizophrenia, depression, and bipolar disorder by a psychiatrist according to the diagnostic criteria of the Diagnosis and Statistics Manual (DSM)-5 in American Psychiatric Association; (3) those residing in South Korea or receiving psychiatric treatment in South Korea, Ulsan metropolitan city; (4) those with no acute symptoms  or behavioral disorders ; (5) those without mental retardation or psychiatric double diagnosis; (6) those who are medically free of organic brain damage or nervous system disease; (7) those who can perform their daily activities easily; (8) those who provided informed consent to participate in the study; (9) those who were able to understand and communicate in Korean language. The exclusion criteria of the participants were as follows: (1) those who did not provide informed consent to participate in the study; (2) those who were deemed incapable of understanding the study or providing valid responses due to severe cognitive impairment or intoxication at the time of assessment; (3)those with a history of alcohol use disorders, drug use disorders, and multi matter disorders or who were recently diagnosed with any of these disorders; (4) those with medical conditions that may significantly affect their psychiatric symptoms or confound the study’s results ; (5) those who could not communicate effectively in Korean language; (6) those below 18 years of age or over 65 years of age; (7) those who were pregnant or consumed alcohol (drugs); (8) those who faced difficulties in performing daily activities.This study used a structured self-report questionnaire that comprised 45 questions, including 10 questions on general characteristics, 20 on depression, 10 on alcohol use, and 5 on suicidal ideation.To measure the level of depression inpatients with mental illness, the depression scale for the Center for Epidemiological Studies  was used , which wTo measure the level of alcohol drinking inpatients with mental illness, the Alcohol Use Disorders Identification Test was used , which wTo evaluate suicidal ideation inpatients with mental illness, the Suicidal Ideation Scale was used, which was developed by Harlow et al.  and tranAfter receiving approval from the Institutional Review Board of the University of Ulsan (IRB NO: 2020R0012) in July 2020, a questionnaire survey was conducted for approximately 3 months from July to September 2020. According to a previous study, if a questionnaire survey is conducted without the formation of patients’ trust with mental illness, obtaining honest answers is difficult due to their uneasiness; therefore, allowing the staff of related institutions to perform the survey directly is necessary ,25. In tThe data collected in this study were analyzed using the SPSS/WIN 27.0 program. The statistically significant level was 0.05. The values of frequency, percentage, mean, and standard deviation were calculated to measure the subjects’ general characteristics, depression, alcohol drinking, and suicidal ideation. To identify the differences in general characteristics, a t-test and one-way analysis of variance were performed, and the Scheffé test was conducted as a post hoc test. The correlations between the subjects’ depression, alcohol drinking, and suicidal ideation were analyzed using Pearson’s correlation coefficients. Hierarchical regression analysis was performed to analyze the factors influencing the subjects’ suicidal ideation. The mediating effect of alcohol drinking on the relationship between the subjects’ depression and suicidal ideation was analyzed using the multiple regression analysis-based three-step mediation analysis approach of Baron and Kenny . The SobThe general characteristics of the study participants were analyzed. Men accounted for 50.3% of the study participants. The mean age of the participants was 44.10 ± 13.29 years; those in their 40s accounted for the highest percentage (24.8%), and those in their 20s to 60s were distributed evenly. Regarding religion, 50.3% of the study participants replied that they had no religion. Regarding hospitalization status, 58.4% stayed in local communities. Regarding DSM-5-based diagnosis, 50.3% had schizophrenia, 30.1% had depression, and 19.6% had bipolar disorder. Regarding the first onset, 30.3% had the first onset at the age of <20 years, and 27.6% had it at the age of ≥40 years. Regarding the number of admissions, 31.4% experienced no admission. Regarding daily average sleep time, 31.9% had 7–8 h of sleep, 30.9% had over 9 h of sleep, and 21.1% had less than 4 h of sleep. Regarding sleep satisfaction, 34.1% were neither satisfied nor dissatisfied, 33.5% were not satisfied, and 32.4% were satisfied. Regarding previous suicide attempts, 50.3% had not attempted suicide .p = 0.005), diagnosis , sleep time , sleep satisfaction , and previous suicide attempts   . With reDepression in the study participants was measured. Out of 60, the mean ± SD score was 26.97 ± 13.62. Out of 40, alcohol drinking scored 4.32 ± 8.48. Out of 20, suicidal ideation scored 9.15 ± 4.69 .p < 0.001) and suicidal ideation . Moreover, alcohol drinking was significantly positively correlated with suicidal ideation   .p = 0.007), age , diagnosis , sleep time , sleep satisfaction , and previous suicide attempts  significantly influenced suicidal ideation. The explanatory power in Step 1 was 42.6%. In Step 2, control variables were controlled, and depression was applied. Of the variables used in Step 1, gender , age , diagnosis , previous suicide attempts , and depression  significantly affected suicide. The explanatory power in Step 2 was 52.3%, 9.7% higher than that in Step 1. In Step 3, control variables were controlled, and depression and alcohol drinking were applied. Accordingly, gender , age , diagnosis , previous suicide attempts , depression , and alcohol drinking  significantly influenced suicide. The explanatory power in Step 3 increased by 2% from that in Step 2. Therefore, regarding the influence of depression and alcohol drinking on suicidal ideation, the explanatory power was 54.3%. Furthermore, the presence of multicollinearity between variables was analyzed. As a result, the variance inflation factor value was 1.01–1.45. No multicollinearity was found between variables lower than 10. Hierarchical regression analysis showed that the value of Durbin–Watson was 1.811. Therefore, the correlation between errors had no problem.The factors influencing the subjects’ suicidal ideation were analyzed using the hierarchical regression analysis approach. The results are presented in p = 0.001). In Step 2, the independent variable “depression” statistically and significantly influenced the dependent variable “suicide” . In Step 3, depression and the mediating variable “alcohol drinking” as independent variables and “suicide” as a dependent variable were used. As a result, depression and alcohol drinking significantly influenced suicide . A comparison of regression coefficients demonstrated that the influential power of the independent variable “depression” on suicide in Step 2 (β = 0.63) was lower than that in Step 3 (β = 0.57). Therefore, alcohol drinking partially mediated the relationship between depression and suicide. The value of R2 that represents explanatory power was 6.3%, 39.8%, and 43.5% in steps 1, 2, and 3, respectively. The Sobel test was performed to verify the significance of the mediating effect coefficients. As a result, the absolute value of Z was larger than 1.96; thus, the mediating effect of alcohol drinking was found to be statistically significant .Regression analysis was performed on the mediating effects in this study. The results are presented in Depression and suicidal ideation are significant mental health concerns worldwide, including in South Korea. This study aimed to explore the relationship between depression, suicidal ideation, and alcohol drinking in patients with mental illness in South Korea, with a focus on the mediating effect of alcohol drinking. Understanding these complex interactions is crucial for developing effective interventions and support systems for individuals facing these challenges.In this study, the factors influencing suicidal ideation in patients with mental illness included depression, previous suicide attempts, age, alcohol drinking, gender, and diagnosis. Prior to analyzing the mediating effect of alcohol drinking, the effects of depression and alcohol drinking on suicidal ideation were analyzed. Consequently, depression and alcohol drinking were found to significantly affect suicidal ideation; this finding was consistent with the results of Tidemalm , Kim et This study showed that alcohol drinking partially mediated the association between depression and suicidal ideation, indicating that the higher the depression is, the greater the level of suicidal ideation is, and the higher the use of alcohol is, the greater the level of suicidal ideation is. In other words, excessive alcohol drinking increases the risk of suicide by causing psychological devastation, social isolation, economic loss, and family troubles . MoreoveDepression in patients with mental illness was found to indirectly affect suicidal ideation by way of increasing alcohol drinking. In other words, alcohol drinking increases with depression, which causes impulsive suicidal behavior through suicidal ideation. Previous studies ,35 have The present study found compelling evidence to support the hypothesis that alcohol drinking mediates the relationship between depression and suicidal ideation among patients with mental illness. This suggests that alcohol drinking serves as a mechanism through which depressive symptoms contribute to the emergence or exacerbation of suicidal thoughts in this vulnerable population. The findings underscore the importance of holistic mental health care that considers the interplay of multiple factors in patients with mental illness. This approach should encompass not only the treatment of depressive symptoms but also the identification and management of alcohol use disorders.Further research is needed to understand in depth the dynamics of depression, suicidal thoughts, and drinking in Korea. In addition, to reduce suicide accidents, it is necessary to develop targeted prevention and treatment programs to reduce depression and alcohol consumption. Moreover, the COVID-19 pandemic might have exacerbated the challenges faced by patients with mental illness in South Korea, including depression and suicidal ideation. The mediating effect of alcohol drinking, as a potential coping mechanism during the pandemic, should be further studied to develop effective interventions and support systems for individuals dealing with mental health issues in such challenging times. Providing accessible mental health services and addressing substance use issues are essential components of this effort.The limitation of this study is the possibility of generalization. Data collection and analysis were performed targeting only one city; hence, interpreting and generalizing these data to every patient with mental illness needs to be performed with caution.This study verified that among psychiatric patients, alcohol drinking partially mediated the association between depression and suicidal ideation. Therefore, to prevent suicide among patients with mental illness, active intervention is necessary to help them reduce their depression and give up drinking.While this study provides valuable insights, it is essential to recognize that the relationship among depression, suicidal ideation, and alcohol drinking is complex. Further research is warranted to explore the nuances of this relationship, including the impact of specific types of alcohol and the effectiveness of tailored interventions.In this study, the association between depression, alcohol drinking, and suicide and the mediating effect of alcohol drinking was confirmed. However, it was not possible to confirm the reverse association between depression and alcohol. Therefore, in future studies, it will be suggested to study the reverse association between depression and alcohol.In conclusion, this study highlights the role of alcohol drinking as a mediating factor between depression and suicidal ideation among patients with mental illness. It emphasizes the importance of personalized, comprehensive mental health care that addresses both depressive symptoms and alcohol misuse. The findings of this study have practical implications for risk assessment, intervention strategies, and the overall well-being of individuals grappling with these challenging conditions. While this study focuses on South Korea, the findings can also be used to understand the relationship between depression, suicidal ideation, and alcohol use in patients in other countries, especially those with similar societal and cultural characteristics.


In this report, we present the case of a patient with an uncommon triple diagnosis of (1) follicular (nodular) lymphoma, (2) nodular lymphocyte predominant Hodgkin lymphoma, and (3) diffuse large B-cell lymphoma non-germinal center B-cell (non-GCB) subtype. Although transformation of follicular lymphoma and nodular lymphocyte predominant lymphoma to more aggressive forms such as diffuse large B-cell lymphoma is possible; it generally happens many years after diagnosis. Moreover, there have been reported cases of follicular lymphoma with transformation and nodular lymphocyte predominant Hodgkin lymphoma with transformation at the time of diagnosis, but it is very uncommon to see all three present on initial diagnosis. Our patient presented with a large right axillary mass, which, upon excisional biopsy and subsequent histology, showed the aforementioned lymphomas. The patient did not present with a prodrome of any symptoms except intermittent night sweats. The unique aspect of our case is that transformation and all three lymphomas were seen at the time of diagnosis. The R-CHOP  chemotherapy regimen is still the standard method of treatment as it has been shown to be effective in treating follicular lymphoma and nodular lymphocyte predominant Hodgkin lymphoma with and without transformation. However, there is insufficient literature on its efficacy when all three are present concurrently. Follicular lymphoma (FL) is a B-cell lymphoproliferative neoplasm that originates from the germinal center. The diagnosis and morphological assessment of FL is made via lymph node excision and biopsy. Transformation of FL to large cell lymphomas can be seen in up to 60% of patients . NodularThe transformation presented in our case belonged to the postgerminal immunohistochemical variant of DLBCL , a molecular analog of the activated B-cell (ABC)-DLBCL subtype, which presents an unfavorable prognosis. This subtype is characterized by the constitutional activation of the B-cell receptor signaling pathway and the transcription factor NF-κB (nuclear factor kappa-light chain enhancer of activated B cells).This article discusses the case of a triple lymphoma finding. Our patient was found to have all three: FL, NLPHL with transformation to DLBCL concurrently at initial diagnosis. Upon review of the literature, we were unable to find any other case reports discussing such a presentation as such, and this may be the first reported case.A 36-year-old, Hispanic male patient presented to the general surgery clinic with a large, painless right axillary mass measuring approximately 3 inches in diameter. He had no history of serious illness, and family history of any cancer was unclear. He does not smoke or use any illicit substances and drinks alcohol socially. He was not taking any prescription medication. He appeared well and was not in any distress. On palpation, the mass was hard and mobile with enlarged surrounding lymph nodes. He did not present with weight loss, fatigue, or fever. The only symptom he had prior to diagnosis was intermittent night sweats. Positron emission tomography combined with computed tomography (PET/CT) revealed an increase in the size of multiple right axillary lymph nodes. The two larger lymph nodes were 5.8 cm and 6 cm in diameter, with several smaller ones located medially and posterior to the pectoralis. There were no enlarged lymph nodes elsewhere.Lymph node biopsy revealed enlarged lymph nodes with effacement of architecture by a nodular proliferation composed mostly of small lymphocytes and admixed large atypical lymphoid cells consistent with lymphocyte predominant (LP) cells. There were also adjacent nodular areas composed of mostly large atypical lymphoid cells arranged in sheets associated with central necrosis. Histological images directly from our patient's lymph node showing FL can be seen in Figures Immunohistochemistry showed that LP cells were positive for CD20, CD45 (variable), PAX5 (variable/weak), OCT2, and Ki-67, and negative for CD15, CD30, ALK1, and BOB1. There were increased numbers of PD1+ T-cells and CD4+ helper T-cells within the nodules and arranged in rosettes surrounding LP cells.BCL6, and expressed increased PD-1, CD4, and variable weak BCL2. The tumor cells were negative for CD15 and BCL1. FISH diagnosis was positive for extra copies of MYC, BCL2, BCL6, and IgH , and was negative for double-hit lymphoma as there was no evidence of translocation or rearrangements. Thus, the diagnosis was established as follicular (nodular) LP B-cell lymphoma (grade 1), NLPHL, (fan pattern A), and focal area of progression to DLBCL (non-GCB subtype).The tumor cells expressed CD45 (LCA), OCT-2, Four courses of rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) are planned. Serum blood chemistry and LDH will be monitored regularly, and after cycle four, a follow-up PET scan will be administered, likely along with involved field radiation. cycle four, a follow-up PET scan will be administered, likely along with involved field radiation.The case presented in this article is particularly unique as all three lymphomas  were present at the initial diagnosis. Another distinguishing factor in this case was the evidence of transformation to DLBCL at the time of diagnosis. Many retrospective studies have been conducted on the incidence of transformation of FL, with limited data from prospective studies. Acker et al. found the risk of FL transformation to be 20% after five years and 60% after eight years of therapy and observation . ErsbollKenderian et al. performed an analysis of NLPHL transformation to DLBCL using the Mayo Clinic Lymphoma Database. They identified 222 patients with NLPHL between the years 1970 and 2011 . The cohBCL6, MYC, and IgH seen in our patient are relatively common in the pathogenesis of lymphoma. The proto-oncogene BCL6 is most commonly found to be dysregulated and overexpressed as a result of the translocation   is seen in 5-10% of DLBCL cases [BCL6 are seen without any evidence of translocation. The overexpression of the oncogene BCL2 is also more commonly seen as a result of translocation  in approximately 20% of DLBCL cases [BCL2 prevents tumor cells from undergoing apoptosis, thus prolonging their survival. However, the patient presented in our case showed no evidence of BCL2 translocation or rearrangement, which is an unusual finding. Moreover, overexpression of the MYC proto-oncogene was also seen in our patient without the evidence of any translocation or rearrangement, again, making this finding very unusual. The proto-oncogene MYC encodes the Myc protein, which is essential for proliferation, metabolism, differentiation, and apoptosis. Overexpression of MYC causes increased cell proliferation, angiogenesis, apoptosis, genomic instability, and inhibition of cell differentiation [Extra copies of  q2;q32 is sCL cases . In our  q2;q32 is sntiation ; all of BCL6, PAX5, PD-1, Ki-67, and MUM1 [The presentation of NLPHL is usually localized to the lymph nodes; extranodal, mediastinal, or abdominal involvement is uncommon as evident by the axillary mass present in our case . NLPHL iand MUM1 -15.BCL2, an antiapoptotic protein. In some cases, dysregulating mutations of BCL6 are also seen also resulting in an overexpression of BCL6, which is required for germinal center formation as seen in our patient [FL is a B-cell lymphoproliferative neoplasm that originates from the germinal center. The diagnosis and morphological assessment of FL is made via lymph node excision and biopsy. There are two morphologies visible on biopsy; FL displays two types of closely packed follicles: 1) small follicles containing small cleaved cells with nucleoli of variable sizes, referred to as centrocytes, and (2) larger noncleaved cells with moderate cytoplasm, open chromatin, and multiple nucleoli, referred to as centroblasts which are rapidly dividing B cells . Its gra small fo patient .As evident by the pathology and research presented in this report, it is uncommon to see FL and NLPHL with transformation to DLBCL in a patient at the time of diagnosis. The standard method of treatment is still rituximab, cyclophosphamide, doxorubicin hydrochloride (hydroxydaunomycin), vincristine sulfate (Oncovin), and prednisone (R-CHOP). This combination of therapy still provides the most favorable outcome for patients presenting with singular or multiple lymphomas with or without transformation. Early transformation to DLBCL is a poor prognostic factor, and many patients may still respond well to the R-CHOP chemotherapy regimen. The etiology of genetic mutations involved in the development of lymphoma has been under careful research for many decades and continues to this day. Technological advancements and discovery of new genetic mutations give some hope for the development of more targeted therapies.